Kim (00:01.538)
Hello, Dr. Pagliano. Thank you so much for joining me today. I am excited to dive into a topic that I haven't covered on the podcast as of yet. I've sort of like maybe a couple of little comments here and there, but something that I know that you're very passionate about, is returning to run and high intensity activities, all the good things, specifically postpartum, we can probably bring in the post -op piece there as well. But before we dive into all that, I would love for you to tell us a little bit about yourself.
and what brought you to the world of PT, then focusing in pelvic PT, and then this passion that hovers around returning to run and high intensity activity postpartum.
Carrie Pagliano (00:41.604)
Sure, thanks again for having me. I'm Carrie Pagliano. I have been a pelvic floor physical therapist for almost 25 years now. This was not the plan. I wasn't going to be a pelvic floor PT. I was gonna go into neuro and work with patients with strokes and spinal cords and injuries and all sorts of things like that.
I got into it not because of any particular issue I had at the time. When I was first out of PT school, there weren't a lot of jobs.
you know, kind of went back home to upstate New York, kind of laid low for a little bit and then was offered a job doing women's health, which is what it was referred to at the time in Washington, D .C. came down here. Little did I know that was kind of the first step to what was going to be basically the focus of my career. So back then we did orthopedics separately from pelvic health because they were separate universes. Really, really long story short.
mashing those up and realizing that pelvic floor is far more than just this tiny little opening and pregnancy postpartum and things like that. Kind of delved into that for quite a bit of time and then
lo and behold, had my own kids and had to navigate my own issues with leakage and prolapse and diastasis recti and all the things, which added a whole nother layer of understanding. And then as far as the running goes, I've been a runner my whole life. I've been running since middle school. I've always been active. And so for me, kind of getting back to that after kids. And then I also had hip surgery 18 years ago and navigating those two pieces.
Carrie Pagliano (02:28.267)
you
because it's so much a part of who I am was really important. And at the time there really wasn't a lot of information. It's getting a lot better. And then in the process of getting back to that, realizing that there's such benefit in lifting heavy and picking up heavy things and putting them down. And I got into CrossFit about eight years ago and do those things. And so I'm really lucky that what I love to do personally is kind of really crossed over nicely and kind of the patients that I work with professionally. then now
we're diving into menopause and all that fun stuff. So we just keep the good times going.
Kim (03:03.584)
I know. Yeah, the story continues, right? It's this evolution that we're, yeah. So you had your own experiences, which I think a lot of us in pelvic health, either that's what brings us to it, or we experience things along the way as we're already in the profession and we all have our own unique stories, yet they all are very commonly similar to what we see in the people that we work with as well. So can you tell a little bit about
Carrie Pagliano (03:06.21)
Yes, it does. Yeah.
Carrie Pagliano (03:28.12)
Yep.
Kim (03:33.162)
you're, you you've been a runner and then you started to do CrossFit. And I think given the ages that you had shared offline of your children, the CrossFit came kind of after, yeah, yeah. So tell us a little bit about your, your pregnancy postpartum journeys and then you navigating that return to run, but then also adding in the layer of the CrossFit activity as well.
Carrie Pagliano (03:37.795)
Yeah.
Carrie Pagliano (03:41.4)
Yeah. After the kids, yeah. Yep.
Carrie Pagliano (03:56.355)
Yeah.
So my oldest is 13. And so I'd been practicing in pelvic health for probably 12 years at the time. And we didn't really have a lot of information. And at the same time, I don't know society wise if there were a ton of women as much as now running in pregnancy or being as like visibly active. I think there was a lot more shaming back then. You you're going to hurt your baby this, that or whatever. And so I very distinctly remember having this idea that I was
going to do everything right because I was a pelvic floor PT and that I was going to run all the way through my pregnancy right into the delivery room. And reality sorely smacked me in the face at about 19 weeks. I had tried to run a bit, you know, once the morning sicknesses subsided and really just had a lot of pubic bone pain, a lot of bladder discomfort. Got about a half mile from my house one day, sat down on a rock next to the Potomac River, called my husband and said, I can't even walk home. And so
I kind of experienced a lot of right off the bat being like, okay, this wasn't how this was supposed to go. I'm that person that I'm supposed to know how to fix these things and this is happening to me. Then you have this self doubt of like, okay, what do I actually know? That's kind of the theme that sort of ran through a lot of my stuff both with my first and second child was,
You know, we're supposed to know all the things and this isn't working out the way that we plan. What's up with that? And so we have a choice of either accepting the narrative that we were taught and there's a I tell women now I'm like, I treat completely differently now than I did a year ago, two years ago, five years ago, that sort of thing. I could accept the narrative that I was taught and be like, all right, that's it. No more running. We're not doing this anymore. Or you push the boundaries and say, OK, well, why is why is this happening? What's going on? So.
Carrie Pagliano (05:54.116)
had a very interesting childbirth with my first kid. My kids, if it were up to them, they'd still be in there. Both of them are 41 and a half weeks. My oldest, it was an induction, a very long induction, a couple days, got to push a couple hours. He wasn't recovering, ended up with a C -section. So again, not even prepared for that.
a lot of swelling, a lot of discomfort and slowly just kind of building, walking back.
was starting to run. again, I mean, this was back when we were doing really and I know you remember all this stuff. We're like, OK, with their abs, put a piece of TheraBand around and pull it tight. And if you train your abs, if you do exercises with it pulled together, it'll remember what to do. And I'm like, no, this doesn't work like this. We know now it's ridiculous. But we were doing really, really gentle things, which wasn't going to translate. And so I got lucky. was able to.
to get to running and run with my son in a stroller and that kind of stuff. I think first pregnancy, we have a lot to prove. I don't know to whom, but a little bit of leakage, things like that. We, I guess, but.
when he was two, we got pregnant again, unfortunately, a miscarriage at 14 weeks. And then about two months later, got pregnant again with our daughter. And at that point, like I was just scared to death. I was like, I'm not doing much of anything. I'm scared, you know, that something's going to happen. I also have a toddler. I'm at the playground half the day anyway. And so I don't remember doing that much running in pregnancy with my daughter. And then when you've got two toddlers, that was not my focus. And so really, it was kind of when she
Carrie Pagliano (07:35.692)
was getting towards, you know, she could go to preschool. My son was in kindergarten. I'm like, OK, I'm to start to build my way back. But in the meantime, I've got this diastasis because I've had two really big kids and a C -section. And those are risk factors. Was having some leakage, was having some prolapse symptoms. And again, it's like, wait, we're supposed to be the ones to understand and prevent all this stuff. And that really kind of makes you dive into what the heck is going on here. And so.
Again, about the time I had time to rub two brain cells together and I had a little bit more time. I had taken a...
CrossFit class with Anthony Lo, because I was starting getting more patients who were lifters. And I realized, I'm like, ooh, there's something to this. I need to get stronger. And as I mentioned, had hip surgery 18 years ago. This was before kids. And so I'm sure that kind of led to a bunch of the issues that I had in pregnancy. But that was my first big step into getting stronger. And with that,
my leakage got better and my prolapse symptoms got better and all these things got better and I wasn't having as much pain and running. And I'm like, wait a second, we've got to have this nice little combination of things. And that honestly, I'm running further now. I did my first half in my life, I guess it was two years ago now, and maybe thinking about seeing if I can pull off another marathon. And so those are things that, again,
I wasn't taught and it's kind of been this weird experiment that I never planned on. Like if I can't find the answer for myself, how do I expect somebody else to find it? So I wasn't going to accept the status quo and I don't expect anybody else to and that's sort of been my motivation and to just kind of keep moving forward in all of this.
Kim (09:28.404)
Mm hmm. Yeah, I love that. When you say that you were afraid the second time to do anything, was it because of that one day where you sort of sat down on the rock and said, I can't walk? Was that the fear or was there other layers coming in there?
Carrie Pagliano (09:32.836)
Mm
Carrie Pagliano (09:37.806)
Hahaha
Bye!
I think with my pregnancy with my daughter, it was just a lot of things. I like I said, we'd had a miscarriage at 14 weeks. even though logically, you understand these things, you just don't want to go through it again. I just didn't, and even in that time during our miscarriage, like I did not turn to running during that time. I felt like it was too much. I turned to yoga actually and did a lot more yoga during my pregnancy with our daughter, just because that's what I felt my body needed. Like I wasn't feeling like I could
Kim (09:48.182)
Mm.
Carrie Pagliano (10:11.51)
could run, it very much was like an unstable, not strong feeling. And when you're already scared, you don't need unstable. You need grounded. You need good things.
Kim (10:23.02)
Yeah. Yeah. Yeah. I remember doing that as well. was, I was a runner for since same thing from kind of middle school onwards and I didn't run in my pregnancies. Just didn't feel comfortable. wasn't that I was necessarily afraid of it. It just didn't feel good to me. And then, and the other layer was just before I got pregnant, I had kind of the chronic runner's knee pain, IT band syndrome, if you want to call it that, whatever. And, and so I thought, okay, I'll just take the pregnancy off. That'll be my rest.
Carrie Pagliano (10:30.893)
Yeah.
Carrie Pagliano (10:36.376)
Yeah. Mm -hmm. Yep.
Kim (10:52.662)
And then we'll see what happens. then when I went at two weeks postpartum thinking I'm ready to go back to running with all the things I didn't know that I know now. I also was like, this doesn't feel good. I, I feel lumps and pressure and heaviness and no, wasn't so thankfully I listened to that and stopped. However, when you start to realize and pay attention to things and you make different choices and you know more and, but sorry.
Carrie Pagliano (11:06.144)
Yeah. Yep.
Carrie Pagliano (11:10.808)
Yeah.
Carrie Pagliano (11:18.072)
Well, yeah, it's such a history lesson, though. mean, like your kids are a little bit older than mine. like, you know, we're kind of same vintage as far as our understanding of that space is like we didn't have anything. It was just like, all right.
go do whatever. And there wasn't any voices, there wasn't any guidance, there wasn't any research. All the research was like, okay, you know, what's this going to do to harm your baby? And so people find it surprising. And I'm like, we've hit warp speed recently with people being interested in the research and that kind of stuff, which is good. But the history short.
Kim (11:51.522)
Yeah, yeah. when I was, you know, what brought me to pelvic health was my own pregnancy and the, used the EpiNo, the biofeedback device and you know, that led me to learn about pelvic floor physical therapy and you know, anyway, it evolves. But at the time, especially given that I wasn't a PT, I'm not a PT, I am a physical, like a personal trainer, I was going on what,
Carrie Pagliano (11:57.613)
Mm
Kim (12:18.07)
my business partner at the time, physical therapy, was going on what the other PTs were saying as kind of my guiding light, right? My North Star and due to the lack of research and what the guidelines were, it was very restrictive. And the other thing I was doing was training with Katie Bowman, natural movement, move in all the ways, kind of as Anthony Lo says now too as well. But I just kept thinking, okay, like how could it be that we would evolve that as soon as we get birth, we can't do, you know, can't.
Carrie Pagliano (12:21.474)
Yep. Yeah. Yep.
Carrie Pagliano (12:45.634)
Yeah.
Kim (12:46.658)
forward flexion is bad and you have to roll to the side and push yourself. All the guidelines that we were promoting, don't do crunches, don't do this, don't do that. And I just, we were in that world of limitation and it didn't feel fun or good. And I remember my business partner, Julia, was at a course with Antony, with another PT friend of hers. And we were in the area of the area of life where, with the restriction and research that you.
Carrie Pagliano (12:50.648)
Yep. Yeah. Yep.
Carrie Pagliano (12:58.39)
Mm -hmm. Yep.
Kim (13:15.5)
You do, you roll to your side all the time. You don't get off the floor in a forward flexion. And the other PT literally could not get off the floor or off the treatment table or anything. And that was her wake up call saying, I think we're creating more compensation in people by all these limitations.
Carrie Pagliano (13:18.075)
Yeah.
Carrie Pagliano (13:24.066)
Right.
Carrie Pagliano (13:28.802)
Yeah. Yeah. Well, and there's there's kind of fallout from that, too, in two different spaces. One is there are plenty of places in the world where that narrative continues, which especially the don't do this, don't do that. Like, you know, crunches are bad, you know, planks are bad, all that kind of stuff that that.
is still perpetuated and I wish it would just die. The other is in moms are vintage, that all they know is what they learned back when they had kids. And now going into perimenopause and menopause, they still have these postpartum deficits that were never adequately addressed of no fault of their own. But they aren't aware that things are different and that we can still address some of those things, even though, you know, part of it is hormone shift and so on. So I've been spending
a lot of time recently being like, hey, we got to do a little Cliff Note action here and fill in the gaps, get you guys caught up, because we did not have these resources. And I tell people that I'm very clear about that because people blame themselves. I'm like, no, no, we just didn't know. And I'm sorry, because we said a lot of things that weren't right. And we didn't know. But we did the best we could at the time. And we're changing that now. But we can go back and kind of make up for that. So there's still fallout, unfortunately, from a lot of those things.
Kim (14:45.73)
Something that's interesting I've seen you talk about as well is the new term genitourinary syndrome of lactation, we met with the rise in the conversation around menopause there, thankfully is also bringing more light to pelvic health because there's a whole subsection genitourinary syndrome of menopause. And now we're looking at now this other genitourinary, muscular skeletal syndrome of menopause is the newest term. So there's all these.
new, I guess, shifts in awareness that are happening with this transition that all of a sudden we are paying attention to, thankfully, that maybe again, should ideally we would have known a lot more back then. But we know it now the information is here now. So with that, genitourinary syndrome of lactation, if you could talk a bit about that and how you guide your clients who your patients who wish to return to run what what
Carrie Pagliano (15:22.505)
Yes.
Carrie Pagliano (15:41.774)
Mm
Kim (15:44.041)
language, what information are you now imparting on them given that we know more now than we did?
Carrie Pagliano (15:48.718)
Yeah, it probably just needs to go under one big fat umbrella that says, know, genitor urinary symptoms or musculoskeletal symptoms and low estrogen is really what it needs to be. And I think, you know, we almost need to take a big step.
back further to what our general understanding of estrogen is from what we learned in middle school. And having two middle schoolers, have a front row seat to that right now and it's pretty bad. But just like, mean, even just going back to estrogen and testosterone and being like both boys and girls have estrogen and testosterone. And estrogen is not just for making babies and having periods and for your boobs to hurt. So I think.
Kim (16:11.031)
Yeah
Carrie Pagliano (16:28.604)
just understanding that there's fluctuations in a normal menstrual cycle. There's a couple of high points of estrogen, a couple of low points. Some people have symptoms during that time. We have a really big spike of estrogen in pregnancy. It's not all relaxin'. We need to stop blaming relaxin'. And then there's a huge crash after we deliver. And so with that,
we're going into a general low estrogen state. If you're breastfeeding, you're also trying to keep this other human alive. So we've got some nutritional challenges. There's a lot more discussion and overlap too as far as relative energy deficiency.
And a lot of people think about that with like bone stress injuries and things like that in like teenagers with eating disorders or, you know, ultra marathoners who don't eat enough or things like that. But we're finding it kind of in this population as well, because low estrogen state, not getting enough sleep. A lot of women trying to over exercise to get rid of the baby weight. We're not eating enough because we're trying to, you know, go into caloric deprivation, even though we should be eating more because
of all the calories needed to create enough breast milk to keep your baby alive, all these different things. And when you look at it like that, it makes a lot of sense that, you know, common things that we're talking about in menopause, which again, another low estrogen state, joint pain, tendon pain, like think of all your moms with aches and pains, you know, mommy thumb, all of those things. Again, estrogen, low estrogen scenarios. And for me,
you know, even having gone through that, wasn't until I hit menopause where I look back and like, my God, there's so many parallels. But it's also validation that this isn't just pregnancy. This is a situation that's related to a differing, you know, level of estrogen, but then also understanding that we have estrogen receptors in so many parts of our body, in our brain, brain fog, you know, in our tendons, in our
Carrie Pagliano (18:37.846)
In our blood vessels, that's where the genitourinary symptoms come from. Because if we look at the urethra, a lot of the bulk and the integrity of the urethra comes from the blood vessels. And if the estrogen is diminished locally, a lot of people relate to vaginal dryness or things like that. It's a very similar type situation and also is a symptom of low estrogen that
urethra doesn't have as much integrity and support. And so that might be an increased likelihood of urinary symptoms, whether it be leakage or urinary tract infections or things like that, which we've really identified quite nicely in menopause. But now kind of in the rear view, like, OK, we need to be looking at this and looking at local vaginal estrogen and things like that. So.
the bigger conversations I'm having with postpartum moms are pulling this back and saying, this is not going to be the only time in your life we're going to have these conversations. We need to look at all of the potential symptoms related to estrogen. Have a conversation about predicting when we're going to have fluctuations. You can get your period back and still be breastfeeding. You can be breastfeeding and you know.
Like people think they can't get pregnant because they're breastfeeding. Like all those things. That's like my PSA. I'm like, you can get pregnant. One is not related to the other, but we're taught somehow these stories that get passed down. your period won't start until you stop breastfeeding or whatever. But just to understand that all these things are related, your nutrition is important, your sleep is important.
understanding that we shouldn't be trying to get rid of the baby weight, understanding that joint pain and things like that might not just be because you slept on it wrong or this or that. It's really kind of comprehensively understanding the role of hormones overlaying on multiple systems in our body and then how to navigate forward kind of based on kind of what presentation of symptoms there are, what you're experiencing or things like that.
Kim (20:38.693)
Another thing that people think is if they stop breastfeeding their prolapse will get better or their incontinence or other pelvic symptoms will get better. Can you shed a little bit of light on how you guide people through that conversation or that belief as well?
Carrie Pagliano (20:43.958)
Yeah. Yeah.
Carrie Pagliano (20:50.924)
Yeah, the prolapse conversation has come a long ways, which I appreciate having navigated it myself. So for years and years and years, so if people aren't sure what prolapse is, basically, it can be an anatomical protrusion of an organ, whether it be, you know, urethra, your cervix, your rectum, that sort of thing, out the vaginal opening.
But you can have, it comes down also to symptoms. And the symptoms typically are pressure, heaviness, pain, feeling like a tampon's dangling, that sort of thing. You can have women with those symptoms. And if you go look at them and examine them in any particular position, you're not noticing any particular anatomical prolapse. And then you can have somebody that has a great deal of anatomical prolapse, that organ's descending outside the opening.
and they don't experience any of that at all. They just shove it back in and continue on and go to the bathroom. So that's kind of the first part to delineate. And so a lot of people, again, are like, OK, well, I'm worried that if I do one thing or the other, whether it's stop breastfeeding, start breastfeeding, stop extra. The fact of the matter is we all have our own recipe of how we got to have that in the first place. And people don't understand.
that it is normal. And there's been a couple of studies on this up to 50 % of women have a grade one or grade two prolapse, which says to me, our system of measuring prolapse is flawed. Because if you're already starting with a one or two, people think that's dysfunctional. So I tend to look at symptoms like I have some women that in subsequent pregnancies, like if they've had
prolapse with a hormone component to it. I said, when you get pregnant, because we're gonna have that big surge of estrogen, you might feel your symptoms come back. That doesn't mean anatomically things are worse or anything like that. That's just a component of why you have symptoms. And so I think understanding, one, is your prolapse just your symptoms that we're trying to navigate, or is it anatomical and anatomical changes are.
Carrie Pagliano (23:02.414)
pretty much done after that first year. is this, what are we trying to navigate? And then what's kind of like the personality of your prolapse? Like what is it dependent on? Is it dependent on activity, constipation, hormones, all those sorts of things. And so again, it comes back to, need to understand truly what it is, figure out where your fear comes from. And lots of times the women who are afraid, that heightens their kind of awareness and sensitivity to those sensations that they're feeling and can make it a little bit worse.
We kind of use some of the techniques that we have used for years, kind of understanding pelvic pain is like, let's let you understand that that knowledge is gonna help, it's gonna decrease your protective response and reduce your symptoms. that, the prolapses had quite an evolution over my career. I'm glad we're getting some more clarity on it because it was really not clear for a long time.
Kim (23:53.452)
Yeah, yeah. So how do you guide somebody who you're working with, let's say they're in their second pregnancy. Let's say this person may have some mild prolapse, they had experience incontinence that sort of is shows itself every now and then, but isn't necessarily what people consider a real problem yet. In their second pregnancy, they want to continue running. What sort of guidance do you provide to that person?
Carrie Pagliano (24:01.796)
Mm
Carrie Pagliano (24:14.125)
Yeah.
Carrie Pagliano (24:20.152)
Yeah, mean, I think the first part is what their goals are. In the DC area, have a lot of, and I've lived here long enough, I get to say it, we have a lot of type A moms that they use exercise as a method of kind of mental therapy and stress management. And if I have a mom that I know that that's the scenario, we need to have a serious conversation about, okay, where are we going to?
how far do we need to go? What do we need to need to do to keep you safe? And I think that always needs to be considered. Because to some people, it's not just exercise for exercise sake. Sometimes it's therapy and it matters for someone's safety. So that's kind of the first part. It's like, what are your expectations? What is it that you want to do? But then also, what are the logistics of our scenario? Like, do you
Do you always have to be running with a jog stroller? Are you going to be able to run by yourself? Do we have any ability to kind of navigate and modify the scenario kind of moving forward? And then also not necessarily assuming what your symptoms are going to do. Every pregnancy is different. Lots of times, especially after prolapse, have moms that are really scared to get pregnant the second time around.
And what we do know is the first time around that first delivery, especially if it's vaginal, that's where the body goes through the biggest changes. That tends to be where the biggest injuries occur as opposed to subsequent pregnancies. And so a lot of the work that they've done since then really helps them prepare and know how to kind of self -modify. so, or if they notice more symptoms, they again, they understand why it's happening. So if it's happening that first trimester, okay, that's probably.
That's probably hormones. Let's keep our activity level kind of within tolerance that we're not flaring anything or we're not, you know, making use of that. can't, you know, walk around or take care of your toddler. And then from there, it's like, if we do have to step back from running, what do we focus on? What do we do to kind of manage and make sure that the endorphin mental health thing is taken care of? But then also, how do we stay strong so that we're ready to navigate and return to everything in postpartum?
Carrie Pagliano (26:37.538)
So a lot of it's just kind of based upon what sort of symptoms come up, how well they're able to tolerate running. And again, what that desire is. And I bring that up a lot because you don't have to do anything. Some people also are blessed to be able to do it the whole time and some of us weren't. And that's totally fine too. You might have been able to run through your first pregnancy and may not want to the second and that's totally fine. So it's really about kind of establishing nice priorities.
putting those guardrails on so people know that they have help and know that we can make modifications when appropriate but we can still stay active as long as possible.
Kim (27:14.837)
And then when you shift to the postpartum conversation, as you just alluded to right now, as we're working in pregnancy, we're also looking at this through the lens of setting us up for postpartum, for that postpartum period. Now, in this case that I gave you, there would be two, a toddler and a baby, second pregnancy, second birth, what have you. But...
Carrie Pagliano (27:26.424)
Yep. Yeah.
Carrie Pagliano (27:32.462)
Yeah.
Kim (27:38.45)
And Granyadonnelly has put together postpartum return to run guidelines. Is that something that you follow? there any, what would the nuances be, I guess, that you would highlight if any for a return to run for a postpartum? Yeah, postpartum mom returning to run.
Carrie Pagliano (27:51.011)
Yeah.
So funny thing about and I've Grany as a friend and Emma as well, Emma Brockwell. And when those guidelines came out in 2019, I was super excited for a couple of reasons. And this is why, you know, as much as people complain about, you know, the the Internet and social media and that sort of thing, too, I have some very dear friends that, you know, we came to realize that we'd all been kind of thinking similar things. They went so far as to actually put it on paper, which is
is fantastic, but I had been using, and his name escapes me, it was a guy.
He had basically anything in return to run. We've had to bastardize from orthopedics and like return to sport after like Achilles injury or crazy things like that. And there was like a five item screen that I had found from like a professional conference that was like a return to run after screening for orthopedic injury. And so it was as simple as looking at something like balance and a heel raise.
you know, a single leg squat, a wall set, like parts and pieces of what eventually has been on the UK guidelines. And there was a couple other people that were kind of doing similar things. And really, all of us have been pulling and kind of bastardizing what we've found in other areas and trying to come up with some sort of framework. And so what was delightful about this is, one, that it's been disseminated so much. And I talked to both Emma and Granya, like,
Carrie Pagliano (29:24.216)
think it was the beginning of the year. I was like, hey, you guys ready to update this one? Because I feel like we can at this point. It just gave us a way to organize and give people a sense of where they were to start. That was beyond just the pelvic floor, which I think where a lot of us that have been in this space for a while kind of already were.
but it allowed us an opportunity to bring other people in to be like, postpartum is far more than your pelvic floor. We've got to look at your whole body. We've got to look at your balance and your foot and your hip and kind of all these different things. So the context in which I utilize a return to run readiness in pregnancy, I'll actually schedule first postpartum visit at about two to three weeks post delivery. So at that point, we start a very, very basic
coordination program, stuff that we weren't even doing at six weeks when I had my kids. And I know not with you. And then we say, OK, well, at least if you start to get things connected, start walking, of build all that, then when we get to six weeks, then let's see what is going on with a return to run readiness screen. And I know the guidelines talk about closer to 12 weeks for return. And that does align, I think, with more kind of soft tissue healing and that sort of thing principles. Do I have patients that go sooner? Yeah.
Kim (30:24.641)
you
Carrie Pagliano (30:48.942)
Do I have patients that go later? Yeah, absolutely. But again, it allows us a framework for conversation. I have some clients that come in and they are floored at how hard the readiness screen is, just like a simple plank or a simple wall sit. And I love it because in their heads, they're ready to be back out there again. And this is just a really nice way that if I told them don't run, they're not going to listen to me. But if I run them through this and they feel like, whoa,
That's, I'm like, if I go make you run right now, you're be like a baby deer on stilts. Like it's not gonna be good. So it's a lovely way for us to establish just a very neutral baseline. This is where we are. Now I'm gonna give you things that target where your deficits are so that when we do go back to running, we're not risking, you know, increased risk of shin splints, or you're not gonna worry about bone stress injuries, or you're not gonna feel like that baby deer the first time.
So just to have some sort of framework, it's not an algorithm, but a framework to guide and move forward. And I use this with my menopausal moms too, because again, they didn't get this. So we got to go back and fill those gaps in. But it's been really cool. And again, because we're such a global community now, it's been a really nice kind of central point for us to have a lot of discussion over as clinicians.
Kim (32:12.947)
Mm hmm. And you just near the end there, you're talking about if we do these as with a whole body approach, this is something that can potentially play a role in helping mitigate some of the other challenges, injuries. So what it's hard to. It's hard to say exactly, but do you feel if if we are if we are not going through that process of reconnecting and reestablishing
the pelvic floor and movement and the coordination, all those pieces and gradually loading as this protocol takes us through. Do you feel by not paying attention to that, that the baby deer lack of control, instability, whatever word you want to use, is that contributing to the development of other injuries in your opinion?
Carrie Pagliano (32:45.281)
Mm
Carrie Pagliano (33:03.188)
it, the thing is, like, I think it depends. Because you're going to have those moms that they're going to go out and do whatever and they're going to be just fine. And we never hear anything ever again. And maybe they're genetically blessed and who knows? That was not my experience at all.
That's also understanding my bias. am in a situation where I can screen these things out and I, you know, I'm going to keep somebody from getting in that situation. I'm in a position where I can see menopausal women that did not get this and there are deficits that they're still navigating. So in some respects, I'm a very, you know, biased person on this because of kind of who I see in my own experience. But I don't think we know. And that's I think it's tough.
where we wanna say everybody, and this is a funny thing too, there's this cheer like everybody should see a pelvic floor physical therapist postpartum. I don't know that that's necessarily the case, which is, I can say that now, now that I'm not the president of the national organization. I could say what I want. No, but like I think if you can screen things out, if you know, if you experience certain symptoms or like this is the other thing too. I don't.
clear somebody to run unless they have a exercise program that they are consistent with that includes strength, balance, and impact. And that's not what we did before either. So I think if that's something that you're already doing, you're probably going to be fine. But the short answer is we don't have enough information. don't know. I don't think it's fair to demand that somebody that goes and runs three weeks postpartum and they're not having any issues.
I don't know if they're gonna have stuff coming on down the line, but it can't hurt to check and it can't hurt to get strong and work on your balance and work on your impact. Yeah.
Kim (34:54.22)
Yeah.
Kim (35:01.739)
Mm -hmm.
Especially as we're aging, when we think of the balance and the impact, it's been so impact, a lot of people have either been told not to do anything with impact, don't lift anything heavy, don't lift anything over X pounds, or they they've self removed themselves thinking that it's going to be worse or that they have more symptoms during that time. So more symptoms must mean that it's bad for me. And then we get into the menopause and we realize, holy Hannah, I should have really been doing a lot more impact and working on my balance because now I
Carrie Pagliano (35:08.93)
Yeah.
Carrie Pagliano (35:13.592)
Yes. Yep.
Mm
Carrie Pagliano (35:31.352)
Yes. Yeah. I.
Kim (35:34.283)
Yeah, we're in that new estrogen low state.
Carrie Pagliano (35:38.132)
I have never had such a, so I started going through, let's put this very, very long story short, abruptly rammed my head into menopause last fall. And I have spent more time reconsidering postpartum in this new light because you're right, we don't teach impact and then you get.
people who fall and shouldn't be falling. And what we know about impact is certain types of impact and drills improve bone density and certain types improve tendon integrity. And why shouldn't we be targeting both in postpartum and by the way, it's also gonna get your pelvic floor and the rest of your body ready for return to run. Like all these things that like they're cramming down women's throats right now in menopause, why can't we just talk about this sooner? Like, why can't we be talking about this?
It's almost like you get the pre -training and postpartum and so by the time you get to menopause, you're like, I've read this book already, I'm good. I've already done the low estrogen thing. There's not that much different, except for I don't have to raise a baby. Yeah, yeah. Right, exactly.
Kim (36:40.054)
Mm -hmm.
Yep. Yep. Yeah, exactly. Yeah. Yeah. Yeah. Remove some of the obstacle there. Yeah. How would you you talked about the difference, the impact for bones and the impact for tendon integrity. What's the difference? Can you explain the difference there and how we would train that?
Carrie Pagliano (37:01.004)
Yeah, so bone tends to be quick, abrupt and tendon training, it's slower kind of loading. There's people who are far more far more experts than I in that. But that's that's the lovely part of having an orthopedic and a kind of public health background is I'm always looking to orthopedics have been like what they're learning and how can I bastardize it and pull it over to our stuff. But yeah, and that's the other thing, too, like
We don't need to get into those weeds if we're not doing impact period. And again, this is a lesson I'm learning from Menopause land where people are like, zone two training, it's bad. You should just be lifting. I'm like, OK, why don't we just start with exercising? At least here in the States, we're not exercising enough. So let's start with that before we guilting people about what they're doing. So let's do impact first, and then let's look at what your needs are and where you are in life.
Kim (37:44.533)
Moving, yep.
Carrie Pagliano (37:55.584)
And yeah, if you have the privilege and the time to be able to incorporate a couple different types of impact because you're actually doing it, great, build consistency first and then we'll target whatever it is you need. But understanding kind of the physiology and the physiological demands of different exercises and understanding what you're trying to target can be incredibly helpful.
to kind of meet what that person's needs are. And again, we have bone needs, we have tendon needs, we have pelvic floor needs, impact good. Let's just leave that one. Yeah.
Kim (38:24.651)
Yep, yep, yep. I love it, I love it. And I think that I talk a lot about constipation and gut health being that that's such a, it's so closely tied to pelvic floor. I want to highlight and bring lots of people in and Dr. Will Bulsiewicz, his episode will be launching shortly, but from a gut health, he's a gastroenterologist. He's always talking about the need for diversity in our diet to feed this microbiome that we have.
Carrie Pagliano (38:34.905)
Yeah.
Carrie Pagliano (38:47.62)
Mm
Kim (38:52.181)
that movement has always been something that I, well not that movement, that word has always been something that I strive to with movement as well, the diversity of movement. And kind of to your points, like so many people are looking for what exact exercise should I do and how many exact reps and how many of this. And sometimes we just say, just do what you love, Anthony Lo, do things differently, know, explore different things and enjoy different things and just be moving.
Carrie Pagliano (39:00.665)
Yeah.
Carrie Pagliano (39:14.425)
Yeah.
Carrie Pagliano (39:19.182)
Yeah.
Yeah, but also I think it's a different mindset than when we were in our 20s in our younger years. Like I'm a runner, I run. Okay, well, I'm a runner now too, but I also run smarter. I take at least two of the workouts that I would have done as a run younger and those are my strength workouts now. So by me being diverse, I am actually faster.
Kim (39:22.497)
globally more often.
Carrie Pagliano (39:47.628)
and I'm improving my longevity, so I'm running smarter. I don't wanna run like I ran in my 20s, I really don't. I was kind of an idiot back then. So I think the more you can kind of wrap your head around, when you're like, I used to do it when I was younger, I'm like, this is a different body now, but it's stronger and it's more resilient. yeah, mean, and one of my favorite Anthony stings is, know, variability builds resilience and resilience makes you harder to kill. Like that's the plan right now is to be harder to kill. So.
Kim (40:13.557)
Yeah, yeah, yeah, yeah, yeah, I love that. was the classic, all I did was run, just run, just run, run, didn't do anything else and no diversity at all. And I know that the knee challenge that we were talking about that is I'm sure a big contributor, but okay. Quick question about, do you have any thoughts on how somebody has birthed their baby, cesarean or vaginal? Does that change the...
Carrie Pagliano (40:17.976)
Yeah.
yeah! Mm -hmm. Mm -hmm.
Carrie Pagliano (40:30.882)
Yeah.
Kim (40:42.665)
return to run guidelines, kind of the timeline, does it change anything about the exercises that you would begin with or not, what changes.
Carrie Pagliano (40:52.388)
Short answer is no. And I think what's important is to understand you could have had a vaginal delivery, but how long did it take you to get there? Shorter sometimes isn't better. And then also that mom with a C -section that like myself, you know, labored for a couple of days and, you know, got to push for a couple hours. And so basically you had two deliveries, you know, that kind of situation. So I think those
pieces can set up expectations. like a quick short delivery might be more traumatic. Something that was longer might be just as traumatic as well. But tissue healing is tissue healing. You cannot speed up physiology. You can't speed up healing for the most part. It's going to be what it's going to be. I think, you know, when I'm talking to somebody about, you know, returning to movement after
delivery that trauma aspect of is incredibly important. Understanding their history with exercise incredibly important. But at the same time too, it's about complications and other things that are going on. But also are you getting sleep? A lot of the stuff that we discussed before. If you're not getting any sleep and you don't have help, I need you to sleep before I need you to run. Because if not, we're going to be in trouble.
Where are you nutritionally? Where are you with the stressors of breastfeeding? Does your kid have colic? Like, you those sorts of things. That's the big picture I'm looking at. And so really it's not much different between one and the other. I've had clients that were three, four weeks post C -section that I have cleared because strength wise, they look great. was second kid, second C -section.
It was also a mental health, like if I don't get out there, I'm gonna go anyway whether you tell me or not. And so I was like, all right, well, if that's gonna be the case, then this is what I need you to do. I need you to go back this way. So we're not bull in a china shop that we're going back very intentionally. So I think there's a lot of unique variables that can kind of create whatever that program is moving forward, but vaginal versus C -section, one is not better than the other.
Kim (42:43.916)
Mm
Kim (43:05.589)
Yep. Yep.
Carrie Pagliano (43:07.266)
When it when I know, you know, people have one they think the other is easier if they had a rough time like it doesn't really work that way.
Kim (43:11.797)
Yep. Yep.
What about the people who, just as we're wrapping up, I'm thinking about the people who have done all the right things. So they've seen the pelvic PT, they're using vaginal estrogen, they've done all the exercise, they've been consistent, all the things, and they're still leaking only when they run. What are some of the other avenues to explore in the people who, even though they've done everything, they still leak?
Carrie Pagliano (43:22.36)
Yeah.
Carrie Pagliano (43:38.254)
Yeah.
Carrie Pagliano (43:41.764)
Yeah, so I get that question a lot. I get a lot of second opinions where people have gone to see pelvic floor PT. The good news is in the 25 years that I've been in practice, we have gone from just, you know, at least in the DC area, and I'm sure it's elsewhere, about five to seven of us to now, I couldn't tell you who's around in the area. There's so many of us. There's been such a growth in helping the postpartum mom. That being said,
The first part I always say is let's just make sure that you're seeing a running informed PT. What that means is somebody who is used to working with runners, they have a background, they know more than just the return to run screen and there is a difference. And so sometimes if that pelvic floor PT doesn't have that background, maybe they pair up with an orthopedic PT that may be able to kind of help with different parts and pieces of it.
or to collaborate with a pelvic floor PT that is running informed. Let's make the assumption that you are working with somebody that is running informed, you've done all the things, then it's a matter of what other things are we considering? If it's leakage, if it's prolapse, is it worth having a consult for a pessary support? In the United States now, PT's are fitting pessaries. I started doing it a couple years ago.
Is it worth having a conversation with a urogynecologist about surgical interventions? I have some great urogines that I have worked with for years here that if I send somebody to them, that means we've done all the stuff. And that person, that urogyne is going to give them a really nice straightforward, hey, here's your options. If you're done having kids, we can kind of have further discussions. If you're not, let's talk about this.
and not force people into making decisions. again, it's, and that's the best way, honestly, if you have, if you're looking for a year, guy and talk to those of us who are in the space, we'll send you the ones we like. And I'm sure you understand that as well. But it's, there's some situations that we can't solve everything. But I think also too, I think it's important.
Kim (45:38.837)
Yes.
Carrie Pagliano (45:51.05)
Again, if you're that person going through that, you understand the steps that you took. You understand why you're having those symptoms. You understand why those symptoms aren't improving. Maybe there's levator avulsion or that muscle's torn away from the bone and there's nothing that we can do as far as that goes. I think it's so important to understand what's going on in our own bodies so we can make choices about it.
because I think for so long it was like, it's just childbirth, this is what it is. And we have so much more information now. We deserve to have ownership over kind of understanding what happened to us, the steps that we can take to move forward, and then kind of the people we choose to bring into our teams.
Kim (46:32.663)
Just one quick question because you said levator avulsion. This is something that we know it's actually pretty common. It happens more than we think, but historically, and I want to know if you feel like this is changing a little, but historically this was not something that was screened for by pelvic PTs. it took, I mean, I had been seeing a pelvic PT for over 10 plus years and then
Carrie Pagliano (46:35.107)
Yeah.
Carrie Pagliano (46:40.492)
Mm -hmm. Yeah.
Carrie Pagliano (46:49.358)
Right, right.
Kim (46:59.477)
went to a different one prior to my surgery and she was the one that used the term like saying, I think you have an emulsion. so do you feel that that is missing from or is it being added into PT training? Do you think it's something that we should be screening for more often? Or I guess, what are your thoughts on that?
Carrie Pagliano (47:05.422)
Mm
Carrie Pagliano (47:18.168)
Yeah. I mean, again, just looking back at my basic training, that wasn't anything that we were ever taught, you know, to even consider. And I think
Again, it goes back to our understanding of the pelvic floor. We were taught the same 2D that so many people get in middle school where it's like, is a hammock between your pubic bone and your tailbone. It is not that at all. I actually have a researcher coming on my podcast in a couple of weeks where she is a engineer that does 3D models of the pelvic floor and all the fascia and all the ligaments. I think this conversation about avulsion
is coming about because we're considering it in such, and we have the ability to image it in a way that helps us understand what the heck is going on. The pelvic floor is far more than just a Kegel, a contraction, a relaxation. It's far more than just the muscle. It's the tendon attachments, the fascial attachments, like the pole, the scar tissue, all that kind of stuff. And I think all of us have a lot more to learn.
And so, and I think also to newer therapists, I'll never forget the first time I went to a class and we did our first internal exam and the instructor Holly Herman, she's like, okay, what you're gonna notice, it's just a warm place. And like, that's all you're gonna notice, because you're just trying to get over what you're doing. And so I think the more, you know, experience you have under your belt, the more you understand that there's a lot of variability and anatomy. And then,
Within that variability anatomy, how do you pull that together with the symptoms that you're hearing from the patient, what your exam findings are, and then do we even consider that idea? And again, that wasn't even anything that was taught for so, very long. So we have far more to learn and understand than just how we perceive the area. And then how do we...
Carrie Pagliano (49:14.946)
take that and move forward. Because here's the other thing too. I have a client right now that she saw your gynecologist and this person's a CrossFit athlete. And he's like, yeah, I think you have an evulsion. And she saw another PT that's like, maybe it is, maybe it isn't. And basically, your gynecologist is like, all right, when you're done having kids come find me, but until then, stop lifting. You just need to sit. And I was like, no. Because the other thing too is we
don't know how far she can go. But if you don't try, we're not going to know. So I think there's a, again, like this isn't written in stone. How far can we get with what we have? And does that set us up to be better if she were to have some sort of surgical intervention or something along those lines? So short answer is a lot to know. Yeah, no, I was the same way. was like, come on, let's get started. Let's see how far we get. Yeah.
Kim (49:57.599)
My bias is absolutely yes. Yeah. Yeah.
Yes, yes, yes, yes. Yeah. Amazing. Thank you very much for your time. Where can people learn more about you? And you've mentioned your own podcast. Where can we, what's the name of it and where can we listen?
Carrie Pagliano (50:13.976)
Yeah, yeah, so my podcast is Active Mom Postpartum Podcast. We might be switching it to Active Mom since we're kind of diving into menopause now these days. You can thank me for that. But yeah, you can find that on any of your podcast platform that you listen to. And then on Instagram, I tend to hang out there at Keri Pagliano. And then website is KeriPagliano .com.
Kim (50:22.529)
Yeah.
Kim (50:37.943)
We'll have all the links in the show notes so people can come and find you easily and follow along. Thank you so much for sharing your wisdom and your time with us today and I'll see you online.
Carrie Pagliano (50:47.416)
Thanks for having me.
