Rivki Chudnoff, MSPT, explains pelvic floor therapy. A physical therapist practicing in Bogota, New Jersey, Chudnoff discusses her training for this specialty and how physical therapy helps women with pelvic health issues.
“Pelvic Health and Pelvic Therapy” – with Rivki Chudnoff MSPT
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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I am your host, Dr. Nathan Fox, an OBGYN and maternal fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. All right. We’re here with Rivki Chudnoff, aka Rivki Rosenzweig from Peterson Park in Chicago. Rivki, welcome to the “Healthful Woman” podcast.
Rivki: Hey. Hey, Natey.
Dr. Fox: This is amazing. We just spent, like, the last, like, half hour catching up before the podcast, because Rivki and I grew up together in Chicago.
Rivki: Go Aces.
Dr. Fox: Go Aces. Yeah. I mean, listen, Rivki’s mom was my teacher in seventh grade, and Rivki’s dad and I played basketball together, and yeah, I mean, I’ve known you since what? We were, like, five years old, plus/minus?
Rivki: Something like that. Something like that.
Dr. Fox: Unbelievable. Good times. And Rivki, you are now a physical therapist, working in Bogota, New Jersey, at Hamakom Physical Therapy, and you are also doing a lot of pelvic floor therapy, correct?
Rivki: Correct. Yeah. That’s what I specialize in.
Dr. Fox: Fantastic. So, let’s jump right in. Tell us a little bit about your background. So, everyone knows, you know, now that you’re from Peterson Park in Chicago and that you have a wonderful family and I’ve known you a long time, but tell us your story. How did you get into physical therapy? How did you get into pelvic floor therapy? Open-ended question. Go anywhere you want with this.
Rivki: I went into physical therapy. I always worked with kids with disabilities in high school and then through college, and I really wanted to work with that population, and I’m just trying to figure out at what point to help them with. And I became a physical therapist with intentions of working with kids with disabilities, which I did. And I married my husband, who was an OB-GYN resident. Two months into his residency, we got married.
Dr. Fox: Real smart.
Rivki: Yeah, by the way. [crosstalk 00:01:58]
Dr. Fox: Let’s marry someone I’m never going to see for the next four years.
Rivki: Let me tell you something.
Dr. Fox: It makes for a good marriage, probably.
Rivki: I wouldn’t have done it that way again. I mean, I would have married him still. Just, the timing wasn’t great.
Dr. Fox: It’s like marrying someone before they’re deployed to Iraq.
Rivki: Pretty much. It’s not so different. Not so different. He came home covered in blood most nights. It was, actually, I was happily working with kids with disabilities, enjoying my job, and my husband, Scott, said to me, he’s like, you know, started telling me about pelvic health physical therapy, which is a relatively new specialty in physical therapy. When I went to PT school in what my kids like to call the 1900s… Do your kids do that?
Dr. Fox: My kids, yeah.
Rivki: In the 1900s…
Dr. Fox: My kids think I lived in black and white.
Rivki: Yes, mine too. Why do they ask me that, actually? When I went to physical therapy school, they didn’t even teach us really about pelvic health physical therapy, because it was such an emerging field. And I had really never even heard about it. So, Scott started telling me about it, and I said, “Oh, that sounds weird. I’ll tell you what, you work with the vaginas and I’ll stay with the kids,” and that’s literally what I said to him. Then we went to a conference. I joined him at a conference where he was presenting, and I met a woman named Holly Rosenbaum, who today is a sex therapist, but at the time was a pelvic health physical therapist.
And she started telling me about what she did and what kind of patients she saw, and how she helped people, and I was just blown away. I was like, “That sounds unbelievable.” My husband pretty much won’t let me live that down. He’s like, “I told you you should go into this, and you had to hear it from somebody else.” But pretty much that’s what happened. And it required a lot of retraining, more training, to specialize in this field. And also, at this point, I had had a couple of kids on my own, and so my understanding of the function and dysfunction of the pelvic floor became clear to me, and I retrained and spent a lot of time, shout out to my mother-in-law who watched my kids. I’d go to courses, and went into specialty. At one point, I was doing both pediatrics, early intervention, not pelvic floor, and doing pelvic floor physical therapy. And over the last, I would say 10, 15 years, it’s really just been pelvic health physical therapy, although I do work with some pediatric patients with pelvic health, and that’s probably for a different podcast, but that’s really what the focus of my career has really been, helping women with pelvic health issues, also postpartum and pregnancy-related issue, and pretty much anything that has to do with pelvic region or women’s health issues related.
Dr. Fox: Wow. So, I want to go into what you’re saying about the training a little bit more. So, when you go to get trained in physical therapy, and if it’s different now from what it was back in the 1900s, when you and I trained, you can definitely point that out. So, what does it entail in general? So, not related to pelvic health. What is the training to become a physical therapist?
Rivki: Right. So, it used to be a bachelor’s degree before our time, even older than us, and then it became a master’s degree. So, I had a bachelor’s degree, and actually, you could probably have it in anything. You just have to do prerequisites. I had a bachelor’s in biology, and I applied to graduate school and got a master’s. I have an MSPT, a master’s in physical therapy. So, it was a three-year program after college. Actually, I went to Rutgers. It used to be called University of Medicine and Dentistry, and people are like, “Are you a dentist?” I’m like, “No.” But now it’s Rutgers, so that makes life much simpler. And it was a three years combination of rotations, kind of like in medical school where you rotate through doing…you know, pretend like you’re a real doctor, pretend like you’re a real physical therapist, to patients who don’t know the difference between you and somebody else in a white lab coat, and also taking courses. And you get trained in all different areas of physical therapy.
You learn about cardiopulmonary, you learn orthopedic, you learn neurology, you learn pediatrics, you learn to work with all those different types of populations. And usually, the first couple of jobs you have really help you determine what fields you would be interested in going into and help you really learn really, as you know probably also, is you really learn most of what you know on the job and actually seeing patients, not in the textbooks. So, that’s really how that works in terms of physical therapy as well. Today, they’ve moved to…Of course, a couple of years after I graduated, they moved to doctorate programs.
Dr. Fox: Yeah. It’s much more, like, intense now. It’s so long to finish physical therapy training currently.
Rivki: Is it long? I don’t know. Is it longer or they just…?
Dr. Fox: I think it’s longer. I think there’s extra years, because you get a doctorate, I guess, a Ph.D…
Dr. Fox: …or something. Yeah.
Rivki: It’s a DPT. It’s a doctor of physical therapy. Yeah.
Dr. Fox: And so, do the training programs now include pelvic health, or they still don’t, as far as you know?
Rivki: Yeah, no, they do. They don’t train them to the degree that you could graduate and go work in pelvic health. I don’t know all the programs, but the ones that I’ve worked with students with, you know, they graduate with, like, an understanding of what the field entails, you know, what kind of patients, a general…I would say you get a general overview, maybe an elective, at best. I can’t speak to every program in the country, but for 100%, like, you need to be taking extra continuing education courses to be able to work in the field. If somebody is interested in going to pelvic health, they absolutely need to take several continuing education courses to be able to help people with pelvic floor issues.
Dr. Fox: And so, what exactly would those be like? What kind of continuing education courses did you take, or what would someone have to take nowadays?
Rivki: Yeah. So, there are different levels of courses, and then there’s extra specialized courses. So, you take, like, a level, what they call it level 1, 2, 2A, 2B, 3, depending on which organization you take it through. Each level is specialized, and usually…I actually teach physical therapists now who want to specialize in pelvic health physical therapy in a company called Herman & Wallace, which is one of the major players in the continuing education of physical therapists in the pelvic health area. Another organization is the APTA, the American Physical Therapy Association, and there are lots of other people who do education, but those, I think, are the two primary ones in this country that do continuing education for people who want to go into pelvic health.
So, I know that, like, Herman & Wallace, they have a level 1 course, which is more of an overview. It’s you do urinary stuff, you learn about, I would say two…Different levels teach different topics more in-depth, so there’s other levels that’ll talk more about colorectal issues, or pelvic pain is gone into in more detail in higher courses, versus, like, one is more of an introduction. We get a little bit of a taste of everything. You learn a little bit about everything. And then the more in depth you go into the coursework, the more you learn more specifically treatments, and being able to make good treatment plans, being able to understand what your exam is and how you do an exam, you know, what you’re looking at, what you’re finding, and how that correlates to how you’re going to be treating that patient from a physical therapy perspective.
Dr. Fox: Is there a formal certification or board certification for people who do pelvic health, or it’s just people who have been trained and doing and practicing it?
Rivki: Yeah, they do, both ways. I mean, you can definitely practice as a pelvic health physical therapist without being board certified, but there are different certifications from different organizations. The APTA has a certification, Herman & Wallace has their PRPC, and different organizations who provide their own opportunity to add lots of letters to the end of your name. Just take their exam if you so desire, you know. And there are plenty of people who just have lots of experience and practice pelvic health physical therapy as well. So, yes, there is. Can get lots of letters, lots of alphabet letters, as many as you want in our field, actually. Just tons of them.
Dr. Fox: Are there any people that you know of who do a lot of pelvic health who are not physical therapists? Like, they come at it from a different original training, like dentists, like you said, for example? Yeah.
Rivki: For dentists, no. So far as I know, dentists are not really training for pelvic floor physical therapy, as far as I know not yet. I do… Although there is…I do find that as soon as I ask patients about pelvic pain, there is some correlation between that and TMJ, where people are holding their tension. Oftentimes, I’ll ask patients who have pelvic pain, you know, “Do you have TMJ?” And so many times they’ll tell me yes. Should do a study on that some time. Anyway, but yes, Herman & Wallace, the APTA will only teach physical therapists, licensed physical therapists, versus a company like Herman & Wallace will also…if you have a license to touch. So, if you are a nurse practitioner, if you are an OT, that’s become very big now…
Dr. Fox: Oh, that makes sense. Okay.
Rivki: …occupational therapists have started doing pelvic floor physical therapy. I’m sure there’s some PAs. I’ve taught PAs, and I’ve had PAs in my course. I’m trying to think who else, nurse practitioners, OTs. Basically, if you have license to touch, then you can come to one of their courses.
Dr. Fox: Oh, that makes a lot of sense. Okay.
Rivki: You actually do… In the course or part of our education as pelvic, or part of our education as physical therapists, in general, unlike medical students where, from my understanding is, like, they hire models when you practice doing pelvic exams in medical school. But in physical therapy school, you actually, your lab partners, you know, whether it’s just regular orthopedic or cardiopulmonary, you in lab, or at least it was how I went to school, is that you worked on each other. You’re the therapist and then you’re the patient, which is nice in that you have the opportunity to understand what it feels like and the vulnerability of being a patient and what that experience is like. And in pelvic health, it’s the same, in that when you go to one of these courses…
Dr. Fox: Woah. Seriously?
Rivki: Yes. Seriously. Little known facts about your pelvic health physical therapist.
Dr. Fox: What do the men do?
Rivki: That’s a good… Well, you know what? Now, actually, it used to be, in the olden days, that they required men to bring with a model or a partner to come with to be their partner, and now it’s very much that men are welcome and people of all genders are welcome. You can choose your lab partner and who you’d feel comfortable working with and you’re encouraged to switch partners, because everybody’s anatomy is a little different, which is really, really interesting, because you really learn about what a 65-year-old woman, how her anatomy might be different or her body might respond differently to exam versus a 22-year-old woman who’s never had children. And so, actually, when you go to these continuing education courses, at least from the ones that I teach, is that in lab, you are both the therapist and the patient, and you get to experience it from both sides of it. So, that’s really an interesting part of our education as well.
Dr. Fox: Wow, I did not know that at all. That is really interesting. When I was in med school, we first practiced on each other for things like drawing blood and IVs, just because, like, you know, like, you poke me, I’ll poke you. It’s like we’ll all suffer together. When we did abdominal exams, we did them on each other, and technically, the abdominal exam includes completely undressing and dressing, like, below the waist as well part of the exam. So, I remember we did…we had that, but we didn’t do pelvic exams on each other or rectal exams on each other. Not in med school.
Rivki: Yeah. So, physical therapists don’t really do. We don’t call a pelvic exam, because that implies that there’s a speculum involved. And in this country, anyway, physical therapists, pelvic health physical therapists, don’t use a speculum. So, it’s all manual, like, digital exam by using a gloved hand while lubricated, hopefully, to be able to do, and you’re really looking at the muscles…
Dr. Fox: Hopefully gloves, hopefully, lubricated, both.
Rivki: Yeah, please. Yeah, exactly. If you don’t, just keep walking. But, and you’re really looking at the muscles. You’re really looking at just as if somebody came into physical therapy or regular physical therapy practice with a shoulder problem or an elbow problem, and I say, “Okay, now I want you to raise your arm over your head, and I want you to, you know, extend your elbow and I’m going to resist your…” anyone who’s gone for physical therapy for any kind of orthopedic issue. And really, pelvic health physical therapy really is like orthopedics of the pelvis, in that people don’t realize is I always say people think their vaginas are existing in outer space, like there’s their body and then there’s their vagina, like, somewhere else. And [inaudible 00:13:20] it’s made of the same stuff, muscles and nerves and ligaments and bone.
And it responds very similarly in terms of, you know, range of motion. Can you contract? Can you relax? Can you push down? What does that look like when you do that, and how that correlates with whatever problem they’re coming in for. Does it hurt here? How about here? How about here? Does this hurt? Being able to find points that are painful just as if you came in with a shoulder impingement or a tendonitis somewhere, then you’re really looking at the nerves and muscles, how they’re functioning, how they’re not functioning, and putting that back in the context of the body overall, like I’m also looking at posture. I’m not forgetting I’m a physical therapist. [inaudible 00:13:59] how are they holding their pelvis in relation to their rib cage? In relation to their breathing? In relation to their shoulders? Because that could really impact, and really help me figure out what the problem is and why they’re having this problem.
Dr. Fox: Absolutely. I want to ask you about all the specific problems you treat, but I have to digress for one second, because it just struck me that I was thinking, if 40 years ago, our teachers at yeshiva day school would have heard us talking about this, they would have thrown us both out of school. And you would have predicted that…
Rivki: They were predicting you, Nate.
Dr. Fox:…if Rivki and Natey…Well, yeah, I guess they would have predicted [inaudible 00:14:34]. If Rivki and Nate are gonna be having this conversation later in life, they also would have thrown us out of school. So, you know, look how far we’ve come. Unbelievable.
Rivki: You know what? I was thinking the same thing, actually.
Dr. Fox: All right. Well, back to the topic. Tell me about some of the things that you treat. Like, what are the most common conditions that women will come to you for in regards to pelvic health?
Rivki: Most common, and whether this is the most prevalent pelvic floor issue or it’s just the one that drives people to want to get to some lady’s office and have her look at their pelvic floor or not, is pelvic pain, for sure. Number one is that women…By the way, there is pelvic health physical therapy for men, so just to put that out there, men do get pelvic pain and do have pelvic floor issues, but we’ll be talking about women. So, in terms of women, if they’re having pain, if they’re having pain with intercourse, or they’re having difficult…like, they can’t go to the gynecologist because they’re afraid of exam because it hurts so much. It’s interfering in their lives in that way, then they will be coming to see me, or they’re just having constant pelvic pain, just pain in that region. That is for sure the number one I think I spend most of my day treating.
Dr. Fox: Is that mostly younger women or older women or both?
Rivki: It’s a good question.
Dr. Fox: Thank you.
Rivki: I see a lot of younger women, primarily women who are finding out for the first time that they’re having trouble having intercourse, but it can happen at any stage in life. And you have women who maybe had no pain at all. They were having pain-free intercourse, no problems in the area at all, and then they had a delivery. Either they had a lot of tearing, they have a scar in the area from something that went on during the delivery, and they have a lot of stitches, and that area becomes very, very tender and painful.
So, I could see them for that, and also women menopausal, perimenopausal, when there’s change in hormones. Women who’ve never had any pain with sex or never had any pain in the area, all of a sudden, you know, it just doesn’t feel like it used to, and they’re feeling a lot of pain and discomfort. And in those women, it’s really so troubling for them because it’s like, “I never had any problems in my whole life. Like, what happened? Why am I having all these problems?” And women in post-cancer treatments. I’ll see women who had chemoradiation for different cancers come in, and due to the changes in the tissue, now are having horrible pain, and they want to get back to their lives, and physical therapy can be so helpful for those women as well. So, really, it could be all different stages of life, and for all different kinds of reasons.
Dr. Fox: In terms of the pelvic pain, so we’ll focus on that first, are the treatments the same for all the groups you mentioned, you know, the women who’s for the first time having sex and it’s painful, or for someone maybe after delivery or someone later in life? Are your modalities and treatments the same, or are they very different based on the cause of that type of pain?
Rivki: I would say that the treatment plan can be different, like how I go about looking at them, but what I ended up doing, oftentimes, is the same. First, you want to take a look and figure out, you know, is something going on orthopedic that’s going on? Is there some back pain? Is there something else that’s going on that’s contributing to this pain? And you want to kind of root all that out first. And also, the modalities that we use are also very similar in terms of what we’re using in physical therapy for any kind of painful area, you know, you’re using manual techniques, using therapeutic exercise, depending on what the problem is. Like, you know, we always say in physical therapy you find what you treat, so I’m not curing anybody’s vulvodynia. I’m not curing anybody’s results of radiation to their skin. But what I can do is help them change the way their body responds, and also change the way that they’re experiencing their symptoms, so that, you know, the tissue isn’t as painful anymore, and they’re able to tolerate sex or maybe perhaps even enjoy sex for the first time, because they’re not having this kind of pain anymore.
So, yeah, oftentimes, what I’m doing… I guess if you were somebody who… I always say that physical therapy is, in general, is kind of a boring thing to watch, but it probably would look, if you were just watching, it would probably look a lot like the same stuff. In terms of where I’m going and where I’m treating, or the techniques I’m using, those can be different, because you’re really looking at which muscle group is giving them the problems. Why are they having this problem? Like, for example, a woman who is having… Let’s say a woman who’s having a hard time, she’s just started having sex. She’s just starting vaginal penetration, and she’s having a really hard time, and every time her partner tries to insert his penis, she starts screaming and she’s agonizing in pain and they can’t have intercourse. This is very troublesome for them, both.
That is a very different picture, because you have to kind of look at… It’s almost like they’re in a fight or flight, because they’ve had this experience of something being so, so painful over and over and over again. So, it’s almost like the pain has tangled itself over on itself, because they’ve had so many experiences of being painful as opposed [inaudible 00:19:35] someone who’s maybe had an experience of sex never being painful in their life and, all of a sudden, it’s being painful.
So, you have a lot more to untangle with somebody who kind of has this, like, in this fight or flight mode about sex, and you have to really go at it from a different perspective and having them… Sometimes they’re lacking education about their own body. They’re scared of what’s going on down there. They’re afraid that they’re going to break. They’re afraid their vagina is going to break. They’re afraid they’re gonna be split open. It feels like that’s what’s happening. So, kind of helping them down-regulate their nervous system, you know, starting with deep breathing, helping them become educated about their own anatomy.
Women across the educational, socioeconomic, cultural gamut really, oftentimes, do not know their own anatomy. They’ve never seen their own pelvic floor in a mirror, they don’t know where anything is, and they’re afraid to touch their own body as if, like, it’s a different… They’re afraid something is going to happen. So, being able to educate them and give them the tools for them to own their own anatomy and not be afraid of it could be something that’s really, really valuable, versus a 60-year-old woman who’s like, “Yeah, honey, I had six kids. I know what’s going on down there.” So, that’s very different experience in terms of what that treatment session looks like.
Dr. Fox: Right. Now, in terms of the scenario you described with the young couple having a difficult time, how effective is what you do? Meaning, is it something that takes a couple of sessions? Is it something that take a couple of years? Like, in between? What do you typically find in that circumstance? And the second question I’m going to ask you is, how do they find you? Is it their gynecologist sends them to you? Is it a family or friend who sends them to…? Like, what is the way that they would find you, that you even exist?
Rivki: In terms of how they find us, oftentimes, it’s their physician. Oftentimes, it’s word of mouth, it’s patients, you know, people… I would say it’s horrible these people suffer in pain and they don’t realize so many other women have had this problem, and when they’ve spoken to, like, a friend or someone else, or reached out to somebody for help, and they’re like, “Oh, yeah, you know, my sister had that,” or, “My friends had that and they went to pelvic health physical therapist and it was great.” And I think in the media, the awareness has just increased about pelvic health physical therapy and pelvic pain, which has been wonderful, opening the conversation, like, you’re not [inaudible 00:21:54] …
Well, it’s not something somebody wants. It’s so much more common than women know and realize. They think that nobody has this problem. They think they’re broken. They think their vagina is broken. They think that nobody in the world else is having this problem. And from the way I see it, like, the whole world has pelvic pain, because everybody comes to my office with pelvic pain. It’s like, you’re having sex without pain? That’s, like, a miracle because that’s all I see all day. But for them, they think they’re really the only person. Yeah, so it could be word of mouth through friends. It could be through doctors, it could be through mental health professionals who are becoming more aware of the importance of our fields. So, any of the above and what was your other question? I know I was going to remember both questions.
Dr. Fox: Well, I mean, we are from the 1900s, so we are to be…
Rivki: That’s what happens.
Dr. Fox: …forgiven. But I’m going to get back to my first question. But I think that what you mention is so important because a lot of people, not only do they think that they’re the only person who this happens to or the only couple it happens to, however they want to look at it. They then somehow think that they have a mental health problem because of it, you know, that somehow because of this, they therefore have an anxiety disorder, or they’re somehow not attracted to men or whatever it might be.
Rivki: Or they don’t like their partners.
Dr. Fox: Right. They don’t like their husbands, which might be true, might not be true, I mean, but it doesn’t work like that. Like, a lot of people, they have everything, you know, they have desire and they love their husband. They want to be with him.
Rivki: And a great relationship.
Dr. Fox: And yeah, everything is wonderful. It’s just, it’s physical. Purely a physical response that they have, and it builds on itself. And so, they’re made to think that not only is there something wrong with them, but now it’s not just their body, it’s their mental health. And it could be none of that, obviously. So, I just think it’s so important what you’re saying that it’s so common and it’s treatable. And that was my question, my forgetful friend, is how…?
Rivki: You can edit that part out.
Dr. Fox: I already forgot your name, so forget about it.
Rivki: Yeah. It’s all good.
Dr. Fox: How effective are the treatments that you use in terms of, should someone who comes to you for this, like, expect that it’s going to work, and in what kind of timeframe is typical? I know, obviously, there’s a range, but what should they expect?
Rivki: Yeah. So, I always say people call on the phone and they always ask three questions, you know, do you take insurance? How much do you charge, and how long is this going to take to fix? So, in terms of this how long does this take to fix…
Dr. Fox: Like a car.
Rivki: It’s always that question. But I understand, like, I get it. So, I always tell people that, you know, I don’t have a crystal ball so much. But what I’ve really learned over the years is that the longer the problem has been going on for, the longer they’ve been struggling with this, the longer it takes to kind of unravel.
Dr. Fox: That makes sense. It’s almost a mirror.
Rivki: Yeah. When people come in early on, and sometimes I’m of the thought, like, people are just getting, you know, too much therapy is too much therapy, like, everything needs therapy. But sometimes, getting in early really…not sometimes. I really believe at this point in my career that getting in early with the problem, with pelvic pain saves people years of aggravation, because if it hasn’t had a chance to really become, like, a whole pain cycle, then it’s so much easier for them to be able to work through it.
Oftentimes, I’m not saying always, but in my experience of that kind of particular scenario, the less time that this has been going on for, the much shorter time usually a treatment takes. When this has been going on, and I don’t see it as much anymore because I think the awareness has increased both in the medical professionals and the mental health professionals and all kinds of, you know, in the religious communities, with the bride teachers and all that, that they’re coming for help sooner. And in the beginning of my profession, I was seeing people who were, like, going three years suffering with all these kinds of conditions, and having difficulty with intercourse for three years or whatever it was, never having anybody say, “Hey, you know, there’s help. There’s somebody who can help you with this. You shouldn’t have to suffer like this.”
Dr. Fox: Yeah.
Rivki: Yeah. And when people have been going through a really long time with having this kind of pain, it does take longer, I think, for it to resolve. And in terms of how effective it is, I think people do really well. I think that it’s really important for it to be a team approach. You know, I’m married to a gynecologist, and I don’t think that physical therapy cures everything. I think that there is really an important role in making sure that there’s not something else, God forbid, going on with this patient that is not something a physical therapist treat. Every patient that I see, I want them to be checked out by a gynecologist. I want to make sure that there’s nothing that’s beyond the scope of physical therapy that needs to be treated, you know, an infection or something else.
And once all that is cleared, then I want them to come to me and I want them to, you know, come to sessions regularly. I want them to go home and do their exercises. Just like if you have a tennis injury, you go for physical therapy. They’re going to give you a home exercise program. And while the physical therapy could be beneficial without you doing a home exercise program, you know, when they do, when patients do do their exercises and come to therapy sessions regularly, they do really well, because there is some patient ownership in this, unlike medicine which is…It’s more like the doctor does something to… Like, you have a headache and you take two Tylenol and it goes away, right?
So, for physical therapy, it’s really much more of a partnership in that the patient needs to come to the table and do their part of the exercises or the work at home for the days that they’re not in the treatment room, because there’s just so much that can get done. I always see patients, they’re like, “I don’t know if I should come. I need to do my exercises.” Like, “Do you send your kid to school even if they didn’t do their homework?” Like, I send my kids to school. So they’re going to school anyway. Will they get much more out of the lesson if they did their homework the night before? Yeah. But can they really get something out of school even if they didn’t do their homework, back in the day when kids went to school? Then yes.
So, it is a very active patient, and it’s empowering for patients. When they don’t just feel like they’re laying there on the table and somebody is just doing something to them, but that there’s something that they’re being educated in ways that they can help themselves, and help their own pain, that’s empowering, and they don’t feel victim to their own pain anymore. They understand, A, why this is happening, and a good pelvic health physical therapist will do a good amount of patient education, explaining some of their anatomy, explaining to them why they’re having this difficulty, and then empowering them to help them help themselves, you know, with certain treatments that they tell them to do at home, or for modifications in their lifestyle that they’re suggesting. And taking ownership like that is hugely empowering in and of itself, is, makes patients feel so much better leaving the office even after the first visit.
Dr. Fox: Right. And when you say in your office, just to clarify, I mean, I understood it, but in case anyone didn’t, when you say they come to you for therapy, that is physical therapy. You’re touching them.
Rivki: Physical therapy. Absolutely.
Dr. Fox: They’re not on the couch talking to them about their childhood.
Rivki: No, no, no, no.
Dr. Fox: This is, you’re hands-on. You guys are moving and doing things.
Rivki: Yes, yes, yes. They are getting undressed.
Dr. Fox: Yes.
Rivki: They’re getting undressed, yes. And I only see one patient at a time. I always tell people, like, “It’s not like a gym, you know, everybody walking around.”
Dr. Fox: I hope not.
Rivki: No. I see one patient at a time, and it’s a private room. And then there is talking that goes on, because I think there is… I’m not a mental health professional, but there is, you know…
Dr. Fox: But yeah, you have a relationship.
Rivki: Listen to your patient. You want to know what your patients is, you know, to tell you, they always say, like, the [inaudible 00:28:56] you can really listen to your patient that they’ll tell you exactly what’s wrong. And I think that just by listening to a patient’s story, I oftentimes know exactly what it is that’s going on, and I’m usually right. The exam just confirms what I already know from listening. Like, I’m sure you know at this point in your career too, you know exactly what’s going on before you even do the exam, because you’ve heard it so many times before.
Dr. Fox: Usually. Okay. So, after pelvic pain, which is, again, its own fascinating topic and prevalent, what are some of the other things that you treat a lot of?
Rivki: Yeah. Urinary incontinence.
Dr. Fox: Urinary incontinence, yeah.
Rivki: Urinary incontinence. Stress incontinence, frequency, and urgency. I treat a lot of that.
Dr. Fox: Right. And a lot of that is, I mean, we had a podcast about urinary incontinence and…
Rivki: It was great.
Dr. Fox: Yeah. Oh, yeah, it’s right. You listened, so…
Rivki: So great.
Dr. Fox: So, we were talking about, you know, how he refers, this doctor, Dr. Gurley, refers a lot for pelvic floor therapy, and there it’s really about sort of strengthening the muscles, right? It’s not because of pain, but it’s sort of this idea that if you can strengthen the pelvic floor, you can lower the incontinence, either to the point that they’re cured, or to the point that they can live with it or just improve it, whichever.
Rivki: Yeah. And it’s kind of a little bit of a misnomer, because if it was just the floor that needed to be strengthened, then doing 1,000 Kegels a day would really make everybody in this country continent. But we know by the amount of incontinence products that they sell and that billion-dollar industry that is, that that’s not the case. And there are two things at play here. One is that there was a study done recently, showed that of the women who did or reported to be doing Kegels, when I say Kegels, it’s an exercise of…for people who don’t know, it’s tightening your vaginal muscles or your pelvic floor muscles like as if you’re holding back urine, that kind of sensation. That, of the women who said, when they said that they did Kegels, and then they actually had somebody trained watch them do it, that there was a very high percentage of women who were not doing the right thing.
Dr. Fox: Right. And that’s where you get into biofeedback, right? Yeah.
Rivki: Yes. And also, that women don’t really know… There’s also, particularly women who’ve had, like, trauma to the area via delivery or surgery, they may also have just not even know where these muscles are any more, and they have a really hard time just tapping into those muscles to getting them to tighten. Or they just don’t know what they’re doing, or they’re substituting with other muscles, like they’re tightening their inner thigh or they’re tightening their rectum. Right. So you want to make sure that they’re tightening the right muscle. Yes. And then you said biofeedback. Biofeedback is a great way to kind of mirror what the muscles are doing, so that patients can see on the screen a representation of what their muscle…it doesn’t hurt, but watching what those muscles are doing on a screen, kind of like an EKG shows you what your heart… Your heart is not a voluntary muscle, but you can watch your heartbeat go up and down and up and down. When you tighten the muscle, any muscle of the body if you do biofeedback on, you watch it tighten and relax, you can see whether you actually, in fact, are tightening it and relaxing it like you think you are.
So, but, you know, you could teach patients that in lots of different ways, not just biofeedback. Lots of ways. But also what we know is that it’s not…and the doctor you spoke with also spoke about this, about the pressure system in the body, in terms of…and the role that plays in incontinence. And what we know is that it’s not just the floor that’s important, but the whole pelvic girdle and all the muscles that support it, both in the front and on the sides and in the back, not just the bottom, which is what we typically think of as the pelvic floor.
And when women have instability or weakness in those other muscles, it has a really hard time keeping urine inside or having stability enough to keep supporting the organs the way they need to be. Like, if you think about a tree, and this is kind of a basic example, but if you think about a hammock hanging between two trees, and if the tree…like there’s a nice tarp or a nice canvas that you ordered from Wayfair or something hanging between the trees and you got the rope that’s hanging it, and then you’ve got the trees. So, if the trees are wobbly, and old, and wilt…they’re not strong, but the hammock is really strong and the ropes are really strong, it doesn’t matter. If you sit down on it, it’s going to collapse. And any part of that system, no matter how strong the canvas is, or how strong the trees are, if all the components of that system are not strong and doing their job the way they should be, you’re not going to have a system that’s working or supporting you the way you need it to be.
So, a lot of women, particularly women who’ve had babies or surgeries, they have weakness in other muscle groups, you know, [inaudible 00:33:14] core muscles, but it could be old muscles that supported, you know, gluteus medius, transverse abdominis, multifidus in the back, you know, all those muscles together, a few others, they come together to support the whole pelvic girdle like we call it. So, when you look at a patient and you want to know why are they having incontinence? Why are they leaking? You’re also looking at that whole system, like, what’s their alignment like? How are they standing? Are they holding their body in a way that’s even allowing them to be able to withstand the pressure of a sneeze or a cough, or even allow those muscles to work in their best range of motion?
Just like any muscle, like your bicep, there’s a certain range. If you go to the gym, you have a trainer teach you how to strengthen your bicep, there’s a certain angle that your bicep is the most powerful. We know that the pelvic floor and the pelvic girdle muscles that they need to be…they function best in certain alignments, and people who are standing in kind of like the way women stand after they are pregnant, if they continue to stand like that until they’re 80 years old, until somebody tells their body they’re not pregnant anymore, is really a hard way for those muscles to work. They’re just not in a great position for activating in that position.
Dr. Fox: Wow. That hammock analogy was awesome, by the way, just so you know. That really, with the trees.
Rivki: It wasn’t mine. I don’t know who thought of it, but it’s a good one.
Dr. Fox: No, that is definitely…That’s a really…because, I mean, that’s frequently what I’ll use in terms of explaining what the pelvic floor is, but I never went out to the trees, and I think that that’s a great point.
Rivki: It’s all about the trees.
Dr. Fox: Well, we’ll miss the trees. All right. So, you see, so just explain just so women know what we’re talking about. How does biofeedback work sort of logistically? What happens?
Rivki: Absolutely. Okay. So, it doesn’t hurt. That’s the most important thing I think for people to know, and also, pelvic floor physical therapy should not hurt. I always tell people that, you know, I can’t vouch for every pelvic health physical therapist out there, but I always tell patients there’s one rule in my office and that is there’s no pain. So, I really don’t believe that causing people pain is going to make anything better. They could be uncomfortable. It could be, like, not their favorite activity in the world to do, but it really should not be a painful experience. So, biofeedback does not hurt. Basically, what it is is either you can have it with small electrodes that are sticky, like surgical-grade adhesive, like they’re not getting any waxing job from this or anything. It goes on the pelvic floor muscles from the outside. It actually goes outside the anal sphincter, because they found that to be the best placement to pick up the pelvic floor muscles, in general, from there. So, the placement is one on either side of the anal sphincter, or sometimes the physical therapist will use an internal probe, which looks like…
Dr. Fox: Like an ultrasound.
Rivki: Yeah, like ultrasound, but it’s smaller.
Dr. Fox: Yeah.
Rivki: But they have to be able to tolerate that, and they’ll put that…By the way, these are all disposable, or the one that goes internal is just one for patient. It’s not used from one patient to the next. That sensor goes internally. It inserts like a tampon, and then there’s a wire from that that hooks up to a box that can either have a display that’s like a computer display. We have fancy programs which makes, like, a rose opening and closing. I actually had a patient who once baked me a cake in the shape of a honey cake, no less. And the shape of a cake, if you’re listening, I love you, in the shape of a cake, a rose. And I had done biofeedback with her with the rose opening and closing. Obviously, the tighter you close your muscles, you squeeze them, then the rose closes, and when you relax it, the rose opens. And she baked me this cake, and when she finished therapy, and she wrote me a note that said, “Thank you for teaching me to open and close my rose so beautifully.” And I had it on my table, and my brother-in-law came over and I explained the significance of the cake, and he, like, spit out the cake. But anyway…
Dr. Fox: I’m not eating this.
Rivki: Yeah, [inaudible 00:36:54], but it was really sweet. So, bake your physical therapist cakes. They really appreciate it. Anyway. So, right. So, they have these programs which have fancy, you know, launching of rocket ships, which give you the visual, or it could just be a simple bar, like those smaller devices, where it’s literally just a box, where it’s like old-school Atari, like the bar goes up and the bar goes down, and you tighten your muscles and the bar goes up, and you relax your muscles and bar goes down, and that helps you realize whether you’re really tightening them or not. And conversely, I even do it with my pelvic pain patients, because they don’t realize that they are holding the stress of their entire lives in their pelvic floor. And I say to them, “Okay, now I want you to take some nice deep breaths, and I want you to visualize.”
Dr. Fox: Oh, and you see it relax in the opposite direction.
Rivki: The muscles. Yeah, exactly. So, you can…What we call that, and we call that down training. So, if we’re trying to get somebody to let go of their pelvic floor muscles.
Dr. Fox: You’re trying to get them to open the rose.
Rivki: Open the rose. Exactly. Open the rose.
Dr. Fox: I got it.
Rivki: Versus if they’re trying to strengthen, then we’re trying to what we call, you know, we’re trying to get them to tighten their muscles. But you can have muscles that are both weak and tight also, so just because someone is having pain in their pelvic floor, it doesn’t mean that they have a strong pelvic floor. Sometimes, you know, it could be both.
Dr. Fox: Wow. So interesting. And what about things like in pregnancy, the various pains that women have? You know, whether it’s in their sacrum or whether it’s just their pelvic floor, you know, their pelvis shifting, or I assume you see a lot of pubic symphysis pain. So, how do you work with women, first, during pregnancy, potentially, and then after delivery? Because I assume you see a fair number of women with those.
Rivki: It really depends on what is going on and why they’re having this pain. You know, is there something orthopedic? Sometimes what’s interesting is women will have a pre-existing orthopedic issue, you know, but it doesn’t bother them that much, or maybe they’re not even aware of it. And then you put the strain of like a fetus growing in them, to just throw it all out of whack if they have an old injury or something. And then everything gets thrown out of whack because, A, the ligamentous laxity that occurs with pregnancy, also their center of gravity being shifted forward, you know, all the venous changes that happen. Really getting to the root of why because, like, you know, 10 different women could have 10 different reasons for why they’re having pain and where their pain is in pregnancy, if it’s an SI joint pain problem, or where that’s coming from.
So, sometimes, you know, we’ll be working on stabilizing, helping them. You can get stronger while you’re pregnant. You know, as long as your doctor says it’s okay for you to be doing exercises, and I usually really like communicating with doctors during pregnancy, particularly to make sure that they’re down for whatever it is that I am envisioning will help the patient, and that it’s safe for them. And we’ll work on strengthening other muscles, or even the core muscles, during pregnancy, so that it better supports them, so that they’re not just hanging with all that weight, pulling them forward and putting all this stress on the joints, but strengthening other parts of the body, to help them support themselves, and they really feel so much better when we can give them something else to help hold them up.
So, it could be strengthening. It could be helping them with, you know, alignment in terms of how their…or body mechanics, how they’re getting out of bed. I get this a lot. Women who have so much pain, and they feel like their hips are falling off when they get out of bed in the morning. So, we’re problem-solving, what muscles they’re using, what muscles they’re not using, what position they’re using to get out of bed in the morning, and all those things, to kind of help them recruit muscles that are working for them better, in a way that will keep the pain at bay, or help them feel more comfortable and more supported during pregnancy.
Dr. Fox: Yeah. And, I mean, generally, most of the times, or almost all the time, we, the obstetricians, are going to be totally in favor of these exercises. And, you know, it’s almost never that the physical therapist has to say, “I want to do A, B, and C,” and I’m going to say, “Oh, no, you can’t do that.” I mean, it almost never happens, and if it is, it’s only because it’s a physical therapist who’s never worked with a pregnant woman, and it’s like a unique situation, but basically, they’re basically all fine. Do you find in your own practice when pregnant women come to you with these types of pains it is helpful if they’ve been evaluated already, saying, “All right, the pain is because of this,” or they had an MRI or there’s…whatever it is, or is it like, you see these. You can figure it out. You can treat them. How does that work?
Rivki: Are you saying do I need to have imaging done to know what’s wrong?
Dr. Fox: Not necessarily imaging. For example, you know, sometimes women will first see a physician, like, you know, an orthopedist or a rehab specialist or someone who does this, and they do an evaluation and exam, maybe imaging, maybe not, and then they say, “Okay, you need physical therapy on this region in this way, and I’m going to send you to a physical therapist with a prescription.” So, that’s one way someone has had to come to you, versus someone just walks in your door and says, “I’m pregnant, and my hips hurt.” Does it matter to you in a sense, or you pretty much are going to treat them the same way either way?
Rivki: No. I’m going to treat them the same. I mean, unless there’s something really concerning to me, like a red flag that says, you know, “This really needs further testing because I’m concerned about,” you know, “this symptom seems something that is a red flag that needs to be checked out by a specialist,” as long as it’s within the realm of musculoskeletal. But the exams that physical therapists do are not medical exams. They’re musculoskeletal evaluation. So, I’m looking at their muscles, their nerves. I’m looking at, you know, what’s going on with different forces in their body, and how things are pulling on their bones and ligaments, and then I’m looking at, you know, what is causing this discomfort, and what can we do to help them be stronger, or use their body differently?
Sometimes the way that they’re using their body is causing the pain. Their body mechanics needs to be altered. The way they’re sitting at their desk for 12 hours is really putting a real strain on them. It’s fascinating to find out how people live in their bodies, and what they’re doing in the course of the day really impacts them, and impacts the way that they’re feeling. So, if we could tweak the way that they’re, you know, getting out of bed, or standing and washing dishes, or tending to their children, or riding the subway, whatever it is, we could problem-solve and figure out what we call finding the driver, what is causing [inaudible 00:42:54]… Yeah. And it’s a physical therapy diagnosis. It’s not a medical diagnosis, and it doesn’t really, you know… We always say treat what you find. You look at, the patient is telling you they have pain in their left hip every time they pick up their toddler. So then that’s what we’re treating. We want your left hip to not hurt you, and we want you to be able to pick up your toddler for as long as you can without it hurting you, and what can we do to make that possible for you?
Dr. Fox: Right. You must be so busy, because just the three things you mentioned, you know, pelvic pain, incontinence, and then pregnancy-related pains, what, like 98% of women have that over the course of their life? I mean, these things are so common. I mean, you must have a line out the door, unless you think women really aren’t seeking treatment for these things.
Rivki: You know, I think that it’s amazing that there’s an awareness, and that women know that there’s help. I mean, it used to be in the olden days you come to the doctor with pain and they would tell you, “Yeah, it’s pregnancy,” you know. Like, there’s such an improved awareness that there’s other, like, “Have the baby. You’ll feel better.” But I think that there’s such an improved awareness that there’s something that we can give women to do. Try this, you know, and maybe it won’t help. Maybe really the only thing that’s going to make them feel better is actually to deliver that nine-pound baby…
Dr. Fox: Right, but try.
Rivki: …that’s been sitting on their sacrum for six months, you know. But really that there’s something to offer them to try is really helpful, and it’s helpful for women because it can really help them in that. I would say also that women who are thinking about getting pregnant, being in good shape, and I see this both with urinary incontinence and in pregnancy patients, is that women who are in good shape, who exercise regularly, take care of their health, and are physically active, really do much better in physical therapy. Not that a woman who has never exercised in her life can’t do well in physical therapy, but oftentimes, they’ll get much better outcomes faster as well if they’ve had a general baseline of really being in shape. In some ways, these patients are the most devastated when things go wrong. They’re like, “I’ve been at the gym every day for six hours my whole life. I can’t believe this is happening to my body now.” It’s like they feel like, you know, betrayed by their body, but…
Dr. Fox: We’re all betrayed by our bodies.
Rivki: Yeah. I know.
Dr. Fox: I’m very upset at my body. Yeah.
Rivki: But really, if a woman knows that she’s going to plan on getting pregnant, you know, being in good shape and being active, and throughout pregnancy, as long as the doctor says it’s helpful, you know, being physically active throughout pregnancy is a game-changer for women. It can really prevent a lot of these problems, or really help treatment move along faster if there’s a general muscle tone.
Dr. Fox: I totally agree. Yeah. I mean, I believe that so strongly, and obviously, you can have someone who’s in perfect shape and has terrible pain. It’s not like, for sure, going to prevent things, and it doesn’t mean if someone has pain it’s their fault, obviously…
Rivki: Obviously not.
Dr. Fox: …but the idea of walking into pregnancy, or anything through life, you know, physically fit, in good shape, her body’s used to these things, you know, strength, and mobility, and cardiovascular. If you have those, your likelihood of having an easier pregnancy is so much higher, and an easier recovery is so much higher, and it can’t be stressed how important that is, and people always focus on the baby. Like, what am I eating for the baby? And they just forget about their own general health, and that’s usually going to be the best thing for them, and it turns out for the baby too, obviously.
Rivki: It’s so true.
Dr. Fox: Yeah.
Rivki: It’s so true. And people will say to me, like, “If I do this, will my delivery go better?” And I’m like, “You know what? All bets are off what’s going to happen with your delivery.”
Dr. Fox: But probably, people who are in better shape do better at delivery and they recover better. There’s no question.
Rivki: But, like you said, yeah, going into something, you know, we’ve no idea what necessarily, people could be in the best shape of their lives and have problems and pain, and patients can…you know, but they certainly shouldn’t be blaming themselves if something is going wrong. But [inaudible 00:46:26] knows that there’s something that can be done and they shouldn’t just have to feel, like, hopeless, that this is just my fate in life. This is what happened to my grandmother, and this is what happened to my mother, and this is how it’s going to be for me now because this is what happens. You know, you can get help for yourself. You can go for physical therapy, and you can have an improvement in your life, whether it’s pain with intercourse, or pain with wearing a tampon, or being able to tolerate gynecological exam, or if you’re leaking urine or having pain in your pregnancy. All these things are oftentimes really treatable with physical therapy, and people do really, really well.
Dr. Fox: Yeah. I was going to ask you a question. If you had to pick one condition that women have that they don’t realize is treatable, but when they come to it is, meaning what is the thing that women just don’t even realize, “Oh, my God. I have this,” but it can be treated that they’ve sort of resigned themselves to living with when they don’t need to?
Rivki: That’s a good question. I think the pelvic pain. I think some women just think… I think for the urinary incontinence, if they’re coming to me already for urinary incontinence, they already really think that I have something to offer them, you know, and I hope I… And they do, they do well most of the time. As the urologist spoke about, there are some cases that, absolutely, there’s a limitation to physical therapy. Sometimes structurally, things need to be fixed in other ways. There’s limitations, but women could do really well. I think with the pelvic pain, I think women who are having pain with intercourse, or pelvic pain, they think that there’s just sort of like, they feel like “This is just going to be my life forever. I’m just going to have to suck it up, and if I want to have penetrative sex that I’m just going to have to live like this and just grin and bear it, or scream, or figure something else out, because this is never going to get any better. I can’t even imagine that this is going to help.”
And women who say to me, you know, I’d ask them about orgasm, like, “Do you have arousal? Do you have any enjoyment, not necessarily with intercourse, but with any sexual activity?” And oftentimes, women will tell me they don’t, and that it’s…you know, and I say to them, “Well, if you’re having this kind of 10 out of 10 pain, or you’re anticipating that this is going to lead to penetration, which is going to be a 10 out of 10 pain, then, of course, you’re not having arousal with foreplay or anything else, because you’re just waiting. You’re just waiting for that awfulness at the end, you know, if it’s going to end with vaginal penetration. So, of course, you’re not going to have an orgasm, because nobody is…If you’re in fight or flight, your body, it’s very hard for you to be able to be in rest and digest or enjoyment part of life. So, women realizing that once they step out of the pain that they can more fully embrace their relationships with both their own body and with their partner, I think is really…they really just can’t believe that they’re able to do it, and it changes everything for them.
Dr. Fox: Is that the best part of what you do? I was going to ask you what’s the best part of your job?
Rivki: Yes, can you tell? Yes, 100%. It’s really been the most rewarding. I love helping them at all stages. I love being able to…women who have been wearing pads and now they’re not having leakage, all kinds of problems, but absolutely, when women can trust their bodies again or feel connected to their body and feel like they’re able to trust that something is not going to hurt when that is their goal. Like, listen, maybe penetrative sex isn’t important to them. And then, you know, that’s fine, but in terms of women who that’s important for them, then being able to have that is such a wonder, and just being able to see the smile on their faces. They’re just so happy that they’re able to have sex without pain, or even go to the gynecologist. They know they need to go to [inaudible 00:49:52] like this, like, cloud over their head, like, “I know I need to go. I need to. I need to go, but it’s so, it’s going to hurt. It’s going to hurt.” And then they send me text messages literally from the waiting room, like, “I [inaudible 00:50:02] had a pap smear and it didn’t hurt. I love you,” and I’m like, “I love you too.”
Dr. Fox: Amazing. Wow. Rivki, I’m so glad we caught up. This is awesome. What you’re doing is amazing. It’s really important stuff.
Rivki: Thank you so much for having me. This is so wonderful. And I love that you have this podcast and you’re giving such wonderful information to women, and they can listen to this and not be afraid to ask questions. They can get so much information about topics that normally would have been taboo. And like you said, our high school teachers would never believe that we were talking about it on a podcast, but look at us, and I’m sure you’re helping so many women by providing the awareness of all these important topics.
Dr. Fox: Awesome. Well, thank you so much for coming on. Please send your entire family my love.
Rivki: Thank you. Likewise.
Dr. Fox: And I miss seeing them around the streets of Chicago, but, whatever, we’ll see them at some point.
Rivki: Thank you so much for having me. I really appreciate it.
Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at firstname.lastname@example.org. Have a great day.
Man: The information discussed in “Healthful Woman” is intended for educational uses only. It does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.