30: Your Pelvic Floor (Part 1) with Specialist Dr. Mary Ellen

Today, I would like to welcome a very special guest, a professional, as well as a mother to the podcast.  Mary Ellen Kramp has a doctorate of physical therapy from Boston University and has worked in women's health for almost 20 years now.  In that time, she has owned her own practice, developed and taught continuing education courses to other physical therapists, and helped many, many women.  

Mary Ellen is a certified lymphedema specialist, pelvic floor specialist, and has even published a series of case reports for the use of manual therapy techniques to support fertility in women. Perhaps her most impressive feat is having worked with me. (Haha I'm just kidding.) Mary Ellen and I know each other because I actually was her patient, but we've also worked clinically together to help mother and infant dyads. 

What I have learned working with her is just how much poor information is out there and how little is being discussed about in the pelvic floor. That's why I really wanted to have her on the podcast. To ask her some really important questions about the pelvic floor.

Read on to learn more about Dr. Mary Ellen Kramp and to see what she has to say about this important topic.

What drew you to specialize in the pelvic floor and how did you get into this very specific niche?

It was actually by accident. I was raised in a very conservative Catholic family. I honestly was taught that I didn't exist from my belly button to my knees and sex education was not a thing. Nothing that had to do with the pelvic floor was discussed ever at all. That topic is not brought up, it doesn't happen or exist. So it was a real journey for me to even get to the point where I could discuss that type of stuff with patients because I had to first get comfortable with it myself. 

I've been a PT (physical therapist) for 32 years, but I'd say for the first dozen years I was growing as a PT and working in inpatient rehab and other settings and not yet working with pelvic floor health. Then, a little over 20 years ago, I had a patient who was very insistent that her issues were pelvic floor related and asked if I would, ‘please, please, please work on her pelvic floor’. 

At the time, I wasn't even aware that there were pelvic floor courses out there so I began self-educating, picking my husband’s brain (my husband's a physician), and applying the therapeutic techniques that I normally use to the pelvic floor. And that patient got remarkably better very quickly.

I was like, oh my God, this is, this is a thing. This is an amazing thing and I need to be doing this. I found out that there were actually some pelvic floor courses so I went to those as well and just started expanding my practice very quickly from there. 

What is the pelvic floor exactly? What does it mean when people talk about the pelvic floor? 

A lot of people don't really even realize where the pelvic floor is and what it does include. The pelvic floor are the muscles that you basically sit on.  It's the muscles on the inside of the pelvis. So if you look at a skeleton and you look at the bones in there, it's the muscles that are going to attach the front of the pelvis to the back of the pelvis and to the sits bones on the sides. 

They are the muscles that help you not pee yourself. They are the muscles that hold poop in and let poop out and pee out. They are the muscles that surround the vagina. They're the muscles that have to stretch and expand when you deliver a baby. Those are the pelvic floor muscles. They surround and support bladder, bowel, and sexual function.

Do the pelvic floor muscles stretch and change during pregnancy?

Well, no not really, because the baby's sitting well above the pelvic floor itself. The uterus actually is not within the pelvic floor. It's within the bowl of the pelvis, but not the pelvic floor. 

If you were to put your own finger in the vagina, you would feel kind of a bulk of muscle (like you're putting in a tampon that doesn't have an applicator). You would feel this bulk of muscle and then once you get above that, you no longer feel it. That bulk of muscle that you feel in there is your pelvic floor muscles.  Those muscles are attached to the pubic bone, from the front and all the way to the back (to the sacrum and coccyx).  

So it's not until the birth that they are greatly adjusting to accommodate the baby?

Right.

What happens to your pelvic floor with birth? 

Well that's a funny question just unto itself. I was at a conference several years ago and one of the physicians who was presenting was saying that they wanted a computer model of what the pelvic floor does with birth. So they talked to some biomedical engineers and said, “Here are the muscles, we'd like a model of what happens to these muscles during birth.”. 

So these biomedical engineers ran and re-ran, and kept trying to find a model that would explain what the pelvic floor muscles do during childbirth. And their conclusion was that it's impossible! 

Based on what a normal muscle is capable of doing, the pelvic floor muscles should not be capable of doing what they do during childbirth. So it is amazing what the body can do!

Speaking of birth, what can someone do to prepare their pelvic floor for birth so that those muscles do not tear?

There's a lot of, in my opinion, kind of crappy research out there about pelvic floor preparation. Most of it is labeled “massage” (perineal massage).  Which is really vague and done by the midwife, nurse, or the partner. For the most part what I'm reading in these studies, is that the birth preparation “massage” is rather unskilled and unspecified.

One of my goals is to be able to do research in this area. What I want to do is look at where the trigger points are within these muscles. Think of a trigger point as a section of muscle in spasm. Now, that muscle(s) has to expand width wise to each side of the sits bones and lengthwise from the pubic bone to the sacrum because that's how much space that baby needs to get out between head and shoulders. If there are sections of muscle in spasm, then they may not give (stretch) when that head and those shoulders start coming through. And if they don’t, then what's going to happen? Well you're going to end up with tears, or the baby's going to get stuck, and they're going to have to do an episiotomy or a c-section. 

I'd like to research this by looking objectively at the pelvic floor and those trigger points with ultrasound. Then treat it with specificity for each woman.  Then we can see if we treat this group of women with their specific trigger points, do they go on to tear and to what level. Does this skilled approach reduce the risk of trauma to the tissues?

What can someone do right now, before that research is available? 

There are quite a few pelvic floor therapists out there that are working hands on with specificity on the pelvic floor. Unfortunately, there are many therapists who have just had one weekend course and they tend to be more exercise based (e.g. Kegels are really pushed). Often they are not working from a manual therapy perspective to find root issues first.

You want someone who is making sure that you know how to relax those pelvic floor muscles, because sometimes you say “go ahead and relax” and the person contracts. Or you say “push” and they’re pulling. That's going to make it really difficult for them to push that baby out. 

This can even be the case for women who are strong athletes, but they still don't realize with pelvic floor that they need to push down and relax versus contract. There have been studies that have shown that 70 percent of people who are asked to move their pelvic floor in a certain way cannot.

And of course, you should be comfortable with anyone working with your pelvic floor.

Can you use insurance, HSA, or FSA money for pelvic floor therapy?

It's going to be whether or not the therapist takes insurance. Not all pelvic floor Physical Therapists take insurance. For a long time insurance companies weren't covering pelvic floor therapy. I think most insurances are covering it now. Some won’t cover “birth preparation”, but if it's coded as restrictions in your pelvic floor it should get covered. 

If it's not covered by insurance, you should be able to use FSA or HSA dollars. Even if you go to a cash pay practice, you can try to self submit for reimbursement or at least throw it toward that deductible. 

Wow. For me, this episode was very educational and it's only part one.  We are going to pause our conversation here with Mary Ellen until next week to keep these episodes short and digestible. In part two, Mary Ellen teaches us about the postpartum pelvic floor. She shares what's considered normal and part of the healing process after giving birth and also, what might be a sign that you have pelvic floor dysfunction.

So tune in next week to hear part two of the Pelvic Floor Series!

Links mentioned in the show:

Work with Dr. Mary Ellen Kramp in the Washington area at https://thriveagainpt.com/about-us/

Email Mary Ellen personally at: maryellenpt@evolutionmedical.org 

Find Mary Ellen’s courses for professional pelvic floor therapists: https://evolutionmedicalassociates.com/courses/