Expert Interview — Annemarie Everett PT, DPT, WCS
Interview with Annemarie Everett, PT, DPT, WCS, pelvic floor physical therapist, co-founder of PopUplift, @popuplift
What is pelvic floor physical therapy? Why should I consider it during pregnancy and postpartum?
Pelvic floor physical therapy (PT) applies the same principles used in treating other concerns (like knee pain, back pain, etc) to potential issues in and around the pelvic floor. It is the gold standard for addressing issues with bowel and bladder continence and sexual function, but also becomes very useful when someone is recovering from pregnancy and childbirth! Many people misunderstand it as "alternative medicine," but it is very much a part of evidence-based care.
I see the majority of my patients for the first time around pregnancy and birth because it's the first time that many experience any pelvic floor dysfunction — and understandably so! The changes that the body undergoes during this time are profound and often bewildering, and a pelvic physical therapist is the expert in navigating recovery and a return to exercise and activity. OB-GYNs and midwives have expertise in very different areas, so it's important to recognize that experts in the musculoskeletal system are needed here too.
Why did you become a pelvic floor PT (PFPT)? What inspired your new venture, PopUp?
I became a PFPT because I believe that people deserve high-quality care for these incredibly common issues. When I was in graduate school, I was disappointed to learn that people simply do not have adequate access to information and care for pelvic floor dysfunction — even in a city like San Francisco with a wealthy and highly educated population. I think that we can and must do better for women and men who need this kind of help, and statistically speaking the majority of us will need it. It's a unique space to work in that involves a lot of very personal connection, and the longer I work in it the more I see how much difference I can make by working with my patients to address fundamental quality of life issues.
I co-founded POPUp with my dear friend and colleague Haley Shevener, a perinatal exercise specialist with whom I have shared clients over the years. POPUp is a web-based educational resource for people with pelvic organ prolapse (POP) who needanswers to questions large and small. Internet searches yield inadequate or incorrect information, provide answers from questionable sources, and generally leave people more scared and less empowered. POPUp hopes to meet this need with a comprehensive guide written with the highest standard of evidence. We recently launched POPUp Pro, an extensive course for rehab and exercise professionals, to help ensure that our work with people with POP continues to reflect modern, high-quality, evidence-based care.
As a culture, we typically visit doctors, physical therapists and others in response to something going wrong — we’re sick, we sprained something, we had surgery, we need rehab. How can we be more proactive and less reactive to the health of our core and pelvic floor?
I think we need to be careful about how we frame "proactivity." The birth community and many PTs and fitness professionals have oversold our ability to "prevent" issues and "prepare" for pregnancy and childbirth in a way that doesn't align with the evidence. I unfortunately see this create a lot of anxiety and guilt in those for whom the process didn't go as planned.
We have far less control over birth outcomes than we have been led to believe. If someone is told that a given exercise program will "prevent" diastasis recti or prolapse, and then those things occur, they don't blame the exercise program— they blame themselves for not having done enough or done an exercise correctly.
We do, however, have evidence that being active, having strength, and promoting good mental health and stress coping skills are incredibly powerful in reducing risk of pain and injury. So, my fundamental goal is to make exercise and movement accessible to as many people as possible, and to mitigate the fear and other barriers that often keep people from doing what they want to do. We see that those who are regular exercisers have better pelvic floor strength and function, and have a lower risk of issues like urinary incontinence. As a pelvic PT, I will work with patients to address control, strength, or other pelvic floor issues specifically, but in the larger context of promoting their overall healthy lifestyle and activities in which they find fulfillment. There are far more ways to "do it right" than we think!
How do we continue to shift the conversation that pelvic floor injuries/symptoms should be viewed like any other injury?
We need to continue educating providers in primary care, women's health, obstetrics, and urology about the limitations of their scope of practice and expertise, and the ways in which physical therapy can be not just a complementary treatment but a cornerstone of successful diagnosis and treatment for many common conditions. This way, they can appropriately refer their patients to get the care they need. We also need to be as candid as possible with friends and family — the majority of my patients come from word of mouth referrals.
Every day, new mothers are getting diagnoses like diastasis recti and pelvic organ prolapse after giving birth. What are these conditions and how can we healthfully approach healing?
Diastasis recti (DRA) and prolapse (POP) are both normal parts of pregnancy and postpartum physical changes. Yes, I said it —they're normal. DRA is a softening and stretching of the connective tissue line down the middle of the abdominals. It occurs in all pregnant women, and goes away on its own within a few months postpartum in about half of the population. We don't actually have the ability to predict who will and won't have a persistent DRA, but we do know that for the vast majority in whom it remains, it is cosmetic and not a risk factor for other issues.
POP is a descent of one or more of the pelvic organs towards the vaginal opening. Iappears almost universally in female anatomy by the time we reach menopause, along a spectrum of degree of descent. Some will have symptoms from this, but the majority go undiagnosed because it simply isn't a bother to the patient. Ironically, we don't see a strong association with the degree of POP and the severity of someone's symptoms — someone with a very mild POP could be much more symptomatic than someone with a severe one.
While building awareness is important, I fear that we have gone to the other end of the spectrum in terms of creating hyper vigilance about these conditions and spreading a narrative that they are avoidable and "reversible." Evidence and experience suggest that someone can have both anatomical features of DRA and POP and be incredibly active, strong, and symptom-free. On the flip side, someone can have no DRA and no POP and be very limited in their physical capacity because of weakness, deconditioning, and other issues
I always validate the concerns and symptoms of my patients, but I also do a lot of education about what normal changes are associated with pregnancy and aging, and how much we can improve function even outside of "reversing" these changes. The predominant narrative is that someone has to "heal" these in order to be functional, but that simply isn't the case. I work with patients to improve strength and function with those diagnoses in mind, but we never make it our goal to turn back the clock on our anatomy. We don't have strong evidence that we can reverse these changes! It's such a shame that a lot of people with DRA and/or POP are relegated to low-level, "safe" exercises trying to "fix" these changes, when in fact they are capable of so much more and are being told they can't return to what they love until their POP or DRA goes away. I think the story we should be telling is of our bodies' resilience and adaptability, and of the need to do the hard work accepting our bodies, even amid the dramatic changes of pregnancy.
Many women are afraid to visit a PFPT - whether it’s because they’re afraid what the PFPT might say, or believe that the symptoms they’re experiencing are common and normal after giving birth. Can you explain how a PFPT can help with these symptoms?
I think that those symptoms can be considered common and normal, and also be very treatable! PFPT offers a way to normalize and contextualize these concerns, and also give actionable steps that give a person control over their symptoms. I believe that good PT puts the patient in the driver's seat —they get to decide what the goals are, and they're the ones who do the work to get there with the expert guidance of a PT.
Pelvic PTs are experts in identifying issues with the musculoskeletal and neuromuscular systems, and prescribing exercise and/or activity modification to address those. Because we understand these principles in the body at large, we apply them specifically to pelvic floor issues to elicit adaptations in strength, control, and other areas that can influence symptoms.
As we all get more educated on the benefits of PFPT, there is a real issue that there just aren’t a lot of PFPTs out there — or it can be expensive/feel out of reach. If you’re pregnant or a new parent interested in learning more about how you can prepare for birth/ease back into your normal activities after having a baby, where can you go?
There are a few resources available that can be helpful. First and foremost, asking about qualifications and training is important —there are so many people selling programs and giving advice, and many have no other experience other than (maybe) having been pregnant at some point themselves. I try to be a critical consumer of information and empower my clients to evaluate what they're being told by in-person providers or web-based programs. In my opinion, anyone that makes broad generalizations, provides rules that apply to everyone, or never says "it depends" deserves to be heard with a healthy dose of skepticism. Experts are those who understand nuance and are willing to live in the gray area — as with all things, there are no black and white answers in this area.
I like content from Haley Shevener (my partner in POPUp), Brianna Battles, and Jessie Mundell. I also strongly encourage my patients to go to birthing classes offered by their facilities (hospital, birthing center, etc.) or through local doulas or midwives. Aside from technique-specific classes like hypnobirthing, I think it's important to be educated on the basics of what happens during the process of labor and delivery. Without a good foundational understanding of what is actually supposed to happen and why, it's hard to make decisions in an educated way.
What are three pieces of advice for pregnant women and new parents?
While I advocate for women to have autonomy and choice in their health decisions, I also believe that the culture is shifting towards messages that they have a lot of control over pregnancy and birth outcomes if we "do the right thing." I have been working long enough now to know that we have far less control than we want to believe, and that feelings of failure or guilt when women don't get the outcomes they worked towards can be incredibly detrimental. I want to instill the message that we do the best we can with what we have, reduce risks in the ways that we can, and then prepare for handling whatever outcomes result. That mentality can be far more empowering, though it certainly is scarier than the alternative.
Movement is better than no movement for pain reduction, general health, and promoting healthy pregnancies and postpartum recoveries. If we're scared about moving the "wrong" way, we often stop exercising altogether and lose both the physical and mental benefits of doing what we love.
Our bodies are amazingly adaptable things, but they also need time and consistency. If you are six weeks postpartum, you should not feel back to normal because you aren't! I hear from a lot of people who think they are outliers because they haven't recovered by a given time frame, and I encourage them to remember how long pregnancy is and how significant a change has occurred in the body. We need time, consistency, and progressive overload to regain our physical capacities, and that might not always be possible in the early postpartum period. Again, we do what we can with what we have, and there is always time for strengthening and exercise.
