Supporting the Pelvic Floor with Jeanice Mitchell, PT

[00:11] Jennifer Milner: Hello and welcome to Bendy Bodies with the Hypermobility MD, where we explore the intersection of health and hypermobility for dancers and other artistic athletes. I'm Jennifer Milner, here with co-host Dr. Linda Bluestein. Before we introduce today's guest, we'd like to first remind you about how you can help us help you. First, subscribe to the Bendy Bodies Podcast and leave us a review. This is helpful for raising awareness about hypermobility and associated disorders. Second, share the Bendy Bodies Podcast with your friends, family, and providers. We really appreciate you helping us grow our audience in order to make a meaningful difference. This podcast is for you.
[00:48] Our very special guest today is Jeanice Mitchell, licensed physical therapist, founder of MyPFM, president of Integrity Rehab, and administrator of Integrity Home Health. She graduated from Loma Linda University with her Bachelor of Life Sciences and Master of Physical Therapy degrees. Practicing since 1995, Jeanice has worked in a variety of settings, including inpatient and outpatient orthopedic neurologic rehab, acute rehab facilities, skilled nursing facilities, home health, long-term care, and sports medicine clinics. Jeanice's area of expertise is pelvic floor rehab for men, women, and children. Jeanice, my first question for you then is, how did you become so passionate about education and about pelvic floor?

[01:57] Jeanice Mitchell, PT: Thank you for the honor to be on the podcast today. I'm really excited to be here and I talk really fast and I have a lot to share, so I'll try not to go too fast. I graduated in '95 and at that time pelvic health was not discussed in physical therapy school. We didn't dissect the pelvic floor in gross anatomy or anything. I had my first baby in 1999, and at that time I saw a little ad for a pelvic health course in a PT journal. So I went to that course to get help for myself after my own pelvic floor dysfunctions as a result of my first baby. That was really transformative personally and professionally — understanding our anatomy and our body and how it works. I felt like, wow, I have this information now. How can I not share this with others? Other people need to know this. And that's really been the start of my passion for pelvic health.

[02:54] Jennifer Milner: There's always some sort of personal connection, right? When you experience it yourself, then you go, oh my goodness, everybody needs to know about this. How can I share that information and talk about it? That's great. So let's have you share that information. What is the pelvic floor, and why specifically should bendy people be interested in this topic?

[03:15] Jeanice Mitchell, PT: So most of the people listening — if you could just envision a hammock.

[03:21] Jennifer Milner: A hammock.

[03:21] Jeanice Mitchell, PT: You have a hammock that's attached to the front and the back, like a tree, right? And the pelvic floor is like a hammock. It literally connects to the front of the pelvis at the pubic bone, stretches back to the tailbone, and then it connects side to side. It's like a little miniature trampoline there at the base of your pelvis. So it holds up your pelvic organs. Most female bodies would have a bladder, a uterus, and a rectum. The pelvic floor muscles are one element to help keep those organs in place. The pelvic floor muscles also help to control our bladder outlet and our bowel outlet. If the muscles aren't doing the right thing at the right time, then all kinds of things can happen that I think we're going to dive deeper into.
But bendy bodies specifically are generally more hypermobile, more flexible. There's a lot of exciting research that's happening, but basically, potentially they're more at risk for that pelvic floor — like our little trampoline — getting stretched out a little bit more, or it doesn't rebound up quite as well. Some of the ligaments, the collagen, the fascia — that integrity can be affected. All of these structures work together to provide that stability and support. That's why bendy bodies would especially be interested in some of the information we're going to share today.

[04:53] Jennifer Milner: I know we're going to go in depth in a little bit here, but what kind of problems show up in the pelvic floor? You mentioned supporting the organs and controlling the urinary tract, but are there other things that might be problems?

[05:10] Jeanice Mitchell, PT: Absolutely. If you look at it from a muscle dysfunction standpoint — if you could interlock your fingers together, and this is an advantage for people watching on YouTube where you can see it — on a muscular level, when you go to make a muscle contraction, those fibers glide together to make that firm, hard contraction. Then when you relax, they return to baseline, and those muscle fibers should also be able to stretch. The pelvic floor muscles are a voluntary muscle group, designed so that when you contract, those muscle fibers glide together, relax, and stretch.
[05:53] If the muscle fibers are too lengthened or too stretched out, you can have issues with urinary leakage, bowel leakage, gas leakage, pelvic organ prolapse, and so forth. Those are weak, overstretched muscles — that hammock is stretched out. But you can also have overactive pelvic floor muscles where you might have pain, and you could also have some of those same issues like urinary leakage or pelvic organ prolapse. So you really want the pelvic floor muscles to do the right thing at the right time. They need to be able to completely and correctly contract, but they also need to be able to lengthen and let go.

[06:33] Jennifer Milner: Interesting. It's so easy for us to think, I know when I need to go see a doctor about my calf muscle because it hurts, or because I can't walk — something very easy for me to say, oh, that's my calf muscle, it bothers me. But I think for a lot of us, we don't think, oh, this is an issue, I must go get my pelvic floor checked out. Because sometimes you'll say, oh, my bladder was too full, and so when I sneezed, that's why I had some leakage. Or people might say, I just have a hard time getting strength here, and that's just me, that I'm just weak. So we don't automatically think about our pelvic floor and think, I should go seek out help for it. What would be the type of thing that would make someone go, maybe I should get my pelvic floor checked out?

[07:24] Jeanice Mitchell, PT: Constipation, straining, really having difficulty with a bowel movement, pain. Pain with urination, pain with intercourse — whether it be penetrative vaginal intercourse or pain with orgasms — difficulty emptying the bladder, urinary urgency, urinary frequency, bladder pain, bowel pain. All of those are warning signs. Now there may be other things going on too, but definitely if you're having pain kind of in between the belly button and the hips, the pelvic floor may very well be involved.
[08:00] Even hip pain and low back pain and sacroiliac pain can be a warning sign of pelvic floor dysfunction. You have a muscle inside your pelvis called the obturator internus muscle. It's a hip muscle technically, but it really shares a fascial attachment with the pelvic floor. A lot of times with hip pain, and sometimes even with pelvic pain, that obturator internus is affected, and a regular PT really isn't going to be able to access, identify, and provide great interventions for the obturator internus. So that's another sign that a pelvic health physical therapist would be a good choice.

[08:35] Dr. Linda Bluestein: That's super interesting for our dancers especially, because they of course are using their hips a lot and in external rotation a lot if they're doing classical ballet, for example. So they may be having more of those types of symptoms. That's probably particularly important for that population.

[09:03] Jennifer Milner: Absolutely. I also see — when I train dancers on their turnout, I check on their pelvic floor within my scope, obviously — I see a lot of dancers will actually be a little hypertonic in their pelvic floor, like they have trouble releasing it completely. Their obturators are also turnout muscles that we train and want to be able to use. But the pelvic floor work that I do breath-wise and contraction-wise, it's just as important for them to learn how to release it and let go as well. So for dancers and athletes, it's not just your pelvic floor — it's also the thing that connects to the hip, that works with your turnout, or it's something that you really use every day in your art as well.

[09:56] Jeanice Mitchell, PT: You're right. And the pelvic floor is part of the core. If you think about your core, the top is the diaphragm, the front are your deep abdominal muscles, the back your deep low back muscles, and then at the bottom are your pelvic floor. So pressure management and breathing and how you do things is super important, not just for your abdominals and your back, but also for the pelvic floor.

[10:19] Jennifer Milner: Now, in the beginning you mentioned one of the things the pelvic floor does is support your organs and hold them up. I wanted to bring up pelvic organ prolapse. Can you talk about that briefly and why this is particularly relevant again for hypermobile folks?

[10:39] Jeanice Mitchell, PT: I'll try to be brief. So basically, if you think about the pelvic organs — remember we have the bladder, uterus, and rectum for most female bodies — each of those organs has a little canal or tube that goes to the outside, and it goes right through that hammock of pelvic floor muscles. Pelvic organ prolapse is basically where one or more of those organs is starting to drop or descend into the vaginal canal.
[11:11] The bladder is the most common. So the bladder would start to drop — if you've ever heard of a bladder drop, or your mom or grandma had a bladder suspension surgery, that's what it was for. The bladder can start to drop into that vaginal canal and, depending on the level of descent, can even bulge outside of the vaginal canal. And then you can have multi-compartment prolapse where you might have the bladder, uterus, and rectum all starting to drop. This population is especially prone to that because of that very stretchy connective tissue.
[11:50] I want to give you one more analogy that I think would be helpful. Think about a bungee trampoline — like at an amusement park where you get strapped in and you're able to jump up and down. The trampoline is your pelvic floor. You, the person jumping, that's a pelvic organ. And those bungee cords are your pelvic ligaments that help keep those organs up. So it's not just the pelvic floor. Looking at the collagen content and collagen 3 — we won't dive deep into that research today — but potentially this population may have more of that collagen 3, making even those ligaments less supportive of those organs and affecting that pelvic floor from below. So that was my brief explanation.

[12:48] Jennifer Milner: That was fantastic. That was an excellent illustration that makes a huge amount of sense and was very clear. Thank you. So you mentioned earlier seeking out physical therapy. What sort of things could pelvic floor physical therapy help with?

[13:11] Jeanice Mitchell, PT: Bladder issues, whether it be leaking — and I just want to say this: a lot of times people think, oh, leaking means wearing a diaper. No, even if you're leaking a few drops when you cough or sneeze, or if you exercised and went to the bathroom and realized you had some urine leakage, that is leaking. Anytime urine or gas or stool is coming out when you didn't intend it to, that's a warning sign that your pelvic floor isn't doing the right thing at the right time. Now, does that mean that everyone who ever has a drop of urine in their life has to go see a pelvic floor PT? No. But if it's an ongoing and persistent issue, it's likely not going to get better on its own.
[14:00] So bladder and bowel leakage, whether you feel it or whether you don't. Really rushing to the bathroom — that's one type called urinary urgency. And then we have pain: hip pain, tailbone pain. Remember your pelvic floor muscles connect right to that tailbone, so if they're overactive or hypertonic, that can actually be putting a pull on that tailbone and be uncomfortable. Pubic bone pain, pain with any kind of insertion, pain with urination or bowel movements, or even pain with orgasm, hip pain, low back pain, pelvic organ prolapse.
[14:45] Some of the symptoms of pelvic organ prolapse would be a dragging or a heaviness feeling, or even grabbing a mirror and looking and seeing if you see a little vaginal bulge. It's not going to be yellow — we often make the bladder yellow and the bowel brown in illustrations just for ease of identification and teaching, but basically with pelvic organ prolapse, that bladder can drop down into that canal and make it really difficult to empty the bladder. So if you're someone having to shift side to side, forward and back, trying to get that bladder to empty, or you stand up and then have leakage after you stand, that could be a sign of pelvic organ prolapse or some other reason the bladder isn't emptying all the way.
[15:40] And then the same concept with the bowels. A lot of times people are constipated and straining, but if that bowel has dropped into the vaginal canal, it can create a little pocket of stool there. If you envision that canal coming down from the rectum, but with a little pocket off to the side, it can be really difficult to empty. That's another warning sign that pelvic PT might be indicated.

[16:12] Jennifer Milner: Those sound like a very long list of things that we might want to get checked out if we have pelvic floor issues. I know a common misconception is that people who need to see a pelvic floor specialist are older, have had multiple children — especially women of an older age. Is that who you typically see, or do you think this spans all age ranges, especially with hypermobility?

[16:39] Jeanice Mitchell, PT: It definitely spans all age ranges. The youngest person I've worked with was 3, though generally we say age 5 and above, and the oldest has been 94. All genders, all ages — it may look different in different ages, and different populations may be more prone to different types of dysfunction.
[17:05] Something interesting: a study was done of high school females who had never had a baby, and 40% of them had some kind of urinary leakage. So just because you're young doesn't mean you're dysfunction-free. You could very well have something going on with your pelvic floor. And then another factor to consider is the hormonal impact. When you look at estrogen and when our estrogen peaks in our lives — certainly in the teenage years we have a huge influx of estrogen, and then also in the third trimester of pregnancy — estrogen's impact on the tissue makes it more elastic. So if you're in that teenage age range, you're already a very stretchy person, and then you have huge amounts of estrogen flowing through your system as well — that's one more piece of the puzzle.

[18:10] Dr. Linda Bluestein: I'm really glad that you mentioned hormones, because so many people may have seen a gynecologist and talked to them about birth control and things like that. But in my experience, gynecologists don't understand the pelvic floor anywhere near as much as pelvic floor PTs do. I was talking to a gynecologist friend of mine quite a while ago, and she said, I think you need to see a pelvic floor PT. She said, for the rest of us, the pelvic floor is like a black box.

[18:43] Jeanice Mitchell, PT: That's great — well, maybe not great. It's a great analogy.

[18:50] Dr. Linda Bluestein: Right, right. So pelvic floor PT is appropriate for so many different things. What kind of things do people come to you for where you think, this person needs to go back to their physician or get some other type of workup — this isn't appropriate for pelvic floor PT alone?

[19:11] Jeanice Mitchell, PT: I would start off by saying that pelvic floor PT is not a magic pill. Physical therapy isn't a magic pill. It's going to take work, follow-through, and a genuine desire to get better. If your mind isn't there and you're thinking this is a waste of time, it's likely not going to be effective.
There are some red flags we have. Unexplained pain or bleeding — especially if you're having constant pain that isn't changed with movement or position, that's really a warning sign to dive deeper into where that's coming from. Unexplained weight loss or gain, infection, fever, trauma — that kind of thing. But in general, if I'm working with a patient, I expect to see some kind of improvement within a couple of visits. That does not mean the symptoms are resolved, but it means we are on the right track. If I'm not seeing some improvement, I need to readjust what I'm doing. If I readjust and I'm still not seeing improvement, then I might bring in other providers around me — maybe an ortho PT who's really good at SI work, for example. And if I've tried everything I can and symptoms aren't getting better, then I'm going to send them back to the referral source. Is it something hormonal? Is something else going on with other body systems?
I think about people reaching out to me on social media saying, hey, I've been going to pelvic PT for a year and I'm not seeing any improvement. That's heartbreaking. As a PT — as any healthcare provider — it's our responsibility, if we're not helping patients achieve their goals, to send them back or to say, hey, maybe you need imaging, maybe check out this other avenue.
[21:19] Also, in terms of who's providing pelvic floor PT: make sure that when you're selecting a pelvic physical therapist, they have gone to advanced training on the pelvic floor. Have they gone to training for intravaginal and intrarectal work? If they haven't, they really shouldn't be putting their fingers inside your body. There are even massage therapists out there doing intravaginal and intrarectal work. So I would really caution you to research that pelvic physical therapist. It's okay to ask questions like, what training have you gone through? Do you have any advanced certifications? You would think this would be regulated everywhere, but it's not. There are a lot of people out there calling themselves pelvic PTs who may not have gone to advanced training.
[22:19] If you go to our website, mypfm.com, and click on Find a PT, we have links to four free searchable databases where you can put in your zip code and what kind of therapist or dysfunction you're looking for, and see who may be closest to you. When you find someone, I would definitely recommend reaching out and asking some of those questions about certification and training.

[22:46] Dr. Linda Bluestein: Those are great points. And what about men? In terms of how their pelvic floor problems present differently than women — can you talk a little bit about that?

[22:59] Jeanice Mitchell, PT: Absolutely. The same kind of concept exists with the pelvic floor stretching front to back and side to side. Male bodies are going to have two pelvic organs: the bladder and the rectum, and they also have tubes that go to the outside of the body. The bladder's urethral outlet in male bodies goes down through the pelvic floor and then all the way through the penis — it's a much longer path to travel to get to the outside of the body. Males can certainly have leakage, urinary urgency and frequency, pain, constipation, and so forth.
[23:41] Some of the sexual dysfunctions are going to be a little bit different on the male side. Erectile dysfunction is sometimes a pelvic PT issue, and premature ejaculation is another one you wouldn't see in female bodies.

[23:56] Dr. Linda Bluestein: In terms of specific indications or contraindications to pelvic floor PT — are there certain things we should be aware of for men specifically?

[23:58] Jeanice Mitchell, PT: I'll share this: for erectile dysfunction, think about this — erectile health is a sign of heart health. I don't want people to listen to this and say, oh, I have ED, so my issue is only pelvic health. You really need to get your cardiovascular system checked out and go to your urologist first. Pelvic PT can help a lot of cases of ED, but you want to make sure the heart is doing well and that your system overall is healthy. That's one of the big things there.

[24:46] Dr. Linda Bluestein: That makes sense. What about some of the common problems that people with hypermobility disorders face? We know that constipation is a lot more common in people with Ehlers-Danlos syndromes — especially, for example, classical EDS. People can have constipation from a very young age. Can you talk in a little more detail about how you as a pelvic floor physical therapist would treat that, or what somebody might expect if they went to see a pelvic floor PT — assuming they've already seen a physician and a lot of the other things have been ruled out?

[25:18] Jeanice Mitchell, PT: Yeah, the red flags are cleared. So we'd want to look at the pelvic floor: is it lengthened and weak? Is it overactive and tight and weak? That's one thing. And one comment I want to interject here is that a lot of times people think a tight muscle is a strong muscle, and that is a myth. If you think about making a fist and keeping that fist tight for even 5 minutes, when you go to try to use your hand, that's not a strong hand. Constant tension in the muscle fibers can reduce blood flow, sometimes even impact the nerves, and certainly the fascia and the function. So understanding that a tight muscle is not a strong muscle.
[26:09] Going to constipation and really looking at what the pelvic floor muscles are doing — are we having more of the laxity issue, or is it more of an overactive hypertonic issue? That's a really important starting point. Once we've determined that and we do pelvic floor muscle training — the approach really depends on the age and the person's comfort level. If we're working with teenagers who aren't sexually active and we don't want to do anything internal, there's still a lot that can be done externally.
[26:49] We have a tool called biofeedback because I love using technology to help train the pelvic floor. Let's say we had a 13-year-old with constipation, not sexually active, and we didn't want to go inside the rectum or vaginal canal. We use little electrodes — kind of like EKG electrodes where you put stickers on the chest and hook it up to a machine to see the activity of the heart on a screen. It's the same concept with biofeedback, or surface EMG of the pelvic floor muscles. We can put those little stickers around the outside of the anus and hook it up. In our clinic, we have people put their clothes back on after placing the stickers, because lying on the table even while covered can be uncomfortable — a lot of people are more comfortable once they have their own clothes back on. Then we use that biofeedback to retrain the pelvic floor, working on the strengthening phase and the relaxation phase.
[28:03] One really key point with constipation is whether the muscles are letting go as the stool is coming out. If you envision the anus — and this is actually one of the best ways to find your pelvic floor: grab a mirror and look at your anus. When you squeeze, that anus should kind of pucker up and in, and then when you relax, the anus softens and drops. That's what should happen during a bowel movement — the anus should relax and soften. But if that anus is tight and closed, whether from pain, trauma, or just poor coordination, when you go to have a bowel movement it acts like a plug — nothing is getting through. So you might strain even more, and that straining may cause those pelvic floor muscles to activate even more. It's a vicious cycle. And think about the impact that straining has on the pelvic floor and those surrounding structures. Going back to our bungee trampoline example, the pelvic floor needs to support from below and those ligaments need to support from below — but if we have a lot of force pressing down from above, that strains those tissues. Over time, that could even contribute to pelvic organ prolapse. So we definitely don't want that.
[29:34] The Squatty Potty — so many people have heard of it, and the squatting position is really effective to help empty the bowels. Our regular sitting position with hips and knees at a 90-90 angle works for some people, but if you're having difficulty, try squatting more. Elevate your feet on a couple of stools or a Squatty Potty. You don't have to go out and buy one — you might have something at home to use, or stack up a couple of books. And then also thinking about what you are putting in your mouth, because what you eat and drink is going to affect what comes out. If you have more water and more foods with fiber — whole grains, fruits, and vegetables — that food is going to go through your system easier and be softer to come out. Because if you're passing rabbit pellets once a week, that isn't good for your digestive system or your pelvic floor. You're likely straining and you may be having pain. So that's some of it.

[31:48] Dr. Linda Bluestein: That is definitely some of my patients. I cannot believe how many of them are going once a week. And this may be a little bit of a side note, but one thing I wonder about — I'm as addicted to my phone as the next person, maybe even worse than average — do you see any differences as people are on their phones more and perhaps bringing them into the bathroom? I've heard things from some of my other colleagues about perhaps an increase in some of the — maybe not constipation per se, but like hemorrhoids, for example.

[32:28] Jeanice Mitchell, PT: I would love to see some research on that specific topic. Hanging out on the toilet longer — just think about the position that pelvic floor is in. Your pants are down, you're sitting, the pelvic floor is just hanging there. This hammock is hanging in an unsupported position. Hopefully it's relaxed, but if you add straining on top of that, it's a very vulnerable position. The longer you're sitting there, the more potential for possible issues.
[33:09] I've heard some people say you shouldn't read on the toilet or do X, Y, or Z. In my opinion, it's important to do something that's relaxing. If you're looking at emails and all your to-do lists for the next day, that's probably not the best thing to be doing on the toilet. But if it's something relaxing, I don't see a big issue with it. It's more the length of time that you're sitting there.

[33:35] Dr. Linda Bluestein: That makes sense. And what about pelvic pain? That's a super common symptom that I see in my patients. How do you work that up, and what kind of things can pelvic floor physical therapy help with in terms of pelvic pain in hypermobile people specifically?

[33:55] Jeanice Mitchell, PT: That's just so very broad, right? Because pelvic pain can present — the definition of pelvic pain is really pain between the umbilicus, which is your belly button, and your hips or your knees. So it encompasses so many things. I guess in general, whatever the cause of pelvic pain is, we're going to be looking to see if we can reproduce that pain in the assessment. That doesn't mean we're trying to cause you pain, but if we can find the pain and what we're doing reproduces it, that gives us a much better sense of what's involved.
[34:37] Let's say it's pain with insertion. If you think about the vaginal canal and that area — that smooth area of skin between the opening of the vagina and the anus — if pressing on that area is really painful, that gives us a cue. Maybe some of the more superficial pelvic floor muscles are involved. If we go deeper, maybe some of the deeper muscles are involved. So we're going to try to find the cause, and then once we find it, work out an intervention plan.
[35:16] Most of the time, this is going to involve some kind of intravaginal work. But if you're not comfortable with that for whatever reason, we can still do a lot externally. I think it's been kind of a myth in the past that pelvic PT has to go inside — no, we can do a lot of things externally. Biofeedback is one of my favorites, as well as hands-on stretching where I'm actually working on the tissue and teaching the patients how to do some of it themselves — whether it's scar tissue mobilization or perineal massage.
We also use something called dilators. If going inside the vaginal canal is painful, dilators are cylinders that start very small, maybe about the size of a finger, and then get larger. They're graded, so you start small and work larger. For stretching, if the obturator internus is involved, in the clinic I'm going inside the vaginal canal and hooking my finger over to the obturator, because that muscle is way over on the side of the pelvis and you have to hook over there to access it. A wand is also a good tool for patients to use at home for deep obturator internus trigger points.
[36:48] And then ultimately function: stretching, strengthening, coordination exercises, and simulating the patient's goals — what do they want to do? We may have to break it down into small, graded activities and then build from there. You're unlikely to go from zero to sixty in one session, but breaking it down into pieces and ultimately helping to get them where they want to be.

[37:22] Dr. Linda Bluestein: That makes sense. And when it comes to — because I feel like when you're talking about insertion, that's a common thing for my female patients that they definitely have problems with. That could come from a whole lot of different reasons too, right? If they have joint instability in their hips, for example, there could be a lot of different confounding variables — so you kind of have to address each one in order to actually get some improvement.

[37:54] Jeanice Mitchell, PT: Exactly. And I hear Jennifer saying yes, yes — exactly. So it's a multi-faceted approach, and sometimes you may need other disciplines too. It's very helpful to work with nutritionists and dietitians, with mental health and behavioral health, and with other medical specialists if needed. Looking at the hormones as well.

[38:16] Dr. Linda Bluestein: Okay. Let's maybe round out this part by talking about the bladder. If someone is having problems with bladder leakage or bladder pain, is there some component of the workup that you do differently, or would your approach to treatment be a little bit different for that?

[38:34] Jeanice Mitchell, PT: Absolutely. Let's take leakage — let's say when they jump, they leak, and they're not leaking at any other time. Again, I'm looking to see: is the pelvic floor stretched out and lengthened, or is it overactive and too tight? Starting there, addressing whatever component that is, and then really working on the coordination piece.
[39:01] We call it a pelvic brace, or pre-contraction, or a NAC — there are different names in the pelvic PT world — but basically engaging that pelvic floor just before doing that activity to help brace it. If you think about the bladder like a water balloon, as it fills it expands, and the pelvic floor muscles are what wrap around that bladder outlet to keep it closed. If someone is leaking with a certain jump, the pelvic floor muscles might have the strength and coordination for all the other activities of the day, but when they add that increased intra-abdominal pressure with that jump, the muscles either don't have the strength or the coordination to counteract that force. So we focus on pre-contractions, and I would probably back it off — start with a baby jump and then grow that jump, building success along the way.
[40:12] Also looking at healthy bladder habits: generally we want urine to be a very pale lemonade color, and generally urinating every 2 to 4 hours. If you're going every hour throughout the day, that's urinary frequency. If you're holding it for 6 or 7 hours, that can also be problematic. So healthy bladder habits, healthy bowel habits — because the bowels do impact the bladder.
[40:46] In terms of pain, there's something called the bladder as the innocent bystander. About 90% of bladder pain isn't really even coming from the bladder. You think the bladder is the cause, but most of the time the pelvic floor muscles are involved. So addressing the pelvic floor muscles and the fascia and the tissue — and don't forget the abdominal wall. If you had an abdominal surgery, a cesarean section, any kind of scarring there, all of those things can make an impact. Even from a cosmetic standpoint, we spend so much time not wanting a poochy belly, so we're guarding and holding that belly in all the time — and are we ever really stretching it out? That can cause some overactivity there too.

[41:38] Dr. Linda Bluestein: Interesting.

[41:41] Jennifer Milner: I would add to this — you mentioned that you like to work with a lot of nutritionists, and it's sort of a rounded group of people all working together. The other piece, just from my side of the table, is working with someone who does conditioning or is in the ballet studio and can watch them, because a lot of times dancers' bad habits develop around pelvic floor issues. As athletes and artists try to address their pelvic floor, I would encourage them to have a trainer or coach of some kind keep an eye on what they're doing in class.
[42:20] There's a whole category of hypermobile people who brace really hard from their lower back, and when I see them doing that, I know their whole core is not working as well, and I know we have to do some work on that, and pelvic floor goes with it. So if people are working on their pelvic floor — or whatever issue is coming up, whether it's bladder issues or something else — I would encourage them to also work with their coach or trainer and make sure that what they've been doing gets corrected through their technique as well, so that they don't have issues that come up later down the line.

[42:54] Jeanice Mitchell, PT: Absolutely. It's definitely a team approach, and if we're just seeing them in the clinic, we're not seeing what they're doing and how they're doing it. That perspective is incredibly valuable.

[43:04] Dr. Linda Bluestein: And it's all those day-to-day things that add up, right? If Jeanice is seeing them once every couple of weeks, but in between they have all of these other contact points — working with someone more frequently, you can see where there would be a lot of benefit in that.

[43:22] Jeanice Mitchell, PT: Absolutely. It's the straw that broke the camel's back, right?

[43:25] Jennifer Milner: Right.

[43:26] Jeanice Mitchell, PT: All the little things add up.

[43:27] Dr. Linda Bluestein: Yeah, definitely. Can you talk a little bit about the pubic symphysis — what it is, how problems can develop with it, and what kind of things you might do to treat it?

[43:36] Jeanice Mitchell, PT: The pelvis is like two halves, and at the front they join together with a little cartilage disc. It's a soft disc, and it's not meant to really move — other than during pregnancy and labor and delivery, when it does expand some — but it's meant to be a very stable structure. Sometimes it does move too much. If you're someone whose tissues have extra give, it might move, and your pelvis could even rotate a little bit, and that can be painful.
[44:11] So we want to look at the actual alignment, but then also look at all of the muscle players that are attaching to the pelvis: the legs, the quads, the hamstrings, the hips, the glutes, the pelvic floor, the obturator internus, the other deep hip rotators. How are they all impacting it? Are they overactive, hypertonic, and tight? Are they stretched out, weak, and loose? You might have a combination — the front is tight, the back is loose. So figuring out what that equation looks like and then addressing those specific issues, really helping to control and stabilize the pelvis. Like we've talked about with other movements and positions, you may have to start small with small graded movements, get successful with stabilizing and controlling those, and then add onto that. And what Jennifer was saying about having carryover into the studio is critical — so what if we do fabulous things once or twice a month in the clinic? If there isn't regular, consistent carryover into how you are doing what you are doing, it is not going to make a huge impact.
[45:36] Some people can even feel popping in their pubic symphysis, and that can be incredibly painful. We see that a lot during pregnancy — that's probably the most common presentation. But if you're someone who's super flexible, you're at risk, because that's not a bone, that's a joint with cartilage connecting it.

[45:57] Dr. Linda Bluestein: Do you see that very often in men?

[46:03] Jeanice Mitchell, PT: Right off the top of my head, I can't think of a pubic symphysis problem that I saw in a man. That doesn't mean it couldn't exist — I just haven't seen it, and it's not common.

[46:13] Dr. Linda Bluestein: Sure.

[46:14] Jeanice Mitchell, PT: I do have one male patient who feels popping in the pubic symphysis, so I wouldn't discount it entirely, especially if someone has that extra give in their tissues.
[46:28] I like to use external compression too. We want the muscles to do the stabilizing, but sometimes that may not be enough. Using a sacroiliac belt is a great option. There are a lot of different brands out there — you want one that gives some compression but also gives a little. If it's so tight that you're locked down and can't even rotate, that's too much. But some are so stretchy that you wonder how much impact they're really making. Try out different things.

[47:10] Jennifer Milner: I think I lived in my SI belt for my two pregnancies. It felt so different when I wasn't wearing it — like everything was running away. My pubic symphysis subluxed a couple of times but never fully dislocated. And that SI joint — I'm here to tell you, find a good belt and it really does make a difference.

[47:31] Jeanice Mitchell, PT: Yes, absolutely. And the nice thing about some of the maternity versions is that they also have a belly lift. Not only are you stabilizing that joint, but it's also giving that belly support — because if you're someone with stretchy tissue, as that baby grows, think about all that stretch and the gravity pulling down. Supporting underneath and giving it a little lift can really, really provide some relief.

[47:58] Dr. Linda Bluestein: And that's a great tie-in to my next question about the sacroiliac joint. A lot of people don't even appreciate that this is a joint, like the pubic symphysis. Could you maybe explain a little bit how the SI joint works and what kinds of problems you see with it?

[48:26] Jeanice Mitchell, PT: Very similar to what we were talking about with the pubic symphysis, but you have ligaments in the back that help connect these two halves of the pelvis to your sacrum. The sacrum is kind of like a triangle bone at the base of your spine. These ligaments connect the pelvis to the sacrum, and ideally they are so strong and stable that you don't have any movement there. But I'm here to tell you personally and professionally that movement can happen — you can have clicking and popping. These halves can rotate or kind of slip up, and think about how that throws everything off, throws your muscle balance off. It can be very painful.
Finding a PT who's good with sacroiliac joint assessment and stabilization is key, and an SI lock brace is a great option. Ideally, we want to assess all those muscles: are they tight, are they weak, are they uncoordinated, and how are they working during activity? But in the event that you need something more, there are many different brace options out there. One of my favorites is from a company called OPTP — it's called the SILOC brace, S-I-L-O-C — and they have a maternity version as well that I used during my third pregnancy. It can really give a lot of relief and some external compression. Ideally you don't want to have to rely on that for function, but if you've tried everything and need some extra support, what's the downside ultimately of wearing a brace so that you can do X, Y, or Z?

[50:15] Dr. Linda Bluestein: Well, I think there's a misconception — whether it's a brace for your pelvis or for your wrist — I hear this a lot: if I use a brace, I'm going to develop weakness in the muscles. But sometimes you need that brace to stabilize the joint in order to use your muscles, and your muscles will get weaker without the brace than they would if you used it. And sometimes you need the brace just to get you over the hump — you've got a flare of something, you put the brace on, it helps calm down that local inflammation and gets you moving forward more quickly than if you hadn't used it.

[50:55] Jeanice Mitchell, PT: Absolutely.

[50:57] Dr. Linda Bluestein: Well, I would love to hear about the 501(c)(3) that you founded, My Pelvic Floor Muscles. What can you tell us about that?

[51:07] Jeanice Mitchell, PT: I've been a pelvic PT since I took that course in the early 2000s, and it's been incredible to work with people in Central Texas and make an impact on their lives. But then I thought — okay, how can we impact people outside my sphere of influence? I've always wanted to have better pelvic floor pictures and animations to share with my patients. That was really the start: let's create some of these things, let's create a YouTube video. I just knew it was going to go viral and everything was going to be fantastic. It didn't go viral, but we're getting a lot of good engagement.
[51:45] Instagram has been — wow. And honestly, I started off not even wanting to do my own voiceovers. I had stock photos and custom images of the pelvic floor, but I didn't even want to do the voiceover. I hired somebody to do it and I was like, there's no passion. Where's your enthusiasm for this topic? So I started doing the voiceover, then started sharing a little bit more on social media, and now I'm just out there. You haven't seen my actual pelvic floor yet, but it's been really exciting to share my journey and my struggles. I think that really helps to connect people with you too.
[52:32] So basically, with MyPFM now, we have a lot of different things happening, but we have 35 different language translation groups. We take an infographic — for example, the one on constipation with 14 tips, which I am going to post soon — give it to our volunteers in these other groups, they translate it and send us back the words, and then we create it in that language and they share it with their sphere of influence. Kind of like the ripple effect. That is the ultimate goal: to reach everyone. Pelvic health for all — everyone, everywhere, every language. That's really my mission and my vision. It's taking a different path than I initially thought, but I feel like I'm floating on a cloud most days. I love doing what I'm doing.
[53:26] I love connecting with people — like yesterday, a pelvic PT in Canada reached out and said, hey, do you know of a pelvic PT in Bangalore, India? I have someone reaching out to me looking for someone there. I said, well, I don't know, let's put it on the Instagram story. I put it up, and right away someone said, hey, I'm a pelvic PT in Bangalore, here's my clinic information, here's my number. And we're able to connect people all over the world. That alone just — it makes me almost want to cry. It's such a happy feeling to be able to connect people with hope and help. So many people are out there suffering and they don't know that there are solutions. That's MyPFM in a nutshell. It's a nonprofit. We have a membership program, provider pelvic health webinars, and we're just moving forward with that.

[54:23] Jennifer Milner: I love your passion and your enthusiasm. It is so beautiful to see somebody able to live out this passion this way and to serve so many other people. It's incredible. Thank you so much.

[54:35] Jeanice Mitchell, PT: Absolutely. My pleasure. And thank you for the support — you never know who's listening to this that might be able to share it with someone else, even if you're not having a pelvic floor dysfunction yourself. Three out of four women will have pain with sex at some point in their life. This isn't a very small population. And when you look at all of these issues, I would venture to say 99% of people have some kind of pelvic floor issue at some point in their lives. Just being able to connect those symptoms and being empowered to know — okay, I have this, but there's hope, there's help, I don't have to live with this forever.

[55:13] Dr. Linda Bluestein: That's fabulous. I couldn't help but chuckle over your story about the voiceovers, because having met you fairly recently and seeing your fantastic, quirky videos that take a topic that can be really challenging and make it so much more interesting — I think they take away a lot of the anxiety that people might have about going to see a pelvic floor physical therapist and make it much easier to have conversations about these things. I think it's just fabulous what you're doing.

[55:48] Jeanice Mitchell, PT: Thank you. You're amazing. Ever since I first reached out to you, Linda, you've been incredible. I can't wait to continue to do more things with you and with Jennifer as well. I'm really honored to be a guest on here, and thank you for the opportunity.

[56:04] Jennifer Milner: Absolutely. We appreciate you coming on.

[56:06] Dr. Linda Bluestein: Yes, most definitely. Could you share with everyone where they can best find you, learn more about what you're doing, and access some of those resources?

[56:20] Jeanice Mitchell, PT: Absolutely. My patient- and consumer-oriented social media content is on Instagram at @mypelvicfloormuscles — no spaces, no dots, just @mypelvicfloormuscles. If you may be interested in multilingual resources, that Instagram channel is @mypfm. And if you're interested in our provider pelvic health webinars and advanced learning, that Instagram channel is @mypfm.ambassadors. So we have three Instagrams. Then we have YouTube, which is My Pelvic Floor Muscles — no spaces — and then mypfm.com. You can also always email me: [email protected]. Nothing is TMI, so email me. You make my day when you reach out, because I'd love to connect people with help.

[57:20] Dr. Linda Bluestein: Great. And those courses — are they available for both patients and providers?

[57:26] Jeanice Mitchell, PT: The bulk of the courses at this point are for providers. We are developing more. I have one right now called Sex After Baby, which is for consumers or regular people. I'm creating two more for sure in 2021, and then we'll see as time goes on.
[57:49] If you go to my Instagram @mypelvicfloormuscles and look at the IGTV, I'm doing a lot of free interviews on different topics where you may find your answers. That's free — you don't have to buy a class. For example, this week we did one on anal fissures, a good 30-minute resource if that's something you're dealing with. Linda and I even did one on hypermobility, so that's on there too. I would encourage you to check those out, and if you want to see a course on a specific topic, let me know. I'm trying to create as much as I can without having to charge for it. Ultimately there are costs in everything we're doing — all the platforms and so forth — so I do need to generate some revenue. But it's a nonprofit, and the goal is to reach as many people as possible, so we're also creating a bunch of free stuff.

[58:48] Dr. Linda Bluestein: The amount of material that you have on Instagram alone for free is amazing. You have such fantastic videos, graphics, reels, all kinds of things. In fact, you're the one who taught me how to make a reel.

[59:04] Jeanice Mitchell, PT: Yes, I love saying that. It's so exciting.

[59:09] Jennifer Milner: Thank you.

[59:10] Dr. Linda Bluestein: Well, this has been so much fun to chat with you, Jeanice, and we're so grateful to you for coming on the show today and sharing your expertise with our audience.

[59:20] Jeanice Mitchell, PT: Thanks so much for the opportunity, Linda and Jennifer. You guys are incredible. Keep doing what you're doing because — I am a hypermobile bendy person myself — and I think there's this myth out there that there's just a few of us, that there's not very many of us, but I think there are way more of us than is even recognized in the medical community. When I posted some of my content about hypermobility and pelvic organ prolapse, you would not imagine the comments and the feedback that I got. I think it's very important to help connect with this population and help them understand — hey, this symptom may be impacting this — and fit all those pieces of the puzzle together.

[1:00:13] Dr. Linda Bluestein: Yeah, definitely. Well, it's been so great to chat with you, Jeanice, and to see you again, Jen, of course. You all have been listening to Bendy Bodies with the Hypermobility MD. Today we have been speaking with physical therapist Jeanice Mitchell. Jeanice, we are so grateful to you for coming on the Bendy Bodies Podcast today and sharing your expertise, and we'll catch you next time.

[1:00:36] Jeanice Mitchell, PT: Thanks again, everybody! Bye-bye!

[1:00:38] Dr. Linda Bluestein: Bye-bye! Thank you for joining us for this episode of Bendy Bodies with the Hypermobility MD, where we explore the intersection of health and hypermobility for dancers and other artistic athletes. Please leave us a review on your favorite podcast player. Remember to subscribe so you won't miss future episodes. Be sure to subscribe to the Bendy Bodies YouTube channel as well. Thank you for helping us spread the word about hypermobility and associated conditions. Visit our website at www.bendybodies.org for more information.
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[1:01:25] The thoughts and opinions expressed on this podcast are solely of the co-hosts and their guests. They do not necessarily represent the views and opinions of any organization. The thoughts and opinions do not constitute medical advice and should not be used in any legal capacity whatsoever. This podcast is intended for general education only and does not constitute medical advice. Your own individual situation may vary. Do not make any changes without first seeking your own individual care from your physician. We'll catch you next time on the Bendy Bodies Podcast.