Kim (00:01.529)
Dr. Jocelyn Wallace, thank you so much for joining me today. I am, as I was saying offline, really excited, extra excited about this conversation because I've been supporting a lot of people through hysterectomy and just really have this, I really want to reduce the amount of hysterectomies that are done, but if we can't do that, make the experience better for people. And I found you, I heard you on, I think it was Hit Play Not Pause with Celine Yeager.
Jocelyn Wallace (00:28.916)
Mm
Kim (00:29.971)
and I reached out immediately and really wanted to have you on the podcast. So thank you for joining me. I would love to start out with you telling us your story, what brought you to the world of physical therapy, pelvic physical therapy, but then also now this specialization in hysterectomy.
Jocelyn Wallace (00:47.864)
Mm hmm. Thank you so much for having me. And I'm so happy to hear that you are helping this population as well, especially with having a large audience. It's so much needed for people to see that life is possible after these surgeries. A good life is possible after these surgeries. But as far as me, I got into physical therapy through my journey with CrossFit and becoming active for the first time in my adult life in my early 20s. And.
decided to go to physical therapy school so I could help other people find their physical function and live their best lives. And at the same time, I was diagnosed with fibroids and have lived with fibroids my, really my entire adult life, horrible, heavy periods, pain, all the different, all the things that fibroids cause. And I had my first open myomectomy during physical therapy school. So an open myomectomy is like a C -section incision at the bikini line.
and then they go to the uterus and remove fibroids. So I had that done while I was still in school. It affected my pelvic floor health. And we had one instructor in school that had any kind of pelvic floor training. And I asked her for advice on how to get back to powerlifting and stuff after surgery. And she didn't know what a myomectomy was. And this was the only person that I had to glean any sort of mentorship about the pelvic floor from. So I vowed at that moment to help to fill that hole in.
in pelvic floor physical therapy and physical therapy in general. So along the way, I started practicing pelvic floor therapy. And then by 2021, I made the choice to have a second open myomectomy after a journey with infertility. And I had 47 fibroids removed in that surgery. Got pregnant three and a half months later, had a c -section to deliver my daughter, who's now two. And my fibroids grew back in pregnancy, which is quite typical.
Kim (02:28.578)
Wow.
Jocelyn Wallace (02:38.292)
And I had a hysterectomy. It's been about almost four months now. So now I've had over 60 fibroids removed, two open myomyctomies, a C -section and a laparoscopic hysterectomy and have built my practice along the way to serve only this population. So people who have had pelvic surgeries, hysterectomies, endometriosis excisions, prolapse repairs, everything that doesn't have to do with having a baby because those populations, these populations are so underserved.
Kim (03:07.405)
Yeah, I think that's very common with pelvic PT. There's definitely an emphasis on prenatal postpartum recovery, which is absolutely needed for sure. And I sort of recognized the same thing when I was going through my rectocele repairer three and a half years ago was it took me a long time to make the decision for one, because I felt like a bit of a hypocrite. But then I sort of shifted the way that I was looking at it and said,
Jocelyn Wallace (03:15.91)
Mm -hmm. Yes, of course.
Kim (03:31.907)
But this is something that people are choosing. This is something that people need. It needs to be an option that's available. We just need to maybe go down that path with more information from a preparation and recovery perspective. So we share that same mission. And I just want to come back to the fibroid conversation for a second. What contributes to the development of fibroids? And why is it that during pregnancy it's more likely for them to come back?
Jocelyn Wallace (03:49.448)
Mm
Jocelyn Wallace (03:58.824)
We don't have clear answers on why fibroids happen in the first place. We have some ideas, some correlations, but fibroids tend to come back during pregnancy because of the surge in estrogen. So it starts to drive their growth as well as the blood flow to the uterus.
Kim (04:13.849)
Got it. so would there, if somebody was, guess, first question, do you have to have them removed always?
Jocelyn Wallace (04:23.636)
No, you do not have to have them removed always. Up to 80 % of women will experience fibroids in their lifetime. They don't always cause symptoms. Some people wouldn't even know that they had them unless they had an ultrasound during pregnancy. The reason I've chosen to have mine removed for one to conceive my daughter and then two because mine were very numerous and very large and we're creating all kinds of symptoms that were affecting my urinary and bowel function, my ability to exercise extreme anemia from the
the extent of my heavy bleeding, but I'm definitely more of an outlier amongst people that have fibroids. A lot of people live with them and they never give a problem.
Kim (05:00.92)
Given the role that estrogen is playing, if somebody is living with them, maybe with some sort manageable symptoms, would it potentially improve postmenopause?
Jocelyn Wallace (05:05.047)
Mm
Jocelyn Wallace (05:14.322)
Yes, sometimes it does improve for people. Sometimes people also find that in the waves and the ups and downs of perimenopause that actually sparks them to grow. So some people find that they have their first encounter with severely symptomatic fibroids during perimenopause and during that transition because of all the ups and downs in people's hormones. But some people do choose to wait it out and see if as their cycle starts to peter out, are their fibroids livable? Are they affecting their quality of life?
But I think a lot of people also don't realize and the medical system doesn't give enough attention to how fibroids can affect the bowel and bladder systems. So a lot of people are dealing with prolapse related to fibroids related to the constipation that fibroids can cause, the bloating and swelling that fibroids can cause. So I think taking a well -rounded look at it and making sure that you're looking at how they're affecting your function and not just how they're affecting your periods is really, really important.
Kim (06:12.387)
Yeah, you mentioned constipation and that's obviously a well -established contributor to the development or exacerbation of prolapse. Are there other contributing factors specific to fibroids and how they contribute to the development of prolapse?
Jocelyn Wallace (06:27.102)
The, this isn't well studied. The symptoms of fibroids outside of bleeding and whatnot is not well studied. But from my clinical experience, the placement of fibroid seems to matter. So I've worked with people that had a fibroid directly underneath their cervix, where it's just like constantly bearing down on the space between the vagina and the anus. Like a constant pressure. Some people even have a visible bulge in that area when their fibroids grow so large. And we have to assume that that would put you at risk of prolapse.
It's kind of like being pregnant for decades in some cases.
Kim (06:58.723)
Right, right. So myomectomy is essentially, and you said you were distinguishing between, so yours was an open, meaning it's like, as you said, similar to caesarean, above the bikini line going in and excising, is that essentially how a fibroid is removed?
Jocelyn Wallace (07:06.739)
Mm
Jocelyn Wallace (07:10.196)
Mm
Jocelyn Wallace (07:17.18)
It depends on the placement of the fibroid. So sometimes they don't have to cut through the uterine cavity and they're just kind of like dissecting them off the outside of the uterus. Mine were so all over the place. They had to go in and they basically take her uterus apart and put it back together.
Kim (07:32.611)
Wow, wow. But you were still able to conceive, which is amazing. You have your daughter now, two years, as you said, and then it was four months ago you've had your hysterectomy. So I guess before we go down the path of kind of how you're supporting people through that process, can we talk quickly about the different types of hysterectomy? And I know that sometimes the type of hysterectomy that would be presented as an option can be dependent on
Jocelyn Wallace (07:37.264)
Mm -hmm.
Jocelyn Wallace (07:52.148)
Absolutely.
Kim (07:59.719)
reason for the hysterectomy. So maybe if you can highlight the types of hysterectomies and what the one you had laparoscopic correct? Yeah so okay so what led you to that being the best option for you?
Jocelyn Wallace (08:07.72)
Yes, robotic assisted laparoscopic.
Jocelyn Wallace (08:13.972)
So an open incision is a harder recovery. Most of the time it can vary, but most of the time it's a harder recovery and I had already had three of those. So this time around I made the choice to have the situation resolved prior to where they got big enough where I would need another open surgery because of the ease of recovery and the opportunity to be able to have it done robotically, which does speed up recovery times as far as like back to activities of daily living.
It doesn't necessarily speed up recovery time to like full blown athletic activity, but it can be an easier recovery. So that's why I personally made the choice to go laparoscopic. The choice to go to laparoscopic also typically includes they're going to remove the uterus vaginally. So that's what I had done. So they dissect the uterus away from all of its parts and then they take the uterus out through the vaginal canal. So I had some vaginal tearing during my surgery.
So that can be a risk of laparoscopic compared to an open. So during an open, they're going to remove the uterus through the incision that they create in the abdomen, whether it's horizontal or vertical. But for me personally, the risks of another open incision outweigh the risks of the vaginal tearing situation that I have found myself in.
Kim (09:31.992)
So actual tearing to the walls of the vagina? Got it.
Jocelyn Wallace (09:35.4)
Yes, so they had a minor tear, but they had to suture it and that did create some discomforts and some extra bleeding compared to what people typically experience when they don't have that happen to them.
Kim (09:45.935)
Got it. When there's an abdominal incision, is there best practice with regards to, as you said, sort of a bikini line or one that's more vertical? there a different, like why would one choose one over the other?
Jocelyn Wallace (10:00.02)
I am of the opinion that a bikini line is far superior. Having a vertical incision is quite rare. I definitely encourage people to do their research with surgeons. It's much more common these days for people to have hysterectomies laparoscopically. And you want to make sure that you're seeking out a highly qualified surgeon that handles complex cases if you fall into that bucket of having a more complex case. But don't just take the first person that tells you they need to do
an open incision, whether that's vertical or horizontal, because it might just be a matter of their training and experience. There are very rare cases where, in my personal opinion, they should be doing vertical incisions these days. One that I can think of from my clinical experience, this woman had fibroid tissue grow into her veins. It's an incredibly rare condition, but she had to be cut vertically from sternum to pubic bone to have the fibroids dissected from the veins in her body.
was fiber like tissue. So in a situation, extreme situation like that, yes, but most of the time they can be removed with a less invasive incision.
Kim (11:07.097)
Wow, people who are not watching the video did not see the fact that my eyes were bulging out of my head. Wow. So your preference would be laparoscopic. So the small sort of small holes, if you can say in the abdomen where the instruments go in, they cut what needs to be cut. And then the uterus itself is removed through the vagina after those cuts have happened. Is that correct?
Jocelyn Wallace (11:26.887)
Mm
Jocelyn Wallace (11:34.994)
Yes, and sometimes they do cut up the uterus internally. They have to like shrink it down and cut it into pieces and pull it out that way. They used to do something called morselation and some surgeons still do where they kind of chop it up into little pieces and pull that out. But those are all great questions to ask your surgeon of exactly how are they going to get it out of you, depending on its size.
Kim (11:53.497)
Yeah. then if there's like the other, the other thing, so there's the different surgical procedures and then there's also a complete, so like a radical hysterectomy, which would be everything, a subtotal, which would just be the uterus and then a total, which would be uterus cervix, correct?
Jocelyn Wallace (12:13.938)
Yeah, so having your ovaries removed is a separate procedure called an oophorectomy. So typically when you see complete or total, they mean the removal of the uterus and the cervix. And then the removal of the fallopian tubes always goes along with that. But that's also technically a separate procedure called a salpingectomy. And then a subtotal is they take the uterus and they leave the cervix and the ovaries.
Kim (12:37.57)
Okay.
jumping ahead to one of my questions, but I think this it makes sense to put it here. If the cervix is removed, sorry, let me say it differently. When the cervix is not removed, there is still an element of support to the top of the vagina because part of really the role of the uterus and cervix is suspending the top of the vagina, so to speak. So when the uterus only is removed and the cervix remains, there wouldn't need to be
Jocelyn Wallace (12:42.078)
Yeah.
Jocelyn Wallace (13:02.599)
Mm
Kim (13:09.772)
or maybe there would, I don't know the answer. Is there still the concern of a vaginal vault prolapse and do we need to be asking our surgeons about how they are re -suspending the top of the vagina?
Jocelyn Wallace (13:12.157)
Mm
Jocelyn Wallace (13:21.062)
Yes, whether you're keeping your cervix or not, that's a great question. So many, surgeons now resuspend the top of the vagina anyway, even if you take your cervix. So they resuspend the utero sacral ligament so your vaginal vault has support. That's becoming common practice now.
Kim (13:37.07)
Okay, and in the literature that I've read, the most common type or the name of that procedure is McCall's cauldoplasty, or one of the names that's associated. Are there others, or is there one that's superior to another?
Jocelyn Wallace (13:52.018)
There's not a clear answer in the research. There's a few studies that have compared where they suspend the ligament to, like how high they do it in the amount of support, but it's not well researched enough to say exactly which one is better. Those would be, again, be great questions to ask your personal surgeon, especially based on your anatomy and your symptoms. And if you're having any urinary dysfunction, any bowel dysfunction, all of that can play into
Kim (14:04.984)
Okay.
Jocelyn Wallace (14:19.464)
their decision of how strongly or how high to suspend your ligament.
Kim (14:25.271)
And are they, how are they making that? it with the same material they're using for the incisions? Is that how they are, what they're using to reattach it?
Jocelyn Wallace (14:36.868)
They use sutures. They don't like put any external material into the body like a mesh or anything like that.
Kim (14:42.479)
Got it. Okay, perfect. Moving back now to kind of you made the decision and part of now what your, as you say, you support only this population, the surgical procedures. And if I think back to when I was working with pregnant women, was under the, I was preaching that we need to train for this. This is a physical event. Birth is a physical event. We need to train for it just like we would.
Jocelyn Wallace (14:51.028)
Mm.
Jocelyn Wallace (14:56.637)
Mm.
Kim (15:10.911)
mountain climb or a run race. And then when I was going through the surgery process myself, I looked at it and said, this is kind of mimicking what I was saying before, and really, we should be training for our surgery. And this is something that you also are promoting. Why do you believe that? And how would you recommend somebody train for a hysterectomy or any other type of pelvic surgery?
Jocelyn Wallace (15:25.748)
Mm.
Jocelyn Wallace (15:33.096)
In the broader sense, any surgery is like recovering from an athletic event. It's a huge trauma, a huge stress on the body. Just going under general anesthesia is an enormous stress and trauma on the body. And why wouldn't you want to be as maximally recovered as possible? In a hysterectomy specifically, you've lost some support to the pelvic floor. You've had a absolute change in your anatomy permanently. Like your body will never be exactly the same again. That doesn't always have to be in a negative light, but it's
different. So why wouldn't you want to support your body and be as well rounded as possible with your muscle strength, your pelvic floor function, everything that affects our foundation, our pelvis is our foundation. As far as the specifics for preparing for surgery, I think an overall fitness program is imperative. So you want, I like to talk about it like you want to have ease of movement about your day to day life. If it's hard for you to get up out of the couch or sit up out of bed or get on and off the floor.
those all start to become higher pressure activities than they need to be. So then now you're post -surgery and you're trying to clean your baseboards and that's creating a major stress on your pelvic floor when it doesn't have to. When if you're more prepared for those sorts of activities, then getting back to a day -to -day life will just be so much easier. Depending on the reason why someone is heading into a hysterectomy, also addressing whatever symptoms that they already have.
can help to improve their outcomes. So for example, if your fibroids are causing constipation, dealing with that and not just straining and pushing through it. If your fibroids are stretching out your abdominal wall, you can still be strengthening your core around that situation so that you are more able to get back to things more easily after your surgery. So addressing whatever deficits the condition leading to your surgery is causing can make a huge impact on people's recoveries. And then nutritional strategies, just like you would
train and use nutrition to recover from running a marathon. Same thing, you want to be having ample protein, lots of nutritious food, go into surgery while rested, well nourished. It really, really makes a difference.
Kim (17:40.002)
Yeah. And are there any kind of nuances there that would be different for a hysterectomy versus a bladder prolapse repair versus erectocele repair? Any changes that you would make or any tweaks that you would make adjustments for?
Jocelyn Wallace (17:45.832)
Mm
Jocelyn Wallace (17:57.416)
Yeah, it depends on how severe someone's symptoms are. So if someone is going in for a prolapse repair, usually they're at the end of their rope trying all kinds of things to help their prolapse. So I wouldn't advise like squatting through their prolapse symptoms and doing things that tend to make their prolapse symptoms worse. But strengthening around it, doing whatever if they've already tried pelvic physio, doing whatever they've been able to do to help improve their symptoms will get them into surgery in a better place.
versus I think a lot of people when they resign themselves to having surgery, they just give up on all the other things. They just resign themselves to like, OK, I'm going to have surgery now, so let me just take this pre surgery time as a break and stop working on my pelvic floor. Get rid of all this stuff when really that stuff is still supporting you and having the best possible outcome towards surgery. Like you're not a failure for ending up in the shoes where you're choosing to have surgeries. Your pelvic floor are still muscles. They still need stimulation. They still need to
and maintain the muscle mass that you have in your pelvic floor, just like the rest of your body. So keep training it in the way that works for you. If you haven't found the way that works for you, that's where a professional can come in.
Kim (19:07.159)
And then switching to recovery, said a few that was sort of like a preparation and recovery. Some of the things you were talking about, so high protein and like nourishing the body. But basically, as you're saying, preparing for what you need to return to so that those activities are easier rather than creating situations that are hard and causing a lot of strain. From right now, the protocol and it can depend on the surgery, but generally it's
Jocelyn Wallace (19:13.373)
Yeah.
Jocelyn Wallace (19:29.554)
Mm
Kim (19:37.379)
Don't do anything for six weeks. Like don't lift, really don't do much. You might do a little bit of, they kind of give you generic guidelines like some gentle yoga, some gentle stretching, gentle walks. And sometimes that can, I mean, what's gentle to one or what's hard to one, it's hard to, there's not really firm guidelines on that. There's also, even my surgeon, when I asked when would I resume pelvic floor muscle training, he had said, you know,
Jocelyn Wallace (19:39.592)
Mm
Jocelyn Wallace (19:47.282)
Mm -hmm. Mm -hmm.
Kim (20:06.391)
not you don't need to for six weeks or so just kind of leave it as it is and I think a little differently than that. I think we don't need to get started right away but I wouldn't wait six weeks or I didn't wait six weeks I started some gentle pelvic floor activation for blood flow circulation. So my general recommendation still is you need to go like I need to cover my ass so go by what your surgeon is saying but from a pelvic and ideally they were working with a pelvic floor physical therapist who may provide some different guidelines but
Jocelyn Wallace (20:13.246)
Mm.
Jocelyn Wallace (20:19.55)
Mm
Jocelyn Wallace (20:29.682)
Mm -hmm.
Jocelyn Wallace (20:36.468)
Mm.
Kim (20:36.65)
from your experience and what you recommend to your clients and patients, do you put in any pelvic floor muscle training in that first six week period? What do you, this is a long, gonna be a long question, but, what are, what from a lifting limitation perspective, what are your stance, what's your stance there?
Jocelyn Wallace (20:54.982)
Mm -hmm. Yeah. Yeah. So I'm going to answer this question first as if I'm working closely with somebody and have like had to have a very in -depth conversation with them and consider their lifestyle and everything. In a situation like that, I have almost everybody start with deep breathing immediately. So when people are in the hospital, most hospitals give out incentive spirometers. So it's a little breathing device that you take a big deep inhale into.
And that inhale can help to flush the fluid out of your body, get the swelling and the gas moving more quickly and get length back to the pelvic floor. Because when we think about should you train your pelvic floor or not, your pelvic floor is involved in everything that we do. Every cough, every sneeze, every vocal expression, every step that we take. It's always training. It's always training. So why wouldn't we start bringing some blood flow, pumping some fluid out, getting the swelling and the pressure off of the pelvic floor that surgery creates?
So that's where I start with most people. And then as far as return to lifting and exercise, I think that the system doesn't allow for enough nuance from one individual to another. So they have to just cover their asses, like you said, and use the six week, just don't do anything because they don't have time to dig into the nuance with people. So for your average person, I'm typically recommending no val salva, hard bracing or bearing down until at least 12 weeks.
because it takes about 12 weeks for the sutures to reach maximum tensile strength. Even if someone has been cleared for activity, I still think that they shouldn't be bearing down on their pelvic floor. There's also an argument to be made that if you're just exercising for general health and well -being, maybe you never need to bear down on your pelvic floor, but at least 12 weeks in my opinion. But for some people, they might bear down on their pelvic floor just getting up off of a low stool while they're sitting at their friend's house and they sit down on a chair that's too low and they might be doing that.
two weeks after surgery. So there has to be a lot of nuance and a lot of conversation about what does bearing down on your pelvic floor feel like and what scenarios might you find yourself in a situation where you might be bearing down on your pelvic floor for you and your fitness level and your lifestyle. If you have a toddler, you have to pick up a few weeks after surgery or as soon as possible after surgery. How can you do that without bearing down on your pelvic floor? So I think that
Jocelyn Wallace (23:15.508)
just a pure lifting restriction and just using numbers, just 10 pounds, five pounds, whatever it is, does women an enormous disservice because 10 pounds for me might be like lifting a pen, 10 pounds for somebody else might be a major strain to them. And even if they're cleared, 10 pounds might still be too much. So it really, really depends on the individual and the jump from nothing to whatever feels good is just a huge disservice to women.
Kim (23:41.827)
Yeah, I couldn't agree more. And it's it's almost like kind of when if we we reflect back to the preparation, training and preparing for yes for fitness, yes for pelvic floor, yes for managing pressures. And some of those nuances could also be dependent on the person prior. So what how much did they do? Have they been an avid pelvic floor muscle trainer for
years and years and years or were they just starting prior to surgery? And so as you say, it's going to be very nuanced and individual. But unfortunately, as you say, it's we kind of just have to say, well, it's generally, you know, six weeks is the superficial tissue healing. But we haven't I haven't heard anybody say the suture tensile support there. I haven't never heard that guideline shared anywhere. So that's really, really important. Thank you for sharing that. The the the lifting piece, too. So, you know,
Jocelyn Wallace (24:29.255)
Mm
Jocelyn Wallace (24:34.729)
Mm
Kim (24:40.078)
Yes, in that first period of time, and I hate even now, don't lift anything over X pounds. Even if somebody was dealing with a prolapse or even if somebody, you know, didn't have surgery, it's still these limitations are placed. And you, as you say, 10 pounds could be like a pen for you and could be incredibly hard for me. So it's not a number that we're looking at. It's the effort and how somebody is managing that pressure. So let's say they've
Jocelyn Wallace (24:48.563)
Mm.
Jocelyn Wallace (25:07.666)
Mm
Kim (25:09.295)
worked with you or a pelvic floor muscle, sorry, a pelvic floor physical therapist, they've gone through sort of a retraining rebuilding and now they're at that 12 week mark. They now want to go back to what you have been doing, which is powerlifting or CrossFit, like the really high intense work. What have you done differently now, if anything, compared to when you were training before you had your surgeries?
Jocelyn Wallace (25:36.948)
So my approach to strength training has definitely changed a lot over my time lifting. The way that I think about it now is I want a strength buffer. I want a fitness buffer. I want to be stronger than anything that I might encounter in my day to day life. But stronger doesn't mean one rep max. Stronger means I want getting off the floor over and over again to be so ridiculously easy that I could do it 200 times in a row without feeling.
without feeling any pressure, any fatigue in my hips. Like I want climbing stairs to be easy breezy, not something that makes me pant and get out of breath and put pressure in my abdominal cavity. I want my core to be rock solid strong before I do kipping pull ups again. Like I want my strength levels to far, far exceed the things that I'm exposing my body to. So I place a lot more emphasis now on making sure that I keep my core strength very good.
I'm a huge proponent of exercises like hollow holds, sit ups. think sit ups have got a really bad rep in the pelvic floor space, but I think they're really integral. It doesn't have to be high repetition sit ups or tons of sit ups or weighted sit ups, but some form of putting downward pressure on the pelvic floor and being able to work against that pressure, I think is really, really important and gets missed a lot. So.
That's kind of the way I think about strength training bigger picture is like, are the demands of my life and my sport? And how can I make sure that my body is above and beyond prepared for those demands?
Kim (27:09.999)
Yeah, I sometimes will say to my audience, I'm sorry for what I did when I first started this work, because this is going back, you know, for 15 plus years ago, where there wasn't really a ton of research we were and me being a fitness professional, not a physical therapist, I was really I worked very closely with physical therapists and was going on the guidelines at the time, which was don't crunch, don't plank, don't twist, don't jump, don't don't don't don't don't. We had this huge list and
Jocelyn Wallace (27:20.755)
Yeah.
Jocelyn Wallace (27:37.811)
Yeah.
Kim (27:39.5)
That being said, though, I remember being at a course with, I won't say the name of the person, but one of the pioneers in the diastasis space. And I was attending her certification and my intention was I was going to bring this to Canada and, and, know, kind of bring, bring this technique to more people. And the assessment for diastasis is basically it's a head lift. like a little mini crunch yet. And during that test, we're feeling for the rectus to approximate.
Jocelyn Wallace (27:46.711)
Mm
Kim (28:07.905)
yet we were told never to do crunches. And I kept, I thought that was a bit hypocritical in a way because well, if we're looking to close the diastasis or re -approximate the muscles, is that not going to be one of the most important movements? And yet crunches were vilified. We can't do them if we have a prolapse. We can't do them with this because inter -abdominal pressure. But then I was also taking certifications in more natural movement and
And that's a very fundamental movement pattern. And so there was this dichotomy of, we're telling people not to do this, but yet it's a movement that we really should be able to do. And if we totally eliminate it, then we're only going to make that movement harder so that when it does happen, we're not prepared for it. I apologize for the people that I limited in crunches before, but this is something that I do believe. And another one, I'll give one other example. I give a lot of credit to Anthony Lowe, who I'm sure you know.
Jocelyn Wallace (28:36.969)
Mm
Jocelyn Wallace (28:49.576)
Yeah.
Jocelyn Wallace (28:53.437)
Yeah.
Jocelyn Wallace (29:04.862)
Mm
Kim (29:05.697)
In terms of opening up this conversation and there was a pelvic floor physical therapist friend of mine who I was not at the course, but my business partner at the time also a pelvic floor PT. They were both on this course together with Anthony and this other PT. She really had trouble getting off the floor because she had restricted that movement from her life. And it was an eyeopening experience for both my business partner and this other gal to say, hold on. I think we're creating more compensation by limiting this movement.
Jocelyn Wallace (29:25.863)
Mm -hmm.
Jocelyn Wallace (29:34.227)
Mm
Kim (29:35.094)
in our patient population. So a follow along to that is from a breath strategy. A lot of pelvic floor muscle training is exhale just before exertion or exhale with exertion. However, when you get into Olympic lifting or CrossFit, there may be different breath strategies. What do you use and does it vary depending on the exercise?
Jocelyn Wallace (29:57.618)
Mm
Jocelyn Wallace (30:02.64)
It varies depending on the exercise and someone's goals from exercise. So it depends on what they want to get out of their exercise or the exercising for performance where they are doing those Olympic lifts and they are going to be catching a squat clean at the bottom with their pelvic floor, like maximally loaded. Then their best strategy is definitely going to have to be different. I do use the exhale with exertion thing in early recovery to teach people, especially beginners who've never done any of this work.
to teach them how to manage pressure off the pelvic floor. So for example, after hysterectomy, a lot of people deal with something that's commonly called phantom tampon, like a sensation of pressure down onto the vagina. So a lot of times an exhale strategy can help to reduce that pressure, reduce those symptoms for people. So that it is something that I use a lot, but I actually like to wean people off of that strategy as they go through their recovery program with me.
to make sure that they are then prepared for that scenario where they're at the end of a set or they're trying a mega former class because that's all the rage now and they find themselves in a situation where they're holding their breath because something's hard. I want to make sure that they are ready for that instead of teaching them that they can never ever do that again in their life. So I do like to work people up to Valsalva, hard bracing, stuff like that in time. So to make sure that their body is ready for it.
which is I think another big disservice that the system does for people is we view physical therapy as six weeks, know, two appointments a week for six weeks is a typical prescription. But I like to work with people for months, seeing them less frequently. And I don't consider myself done working with someone until they can hold their breath without symptoms and they can do a sit up and they can do a plank and they can do a crunch because you put it beautifully earlier that that's a natural movement we find in life. Like you do a crunch to roll over in bed.
and you're gonna need to do that for the rest of your life. So it's very important.
Kim (31:58.05)
Yep. Yep. What's the difference between a hard brace and a Valsalva?
Jocelyn Wallace (32:05.714)
Yeah, a hard brace is contracting the full abdominal wall is how I would define that. A hard brace is where you hold your Valsalva is where you hold your breath and close off the epiglottis and it creates like a pressure effect. So you're putting pressure down into the abdominal wall and towards your pelvic floor and you're holding that pressure internally and that creates maximal stability for the body. But it's also the most stressful way to breathe.
versus you can brace without holding a large amount of air in your abdomen like a balsalva does. So you can contract your pelvic floor, your abs, all the muscles that wrap around your whole body. I like to describe it like a corset. Like imagine you're getting a hug from a corset. You can brace all those muscles without holding maximal intra -abdominal pressure.
Kim (32:56.611)
When, like switching back to hysterectomy now, if somebody in the literature, there is some evidence that having a hysterectomy can increase your risk of prolapse, especially posterior compartment, which would be considered rectocele. How do we mitigate, how do you in your own body with your patient population with
Jocelyn Wallace (33:14.036)
Mm.
Kim (33:21.146)
anybody that we're working with who has had a hysterectomy, how can we mitigate that risk? Whether it's with posture or breath or lifting strategies, what do do there?
Jocelyn Wallace (33:31.541)
I think the biggest one is we have a constipation epidemic in the Western world. The big, big, big deal. So many people don't realize that they are constipated. They think that constipation means that you're just like pushing a giant log out and it's not coming out. There's so many other ways to be constipated and the medical system does not, first of all, teach us this in the first place. Second of all, they don't ask any questions after someone has had a hysterectomy.
Kim (33:36.568)
Mm -hmm.
Jocelyn Wallace (33:57.362)
It's just, you in pain? Are you okay? Do you have any questions? And if not, then okay, you're good to go. When people should be getting a full blown screening of what their bowel habits are like, so they understand what things there are to work on. I believe firmly that that is like the most powerful thing that people can do after surgery to avoid vector seal specifically is not making sure that they're not constipated and they're not just accepting that as a normal part of life because it is not.
I think lifting exercise and lifting is so much attention as being a big risk factor. And the thing that we're all worried about, we need to be way more afraid of being constipated after surgery. So that's that's number one. Number two is I see a lot of people really struggle with length in their pelvic floor, especially their posterior pelvic floor. I think a lot of this comes from just like the last 20 years of fitness, queuing of like a lot of butt tucking, a lot of neutral spine, a lot of flat back.
Kim (34:34.99)
Hallelujah.
Jocelyn Wallace (34:54.364)
are a lot of the cues that have been given. So people are doing exercise with their pelvis tucked all the time. And it's sometimes been years or forever since they've learned how to do a good hinge and really find length in their posterior pelvic floor. And if you're not finding length in a muscle, that muscle is going to weaken over time. That muscle is going to be prone to being strained over time. So sometimes people come to me expecting that I'm going to be like working their core or having them do Kegels. But the first thing we're doing is learning how to
relax their butthole and do a good hinge and really sit back into the length and find their glutes and find their posterior pelvic floor again. And then another thing that I think is really important is that as women, as we get older, we need to make sure that we can still tolerate impact and stop letting the way that the medical system speaks to us and treats us make us stop those things so early in life.
So many women come to me saying like, I don't run, you know, and they're only 35. And like they've already given up on being able to run or jump on a trampoline or skip around outside, whatever the thing is, they've already given up on that. So how are they going to feel when they're 70? What state is their pelvic floor going to be in when they're 70, when they step off a curb and they need to be able to absorb impact into their pelvic floor? It's not going to be a good situation. Yeah, yeah.
Kim (36:14.891)
and their bones. Yeah. Is it like the the ink? So you've mentioned obviously constipation. And it's funny, I sometimes feel like this is a constipation podcast, because I have so many people on here talking talking about constipation. But is it to do with the and perhaps it would be interesting to see now that it is common practice for the top of this, the vagina to be resuspended is becoming more commonplace? Where is it hasn't before? Is that
Jocelyn Wallace (36:41.323)
Mm
Kim (36:43.456)
also part of what's contributing to that posterior, well, any type of increased risk of prolapse, but especially posterior to do with it, if there is lack of or not a good resuspension of the vagina.
Jocelyn Wallace (36:57.384)
I think potentially, I think there's also the factor of like, like my uterus was basically the size of a 20 week pregnancy for 10 years, including being pregnant. So once that's removed, now there's a space that needs to be filled. Now everything is resettling into new positions and that can definitely create constipation. I had pain with bowel movements for a while. It's a really common experience that people have.
that a lot of people don't realize you shouldn't be pushing through and just like forcing your bowel movements out. So I think there's also just a lack of education around it. I think a lot of people live in fear after surgery that this stuff is destined to happen to them. But I think if women had the support and the information that they deserve, we wouldn't see the same things in the research that we do.
Kim (37:47.966)
not agree more. So if somebody has had a hysterectomy, maybe they did or didn't have the proper resuspension, maybe they're now dealing with a vaginal vault prolapse. So the surgical repair for that would be kind of like a maculoplasty and resuspending the top of the vagina. But if they weren't ready yet to go down that path, what are ways that people can lift, manage symptoms,
Jocelyn Wallace (38:01.476)
Mm -hmm.
Kim (38:17.302)
Obviously avoid constipation. what can people do now if they are dealing with a vaginal vault prolapse?
Jocelyn Wallace (38:23.42)
Yeah, so you want to think about what can they remove to reduce downward strain on the pelvic floor and then what can they add to help to strengthen all of the supporting structures? So remove, I mean, like remove straining during bowel movements, remove straining to urinate. A lot of people don't realize that urinary retention is not normal. You should also not strain to urinate. You shouldn't rush when you go to the bathroom and push down to try to speed up your stream so you can get back to work or whatnot. Those things can help to trigger symptoms.
Sometimes things like wearing clothes that are really tight or things that are really tight along the waist can be a symptom trigger. So removing the things that are triggering symptoms. And then what can you add for support? So do you need to strengthen your pelvic floor muscles? Do you need to strengthen all of the surrounding musculature in general? Some women do really well with things like pessaries and external supports. So they make prolapse support underwear and compression garments and all kinds of things that you can add to your life.
to help to reduce symptoms.
Kim (39:24.61)
And then what about from a hormone therapy perspective? I don't know your age, but having a two year old child, could make some assumptions, you're not near the age of menopause. is there, I apologize if you hear the noise, I have somebody upstairs vacuuming. I'm sorry if it got really noisy all of sudden, but were you counseled on hormone therapy, whether that be vaginal or systemic?
Jocelyn Wallace (39:30.397)
Mm
Jocelyn Wallace (39:42.408)
Yeah.
Kim (39:53.307)
And is this something that you talk about with your patients and clients, regardless of the age or stage of life that they're in?
Jocelyn Wallace (40:00.242)
was not counseled on it. do have the surgeon that I go to is excellent and does a great job treating perimenopause and menopause, but she's still restricted to the realities of the healthcare system. So I didn't receive any like pre -counseling about anything, but I'm confident that if I had issues in that realm, like she would be available to answer all of my questions and everything of that nature. I do think that women should get, whether it's...
a pamphlet or video or some kind of video course from their doctors. Like there should be something where they can have all of this information laid out for them so they know what to look out for. I am not personally using any kind of hormone therapy, but I work with a lot of people who do. And a recent study found that it seems like having a hysterectomy can increase or lower your age of going into perimenopause or menopause by about four years.
So that takes the average start of perimenopause from like 40 to 36, for example. So it can start younger than a lot of us, I think, realize. So I do end up working with a lot of people that choose to use hormone support, and they are often very much left in the dark until they have problems. So a part of my first intake call with somebody is just going over all of the things that they should be aware of and how they can communicate with their physician.
Kim (41:16.045)
you
Jocelyn Wallace (41:22.642)
if they're not feeling like themselves. So a way that I speak to people on that is for example, if after surgery you're feeling like your personality is different, you have anxiety, you have brain fog, you can't find your words, you just don't feel like yourself, you wanna go to your surgeon or any trusted provider and tell them I had a hysterectomy six months ago and I'm having XYZ symptoms.
Can you help me navigate whether I could be perimenopausal or menopausal or could I benefit from hormone therapy versus going to your doctor and saying something like, I have brain fog, and then they just get channeled down the antidepressant route. No shame to anybody that uses those kinds of medications, but if it's menopause, antidepressants might not be the best first line treatment. And I think so much of that is just missed because people don't know and they don't know how to communicate about it and they don't know how to ask.
for what they need in that way.
Kim (42:19.352)
Yeah. Last question, which we've kind of touched on, but I just kind of want to wrap up with it. Is there anything for somebody who has had a hysterectomy, regardless of the type of hysterectomy that they have had? Let's say it's somebody who has had their cervix removed. It has been resuspended. The top of the vagina has been resuspended. Any...
Jocelyn Wallace (42:23.74)
Mm -hmm. Yeah.
Jocelyn Wallace (42:34.43)
Mm.
Kim (42:45.816)
Do you think there is a place for limitations for lifting or any activities at all? Or do you feel kind of as we've been talking that it's about building your tolerance, using different breast strategies, modifying as it feels in your body, like making more of a nuanced approach? Or should we still have some global restrictions?
Jocelyn Wallace (43:02.302)
Mm
Jocelyn Wallace (43:06.458)
No, I don't think there should be any global restrictions whatsoever. I know CrossFit athletes that are competing at a high level that have had a hysterectomy. There's no reason to place blanket restrictions on anybody. Of course, you shouldn't progress too quickly. Just like with anything like you're just as likely to get a tendinopathy in your knee or injure your Achilles from going too fast as you are to injure something in your pelvic region. The pelvic region is just so unknowable, untouchable, so taboo, but it
it heals just like anything else. And the way to prevent injury to it is smart training, not doing too much too soon, training consistently over a lifetime. That's the only way forward and putting restrictions on people like telling someone, you can only lift 50 pounds for the rest of your life. That just makes them feel vulnerable. And now they're nervous and they don't even want to touch 50 pounds. So now they're only lifting 25 pounds because
that makes them feel like, I gotta be careful for the rest of forever. And we don't have any shred of evidence to make that recommendation make any sense. If anything, we have evidence to the contrary, that people that are given more liberal post -operative recommendations do better, have less reported symptoms of prolapse, less incisional hernias and abdominal and hernia related complications. And just for perspective,
Kim (44:04.973)
Yes.
Jocelyn Wallace (44:28.5)
My surgeon who is an incredible surgeon does incredibly complex surgeries. My lifting restriction was 25 pounds from the very beginning. So day one, I was cleared to lift 25 pounds. The highest I've seen from somebody with a different surgeon was 50 pounds from the very beginning after surgery. So it seems like post -operative limitations are going into a more liberal direction, a more nuanced direction instead of instilling fear into people for the rest of their lives.
Kim (44:51.042)
Mm -hmm. That's good to hear.
Kim (44:57.869)
Yeah, yeah, that's good. That's really good to hear. Where can people find you and follow along, watch your journey, work with you, tell us how we can connect.
Jocelyn Wallace (45:09.816)
I'm the most active on Instagram, so I also shared my whole hysterectomy recovery there. My handle is dr. Jocelyn Wallace, like Dr. Jocelyn Wallace. And I shared weekly highlight or chunks per week. like weeks one through four and a highlight so on and so forth. So you can see everything that I did and how I progressed in my recovery there and get a lot of information on hysterectomy recovery from a positive state of mind instead of everything you find in the Facebook groups.
Kim (45:37.218)
Yeah, yeah, I know, you have to mind your nervous system in the Facebook support groups. I don't want to take away that they can play a role, but my goodness, they can bring you down a big deep dark hole as well.
Jocelyn Wallace (45:42.152)
Yeah.
Jocelyn Wallace (45:49.448)
Yeah, you gotta look for just as much of the good stories.
Kim (45:52.244)
Yes, yeah, and those are usually you're not usually hearing them there. But sorry, I forgot to ask you one question, if I may. You've mentioned, you know, questions to ask your surgeon finding a good surgeon. How do you know if you have a good one? Do you have a resource that you provide that gives people questions that they could ask from a like surgical like when they're vetting their surgeons, how they can decide if it's a good one or not?
Jocelyn Wallace (45:56.775)
Mm
Jocelyn Wallace (46:16.146)
Yeah, I do not have like a checklist. do have a in the links on my Instagram, I have a pelvic health questionnaire that people can download and it just asks questions like are you experiencing constipation, pain with sex, stuff like that. So you can check all symptoms that you do have and take that to a physician. And I think just their response to that, their openness to having that discussion would give you a lot of insight into the quality of your how your interaction will go with them.
But you want to look for someone that's fellowship trained in minimally invasive gynecological surgery. Ideally someone that's not an OB. So if someone is delivering babies on Monday and doing a hysterectomy on Tuesday and then rejuvenating vaginas on Wednesday, they're not the best choice. The best choice is somebody that does surgeries and specializes in the kind of surgery that you need. And that's what they're doing day in and day out. I am of the opinion that you're
generalist OBGYN should not really be the person doing a hysterectomy. So I had a separate OB for my pregnancy and I have my surgeon who is a surgeon of that type to do my surgeries and making that choice really saved my life in a lot of ways, changed my life for sure. So making sure that you find a surgeon like that, even if you have to travel to them. So there's one in just about every major metropolitan area in the US, but they can be hard to find in more rural places.
But if you're not in an emergent situation where you need surgery immediately, it's worth coordinating to travel, it's worth waiting on their six month wait lists if you can. It really makes an incredible difference in the way that you recover and the techniques that you get exposed to. Like they're gonna be using the latest and greatest technology to do your surgeries.
Kim (47:59.567)
Perfect. Thank you. That's a great place to end. Thank you so much for your time. I'm still following along. I'm really fascinated by your journey. Thank you so much for sharing that. think that there's so much value in seeing what other people do. as you're kind of also showing the possibilities rather than, again, the people who are sitting there afraid of moving. And I really appreciate you sharing all that you have and for your time today. Thank you so much.
Jocelyn Wallace (48:25.601)
Thank you so much for having me. It was a pleasure.
