her therapist at the time, who’s a guru in the field named Dr. Marilyn Friedman, kindly took the time out of her busy schedule to meet with me and opened my eyes to the specialty. And I realize it’s not just about urinary incontinence, there’s so much more to pelvic floor therapy, there’s bowel functioning, bladder functioning, sexual functioning, prenatal, postpartum. And I was…I just fell in love with the specialty and fortunately was able to take courses that help set me on the path.

 

Manon Bolliger  03:00

So, there’s not like a school per se for this. It’s kind of like, you’ve got a basic skill set, which you said was in…what did you say? Orthopedics?

 

Dr Riva Preil 03:13

Physical therapy. General physical therapy.

 

Manon Bolliger  03:16

Okay. And then you kind of went on a search for what might help.

 

Dr Riva Preil 03:21

Yes, exactly.

 

Manon Bolliger  03:23

Okay. And so, what have you found helps?

 

Dr Riva Preil 03:29

So, I have found that, first of all, there’s, there’s just so much taboo around these topics. People don’t sit around at the dinner table talking about their bladder issues, their sexual dysfunction, for understandable reasons. But then what happens is people end up suffering in silence for far too long, without knowing that help exists. And the people who are brave enough to share with their doctors about what they’re experiencing, at times are either not taken seriously. Or if the doctors don’t know about pelvic floor physical therapy, then they’re not referring the patients appropriately. And don’t get me wrong. I have a lot of respect for the medical profession. There are so many wonderful doctors who I collaborate with. But for the most part, very few…this wasn’t included in many people’s medical school training. And in fact, I’m involved with an organization called tight lipped. And that’s an organization that helps women who have sexual dysfunction and they’re working on trying to revamp the syllabus for OBGYN residents so that they receive training on pelvic floor therapy so that more people can get help in a dignified manner.

 

Manon Bolliger  04:44

Yeah, that’s really great because I agree it’s like it’s like a bit like nutrition right, 11 hours. And I think also many of the physical modalities and all the things that it can do are really not known to them. It’s like, yeah, personally believe that they should have a whole list of what, what’s out there? And what kind of results? You know, wait till you know, we’re not going to get that study, that’s never going to happen because there’s no money in it.

 

Dr Riva Preil 05:18

Right.

 

Manon Bolliger  05:20

But I think, you know, results speak for themselves. And I think, you know, really, I think it’ll all change, but I think doctors have to open up to, and there are some very open, I’ve had plenty in my practice saying, What is this Bowen therapy? Why does it do this? And how does it do that? And is this a good candidate for your practice, that kind of thing, that’s the mindset we need. Because otherwise, it’s a secret almost. And people suffer. And that’s the worst thing, you know, at least as a practitioner that you want, you want to see, right?

 

Dr Riva Preil 05:57

Totally. And I always joke around that with pelvic floor therapy, because it’s something that’s so taboo, I joke around that, it’s really hard to get five-star Google reviews, because people want to be anonymous. And they don’t, totally, but anytime I have a patient who has been referred by a friend, I’m just like, hats off to you, kudos to your friends, um, for both feeling comfortable enough to share with each other about what you’re going through. And then the other person was able to share their positive experience and pelvic floor therapy. So, to whatever degree people feel comfortable talking about these matters, it just helps to D stigmatize it. And the same way a person would get their shoulder fixed or their knee rehabbed if they have issues with those body parts, then the same should be the case with the pelvic floor as well.

 

Manon Bolliger  06:48

So, give us some like presentations that, but you know, that you can help, and that otherwise would likely not be helped.

 

Dr Riva Preil 07:02

I’ll quote one of my one of my favorite former patients, and her eval at her initial evaluation, her first session, she said she was coming for sexual dysfunction. And she came in and she said to me, you know, Riva, I just always thought that when I watched the movies, and see people seeming to enjoy sex with each other, like, I just thought, like, oh, that’s just in the movies. And in real life, it’s meant to be painful. She didn’t even realize that sex was something that was forget, like pleasurable, but just shouldn’t be painful. And I think so many times people have misconceptions about how things should be like, Oh, I just had a baby, of course, I’m going to be leaking urine all over myself, like my body’s just changed. My body is different now. Or for the woman who’s first becoming sexually active and is experiencing pain and doesn’t realize that after the first few times, it shouldn’t be painful. These are all people who stand to benefit from physical therapy. I work with people who have constipation. And in order to pass it, the things that they have to do the maneuvers to evacuate stools, pushing, straining, splinting different techniques, which are all crutches, it’s not addressing the underlying issue, which oftentimes has to do with the pelvic floor muscles. Because if the pelvic floor muscles are tight, or they’re more on than they should be, then a person will likely experience difficulty with emptying their bladder or their rectum. So that’s where the bladder and bowel dysfunction can come into place. But people have been doing this 20 years of habits, bad habits that are perpetuated, without realizing that, wait, I shouldn’t have to strain to pee or to poop. And I should be it should be a passive relaxed process. If they don’t even realize that something’s wrong, they’re not going to know to go get help.

 

Manon Bolliger  08:56

Exactly. So, what I mean, we’ve heard about the Kegel exercise. That’s a fairly…that’s out there, you know, and it’s used with childbirth or to prepare, and also, you know, for better sexual relations as well. What else? I mean, feel free to explain what that is, for those who don’t know, but what, what are the one or two things like, you know, there’s a lot of like, dribbling, they say, oh, that’s age related, and whatever. Is that true? Or can women actually do something for that? I’m asking you two questions, feel free. You can answer both.

 

Dr Riva Preil 09:46

Alright, so first of all, yes, women can do something about that. It’s never normal to have dribbling or have to pee 10 minutes after you’ve just gone. That’s often a sign that the pelvic floor muscles weren’t relaxed, fully the first time one tried to avoid or urinate. Therefore, your inner remains in the bladder so the trick is learning how to relax the pelvic floor muscles fully while urinating and defecating so that one can have more successful urination and defecation. Speaking to Kegels, I’m so glad you brought that up. Thank you. Kegels are fortunately making their way more into pop culture what people know about it, it’s being referenced in shows and magazines and people are aware. But what people aren’t aware of is that Kegels aren’t appropriate for everyone. Now, there are two different types of pelvic floor dysfunctions want to use broad categorizations there can be on one end of the spectrum under activity or weakness of the pelvic floor muscles versus the opposite end of the spectrum, which is overactivity or tightness or the muscles are in spasm. So, let’s talk about under activity first. Under activity, that’s where the muscles are weak for whatever reason, classic case scenario is your postpartum woman who was just pregnant for 40 weeks with all these hormones circulating that makes everything laxer. Throw on top of that, especially if there’s a vaginal delivery, labor and delivery pushing, there’s overstretched weakness to those pelvic floor muscles. And symptoms that a woman may experience when there’s weakness in the pelvic floor is she may experience urinary incontinence or involuntary loss of urine, she may experience the feeling of her organs descending, which is called pelvic organ prolapse. And in a case like that an up training or strengthening program would be appropriate via Kegel exercises. Kegel exercises or pelvic floor muscle strengthening exercises. However, let’s think of now the opposite end of the spectrum if we’re talking about over activity, tightness spasm, the muscles are more on than they should be. So, think of patients who have pain during intercourse, constipation, difficulty emptying bowel and bladder. Those patients should not be doing Kegels. Kegels are contraindicated for those patients because strengthening a system that’s already too tight will only make the problem worse. And I’ve heard it from so many patients. Riva, I’m having issues I thought, Oh, it’s my pelvic floor. Let me do key goals. But then it made my problems worse.

 

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Dr Riva Preil 13:30

And that is like a common refrain that I hear because when someone has overactivity, they need to initiate a down training or stretching relaxation releasing program with either dilators which are plastic cylindrical devices that one can insert vaginally to stretch the tight pelvic floor muscles. Similar to what the physical therapist would do during manual therapy in a physical therapy session. Or let’s say a curved wand. These are all devices that a licensed PT can teach a patient how to use so that they can make progress on their own in between sessions. And for patients who have overactivity then they should not be doing Kegels, because that could make it worse.

 

Manon Bolliger  14:11

Okay, so the dribbling that people have you mentioned…so I mean, actually could be under either diagnosis.

 

Dr Riva Preil 14:20

Correct, because there could be dribbling, either due to straight up under activity weakness, or if muscles are so tight, that they can’t then function properly. So sometimes people noticed that with over activity as well. That’s why it’s important to have a physical therapy evaluation to determine what’s the root cause. Is it under activity or over activity and based on that the patient can be taught appropriate exercises.

 

Manon Bolliger  14:48

Yeah, that makes sense. Yeah. And that’s why it shouldn’t be the go-to, you know, exercise that everyone should do.

 

Dr Riva Preil 14:56

Oh, totally. Totally.

 

Manon Bolliger  14:58

What other I insights or exercise, I mean, if people could know, like, I mean, Kegel people can look it up, you could share what it is, if you want, or otherwise another kind of something else that people can do that you’ve noticed, you know, quite, quite useful were big turnarounds, for people.

 

Dr Riva Preil 15:22

Yeah, I know, it sounds so Elementary and simple. But there’s an exercise called diaphragmatic breathing, which is something I teach all my patients on day one. And it’s very profound, and it can have very tremendous impact. And basically, what diaphragmatic breathing is, is it’s inhaling through the nose for five seconds, and then exhaling through the mouth for five seconds. And the connection between the breathing and the pelvic floor is, first of all, the diaphragm, which is a muscle that rests at the bottom of the ribs. It’s like a dome shaped muscle, and when it contracts, it moves down, which then causes the pelvic contents to all move down, including the pelvic floor muscles, and then when one and that’s what happens during inhalation. Then when one exhales, everything rises and returns to its starting position. So, think of the diaphragm as the top of the core, pelvic floor muscles are the bottom of the core, and they work together. So, when one inhales, the pelvic floor descends, stretches releases, when one exhales the pelvic floor muscles rise and return to the starting position. So, the benefits of diaphragmatic breathing is number one, it provides a gentle stretch, a subtle stretch to the pelvic floor muscles. So, if someone’s in spasm and their muscles are on more on than they should be, during the day, without them even realizing it, performing the diaphragmatic breathing can help to literally breathe a sigh of relief and provide a stretch to those muscles that are too tight. And I’ll tell patients to check in every two hours with their pelvic floor, do a pelvic check in perform six diaphragmatic breaths for one minute with a real focus on that inhale open release space of breathing to help stretch and relax and release the pelvic floor muscles. Benefit number two of diaphragmatic breathing is that it shifts one whole mode of functioning from sympathetic fight or flight response to parasympathetic rest and digest response, which means that all of the muscles of the body including the pelvic floor muscles, can relax and release further. So, for people who have difficulty with passing bowel movements or urinating, they feel like they have to strain or push, I encourage them to perform a minute of diaphragmatic breathing before they get up from the toilet. You think you’re done urinating, do a minute of diaphragmatic breathing and see if more urine comes out. And very often patients will say that it worked because that allows the pelvic floor muscles to relax and release, which allows for…it opens up around the urethra. And the pelvic floor muscles are on and tight. It closes off the urethra, which is the tube through which urine exits the body to the toilet. So, when one relaxes the pelvic floor muscles and allows for more opening than one can further empty their bladder more successfully. So, breathing it sounds so simple and elementary, but it really can have a profound impact on pelvic floor functioning.

 

Manon Bolliger  18:09

Oh, that’s a great tip. Easy to do for people to you know, try it and see if it makes a difference.

 

Dr Riva Preil 18:16

Yeah, I hope it does.

 

Manon Bolliger  18:20

All right. Now, what about, like your most surprising or unusual…you know, we all have those days where it’s like, Oh, my God, I had no idea that this, you know, I could help this person. You know, we’re told certain things we might have a certain experience. And then it’s like, oh, wow, you know, maybe it was just for the patient that maybe not for you. But is there like one of those moments where you kind of go, wow, this is so perfect…so perfect. Yeah, that’s,

 

Dr Riva Preil 18:57

I love that question. Definitely. For me, anytime, like a couple has not been able to consummate their marriage because of sexual dysfunction. And then when they come in and give me the thumbs up green light, we did it like that’s always extremely rewarding. I actually this is a story I love to tell if you don’t if you don’t mind indulging me. So, I had been working with a couple for several months. And usually when a couple comes together, if anything, the partner will come to the initial evaluation, but it’s rare for the partner to attend every session with their partner. And there are a few times that I have had the opportunity to work with the couple the entire time. And it’s really nice because then I develop a relationship with both of them. So, this was one couple, and they he came with her to every session got close with both of them, was able to help them achieve their goals and they’re Jewish and they had a circumcision ceremony for their baby boy on his eighth day of life. And I found out because they sent me an invitation I had after we successfully achieved their goals, I hadn’t heard from them in months. And next thing I know, I’m on the train on my way home from work one day and get a notification on WhatsApp from them. And it was an invitation to the bris to the circumcision. And I went, because I really cared about this couple, I was super happy for them. And the husband said to me, he said, Riva, the Talmud says that there are three partners in the creation of humans that there’s mother, father, and God. In our story, we had a fourth partner in creation. So, thank you for being that partner in creation. And I was just like, so moved to be the person to be able to, in any way, shape or form, count me in as a partner of the creation of being an agent of healing for them to impact their lives like that. It’s just such a beautifully rewarding experience. And it’s why I love what I do so much.

 

Manon Bolliger  21:00

Yeah. Well, it’s definitely an impediment to making babies when there’s too much pain.

 

Dr Riva Preil 21:06

Yep.

 

Manon Bolliger  21:09

Have you…have you heard of Bowen therapy? That’s the work I do, I have a school on that.

 

Dr Riva Preil 21:17

I have not, I would love to hear more about it.

 

Manon Bolliger  21:19

I’m not going to explain tons here because this is more your child. But I did want to mention that, you know, one of the things that it really helps with is with conception.

 

Dr Riva Preil 21:31

Cool. Send me all of your information. I’d love to read up on it.

 

Manon Bolliger  21:37

I will know because it’s very aligned. It’s gentle, it also works with parasympathetic because that’s how we heal. Right? But it doesn’t have specific like exercises, which it’s more like a full body restructuring. But there are a couple moves that are taught in our hormonal course, that you might also find, you know, interesting. Because I don’t know, your work, per se, I, you know, it’s hard to know, you’d have to, you’d have to check if it could be helpful, you know, to increase that happiness for couples,

 

Dr Riva Preil 22:18

I would love to, thanks for the tip.

 

Manon Bolliger  22:21

know, many, what they call Bowen babies, you know, it’s like, if it wasn’t for Bowen, this thing, this, you know, life that we’ve created would never have been a thing.

 

Dr Riva Preil 22:36

So, you can relate, right, best feeling in the world?

 

Manon Bolliger  22:40

It is, that’s why I mentioned that. Okay, so I are…yeah, we have a few more minutes. What would you? What would you like to share? I mean, you’ve given some great tips already. What else do people not know or not realize, men or women, you know, that could be very helpful about your existence, I mean, that this, there is actually help.

 

Dr Riva Preil 23:10

Normally, I would say that a lot of people. And again, with all due respect to the medical community, people need to be their own biggest advocates. Don’t wait for a doctor to refer you to pelvic floor therapy. If you can relate to anything that I’ve spoken about today, then chances are you stand to benefit from even if it’s just a few sessions of physical therapy. Even if it’s just an evaluation to learn how to connect with your pelvic floor, what exercises you could be doing to help it be as wonderful as possible and is in as good a shape as possible. That’s sometimes that’s all it takes. And there, like I said, many doctors who don’t, who haven’t fully jumped on the bandwagon yet. That’s in part why I wrote my book, to help educate both the medical and lay communities about the benefits of pelvic floor therapy. But if you think that you would benefit from physical therapy, don’t wait to be referred. In France, all women are sent to pelvic floor therapy by their OBGYN after they go on their six-week postpartum clearance, and then they’re sent to physical therapy. And I look forward to the day when hopefully, that will be the case in the United States. I also hope that insurance companies will recognize the work that we do, and that it’s one on one and reimburse accordingly. Because it’s really hard for us to be in network and not to get political or talk about insurance too much. But this needs to be a service that is in network for the masses, not out of network or just the wealthy upper class to be able to afford. This should be a service that anyone and everyone can stand to benefit from and be able to access there needs to be more accessibility. So, my little soapbox here is, please advocate on your own behalf. If you’d had a baby, you are a perfect candidate for pelvic floor therapy and stand to benefit from making sure everything is doing what it should be down there. And the way I describe it with regards to postpartum is if any other body part underwent a trauma, rotator cuff tear, ACL tear, and then you went for surgery, you would get rehabbed, you’d be sent to physical therapy to rehabilitate from that injury. As beautiful as childbirth is, it’s traumatic. And there’s no reason why women shouldn’t be rehabilitating themselves after childbirth the way they would any other injury, so to speak.

 

Manon Bolliger  25:43

Well, I’m not going to beat that one. I agree completely. Oh, wonderful. So where can people reach you? I know, it’s New York. And I guess, like all physical therapists somewhat physical. If you’re not in New York, you’re out of luck. But at least you can look up the profession.

 

Dr Riva Preil 26:02

Definitely. Thank you so much. I think the best way for anyone to access any and all what I’m about to discuss is through my website, www.revitalizedphysicaltherapy.com. There are educational videos there a review on diaphragmatic breathing, there’s a page there dedicated to my book, which if you are interested in learning more, I encourage you to purchase it through Amazon. There are two versions of it. The blue one is the Jewish version, the green one is the generic version, please purchase whichever one is appropriate for you. And I also have my Instagram on my website, information about my Facebook page, please feel free to like and follow. And we’re always putting out new content and information for people to learn and benefit from so I hope that you’ll be among those.

 

Manon Bolliger  26:58

Okay, thank you. And once again, the name of the therapy if they’re not close to…I mean the websites accessible but what is what did people look under?

 

Dr Riva Preil 27:11

Pelvic floor physical therapy,

 

Manon Bolliger  27:13

Okay.

 

Dr Riva Preil 27:15

Or pelvic health physical therapy.

 

Manon Bolliger  27:18

Okay.

 

Dr Riva Preil 27:19

Well, actually, in my book in the appendix there are, there’s guidelines for how to try to find a good PT near you with questions that you should be asking and interviewing any therapist before you make that decision to start physical therapy, and just information about how to practically find a physical therapist who specializes in this. So, I hope that that was helpful.

 

Manon Bolliger  27:43

Yeah. Great. Thank you so much, and thanks for being on the show.

 

Dr Riva Preil 27:47

My pleasure. Thank you again for having me.

ENDING: 41:33

Thank you for joining us at the Healers Café with Manon Bolliger. Continue your healing journey by visiting TheHealersCafe.com and her website and discover how to listen to your body and reboot optimal health or DrManonBolliger.com/tips.