Kim Vopni (00:01.214)
Welcome, Dr. Garner. I've wanted to have you on the podcast for a really long time and it's finally happening. So I'm excited, really excited to have you here. I've followed you for many, many years. was just, we were talking offline. I didn't follow you closely enough because I didn't quite know all the things that have been happening for your life in the last four years. But thank you for taking the time. And I've got a lot of things that I wanna pick your brain about and share with the audience. Before we go there though, can you...
Let the listeners know who you are, what brought you to the world of pelvic health, and then even kind of more nuanced, we're gonna talk a little bit about the voice and pelvic floor, what brought you down that path as well.
Ginger Garner PT, DPT (00:41.7)
my gosh, well first thank you, Kim, for having me on. I have followed you like forever and ever and you do so many fantastic things. I can't even begin to keep up with it all. So it's just, it's incredible your advocacy and what you do. So first, thank you. And I'm like, if you're watching this, I'm like, thank you. Best in the air. Yeah, absolutely. Second, I was...
Kim Vopni (01:01.312)
Thank you.
Ginger Garner PT, DPT (01:10.222)
in terms of how I got to where I am, I was born into, as a baby PT, really into sports medicine first. I was actually an athletic trainer first. I don't know how I ended up there, but I did play sports and things like that, but I think it was just I knew I wanted to go into medicine, into healthcare, into something in that aspect, and I wanted to be active.
That just made sense because it seemed to be such an empowering thing that puts you in charge of your health and your trajectory and your longevity. And it didn't take too long once I got into all pre-med, pre-reqs that I realized this was gonna be stressful. And then I picked up yoga. I picked up integrative medicine.
Kim Vopni (01:57.301)
Mm-hmm.
Ginger Garner PT, DPT (02:02.141)
know, unbeknownst to me, was going to have lifelong struggles here and there, as everyone does. We're all human beings and all of us are gonna have health struggles. And so that probably helped me pick up the integrative medicine side of things a lot faster for stress management and all the cool things we know about the vagus nerve now. Well, you know, back then we didn't have as much evidence base, but it really...
it kind of integrated itself so well into what I was doing with SportsMed and then yoga and seeing athletes come in, Division I athletes, super stressed, eating disorders and female athletes like cross-country runners and things like that, that you just, your heart went out to them. And you also realized what a genuine disadvantage that generally females were under, whether it was in Division I sports or trying to...
Excel, know, whether it's getting into school or getting a business loan or whatever it is, it's just, it seemed like a constant uphill battle. Whereas men were just naturally thought to be better at pretty much everything, you know, 30, 40 years ago when I was doing my training. And so that was pretty frustrating for me. So it was kind of natural for me, I think, to fall into what then we were calling women's health. Now we're calling pelvic health, because everybody's got a pelvis and
And really, pelvic health is underserved for everyone on the planet, all the people. So, you know, women don't corner that market, that's for sure. And that's kind of how I fell into going from sports medicine, you know, which can be very macho and, you know, and even toxically masculine, but also very fun and cool too. But I realized there was a gap.
there for me in just struggling through what I was doing, just working out, know, just being a female and existing on the planet and then becoming a mom one time, two times, three times. I was like, what the hell? You know, I was like, this is hard. This is not every, with every kid, was like a little bit longer. And then I was like, okay, that was 20 years ago. I was like, I'm gonna have to dive a little deeper. Sports medicine is not enough.
Kim Vopni (04:13.854)
Hahaha
Ginger Garner PT, DPT (04:28.406)
Integrative medicine, great, fantastic. I was doing Ayurvedic medicine and all this, it's not quite enough. And so then I just dove off into the public health realm and now it's been almost 30 years. And I don't know where the time goes, but that's kind of the brief intro of how I got to where I did. And along the way, the voice got folded into that because there's such a unique.
connection between the voice and pelvic floor, which we'll probably get into a little bit later. But for me, was a, I'm going to laugh. I can't say this without laughing. I was kind of a moonlighting jazz singer. And I did that for nearly 20 years. And sometimes I'd have one gig a week, but sometimes I'd have four gigs a week. And that's a lot, you know, because every gig is going to be about three hours from start to finish. Usually play three sets.
Kim Vopni (05:05.619)
Mm-hmm.
Kim Vopni (05:15.092)
Wow.
Ginger Garner PT, DPT (05:22.472)
And by the time you get done, you can imagine that if you don't really have it down, you're gonna lose your voice, you know? And then you're gonna show up to the clinic next day. I was directing an outpatient orthopedic clinic, talking 40 hours a week. I was teaching yoga at night and then doing these gigs. My voice sucked. It was terrible. I thought I had vocal nodules. I started to struggle from vocal fatigue, laryngitis. I was like whispering through patient appointments.
Kim Vopni (05:38.654)
Wow.
Ginger Garner PT, DPT (05:51.444)
And it hurt, it physically hurt. And I knew there must be something else to that. wasn't doing something, I was missing something. Because other people do it, other people are doing multiple gigs a week. They're out there doing Broadway shows, they're doing all their amazing stuff. And so that's what made me kind of dive in and that's the short story.
Kim Vopni (06:13.567)
Cool. I didn't know half that story. So let's start there. There's an image. I don't even know who to credit for it. Maybe somebody just had a designer create it, but it is an image of a side by side between the vocal cords and the vulva, the anatomy. And yeah, it is fascinating when you look at the similarities there. maybe start, I don't know where to start in terms of voice and pelvic floor. I'll just kind of let you run with it. What is the...
Ginger Garner PT, DPT (06:15.275)
Yeah.
Ginger Garner PT, DPT (06:29.368)
Yeah, isn't that awesome?
Kim Vopni (06:43.197)
connection between the voice and our pelvic floor.
Ginger Garner PT, DPT (06:43.383)
Yeah.
It starts at a cellular level, actually. It starts in the endoderm and the mesoderm from like a little, like a nerdy perspective of embryology. So for those of you who love embryology, it starts there in the endo and mesoderm and having things migrate out so that the voice and the parts of the pelvic floor are gonna migrate from the same folds and become different structures, which then ultimately means that at a biochemical level, they're going to respond similarly.
In fact, when biopsies are taken of those tissues, sometimes they are from a cellular level indistinguishable in the mucous membranes of each. That was a little, my hair back, you know, when I was reading the research on that. So that's where it begins, you know, it begins, you know, with embryology. And then it branches out from there because...
Everybody knows, like I have three teenagers and they're all boys and what's happening to their voice right now with testosterone. It's cracking and popping and it's getting deeper and I'm losing their little baby voices and that makes me sad. But at the same time, know, girls, young girls are going through the changes with estrogen and it's posited that and it's more than a theory, it's fact that, you know, estrogen is going to change vocal quality.
and tone. Your vocal folds are going to change shapes based on hormones. And so with puberty, with estrogen, you are going to get a wider range, a higher range. You're going to get a more developed and mature range. You're also going to have a more sustainable voice. And then you think about the other end of the spectrum. go, yeah, yeah, postpartum, perimenopause.
Kim Vopni (08:34.035)
Hmm, that's I was going.
Ginger Garner PT, DPT (08:39.854)
They can feel the same. Postpartum can feel the same as perimenopause. I have a lot of patients coming in. They're like, what is going on with the vagina? But they're also saying, and I always screen for it, hey, how's your voice doing at the same time? Well, I'm tired. I'm yelling at the kids all the time. then we kind of dive deeper from there. But by the time you hit menopause, if you've done nothing for your voice,
Singing is a sport and so is speaking. In fact, speaking is harder than singing. It's why I would prefer to sing all my messages.
That's saying maybe I should start doing it on Instagram or something. The vocal physio or something, I don't know. But it's easier to sing than it is to speak. And that is an aerodynamic principle. So when you hit menopause, if you've not done anything in terms of changing estrogen levels, maintenance, anything like that, you're gonna see a sharp decline. You're gonna see those mucous membranes suffer. Like everything that you know goes wrong with the pelvic floor.
with continents, with the integrity of the vaginal walls, same thing's gonna happen to the voice.
Kim Vopni (09:52.416)
Yeah, I was writing down all most of what you've just shared there, the the changes to the voice when you think of the you know, the aging population. So I'm looking at my parents now in their 80s. And people in sort of that 8090 there, many of them, their voices are changing. And that was, you know, if I think back to even 10 years ago, it never even didn't even cross my mind. And now learning more about menopause being there myself and the education that I've taken.
It's such a huge it affects everything estrogen is so essential for so many things. What the voice not being and then i'm actually. I'm shocked to hear you say that singing is easier than speaking if i sing and maybe this is kind of to your point. With with what you're doing it wasn't something that you're necessarily doing something you're missing if i sing even just singing along to a song i feel fatigued from that.
Ginger Garner PT, DPT (10:27.256)
Yeah.
Ginger Garner PT, DPT (10:35.619)
Mm-hmm.
Ginger Garner PT, DPT (10:47.448)
wow, yeah, yeah, that's part of that process and investigating it. And that's kind of what I look at it as when people come into the office, I will always screen head to toe or a facial all the way down to their feet, but voice to pelvic floor particularly. And if they have those signs of vocal fatigue, then some of the things that I will look at really start with imaging to determine if there's any structural issues going on.
because a lot of times it does start in the respiratory diaphragm because of either the support or lack of support or something has changed. But I'll also look at labs as well. What do levels look like? How is the body actually handling the estrogen that it has or does it not have enough to begin with and they're having those symptoms? But yeah, vocal fatigue is pretty common. It's what I was experiencing too when I was telling you about my...
Kim Vopni (11:33.555)
Mm-hmm.
Ginger Garner PT, DPT (11:43.534)
earlier story, it turns out it was crappy technique. You know, that was what I was doing. I was just taking the vocal folds that I had been given and using them to sing jazz, which was lots of fun soul and you know, like Americana type music, all the things that we think that America gave to the world. Sometimes I think all we can really say that we gave that's good is probably jazz and maybe baseball. Definitely not hot dogs.
But it was crappy technique. And so a lot of times with vocal fatigue it is, even though there can be some systemic drivers too.
Kim Vopni (12:13.257)
Yeah.
Kim Vopni (12:21.513)
So what is fatiguing? Is it literally the vocal cords? it the breath that's, is that, like you mentioned the diaphragm, is that what's fatiguing? Or again, what would you need to do to fix that?
Ginger Garner PT, DPT (12:34.062)
Yeah, that's a really good question. It is, I've been practicing this way for at least half my career now. And in the 15 years or so that I've really, really focused on this, I keep uncovering more things like every just little pieces, even just going into cadaver lab to do dissection, which I've had the good fortune of doing several times just for the voice piece, I learned something new. So you could...
All that to say, boy, there's about, there's dozens of variables that can contribute to it. But the very first one that I would look at would be something like apposition of the diaphragm. So for everyone listening, that's just the shape. Apposition is nothing more than the shape of the diaphragm. Just a fancy word. And I can measure that with ultrasound imaging. So if I look at it and they've lost the shape, that's one thing. For example, I had someone...
come in, she was from out of state and a professional vocalist and she was very attuned to her body and to her voice, which I think you have to be to be able to sing with such nuance. And she said, I can't sustain my voice, my note anymore. I can't sustain the phrase is what I'll often say, sustaining the phrase, whether you're playing an instrument or you're speaking or you're a therapist or you're a trainer, whatever.
Kim Vopni (13:53.087)
Mm-hmm.
Ginger Garner PT, DPT (13:58.766)
You know, it's all the same. She said, I can't sustain it and I don't know why. So came down, did an abdominal wall assessment. That's where we started right in the middle. Yes, the apposition was off, but she also had some very interesting situation going on that for some people, it can be a hernia. For some people, it can be a diastasis. For her, it was something even more different than that. Like we uncovered something new.
that's still in the surgical realm that they're looking into right now, that was causing her to basically lose pressure on the left side of her abdominal wall where she couldn't sustain it with her abdominal muscles, nor the diaphragm on that side. And her breath was just giving out, which means the effort comes out of the vocal folds alone. And if you're just depending on the vocal folds for modulation and not the abdominal wall,
or to push air rather, when I say modulation, I just mean kind of pushing air through to get the sound out. If you're just using the vocal folds, which you can totally do, and you're not using the diaphragm and the abdominal wall and the pelvic floor, it's gonna wear out and you're gonna get fatigued and you could get nodules from that. Yeah.
Kim Vopni (15:11.113)
Huh, interesting. So with the diaphragm then, obviously anybody who's followed me or any other pelvic PTs, there's a lot of conversation around the relationship between the diaphragm and the pelvic floor. And so if there was a change to the shape of the diaphragm, like away from even just voice stuff, that I'm assuming could also influence pelvic floor function as well. Would that be a true statement?
Ginger Garner PT, DPT (15:33.856)
Yeah, absolutely. Yeah, definitely. And I'm sure you've seen tons and tons of variations of that as well. But yeah, for sure. And so oftentimes, if someone's coming in, I could start with imaging of the abdominal wall first, but then we'll actually start to quickly look down and look up and look at all three diaphragms.
Kim Vopni (15:54.388)
Yep, yep, yep. And so what are those three diaphragms?
Ginger Garner PT, DPT (16:00.694)
The three diaphragms, I often just say kind of voice to pelvic floor approach or voice to pelvic floor connection, but it really is the three diaphragms. And so thanks for asking that question. The bottom of the barrel is going to be the pelvic floor and the pelvic girdle, because I also see a lot of problems with pelvic girdle issues like hip pain, SI joint pain, where they think it's unrelated, but it actually is.
And then we move up to the respiratory diaphragm next. And then at the top is the laryngeal diaphragm. It's called a bunch of things though. Some people say cervical thoracic, some people say thoracic, some people say vocal diaphragm, some people say laryngeal, tomato, tomato, like whatever you want to call it.
Kim Vopni (16:43.933)
Yeah, yeah. So if somebody did have a change in the shape of their diaphragm, what would be a treatment path for that person? How would we optimize the shape of the diaphragm?
Ginger Garner PT, DPT (16:57.102)
Yeah, think the first thing would be measuring. So I'll look at their costal angle, you know, and make sure that it's a somewhere around 90 degrees. And then I'll look at lateral costal expansion and make sure that it can go to 110, know, 120 degrees, something like that. I find really interesting kind of hemidifragmatic shapes where one side might be okay, the other side is not okay. So then we have to really do...
kind of just single side manual therapy diaphragm work, which could be anything from myofascial release to just getting in there to do soft tissue work on the respiratory diaphragm, which a lot of people find pretty vulnerable, not to mention uncomfortable in that area. That's not the only thing though, there are other things. I always look at the T-spine, the thoracic spine.
Kim Vopni (17:39.391)
Mm-hmm. Yeah, it could be tender. Yep. Yep.
Ginger Garner PT, DPT (17:50.336)
I'll look at rib cage mobility and separate from thoracic mobility or, you know, Dian Lee's concepts of, you know, looking at the thoracic rings, that kind of stuff. And then there's also all of the soft tissue related to that. And that's where a lot of the yoga that I use kind of gets just organically folded into it because just say we can put them into child's pose or what I like to call a side or lateral child's pose, you know, where they're just
bringing it over to the side, but from the floor in more of a restorative yoga pattern where they can then open up that one side posterior in the back. I call that kind of fish gill breathing, you know, where they can open up one side to kind of fish gill breathe. And then I will layer on, there are so many different breathing techniques that can be used. And then that is where imaging of the pelvic floor comes in because I don't want to just give,
Kim Vopni (18:32.062)
Mm-hmm.
Ginger Garner PT, DPT (18:48.374)
respiratory techniques or breathing patterns out without seeing how it impacts the pelvic floor. And then seeing how when they voice on top of it, how the voicing impacts the pelvic floor. And I would say pretty much 100 % of my patients, even the professional vocalists, are negatively impacting the pelvic floor in order to use their voice. So.
Kim Vopni (19:10.227)
Interesting. And what is, what's the mechanism of action that is, when you say negatively impacting the pelvic floor, in what way and why?
Ginger Garner PT, DPT (19:20.934)
yeah, that's a great question because there's so there's again so many different variables that could be driving that. But I'll just pick one. I'll cherry pick one from a case where we were pretty far along in our therapy. It'd been about a year. And when she first came in, she couldn't even go to the grocery store and like, you know, push a buggy or anything. It wasn't happening. It was too much pain.
So we had moved past that through motor patterning and lots of things. And we were moving into the pelvic floor realm because she did sing casually. She loved singing in a local choir, but could not do it. She had tried to go back and it immediately caused the same pain again. So she was ready to kind of take it to the next level because she was past that first phase of hip pain. So.
I was imaging pelvic floor and she was talking about a stressful event. So that's one of the variables I think that drives it a lot. In fact, if you look in the literature around muscle tension dysphonia and vocal issues, one of the primary like number one reasons is stress. And so she was on the table talking about a stressful event. Her pelvic floor was looking good. She was not adversely
pressurizing the pelvic floor, which means for some people, like if you're not watching, I'll try my best to describe it, but here's the base of the pelvic floor on imaging. And for some people, every sound they make pushes the pelvic floor down. And that is not bad by itself, but do that for a lifetime or even a few years without any other management of the system. It will be like walking around, it's still slouching like,
all the time and never choosing another posture. If you do it once or twice, fine, whatever, it doesn't matter. If you do it as a primary strategy, not great. And so she was not even doing that. She was past that. We could talk and no problem with, you know, the pressure management was excellent. But she started to talk about one thing that was super stressful and immediately the bladder base, which is our surrogate for pelvic floor monitoring, it jumped up.
Ginger Garner PT, DPT (21:43.854)
about 14 millimeters, which is as much as you can expect the public floor to basically lift, you know, on excursion. And I just stopped for a second and I said, did you feel that? And she said, yep, the pain, it's back. And it was almost for her like a pudendal neuralgia type pain. It was a nervy pain. It was a deep.
Kim Vopni (21:47.336)
Wow.
Yeah.
Kim Vopni (22:02.451)
Hmm.
Ginger Garner PT, DPT (22:10.126)
tension as well in the pelvic floor on top of kind of the neurologist symptoms and I said, okay, well, let's talk it down. So we worked on that and then went back revisited the same stressful topic to see if it was a fluke or if she had worked through it and the exact same pattern happened again. So that's just one example of just stress because I think we always say, yeah, yeah stress, but then how does it manifest itself? And I think that's one of the concrete ways in which I see that.
where they really struggle with it. And for her, it was a massive turning point because she didn't know where that pain would come from. It was like a, it was out of nowhere. You know how you'll hear people describe pelvic pain as like sharp and stabbing and immediate and it comes out of nowhere and they're not, you know, they're not sure where it came from. And then they become afraid to move, you know, with what we call kinesiophobia. They're afraid to move. They don't know what to do. They don't know how to exercise. But for her, it was a turning point because she said, now I know.
Kim Vopni (23:00.617)
Mm-hmm. Yep.
Kim Vopni (23:09.235)
Mm-hmm. Mm-hmm.
Ginger Garner PT, DPT (23:09.864)
Now I know what the trigger is and now I know what it is. I can see it. It's right there on the screen.
Kim Vopni (23:14.815)
Yeah, yeah. When somebody is like, if I think about, know, if I'm it's a great song, I'm in the car, I've got the radio up really loud. And there's a there's a certain point where you're you're belting it out loud and long. That is, is that I don't know, but I believe that is increasing intra abdominal pressure, the longer you hold it is would that be a true statement?
Ginger Garner PT, DPT (23:40.78)
I think so, I think in the average person who's belting it out in the car, the longer they hold it, the more you're gonna get that increase in inter-abdominal pressure. It's what happens to the pressure then, where does it go? Yeah, yeah, how do they manage it at that point? I mean, I've had other professional singers, semi-professional singers come in and when I measure exactly how long they're able to properly manage pressure, sometimes it's three seconds.
Kim Vopni (23:45.331)
Yep. Yep.
Kim Vopni (23:53.875)
Right, how we manage it. Yeah, yeah.
Ginger Garner PT, DPT (24:10.348)
And you know, if you're singing, okay, you can't sing. If you only have a three second sustaining phrase. Yeah.
Kim Vopni (24:13.673)
Yeah, yeah.
Kim Vopni (24:18.493)
Yeah, yeah, yeah, for sure. You mentioned vagal tone or the vagus nerve. And I have not, I've not really delved into that a whole heck of a lot. I know it on a surface level. And I know one of the ways that can help improve vagal tone is with humming. And, and that then I'm thinking of vocal cord, and I'm thinking of pelvic floor. So what is the connection there? What's the role of the vagus nerve in this whole story?
Ginger Garner PT, DPT (24:22.926)
Mm-hmm.
Ginger Garner PT, DPT (24:43.682)
Yeah, there are so many different ways that are positive to change tone. And I think that, as a clinician from the researcher side, I always wanna lead with saying, we need more research. Yeah, so that we don't, that I don't sound like arrogant about it, like this is what it is and this is how it's connected. I'm like, we need more research. But I see the profound impacts of actually working on it.
Kim Vopni (24:58.271)
That's a given.
Kim Vopni (25:07.155)
Yes.
Ginger Garner PT, DPT (25:13.27)
day by day, like with the case study that I just mentioned of her being able to then properly and positively manage the pressure and the stress and feeling good about it and no longer having kinesiophobia, that kind of thing. So when I talk about the vagus nerve, you could manually supposedly stimulate that. you
Kim Vopni (25:26.057)
Mm-hmm.
Ginger Garner PT, DPT (25:37.262)
Vegas massage, you know, in the sternocleidomastoid area as it is passing through that area. can, for people who actually have tachycardia, they can actually put ice here. They can do a vagal maneuver. They can change their heart rate. Particularly important in women's health for people with like, POTS and other issues that are like, you know, confounding pelvic pain that often kind of go together.
Kim Vopni (25:43.743)
Mm-hmm.
Ginger Garner PT, DPT (26:04.064)
because of the proximity of the hypoglossal nerve to the vagus nerve, sometimes you can actually change vagal tone through sternocleidomastoid and upper trapezius work. So you could work on the SCM. You could do neck stretches, like quite simply, stretch the upper trap. You can do neck isometrics and press the hands into the head. You can also use sound. And I just, I'm eternally grateful to
Kim Vopni (26:22.399)
Mm-hmm.
Ginger Garner PT, DPT (26:33.24)
Steve Porges and all of his work and his graciousness when I wrote my first book on yoga of contributing to the textbook of helping me edit those chapters and getting everything physiologically correct from that foundation of polyvagal theory and the vagus nerve. And his safe and sound protocol is one that's super cool because that's based on using certain Hertz frequencies to change psycho-biological
and neuropsychological stress perception, or what he calls neuroception, the ability to detect risk. So when I use sound, I try to be really careful. For example, certain vocal tones in certain populations might elicit a stress response for say like a military service member.
you're not gonna, I'm not gonna do Sanskrit chanting, you if they had served in the Middle East and had trauma related to that or CPTSD or PTSD. So it gets real trauma informed, you know, really quick is basically what I'm trying to say. And so that's where the integrative piece gets folded in carefully so that I could use sound. You could use different vocal tones in, I have a diagram that's floating around the internet somewhere on the three diaphragm.
Kim Vopni (27:29.567)
Mm-hmm.
Kim Vopni (27:36.574)
Mm-hmm.
Ginger Garner PT, DPT (27:53.592)
concept that overlaps it with vocal tones and chakras. Because now there's less science on chakras, so if you're a chakra person, great, run with it, you know? But if you're sticking to the science about it, then you would go with the vocal tones resonating in certain cavities of the body, because that's where we get our vocal projection in order to sing well, sing far, and sing for a long time.
Kim Vopni (27:59.636)
Mm, cool.
Kim Vopni (28:05.929)
Yep.
Ginger Garner PT, DPT (28:22.828)
you wanna be able to resonate in the right cavity, in the right area. And those vocal tones will resonate in different areas. So we could get super nerdy and ask new research questions like which vocal tones would actually improve vagal tone the most and give us a better stress response. That's kind of a light answer. Did I answer the question?
Kim Vopni (28:38.814)
Mm-hmm.
Kim Vopni (28:43.699)
Yeah, what? Yeah, what what I guess, can you describe what the vagal what the Vegas nerve is? And what is the polyvagal theory?
Ginger Garner PT, DPT (28:50.816)
Yeah. Vagus nerve is cranial nerve 10. It is the wandering nerve. And that's what vagus means, is wandering. It's the longest nerve in the body. It's super cool for that reason alone. It impacts nearly everything from mood to digestion, from sexual health and sexual medicine. There are articles on women with spinal cord injuries still being able to achieve orgasm.
because of the spine, because of the vagus nerve and its connection that they really didn't perceive to be possible before that. But the only explanation is that the vagus is providing that super cool stuff on sexual medicine and sexual health. And then it also controls the obvious things like the vocal cords and the sinoatrial node and cardiac regulation. So our vital signs, our heart rate.
Kim Vopni (29:32.051)
Yeah.
Ginger Garner PT, DPT (29:50.446)
for one. So if you can, I think the most practical example of the vagus nerve and its anatomy is to look at the research on music and music rehab, music therapy, and to look at people who participate in choirs, have better longevity and lower stress. It's really cool how we can use music.
And you've probably seen some of the research too. I know there was a really popular movie with Robin Williams in it a long time ago called Awakenings where using music brought those people out of their neurodegenerative shell, so to speak. And that is true to a certain extent. You see that. There are case studies of that everywhere. I used to use that with my World War II veterans when they were still World War II veterans around 25 years ago, is I would play music and they would go from being kind of shut down to like,
Kim Vopni (30:24.787)
Mm-hmm.
Kim Vopni (30:36.211)
Mm-hmm.
Ginger Garner PT, DPT (30:42.552)
talking and chatting. It might be something from 20 years ago, but they were engaging, you know. So that's the power of the vagus nerve is to be able to open people up. It's where Mendelssohn said, music speaks where words end. That's the power of music. People always say music is medicine and totally that's true. From a polyvagal perspective, the polyvagal theory created by Stephen Porges posits three things.
Kim Vopni (30:56.905)
Hmm, I love that.
Yep.
Ginger Garner PT, DPT (31:11.934)
Most everyone on the planet knows about two of them already, two out of three. So you have parasympathetic function, which is gonna bring everything down to rest and digest. You have sympathetic function. So think fight, fight, freeze or fawn. So four stress responses. Most people have heard of fight, flight. Most people have heard of freeze, which is relatively new. Fawn is a newer one. And then you've got the dorsal vagus circuit. So you've got on the one side,
good stress response, which can also include freeze, kind of like if you see a lizard in the woods and it sees you, it freezes because it should, it's preserving itself. Or on the happy side of things, if you're a dog person and you have a Labrador and you show that Labrador a ball or a toy, what do they do? They go from being all crazy to like frozen. Yeah, and they're frozen. They're not scared like the lizard.
Kim Vopni (32:03.549)
Yeah, dialed in.
Ginger Garner PT, DPT (32:08.93)
They're happy like a lab, you know? So freeze can be happy. It's also how sexual function takes place, right? That's an immobilization, know? Sexual encounters are a mobilization. A hug is an immobilization, but it's without fear. And so all the concept of, know, polyvagal theory is based on proper neuroception. Can we detect internal threat or external risk?
appropriately. And if we can't, we go into fight, flight, freeze, or fawn. So the sympathetic response, people pleasing and all that stuff, which women, we're pretty bad at falling into. Or when we have had that stress response for so long and our body can't handle it anymore, that's where we go away from the rest and digest, away from fight, flight, freeze, fawn into shutdown. That's where you see trauma victims.
That's where you see dissociation. That's where you see people just, you know, eyes glaze over. They kind of go somewhere else. They don't know, their bodies don't know how to handle that stress anymore. And that's where we don't want to go. It can save our life, but it can also kill you. yeah.
Kim Vopni (33:23.283)
Yeah, yeah. So interesting. I think we should do a whole podcast episode just on the vagus nerve. I want to go into like speaking of the wandering nerve, I kind of want to wander into more of an MSK thing specific to musculoskeletal syndrome of menopause. And we can put in there as well GSM genitourinary syndrome of menopause. So these syndromes associated with this menopause transition
Ginger Garner PT, DPT (33:28.654)
That would be so cool, yeah.
Kim Vopni (33:52.596)
What do you as a pelvic health PT see from an MSK, like not so much like whole body MSK, but just specific to menopause, the syndrome of menopause as well as GSM.
Ginger Garner PT, DPT (34:04.844)
Yeah. my gosh. First of all, when we even, when you even say those phrases, it's like my heart starts getting bigger and I start like getting all passionate and wound up. Although I definitely am excited to talk about the voice and pelvic floor too, but it adds an extra layer because for the previous 20 years, because of the WHI study, although there were some good points of it, it also largely prevented women from getting proper treatment. And that breaks my heart.
but it also does empower us and challenge us to go ahead and seek that proper care. So Gen Xers and older millennials and anybody else older than us, listen up. And really women of all ages because now you have, we have that knowledge is power. Now you don't have to go through, you know, the GSM and the musculoskeletal syndrome of menopause, but...
what I see and what I screen for often is related to menopause more than it is pelvic health because some people will come in, women particularly, will come in, sit down. Okay, what's your feeling? Tell me your story, what's going on? Oh my gosh, I have painful intercourse, know, can't have sex anymore. And then we'll get into the leakage conversation. Yeah, there's a little bit of leakage and well, is there vaginal dryness? Oh yeah, there's vaginal dryness too.
you know, how often do you go to the bathroom per day? And when I have them do their diary, they might say 12 times a day, which is too often. And then we start to see the syndromes present, right? What we know as, you know, GSM of having vaginal dryness, urgency frequency, can be incontinence, you know.
and like painful bladder type syndromes, all kinds of things can kind of fall under, know, GSM and on the MSK side, we can end up with a lot of pelvic girdle issues. Like as we lose vaginal estrogen, goodness gracious, everything kind of seizes up a little bit to oversimplify it, but the pelvic floor is gonna struggle, you know, it's not going to be as strong and as receptive and responsive as it was.
Ginger Garner PT, DPT (36:26.798)
But we think about there's receptor estrogen receptors everywhere, right? So there could be pelvic girdle stuff I see a lot of luteal tendinopathy Stuff like that where they come in and they'll have these other these other things they think that are the primary driver But it really isn't it's perimenopause. It's postpartum. It's menopause and it hasn't been appropriately treated
Kim Vopni (36:32.671)
you
Kim Vopni (36:37.15)
Yeah.
Kim Vopni (36:50.717)
Yeah, 1000%. As you're talking, and I think a lot about hip pain, hip osteoarthritis, hip fracture, which we have an increased risk of post menopause, just especially the people, the population, that generation that was without estrogen. I think that will start to shift now a little bit as more awareness is coming back about it. coming back to the voice,
I remember when I first started working in pelvic health, was, was within the birth world and trained as a doula, recognizing that the connection between jaw tension and the pelvic floor. So part of the reason why we keep people vocal during birth is to eliminate that tension. So then I'm thinking, so there's the jaw tension that could be happening for many different reasons. And then we have a pain syndrome from MSK stuff.
Ginger Garner PT, DPT (37:33.879)
Yeah.
Kim Vopni (37:48.262)
syndrome of menopause, then we have the vaginal dryness, we have the fear of pain that like there's just this this tension all over the place that is inhibiting blood flow circulation, capacity for pleasure, function, everything. And, and yeah, so it's sort of this then unraveling. And I think when people finally get seek seek help from maybe they see a PT, pelvic PT.
Ginger Garner PT, DPT (38:04.59)
Mm-hmm.
Kim Vopni (38:15.571)
They want this to change overnight. They want this to be, you know, just fix me. But as it has built gradually, it's going to take a little bit of an unraveling. But what are your recommendations for people to start supporting that and contributing to that unraveling and getting them back to pain free?
Ginger Garner PT, DPT (38:20.739)
Yeah.
Ginger Garner PT, DPT (38:35.566)
Yeah, that's a great question because we all want to start somewhere and it can be overwhelming. Like already we've talked about 20 different variables. You know, we talked about so many different things and it can feel overwhelming like I don't even know where to start. I think the very first question to ask yourself is where is the most comfortable place for you to start? Like, you know, as the listener, as the person going through whatever experience it is, maybe you have vocal pain, maybe you have breathing pain.
Maybe you have hip pain or pelvic pain. Keep in mind, it could all be the same. It could all be connected. So no matter where that pain is, and I have people who thought they had a shoulder problem, it actually is no, they've got like a hyoid problem. So if you ask yourself, okay, where am I the most comfortable? A lot of people may not be comfortable with getting their pelvic floor prodded again. Like if you've had three kids, you're like, you know what? I just don't want anybody touching that for 10 years, you know?
Kim Vopni (39:31.069)
Yeah. Yeah.
Ginger Garner PT, DPT (39:34.22)
That's enough of that. But then you could say, all right, that's totally cool. Let's start at the respiratory diaphragm. And then there's a lot of, there are a lot of resources out there. I can list some that I have that are free that you can get started with. And there are tons of others out there too that you can start with in terms of really scaling your breathing techniques. I think that's one of the most fantastic things about practicing yoga.
picking up a yoga practice is that you can really master breathing well. And then at a higher level, I would say that when you come into, let's say you go to yoga class, your local yoga class, wherever that is, you do it online, or you play one of the videos on YouTube or whatever. The next thing that I would do is you gotta get a little bit more intimate with yourself. So I would...
take some of those yoga breathing techniques and dress down from the waist down, right? Lock everybody out. This is your self-care time. Get a mirror, like one that is on a stand and you can look at what's going on down there, like the makeup mirrors on the stand with the lights and all that thing. You're gonna use it for the pelvic floor stuff. And if you're doing yoga breathing correctly, and the reason I go to the trouble of saying get the mirror and get undressed is because it is this important.
If you have pelvic pain, if you have pelvic work in prolapse, if you're leaking, if you have dyspareunia or painful intercourse, it's essential that you know what your respiratory diaphragm is doing to your pelvic floor. Now we'll get to the voice piece in a minute. Because if you don't, the yoga breathing techniques are amazing, but they also get very advanced, very fast. I'll give you one in particular, Ujjay, overcoming. Ujjay Pranayam.
Most people that do it the first time when I'm in the clinic with them and I'm imaging them, I don't really just send people off without imaging. They're doing it backwards.
Kim Vopni (41:37.129)
So Jai, this is the kind of the ocean sound in the back of the throat.
Ginger Garner PT, DPT (41:39.784)
Yeah, yeah, exactly. Like, if you haven't heard of it before, welcome to Ujjayi. It's amazing. If you've done yoga, you've probably heard about it because a lot of practices are really based around Ujjayi. And so that's an easy one to cherry pick and go, what's happening with it? If you want to do it, yeah, what do you see happening? You shouldn't see all the skin between the sit bones and the whole perineum and the openings, you shouldn't see them bulge when you are exhaling.
Kim Vopni (41:56.349)
And what do you see?
Ginger Garner PT, DPT (42:09.034)
and yet pretty much 100 % of people are doing it backwards when they come in. Would it cause a problem with time? Maybe not, you're one of the lucky ones. But again, it's kind of like walking around all day in a trauma posture. You could do it for a little while, but after a while it's gonna hurt, you know, yeah. But that's where you could start, because if you've had pelvic floor trauma and you're just over it for now and you don't want any more pelvic floor prodding for a while, go the diaphragm route and then...
Kim Vopni (42:17.855)
Mm-hmm, mm-hmm.
Kim Vopni (42:25.311)
Right, right.
Ginger Garner PT, DPT (42:37.142)
And if you're ready to have your pelvic floor prodded, go see your local friendly pelvic PT and they will help you get started with that. And then you can move up from there. If you wanna start with the voice, one of the probably the best ways that I would recommend and it's free and it's on YouTube is I have a video called, Orofacial Release Part One. Go check it out. It teaches you about the hyoid.
Kim Vopni (42:41.247)
Mm-hmm.
Ginger Garner PT, DPT (43:03.34)
It teaches you about supra and infra-hyoids. I think it's like eight minutes, it's not long, and it just teaches you the basics of testing that area. If you find any pain in that area, if you find any discomfort with what I walk you through, that's a red flag, and that's where you could start too.
Kim Vopni (43:20.831)
That's a good resource in this is kind of a bit of a sidebar maybe but not totally with yoga. I myself sometimes and this was kind of more so back when I was symptomatic with my rectus. And in certain poses I would the breath that was being taught in a specific movement pattern or flow or pose was different than what felt better in my body is there.
Ginger Garner PT, DPT (43:49.481)
Yeah.
Kim Vopni (43:50.076)
Is there, is it okay if somebody were to breathe differently in yoga practices or is that fundamentally changing the benefits of yoga?
Ginger Garner PT, DPT (44:01.836)
Yeah, that's a really good question. Because the breathing techniques that will get taught in yoga class, when I used to teach yoga to the public, when I had to use the yoga studio like 30 years ago, I just taught a breathing class alone because it was that important to break it down. So I think in a lot of yoga classes, it's thrown out there, here, do this, you know, do this oceanic sounded breath. And then that's it.
It's kind of like if someone says, do Moolabanda, which is basically an anterior or superficial, let's be more specific, more superficial pelvic floor in kind of the closure of the pelvic floor mechanism. They can throw that out there, but it doesn't mean people are gonna actually do that. What are they actually gonna do with it? So if it feels weird in your body, that's a really good yellow flag to pay attention to that you might have to shift. You might wanna go.
practice that yoga pose or the yoga breathing that you just got taught in front of the mirror, you know, like I was talking about, because then you could break it down and go, okay, if on the exhale that the perineum should naturally be lifting kind of organically and it's going the opposite way, that's a lot of stress on the system over time. And it could be that you back up and you modify it and you still get the good benefits out of it.
Kim Vopni (45:21.811)
Yeah, yeah, cool, okay.
I guess let's end where we should be ending right now. I guess maybe just a final statement to wrap this all up with and tie it up with a bow is you in your natural journey towards functional medicine, you had made a point to me of how beneficial it is to have a collaborative approach between like kind of marrying functional medicine and pelvic floor PT. would argue marrying lots of different things.
Ginger Garner PT, DPT (45:32.558)
Okay.
Ginger Garner PT, DPT (45:57.368)
Thank
Kim Vopni (45:57.396)
with having a village for our healthcare and having lots of people who are working together to solve problems. But specific to functional medicine and pelvic PT, how do you see those working really well together?
Ginger Garner PT, DPT (46:08.514)
Yeah, that's a great question because I think a lot of people will, I think pigeonhole practitioners because they don't, even practitioners that are referring to pelvic PTs, right, will say, go do your pelvic floor down training or up training and then they leave it at that as if that's the only thing that pelvic floor, pelvic health does. However, we do so much more than that. And I think the longer you're in practice,
the more humble you become, the longer you're in practice, the more you realize, I can't do, I can't cover everything. This is impossible. The more complex patients you get with complex PTSD or whatnot, that's why there's a mental health practitioner next door. She's the next treatment room over. And there's a massage therapist on the other side of me for that reason. And somewhere along the way, gosh, like 20 years ago, yeah, was 20 years ago, was when the functional medicine
bug bit me or I went and found that and it was really through a circuitous route of Ayurvedic medicine and looking at other, you know, indigenous cultures and what they did and ancient practices and things like that. And I really began to appreciate it, but also be super alarmed at what we weren't doing, you know, like what we didn't know and what we were ignoring. And even when I was doing my doctoral work, you know, I would get responses like,
Kim Vopni (47:29.695)
Yes.
Ginger Garner PT, DPT (47:39.022)
and looking at geriatrics and hormones and things like that, like, that's cute. Like, it doesn't matter. We're talking about the musculoskeletal system, but that's interesting, Ginger. Thanks. Yeah. Okay. Moving back to the topic, you know, and it was simply about, you know, at the time it was about geriatrics and hormones. And then the other piece of that was geriatrics, failure to thrive and the gut microbiome. And it was completely dismissed and
Kim Vopni (47:51.935)
Yeah.
Kim Vopni (48:03.007)
Hmm.
and look what's happened now.
Ginger Garner PT, DPT (48:07.264)
Yeah, and look what's happened now. It's like, no, we have to, know, people live in older, older women living in assisted living are going to have a homogenous diet. They're going to eat the same things all the time. It's going to be more brown and not fresh. And then guess what happens? Down the hill they go on all levels. So in terms of what we can offer in pelvic PT, and I can see, I'll kind of say ortho and you know, pelvic PT in bridging that gap.
Kim Vopni (48:10.184)
Yes.
Kim Vopni (48:20.937)
Mm-hmm. Mm-hmm.
Ginger Garner PT, DPT (48:36.882)
is looking carefully at, and you and I were talking before you press record about the importance of things like checking thyroid. If someone comes in and their cortisol levels are flat, and I know that they're not, estrogen, it's not going well. Estrogen, progesterone, and testosterone, we've looked at it, it's not going well. Then we're going to be concerned about things like thyroid. We're not gonna just look at the cortisol and go, this is what I've had happen with, and I'm just.
I'm gonna call out, it's not all, it's not all, you knew where I was going with that. It's not all PCPs, but oh my goodness, this was not even from a PCP, it was a specialty doc that should know better. And I had a woman come in and her diurnal, which means 24 hour cortisol, so we looked at 24 hour cortisol, was absolutely flat, it was flat. And it should be, you know, roughly the bell curve for those of you who haven't looked at it before, that's what it should look like.
Kim Vopni (49:08.255)
Call it out.
Kim Vopni (49:31.443)
Mm-hmm. Mm-hmm.
Ginger Garner PT, DPT (49:36.106)
surge up and be beautiful and then come down in the evening and then go back up in the morning again. So you can imagine how someone would feel if it's flat. And this provider, who should know better, told her, that's a normal for your age. Completely dismissed and gaslit her. Medical gaslighting, like A1 medical gaslighting. And I had to, in a diplomatic way, say, that is not evidence-based. Let's work on that.
Kim Vopni (49:49.533)
Wow. Yeah.
Kim Vopni (50:03.881)
Yeah, yeah.
Ginger Garner PT, DPT (50:06.144)
And so that's where we can come in, you know, in pelvic PT, just one out of many, many ways. And on the other hand, you may have someone who comes in and what if their DHEA levels are very low? That is so easy to be able to support the system with vaginal DHEA, which is evidence-based and safe, and it's over the counter and it's inexpensive. And that can...
Kim Vopni (50:25.524)
Mm-hmm.
Ginger Garner PT, DPT (50:33.582)
create great longevity for the vaginal walls, pelvic floor, et cetera. And then yet there are some people who can't tolerate those things. And then that is where the lifestyle medicine piece comes in, where we have to look more carefully at nutrition. Are there nutritional triggers? Do they have a mast cell problem? And are they having histamine responses left and right? We begin to take out those dietary triggers. We also begin to look at their environment. There are too many xenoestrogens.
Kim Vopni (50:37.407)
Mm-hmm.
Ginger Garner PT, DPT (51:02.868)
in the environment, so fake estrogens basically, that are driving up those numbers in a way that we don't want to see. Because for those of you listening, you may not realize you have three different types of estrogen, and then under those three types of estrogen, all of them have to be metabolized, and those are all going to have values, and all those values of estrogen metabolism do end up mattering. Mattering, that's not a word, they do matter. And the reason we know that they matter
is because even though there seems to be some controversy that I think is misplaced around estrogen metabolism right now, when you look at the literature in the oncology world, which again, we were talking about before we pressed record, because of the scare that I had years ago, when you talk about aromatase inhibition, that is a massive piece of the puzzle when women have breast cancer. They're going on these hardcore drugs that do, they are AI, they are aromatase inhibitors in order to treat.
and prevent the cancer from coming back. What are those things? Those aromatase inhibitors are the same things that are gonna help us with estrogen metabolism day to day. But overall, they are overlooked except for the oncology population. I think it's gonna be like the gut microbiome was ignored and dismissed like it was when I was doing my doctoral work. And now it's like, yeah, that's a given. Gut microbiomes always mattered. I'm like, really?
Kim Vopni (52:25.171)
Yeah, yeah.
Kim Vopni (52:30.247)
If only I had my... Yeah.
Ginger Garner PT, DPT (52:31.65)
because I wasn't feeling too good about it when I was dismissed about it. But that's just kind of scratching the surface. And the other piece of the puzzle is how many women do you see come in postpartum and they had their first cycle and it was a wreck. It was a hot mess and then it just gets worse from there. They're heavy, heavy bleeding, clotting, et cetera. That's where those pieces of the puzzle also matter because you might be looking at
Kim Vopni (52:52.031)
Mm-hmm.
Ginger Garner PT, DPT (53:00.558)
hormone levels, you might be looking at anemia. And if they're not going to their PCP, you know, that often, who does that end up falling on? It ends up falling on us. Because if they're extremely fatigued, that matters to us. They have no exercise, you know, tolerance at all. And they can't do the things that would make their glut-me tendinopathy better or whatnot. And so we end up actually tracking those things and we should
Kim Vopni (53:11.369)
Mm-hmm.
Kim Vopni (53:18.537)
Yeah. Yeah.
Kim Vopni (53:23.859)
Yeah.
Ginger Garner PT, DPT (53:27.742)
ethically be looking at those things. That's due diligence. If we don't know how to refer, we're not doing our jobs. And so we need to be able to screen for all of those things.
Kim Vopni (53:30.26)
Mm-hmm.
Kim Vopni (53:39.198)
Yeah, I was I was that person postpartum and started the heavy bleeding and just kind of morphed into what I didn't know was perimenopause at the time. And then you know, I didn't even really know about definitely didn't know the term functional medicine at that point. This is now like
what, 15 years ago, maybe 17 years ago, naturopaths were something that I had heard of, but didn't really know for lying on the conventional medicine, you're fine. Everything looks normal, except your, your ferritin is really low. Well, no shit. Cause I, and you know, and so I, I invite people to, to seek the opinions and the care from others who are working collaboratively, who are doing the root cause investigation. I always think root cause investigation.
Ginger Garner PT, DPT (54:12.736)
Right.
Kim Vopni (54:30.015)
ties so nicely in with the pelvic floor and in our route and the chakras and we just we just have to dig deeper and we also us we need to know more to be able to advocate so often and this was kind of that that like you're normal for me when when everything looks normal on your labs that was my time where I was like no I have to I have to research this I have to become educated instead of outsourcing these
Ginger Garner PT, DPT (54:32.312)
does.
Ginger Garner PT, DPT (54:51.864)
Yeah. Yeah.
Kim Vopni (54:58.451)
you know, investigations and decisions to somebody else. I have to take control here and be CEO. So, so I invite other people to do the same and it can be a lot of work and, know, and that it's not as easy as just like, yeah, go be the CEO of your health. It's, it's a, it's a, it can be a long process, but if you find the right people to build your team, then you have a lot more support.
Ginger Garner PT, DPT (55:01.826)
Mm-hmm.
Ginger Garner PT, DPT (55:20.054)
Absolutely. I tell my patients all the time that if you think about when women were included even in research, and most of them don't know, it was what, 1996? Yeah. Around that era when it was finally mandated that we had to start including, maybe we should look at women. As Stacey Sims says, we're not just small men. I think that's who said that. And so I have to remind them of that. Okay, here's when we finally,
Kim Vopni (55:30.335)
93, yeah.
Kim Vopni (55:34.513)
Mm-hmm. Yeah, maybe we should look at women. Maybe.
Yep. Yep.
Ginger Garner PT, DPT (55:48.832)
It was mandated we're included, but honestly, I want to get real close to the mic and say that still is not happening. We're still not getting the research that we need. It didn't mean that it was equal. It meant that we started to do research. So when you look at those norms and your PCP, this is why I want to look at all the labs you've had done when someone comes in. Bring them in, please upload them to the portal. And then we can decide what to do with that from that point forward and who to refer you to as part of our team.
Kim Vopni (55:55.987)
Mm-hmm.
Kim Vopni (56:01.491)
Yes.
Ginger Garner PT, DPT (56:19.212)
someone had come in, sat down, and the exact same thing had happened to them. And honestly, it had happened to me too. And until you know what a full anemia panel or iron panel should look like, how many physicians, PAs, nurse practitioners, whatever, who is ordering that, will not even measure ferritin? Or when ferritin comes back, they'll say,
It's fine, it's on the low side when in functional medicine, we know that's not the case. And some people don't function with a ferritin of 25 or 30, they're flat lined. And then other people can be fine. It's an N of one. And I think that that's what we've lost in healthcare today is that they're just gonna look at a normative range, which is probably not even well built based on women at all.
It doesn't look at them. They don't even know how to recognize true signs and symptoms of anemia anymore. And they're just looking at a lab and saying, low normal is fine. And we got to call bullshit on that.
Kim Vopni (57:14.845)
Yeah, hallelujah, hallelujah. Great place to end. We could go on, but this has been, I've already kept you way over, so I apologize. Thank you so much for your time. Yeah. Where can people find you and learn more?
Ginger Garner PT, DPT (57:16.782)
Ha
yeah, absolutely. Yeah, you can go to a couple different places. Come visit me and chat on Instagram at Dr. Ginger Garner. I love the conversations that we have there. Come to YouTube at Dr. Ginger Garner. Also, I have tons of free content and playlists, menopause playlist, a pelvic girdle playlist, a voice palp playlist, all kinds of stuff that you can play with there.
And then my website is Garner Pelvic Health.com.
Kim Vopni (57:56.295)
Amazing. Thank you for all that you do and everything you do to for the advocacy and the treatment and everything you share for free on social media. Huge thank you. Thank you for your time today.
Ginger Garner PT, DPT (58:07.448)
Thank you for all you do too. This is so much fun. Thanks.
