Tackling Taboo Topics with Sarah Miller, DPT

And I'm always excited when I get a chance to reconnect with you , and it's especially special if that's a word or a phrase when we get to podcast together , and so I'd love to think that it was just my shining personality that brought you to this episode , but I think it was might be more about the topic and our special guests than it was me .

This is something I think you don't really learn a lot when you're younger , but then when you get older and I'm almost 30 , I'm 29 , I'm like dang , this is something I need to know now , so can't wait to dive into it and hear all about everything we need to know .

I guess you could say she's got up close and personal with me as my pelvic floor therapist , but she is phenomenal and I am so excited that she said yes to this episode for so many reasons , because in the short time that I've known her and been a patient of hers , I have learned so much about my body and my pelvic floor , and I just .

My only regret is that I didn't meet her 30 years ago , because I think , gosh , I would have been in such a much better place today if I had . So , with all that said , let me introduce you to our guest , sarah Miller . Sarah is a doctor of physical therapy that is trained in treating pelvic health and orthopedic conditions .

She owns her own practice , which is called Revive Rehab , and it's located here in Columbia , missouri , where she treats pelvic health and orthopedic populations . Sarah was able to further her education after graduation to better serve her pelvic health and other clients .

She's earned multiple certifications in internal and external pelvic floor interventions , myofascial techniques , chronic pain treatment , dry needling and , among other things , sarah this I did not know is a former I'm not surprised , though a former collegiate softball pitcher , where she competed at Northwest Missouri State University , go Bearcats , and she received her degree in

biology and psychology Also very interesting mix of , yeah , biology and psychology . She then graduated from the University of Missouri in 2019 with her doctorate of physical therapy . In her spare time , you can find Sarah spending time with her husband and her daughter . She loves her CrossFit gym and she loves getting some sunshine outdoors .

She also enjoys all things active , from skiing to biking on the trails , and she strives to continue this lifestyle throughout motherhood , to show her daughter the importance of movement throughout life . Oh , love that so much . Yeah , sarah , welcome to the show . We are so excited to have you .

So each at least at the University of Missouri where I graduated from we had to do four different clinical rotations where they're treating patients working with our clinical instructor or just experienced seasoned physical therapist .

And I traced into my third clinical so I was in my final year of PT school into an orthopedic physical therapy clinic that had a physical therapist there that specialized in pelvic floor physical therapy , and so what that means is she went and got extra certifications outside of physical therapy school to specialize in this , and so that's sometimes where that gets

muddled . Physical therapists will say they specialize in pelvic health , but you really have to kind of tease out what that entails . So we can kind of talk about that at a later date

. But anyway , I traced in and I knew that I potentially would be interested in pelvic health .

I had no idea what it really entailed , but I wanted to observe with her , and so I ended up kind of sharing my time back and forth between orthopedic , the orthopedic population and then pelvic health population , and I went into the private room with her for our first visit and it was a woman with urinary symptoms and pain with intercourse , and I remember just

the conversations that we had that just felt like such taboo topics that we just don't talk about unless it's behind closed doors , and even then it's just hard to talk about . I just vividly remember thinking , oh my goodness , this is this is exactly what I want to do .

I want to have these hard conversations and make them feel easy , because they should be , and if we have the right people that are listening and really are there with an open ear and an open mindset . It's crazy the healing that can happen with a pelvic floor physical therapy .

So it was just an immediate knee jerk reaction of , okay , this is exactly what I want to do and I'm in the right place , and so since then I kind of took off and I've specialized since .

And having been on the other side of that conversation with you , on the other side of that door , you did just that , like the conversations , like the first time you meet someone and you're going to talk about like the most let's just say it really embarrassing things Right and but it's it's bigger than just the physical aspect and that like immediately you kind

of tapped into like the emotional aspect of the impact of that too .

Even what you said , I probably I wish I would have met you 30 years earlier Like how many of us are silently struggling or dealing with things , just thinking , well , hopefully it'll go away , or I'm just going to ignore the problem whatever it is , before you go and have that conversation and probably once you get to the point where you finally convince yourself

it's time to get help , it is an emotional moment , like you're talking about something that's deeply personal , it is to Robin's point , can be embarrassing and you just feel like what's wrong with me , right , and it just is an emotional time .

So I appreciate you just acknowledging that and knowing that anytime you meet with one of your clients , that you understand it's an emotional moment . But for those of us who don't know where the heck is our pelvic floor and our body and that's so important for women- Totally , that's a great question .

Something I get into quite a bit is I feel like we don't get enough time with our clients one-on-one , and so I always want to make sure that I'm spending time just educating on the anatomy itself , because , as I think any individual listening would know , we just don't get enough , especially about our pelvic health or our sexual health .

We just don't get enough education on it and health or our sexual health we just don't get enough education on it . And so I really like to go through the anatomy , show exactly what was what is going on with each individual and what they tend to have complaints of . I really like to point it out so that they're empowered of knowing .

Okay , this is exactly what my issues are and I can actually now understand the why behind it . And so I have my trusty pelvis .

So the pelvic floor is the bowl of muscles that encompasses our full bottom half , and so the muscles span all the way from the front pubic bone internally and then do a hammock and hammock all the way back onto the tailbone and then into the lower back or like joint area . The muscles also span hip to hip as well and then they go .

So they go laterally as well and then encompass the full bottom half . It's like a bowl of muscles , and so if anyone's ever heard of a Kegel before , that's like contracting the pelvic floor up and in , almost like if you were to do a bicep flex . That's exactly what a Kegel is for your pelvic floor .

But then also , what we tend to forget about most often is we also need to be able to relax that .

So when you're having a bowel movement or when you're trying to let urine come out , that's when we really want to make sure that the pelvic floor is dropping , or that bowl of muscles is dropping down , because the pelvic floor has , and it houses , three major organs it houses the bladder , and then it houses the vaginal canal and the uterus , and then it houses

the rectum , and so that's why I love to talk about peeing , pooping and then sexual and menstrual health , because all four of those really contribute to exactly what's going on at your pelvic floor , and the pelvic floor just suspends those organs and tends to contribute to a lot of those symptoms and struggles that specifically women tend to struggle with .

And so a lot of times I see people who have just been beating up their tissue , stretching their hips , stretching their low back , feel like there's no , no relief . And a lot of times I see people who have just been beating up their tissue , stretching their hips , stretching their low back , feel like there's no relief .

And a lot of times it's because it's so much deeper than that . It's really contributing to a deeper muscular layer that tends to be the pelvic floor . Wow , a lot of different . I always have like a nice laundry list on my social media . Okay , if you have any of these issues , they might be contributing to you from your pelvic floor .

So I have had I don't know at least six different surgical procedures over the last 25 years to help with this , like childbirth wrecked me , which I think you might be able to identify with now as a new mom of a . She was close to 10 pounds .

It's like , yeah , it's not all sunshine and rainbows .

It doesn't have to be immediate , the sooner the better , yes , but you're a lot of times just in survival mode , that first year specifically , and so if you can give yourself time to set aside to come see a pelvic floor physical therapist , at least for one visit , that's incredible .

But I also understand that there's a lot of different contributing factors as to getting into the door , and so there's no bad time postpartum , just check , get your pelvic floor checked and see what's going on .

So what that means is you could just walk in the doors , as you would with a chiropractor , as you would with a massage therapist , you can just get on the schedule , and then what you can do is you have 30 days to work with that physical therapist .

If , then , you need more care past those 30 days to work with that physical therapist , if , then , you need more care past those 30 days , then , it would require a physical therapy script from either your primary care , your OB-GYN , a chiropractor a lot of just different providers can refer or send a script in after that point .

But the more conversations you have with them , the more you're like oh , there's such an opportunity to help you in ways that you didn't even realize oh , heck , yeah , I always joke .

The major complaint is what someone always comes in with , but there's always layers that have built over time and so , although they might be coming in for urinary incontinence , a lot of times there's a tailbone injury that happened five years ago that they that we start to kind of uncover after a few visits , or some hip pain that's also flared up , especially

around the time of , maybe menstruation or ovulation or when you're going through perimenopause .

So we just start to unpack a lot of different contributing factors that didn't seem like a priority when the individual came into the doors , but then their mind starts rolling up Okay , I'm now starting to pick up on like this could have been contributing to my symptoms specifically , to pick up on like this could have been contributing to my symptoms specifically .

And so we really get to unpack a lot . And that's why I always say I need a long time to talk to people , because a lot of times , by the time they come and see a pelvic floor physical therapist , there's a lot to uncover , and so I want to really make sure that I'm teasing out and really brushing away .

Okay , let's get down to the meat and potatoes of where your symptoms stemmed from whether it was emotional , physical trauma of some sort ? Or was it just something that came about five years ago that we need to uncover ?

So I would say they are the same and so if I can work on an emotional being piece that tends to really help with the pain or the urinary symptoms , those types of things . So I see a lot of women who have had either sexual trauma , physical trauma , medical trauma from maybe an aggressive childbirth situation or traumatic childbirth situation .

There's a lot of different ways that that can then create either fear or avoidance of the pelvic floor specifically , and so that can really turn into urinary symptoms because you're just ignoring the symptoms . There's just been a lot of trauma to the bladder , to the urethra , things like that .

Very often I see pain with intercourse being very prevalent in anyone that's had traumatic events to the pelvic floor themselves , and so we really try to talk through events to the pelvic floor themselves and so we really try to talk through okay , what's driving these symptoms and then how is it manifesting into your physical being , and can we really marry the two

and make sure that we partner up and really address the whole human ? And so , if not , if any of my clients have any type of trauma , whatever that may look like for them , I always recommend having a counselor or therapist on board or being familiar with .

Okay , how do we manage these things and how do I , when I'm really having these flare ups , how do I manage it and how do I have tools in my toolbox to really help with these , these symptoms ?

Sometimes that's the beauty of my job is I get so much time with the individual , not just the first visit but subsequent visits . I really get to unpack a lot and I always joke that I'm kind of the built in bestie , like I get to hear all of these crazy stories and I want to hear about , you know , what's going on from a sexual health standpoint .

I want to know what's going on from a pooping function standpoint and how , how things are going , you know , with just day-to-day pain , things like that . And so some of this just comes out as time goes on . It's not necessarily something that you just open up on the first day and we just meet , have this connection and we talk about all of these things .

It's really something that we just have a very organic conversation and a lot of times it ends up just coming out later on .

So I always , after kind of talking about the history and what you're struggling with , and really unpacking symptoms , what we start with is always an orthopedic assessment . So really checking hip mobility , hip stability . I'm looking at the foot , I'm looking at the ankle of how you translate force from one leg to the other .

And then I really look at how the rib cage moves on the trunk , like how you're able to really carry yourself . And then I really look at how the rib cage moves on the trunk , like how you're able to really carry yourself .

And then I really look at the deep core , seeing how well you coordinate your core , how you coordinate the core curves , those type of things . So I'm really diving into the full human and then we start to unpack the pelvic floor . So it really gives me a good holistic picture of what's going on with the person in front of me .

And this is why I always joke that I can't just text someone when they tell me that they have symptoms , because it is way more complicated and every human being is so complicated that , typically , like a quick text isn't going to , isn't going to do the trick , because everyone moves and substitutes and has postures that are so different to the person next door ,

even if they have the same symptoms . But anyway , that's just a soapbox . But so then what I do is I assess the pelvic floor . So this is something that we don't necessarily have to do on the first day , and if you're not comfortable at any point , we can do external techniques as well .

But what I tell women is this is the best and the most effective way to get to the pelvic floor is with an internal vaginal assessment , and so what I do is it's very similar to a women's wellness exam .

I just don't use that cold metal speculum , I just have gloves and then a water-based lubricant and then I use one single finger and do a digital exam by assessing the musculature .

And so I always joke it's a funny way of getting to muscles , but they're muscles nonetheless , and so a lot of times that's almost that aha moment of like oh , when I'm on a certain muscle of the pelvic floor , people are like I had no idea this was going to be causing my hip pain or I had no idea this was going to cause my urinary urgency , and so it's

kind of this like I almost just need one visit to just get you to experience what it feels like to have your pelvic floor assessed . And a lot of women are just like light bulbs come on and they're like , okay , this start , this just like unpacks a lot of different emotions , physical symptoms .

It's really kind of cool to see when , when we assess the pelvic floor , yeah , okay .

Okay , nowhere in my lack of research did I realize I was going to take my pants off and have the . Really , I didn't know that . I was surprised by this . I really was surprised . When Sarah's like okay , here's your sheet you can undress from the bottom , I was like Robin has an internal crisis ?

But the tailbone just is housed on this back wall , and so the best way to get to the tailbone just is housed on this back wall , and so the best way to get to the tailbone is rectally , and then you can actually just get on the tailbone and work on ligamentous structures and the actual bone itself .

So there's definitely ways to address the pelvic floor in different holes , for sure .

Or when I am doing an internal pelvic floor examination , I am really thinking , okay , I bet her obturator internus is really fired up , or ? Ooh , I noticed that her rec , her , uh , puborectalis , is probably going to be , um like , just uncoordinated . So , my brain is also going , while your brain is going in a whole different path .

Like you know , you're giving me eye contact , so it never looks , it never feels weird because you're not looking at my anatomy when my pants are off right you know you might be assessing me how I stand up or sit down or other things , but when my pants are on your eyes right here , and I like that , there you go firsthand experience yes yeah , I've also been

on the table and it's it's really not I .

Yes , these this that drove me in the door , but then these other things that really are bothersome and they really do impact my daily life and then also my psychological well-being as well .

You know , maybe they don't have a partner that's involved and can help and watch the kid while they come , or maybe they don't have transportation . So I never want to I never want to put the fear of God into people to come to a physical therapist .

But what I do tend to see is symptoms the longer you go with them tend to turn into more layers of the onion . So maybe it was originally urinary incontinence , just with coughing and sneezing , that you had symptoms with .

And then when you wait 10 years , a lot of times that can come , that can contribute to abdominal pain that you get with certain movements or chronic constipation or you know whatever it may be , insert . You know whatever symptom here . But a lot of times then we tend to get just a bigger snowball , and so I always like to tell people .

That's why a lot of times in social media you're going to see pelvic floor physical therapists really targeting the pregnant population , and it's because that's a lot of times when the symptoms first show up .

So whether you had a tailbone injury at 10 or 12 or 15 , well , when you become pregnant , a lot of times that's when those symptoms really start to get triggered . And so I'll see women that have tailbone issues , for example , that they all it got , it got resolved .

They were 15 years old , they're really healthy and mobile , but then it tends to come back around that pregnancy era , because the pelvic floor has to really grow and expand , and when a baby is growing , the pelvic floor has to accept a ton more weight .

Same with the pelvis , the bony pelvis itself , the pubic bone and the tailbone have to really accept a lot more load . And so then that's when we tend to see a lot of these symptoms show up , and so it's really easy to market kind of toward pregnancy and postpartum , because that's a lot of times when those symptoms are really really evident .

This is just the way it is . This is just the way it is , and at 50 years old , I'm going to have to just just like deal with this and just , you know , be accepted , it's probably only going to get worse .

So instead they're choosing surgical routes that are very permanent and expensive and aggressive on the body and they're really going with , you know , certain arthroscopic procedures or some type of medication , when a lot of times it's really not that complicated . It can really just be stemming from the pelvic floor .

What it is is it's the organs protrude out or bulge out of your vaginal opening , and so what can happen over time and this is more if you're constantly straining with chronic constipation , or when you lift heavy objects , if you're straining down what can happen is the bladder or the urethra with the bladder , or the rectum or the uterus can all basically collapse

into the vaginal canal , and that's when women will see or feel like a bulging sensation in their vaginal opening . And that's very common after having a pushing injury like pregnancy .

So when you're having labor and delivery , a lot of times women will push so hard that you'll get like a bulging sensation , or I see it very frequently around the perimenopausal state as well , just because of low estrogen levels .

But there's a lot of hope and a lot of excellent research out there that you can actually either reverse your symptoms with pelvic floor physical therapy or at least get them to where they're not getting worse .

We have a ton of room to go when it comes to just research in our field , but we know that for urinary incontinence , chronic constipation , pelvic organ prolapse that's just to name a few pain with intercourse pelvic floor , physical therapy is the gold standard , and so to say that is crazy .

I mean , it's really cool stuff and that's why I can shout it from a mountaintop . You might as well do two or three visits and see how the heck it goes before you decide on doing anything drastic with your pelvis .

I am fussy that it's just now , like just now , that my doctor recommended it , but nonetheless I'm very excited and I love hearing you say that it's the gold standard , because 100% it should be like we should start there with the non surgical , non medical or non pharmaceutical and that's coming from somebody that you know .

Pharmaceuticals are near and dear to my heart , but if there's an alternative , then we should be taking it . So you've talked a little bit about childbirth . I'd love to hear about how childbirth , and like being a patient , has changed your perspective on it .

I'm a very avid exerciser so I think movement is super important through all phases of life , especially for women . So I was trying to run at like 25 weeks pregnant and my ego got in the way and I eventually had to stop running because my pubic bone pain was excruciating and so I would see a pelvic floor physical therapist for that .

And then I also had a vaginal tear , a grade two vaginal tear postpartum , and so I was having pain with really everything walking , sitting , any intimacy I was having pain with .

And so I went and saw the same pelvic floor physical therapist for both issues and we worked on scar tissue , we worked on mobilization of the muscles , that kind of attach onto that pubic rim , and it was tenfold what it did for my symptoms . So talk about , you know , just actually having one issue .

I went in postpartum with just pelvic pain after having a vaginal tear . I saw my pelvic floor therapist for five to six visits and I can say I'm at a hundred percent pain-free and have no other symptoms , and so I think it's a true testament to if you really can address it early and have the resources to be able to do that .

It's a good investment early on because then you're only needing three or four visits versus eight or nine or 10 later when you start getting some more complex conditions showing up .

If you had those symptoms build up for that long , it is going to take time , and I think that's the hard part is , sometimes it really is an investment in time and resources , and so I would argue , sometimes , sometimes depending on the chronicity , you'll see even up to upwards of 12 visits , sometimes 15 , but spaced , spaced out appropriately to where you're really

drawing it out , as long as you can .

And the reason why is because your estrogen , your progesterone , a lot of hormones do a really crazy shift , which we know can affect pelvic floor muscles .

So , for example , a decrease in estrogen can really create irritability and like atrophy of the pelvic floor muscles , which just causes weakness , friability , irritation , and so I tend to always talk about postpartum and perimenopause tend to be two of the same .

Very frequently , a lot of women will get like UTIs , or symptoms that feel like UTIs , but they're actually pelvic floor involved , or they'll get urinary incontinence , pelvic pain , vaginal dryness . Those all tend to really be contributing factors to decrease in estrogen . All tend to really be contributing factors to decrease in estrogen .

And so I think really just thinking about what's going on in your life and maybe what your hormones are doing can be really empowering too of what your pelvic health may look like , and so sometimes a pelvic floor therapist can help you with those two .

Although I can't prescribe topical estrogen , I can still look at your vulvar tissue and say , okay , you need to get some type of I always joke it's called like chapstick for the vagina . So you need some type of moisture in the area .

So a lot of times I'm looking at tissue that just has not been addressed or even looked at in three to five years , and so that's why I always tend to recommend is anytime you're having a hormone shift , your pelvic floor can also be at risk as well .

So that's really interesting to think about it , just like how we change throughout our life . But kind of speaking of that , are there any like lifestyles or exercise habits or things that we can do kind of to prevent a bad pelvic floor from happening , or is it just like if it happens , it happens . There's not really anything you can do to prevent it ?

So even if you just Google diaphragmatic breathing , there's also just you can do diaphragmatic breathing , belly breathing there's different types , but any of that where you're starting to send your breath other than up into your chest when you're breathing , if we can start shifting that breath into our lower abdominals and then into our diaphragm , that we know that that

helps tenfold with our pelvic floor mobility as well . And so I think often pelvic floor gets a bad reputation because we hear a lot to do Kegels and I feel like Kegels are the only answer that a lot of providers will prescribe and that is , I would say , 95% of the time . That's not an actual stat , but 95% of the time .

Clinically I see that that's not the case . We do not need to be doing Kegels , we need to be doing mobility before we gain that stability doing Kegels . We need to be doing mobility before we gain that stability .

Now , I'm not saying never do Kegels , but I would say there's a lot that you need to do prior to doing Kegels , and so that would be breath work , like the breathing . And then cat camels child's pose happy baby tends to be the best stretch for the pelvic floor from a stretch standpoint .

So if you can get into a happy baby pose , that tends to be really beneficial . And then just general cardiovascular . So the muscles love movement , they love blood and they love space , and so if we can just give the , give the pelvis what it needs from a vascularascular standpoint , we tend to see really great benefits .

But so I was all about like I'm just going to exercise more and I'm going to do more core work and I'm going to really focus on building my pelvic floor strength , right , and so I was very disappointed that that never yielded the results that I wanted .

Well , we know that the muscles need mobility , so we need to be able to get things moving and grooving appropriately , getting this nice length out of our pelvic floor , before we do core stability work , before we do any type of key goals , those types of things .

So you'll see that a lot on social media , specifically , that you know , do this , do this core exercise , and it's going to help with media . Specifically that you know , do this do this core exercise and it's going to help with your pelvic floor . You know , do these specific exercises . And I'm just like let's pump the brakes on that .

A lot of times we need to actually slow down our system first and get some length before we get strength .

Well , I clicked on that every time and it never , it never worked .

If it's , if these things aren't your issue , great , good for you . But I think that there's probably somebody that you know that needs to hear this episode . And Sarah , tell people where to find you . And then also , if you don't live in Columbia , missouri , how do you find a therapist with a credentials like yours ?

At Sarah Miller DPT I have Facebook and Instagram and then if you ever need anything from there , the website will just direct you to my phone number and my clinic email .

If you are in a different area and are looking for a good physical therapist that specializes in pelvic floor physical therapy , I recommend going to PelvicRehabcom , and it's a very big directory with a map that just shows different providers in the area . So that's pelvicrehabcom .

Not all providers are created equal and also some specialize in different aspects , and so I always advocate that women really look for a provider that they vibe well with but also feel like they're getting the care that they need , because sometimes providers aren't up to research or aren't doing the newest updated practice that we know is well-researched .

So , all that to be said , it really just depends , but I think testimonies are a really good way to ask around , because typically people are going to know if they're with the real deal .

And do you know that you're like scheduled out to like June 10th , which is so exciting for I mean . It's sad for me because I'm like , oh , I wish I could get up . You know an appointment , but I'm so excited for you .

It's been an incredible journey , and I feel like the just the city of Columbia has been really , really supportive in this as well , so it's been fun .

Or if you have a topic you'd like us to discuss on the podcast , use that same email , theproblemwithperfect at gmailcom , to send us your ideas or feedback . We love hearing from you .

And while you're there , make sure you've subscribed to the podcast so you never miss an episode .