Episode 12 - Pelvic Floor Health

[00:00:00] Speaker A: Foreign. Welcome to the Comeback with Boomerang Healthcare, your podcast for relief, recovery and restoration. I'm Dr. Peter Abaci And I'm Dr. Gouzet. [00:00:22] Speaker B: As doctors, we know healing isn't just about treatment. It's about having the right tools, mindset, and support to move you forward. [00:00:30] Speaker A: You can have pain, you might be injured or even hurting on the inside, but with all that you got going on, you can still have a really great life. And that is what we are here for. This is the Comeback. Let's get started. [00:00:46] Speaker B: Peter. So I know that today's guest actually used to work with you in your clinic in Los Gatos. Tell us a little bit about who's here today. [00:00:55] Speaker A: Well, so we've got Jackie Kroll, who is one of my favorite people in the whole world and my very favorite pelvic floor physical therapist. So really excited. Jackie, welcome to the Comeback. [00:01:10] Speaker C: Thank you. Thanks for having me. It's an honor. [00:01:15] Speaker B: Jackie, could you tell us a little bit about yourself and about what you do? [00:01:20] Speaker C: Sure. So I have been a physical Therapist for over 15 years and specialize in bowel, bladder, and sexual dysfunction for all genders and also treat pelvic floor dysfunction for pediatrics. And I really enjoy treating chronic pain. [00:01:45] Speaker B: So what made you specialize in pelvic health? Was there a certain moment or a patient that kind of pulled you in this direction? [00:01:56] Speaker C: It was in school when I learned that we had these muscles that were capable of these very vital functions. So bowel and bladder issues, it just seemed so important to me at the time when I learned that we could help people with pee problems, poo problems, without medications, without surgeries, and was fascinated from the beginning and decided I would go jump right in because there were so many people needing these services and no providers providing them. [00:02:34] Speaker A: Hey, Jackie, I'm really curious. When you specialize, it's such a niche specialty in physical therapy, and, you know, you're a doctor of physical therapy, do you have to do, like, special training or certification to be a pelvic floor guru? And a little bit we're going to ask you what exactly the pelvic floor is. But. But how do you end up in that specialty? What do you got to do? [00:02:59] Speaker C: Yeah, so there's not a lot of training in school, and they're working on that, providing more information now and resources for graduates. But at the time, almost 15 years ago, we had one maybe four hour class on pelvic floor issues and how the pelvic floor functioned. And so I ended up taking extra classes after school. Continuing education and decided. So there's many avenues in which you can go with pelvic floor issues. You can treat pediatrics, you can treat lymphatics, you can focus on rectal issues. I myself see a lot of men often, and so there's all kinds of classes that help you get trained. Also treat transgender surgery, pre and post surgeries. And so each of these are additional classes. [00:04:06] Speaker B: So, speaking of pelvic floor, most people haven't really heard of it until something in that area goes wrong. So wondering if, for our audience, you could explain a little bit about what exactly is the pelvic floor and pun intended, but let's get to the bottom of this. What is it and why is public floor health so important? What are some of the biggest misconceptions that your patients come in with and what do wish more of them understood? [00:04:35] Speaker C: Yeah, I think mo a lot of people think it's not going to work, first off, that their issues are really severe and or significant, especially if they're in a lot of pain. They can often feel like they're not having any control over the situation. And so we end up talking kind of from the get go, aiming to get them really comfortable, because if they're not comfortable, then these muscles are going to react. And often that does result in pain. Too much clenching is often what I'm seeing. Most people think that weakness or laxity in these tissues is the most common problem, but we see a lot of too much tension causing symptoms, and so we're consistently having to explain how that ties in with their bowel and bladder. So we're giving lots of education and aiming for, like, a very comfortable, calm space. We have table heaters, we have aromatherapy diffusers. We start, we don't go straight into the pelvic floor. When we assess and treat, we will aim to, to assess externally and see what also needs to change about the muscles that surround the pelvis and that help control the core. [00:06:14] Speaker A: You mentioned that a lot of your patients are men. So what, what's the, you know, what's going on there with men and how is their, how are their pelvic floor dysfunction problems different than women, or are they all the same? [00:06:31] Speaker C: Yeah. So a lot of pelvic issues for men get blamed on the prostate. And we're learning that there's more often a pelvic floor dysfunction component that's causing a lot of their urinary changes. So slow stream hesitancy, incomplete voiding, or not really being able to relax completely to let the urine out is something that we see a lot. So we can help people who have peeing at night multiple times, or if they have a really strong urgency, sometimes it's the muscles clenching around the urethra and bladder that irritate it. And so we see a lot of urinary issues, we see a lot of bowel issues. So we treat constipation, fissures, hemorrhoids, we treat low back pain, and. And we treat sexual dysfunction. So if the muscles are too tight, that can limit good blood flow to the penis and into the scrotum. And so testicular pain is something that I see a lot of as well. [00:07:45] Speaker A: Is it hard for men to ask for help or women to ask for. For help with pelvic floor problems? And I imagine it's not something they bring up with their doctors very often. [00:07:56] Speaker C: I would say it often. Most men wait until it is quite severe. And I know if they're coming to see me in my office, it is just that it's very significant. It's interrupting their quality of life and they really need help. So my men are often some of my best patients sense. [00:08:20] Speaker B: I think one of the other frustrations that I've heard some patients say is how long it takes to get a diagnosis. You know, there are some that are reluctant to seek help, and then there are some that want help but don't know where to go or what's really going on. So I'm curious about like the diagnostic limitations in public health and why does it take so long sometimes for a patient to get a diagnosis or also to even know that specials like yourself exist? [00:08:46] Speaker C: That's a great question. So we. I really appreciate being on the podcast and spreading awareness. This is. It is not well known that all the breadth of which we can do, how we can help people and many physicians, including urologists who are seeing, for example, overactive bladder, prostate prostatitis, things like this, are continuing to prescribe antibiotics inappropriately when it really is a pelvic floor dysfunction that these men are suffering from. And so, yeah, I've seen men who have seen 10 plus urologists and they come to my office and get better in one or two visits. And so getting the word out about all the symptoms that we see and things that we treat, it does, it has taken some time, but I would say just the lack of knowledge on the pelvic floor and in the symptoms that can arise from pelvic floor dysfunction is. Is really the key there. And we have, we utilize a lot of tools and not all of us are the same and so what one pelvic floor therapist can treat, another may not. And so it is helpful to get to know pelvic floor therapists in your area to learn what, what they kind of specialize in. Some may have taken certain classes, while others may have not. So but it does take an extensive amount of time. But I am seeing in my 15 years that that time is lessening. So I used to see people who were suffering for many years, and now we're getting people in that have only been suffering for weeks. So it is changing and we're pumped about that. [00:10:52] Speaker A: That's great. I was gonna say it seems like you're really in like old school medicine where you're not able to rely on. There's not like great testing. Right. To diagnose some of these problems. It really depends on you as a clinician, you know, understanding the patient, interviewing the patient, examining the patient and trying to figure out what's going on, as opposed to just ordering a CT scan or an MRI or something like that, which I think in this arena is often not very helpful. Correct. [00:11:29] Speaker C: Right. Pelvic floor dysfunction will not show on a diagnostic per se. [00:11:37] Speaker A: So let's talk about some common diagnosis problems, you know, that cause pelvic floor dysfunction. Pelvic pain, maybe starting with vulvodynia. [00:11:50] Speaker C: Yes. So we do see a lot of vulvar pain. And it really does come down to getting to know someone's story a lot of times how their pain started, when it started, and understanding the nuances about their self care that allow me to kind of get a bigger picture of what they need. And so, yeah, vulvodynia, we see a lot of vaginismus, where the muscles are contracting and not allowing for penetration. We see a lot of constipation related issues, prolapse, as well as the diagnoses I mentioned for men. But I am treating more and more things like IBS that we're moving upstream. A lot of times there's dysfunction at the outlet, at the anus, but that backup can cause a lot of visceral disruption. And so we do. I'm trained in visceral mobilization, which can help with gastrointestinal motility. And we work on the nervous system in combination. And so we see a lot of gut issues like post SIBO cases or just good old chronic constipation. But we treat a lot of pregnancy and postpartum, of course, is probably some of the largest population on our schedule, typically. [00:13:49] Speaker A: What are some post pregnancy issues that come up? I bet there's a lot when you imagine what goes on down there during pregnancy and then delivery. [00:14:00] Speaker C: Yes. [00:14:00] Speaker A: Oh, my goodness. [00:14:02] Speaker C: Yes, it is. I believe that every woman should have a pelvic floor assessment post delivery, whether it's a cesarean or a vaginal delivery. There's just. It's a lot of change and a lot of trauma over a short period of time. You know, people. It makes sense that people go to therapy to train for events like a marathon to help keep their body balanced. And I think that women, when they do pelvic floor physical therapy, notice significantly less recovery time, and they're feeling much more connected after. If they do pelvic floor therapy both before and after therapy or before and after delivery. [00:14:57] Speaker B: So I. I think that's refreshing to hear because having treated a lot of postpartum moms, I mean, I recall they would come home with just the handout on how to do a kege, and they'd be reporting these symptoms. And I'm like, have you brought them up with your, you know, medical provider? Right. They're like, well, they gave me the Kegels handout. [00:15:15] Speaker C: And I was like, okay, all right, let's follow up. [00:15:17] Speaker B: Let's let them know about some of these other symptoms. [00:15:19] Speaker C: Right. [00:15:19] Speaker B: Trying to normalize that discussion and making them feel comfortable so that they can [00:15:23] Speaker C: bring it up with their providers. [00:15:25] Speaker B: And maybe they do need a referral and something a little bit more intensive. [00:15:30] Speaker C: Yeah. So what we see a lot is that people will complain of tailbone pain, and so they'll go to see an orthopedist, and then they'll have bowel constipation issues, and they'll go see their GI or colorectal, and then they. Because of all the constipation and pushing, they'll have prolapse and have to see their OB gyn And the. All the dots aren't getting connected. That really, you know, the pelvic floor is really at the root of that. [00:16:09] Speaker A: There's also something called pelvic congestion syndrome. Is that something you come across, Jackie? [00:16:16] Speaker C: A little bit. Honestly, not a lot. It is more rare, but I have had some patients who have suffered from it, and there's more resources now than there were many years ago. But it is not well understood as far as the complexity. Complexity of it all and how it starts in the first place. [00:16:45] Speaker A: Right. And when. When things are prolapsing, are you able to. To treat that so that people don't necessarily always have to have surgery for that? [00:16:54] Speaker C: Yes. We can reverse a prolapse over time with therapy. And I am a provider who fits pessaries, which is, I call it like a bra for your organs. It's kind of like just an insertable device that's custom fitted and it helps to hold things up. Because it's not just your pelvic floor that's doing the support. Your ligaments are also holding up your organs. [00:17:23] Speaker A: I gotta ask you, where does this go, custom device go? [00:17:26] Speaker C: It goes inside the vagina. Okay. Yeah. So many women are adept with tampons and kind of can appreciate that support that it gives from underneath. And so I like to reference it similarly to using a tampon if you are, if you need some extra support to help approximate those ligaments on top and lift everything up over time, those tissues can, can approximate and improve. And so we're seeing that women need less and less of those bladder lift surgeries that they used to. [00:18:08] Speaker A: Fantastic. [00:18:10] Speaker B: You know, speaking of the pelvic floor and how difficult it is to, you know, properly see some of these diagnosis on imaging, MRIs aren't really that helpful. Something we see a lot of is chronic low back pain. And you touched a little bit upon that. And so curious how, how often you see that connection and, and how does it connect to not just low back pain, but also like chronic hip pain? Because we see a lot of that in some of our injured workers and sometimes that's what's preventing them from getting back to work. [00:18:44] Speaker C: Yes. So most of the time, people aren't coming to me for their low back pain, but their low back pain gets better as of treatment with us. And yes, it is in part because the pelvic floor function itself is improving. But we always address the muscles that attach to the pelvis, including all of those spinal stabilizers and core muscles. And so. But I think that the pelvic floor dysfunction is a common reason that people don't get better with traditional treatment. And so I always ask if someone has, if I come across someone and I mentioned I'm a physical therapist, and they mention, oh, I went for my low back pain, but it didn't get better. The therapy didn't help me. I'm always a big proponent of trying pelvic floor therapy because I have seen it time and time again that people come in with low back pain, and that's not their primary complaint with seeing me, but it gets better nonetheless. [00:19:59] Speaker A: So suppose you're working, you're lifting something heavy, you strain your back, and you start getting back pain. And then you notice it's hard to like, control your, your bladder the same way, maybe sexual performance for men and women changes. There seems to be this sort of neurologic and musculoskeletal connection between, you know, the spine and the pelvis and maybe even at a brain level. Can you kind of talk to how you, you sort of coordinate, you know, how do they work together and how do you, you know, because when you're treating it, it sounds like you're making the back better. And what's the connection there? [00:20:53] Speaker C: Yes. So with low back pain, persistent low back pain, the. There are many ties of the pelvic floor into the hips. Here, for example, you can see this piriformis here. And this is another muscle, the obdurator internus, that we're treating a lot with internal treatment. And that can make a big difference when it comes to how the hips are moving and functioning. So if someone isn't properly able to bend well with good mechanics, they might restrain their back consistently due to improper bending mechanics. And so it causes that cycle of, okay, I'm going to bend and now it's going to hurt and then I'm going to bend improperly. And ends up affecting the brain patterning. They start moving differently and choosing different ways to move. And so things end up in a bad cycle. But we are, one of the things we do here at Progressive Pelvis in particular is we always aim to address the nervous system because the pelvic floor is just like the jaw. People who often suffer from pelvic floor issues also suffer from TMJ issues because the nervous system is so deeply tied with these two areas that are areas of our body that respond to instability or lack of safety. So if someone isn't feeling safe, maybe because of their pain or maybe because of their work situation or they, they've had trauma, the areas of the jaw and the pelvic floor can go into over activity mode. And that can in and of itself start a pelvic floor dysfunction episode. [00:23:06] Speaker A: You know, I had a patient not too long ago who I think had a back injury, was working, working for a big university. I'm not going to use names, but was in a situation where she had to go frequently, like every hour, like to urinate. And her supervisor was like monitoring her, like bathroom time. It was like crazy. And so I think it was a, like a domino of the more she would have to go, the more the supervisor would come down on her for having to keep going to the bathroom. And I think it was probably stressing her out more and more and making the urination problem worse and worse. As opposed to like what you're saying, calming down the nervous system. And just curious, like for people listening, what are some techniques that you use or you recommend to help do that? Because we all gotta, we all need to calm down the nervous system at some point, at some time, right? [00:24:10] Speaker C: Yes, absolutely. So we often start with breathing shocker. So if your pelvic floor is the floor of your core, your diaphragm is like the roof. And so we can access the pelvic floor by working on breathing mechanics. And a lot of times people aren't connected to their pelvic floor because I think their breathing mechanics and stress are at the root of that. And so we often work on breathing. There's lots of different breathing techniques. I always encourage whatever resonates with you to, for you to utilize. But so the pelvic floor though, so the diaphragm, as you inhale, it comes down and it flattens, comes down and contracts towards the belly and that at which time your pelvic floor will respond by opening, cueing and opening and relaxing or lengthening of the pelvic floor. And then when you exhale, your diaphragm re domes and your pelvic floor comes up with it. So there's a pistoning mechanism that happens between the diaphragm and the pelvic floor. And so we try and get people feeling this motion together. And so if you're sitting, you can sit ideally on your sit bones and feel your muscles kind of underneath you. And you can accentuate this breath pelvic floor motion. So inhale, relax your pelvic muscles into your chair and exhale, you can engage and so you can pair the two together to help get a little bit more in touch or connect connected with your pelvic floor. [00:26:14] Speaker B: Fantastic. [00:26:15] Speaker A: So interesting. [00:26:16] Speaker B: Yeah. And it, and it makes sense from the sympathetic nervous system activation where we know all our muscles tighten and the importance of right. Breathing to start turning that off and just coming back to basics, our breathing. And for you specifically, to really having them focus on their, you know, pelvis muscles and just connecting that. And so I'm curious, in regards to patients, when they come in and see you, what can they typically expect? Like walk us through not just like their first visit, but like a little bit of their treatment plan. What can they typically expect when they, when they see a pelvic physical therapist? [00:26:53] Speaker C: Yeah, so we take an extensive history, we do ask, you know, about very personal questions, you know, how. What are your bladder habits? What are your bowel habits? Do you have any issues and we always explain that they don't have to answer any questions they're uncomfortable with or if they want to defer the question, that is no problem at all. And, or during the assessment we always encourage that they're in control and if they ever want to stop or take a break, then that's totally okay. And so we'll go through an initial history and then we do a mechanics or alignment screening. We'll check for flexibility and how their hips are moving and then we'll start. Usually I start with the belly and seeing how the belly is moving with breath and then assess any restrictions within the belly because we see a lot of issues with intra abdominal pressure. With that the pelvic floor then has to respond to. And so it's often trying to compensate for intra abdominal pressure challenges, imbalance. And so if someone has diastasis recti or if someone has a muscle spasm in their back, for example, then your pelvic floor is going to be responding to that. And so we will go through and do an assessment of their hips and back and then we'll assess their pelvic floor which may include an internal exam if it's deemed necessary. And then we will go through with treatment, usually day one, and kind of give them an idea of what the treatment will look like, which usually involves some hands on therapy, therapeutic exercise, some of this brain retraining that we've been talking about. I do a lot of nervous system regulation and so giving them tools for that that they can take home. I think empowering a patient from day one with some tools for self care is usually kind of where I like to start. See where in their lifestyle is, is there a little bit of imbalance potentially? And let's address that. If they're not getting enough sleep, we'll talk about that. If their diet doesn't have enough fiber or hydration, then we're going to talk about that. So it's a pretty well rounded approach taking a look at the whole person. And then we do often as we go talk about stress management because your pelvic floor is so rooted with your nervous system, it's going to be upregulated anytime you're in that fight or flight. And so I think that's why we're seeing so many issues related to too much tension. And so we usually will start there as nervous system. [00:29:56] Speaker B: You know, that's really important, the discussion that we're having surrounding the nervous system and the importance of relaxation and teaching our muscles to relax again. And I'm always so curious about the role of trauma in a person's life. And I'm curious what you see in pelvic floor dysfunction, both psychological trauma or even physical trauma. How does that show up and how does that play with the whole triad of muscles and the sympathetic nervous system and what a patient's experienced? [00:30:30] Speaker C: So one of my first questions is always, when did this first start? What was happening in your life at the time? Because commonly there's a thread between a threat and the nervous system. Maybe somebody was having a transition with work or lifestyle or home, maybe they were going through a divorce or they experienced significant emotional stress, grief, whatever it may be, sometimes those things can trigger our nervous system to clench these muscles. Our pelvic area and our pelvic floor is such a autonomically controlled muscle group that it will respond to insecurity, instability, feelings of instability. And so we always try to track back what happened and what it is that they need in their nervous system to feel safe and secure. And that will often help the pelvic floor recover much quicker for identifying their triggers and helping them recognize them in their, in their system. Because usually it's the pelvic floor is one of the last things that will kind of get fired up. So commonly it's like the neck and shoulders, they'll get like heartburn and all these things in the gut that will, they can use as a resource. So I always like to say pain is an opportunity to listen to your body. Or this, this acid reflux is a sign that maybe you're, you're clenching your abdominals and you are not breathing well enough for that acid to come back down. Remember, the diaphragm sits right on top of the stomach and wraps around the esophagus. And so I try and help them connect the pieces in their nervous system in order to really experience a full and long term recovery. [00:32:54] Speaker A: Just curious, Jackie, do you ever see, you know, some people, I suspect have had past traumas and develop pelvic pain later in life. Do you ever see or process that with patients? Or does that even come up when you're working with somebody? [00:33:15] Speaker C: Yes, we, we screen for trauma. We ask, and it doesn't always, they might say no, but then they later identify and it's interesting. I've had experiences where we might press on a point, especially inside the pelvis, and it cues a memory. And many people have had a release, a somatic release on my table, and cried and can now retrack, go back to when they first recall experiencing that pain. And so I like to encourage, like if we can put our finger on it and replicate it, then we can work through it. But trauma is something that I see a lot of affecting my patients, whether it was a long time ago or more recent. This area of the body, again, it responds to your nervous system and those things that you don't work through or process are going to come out just like the book. The body keeps the score. And so the pelvic area is one where that is 100% accurate. [00:34:33] Speaker B: Well said. I'm a big fan of Bessel van der Kolk's book as well. The Body Keeps Score. And I think that's something that patients are always surprised to hear when we're talking about some of their physical symptoms is how much something that has happened to them or that they've witnessed or they've experienced, even if they've unconsciously. Right. Repressed it or didn't think it impacted them so much and have functioned for, for decades, that it can still have a lasting effect and that their body is remembering what happened to them doesn't feel safe. And it might, you know, show up. Like you said, commonly we see neck and shoulders. It could be some gerd, it could be pelvic floor. And so I love the way that you explain that. And I think that's so important for [00:35:15] Speaker C: people to be aware. [00:35:18] Speaker B: So without naming names because we want to protect. Right. Patients confidentiality, we would love a story of a patient that you've worked with where pelvic, you know, PT really changed their, their life in a way that it still, you know, still impacts you or that memory still stays with you even years after treating them. Do you have any particular cases that come to mind? [00:35:46] Speaker C: That's a great question. You know, my patient that I last left off with this morning, she was, I was telling her about the podcast and she, I thought would be a great one to share her testimonial. She ended up losing her fiance in October and developed what she thought. So she had some pre existing issues that she didn't realize. For example, some tension in her back that she kind of brushed off or dismissed. And then she had painful periods and she always had a little bit of pain with intercourse, pain with penetration. But she again, she just kind of dismissed that and was like, oh, that's normal. Which so many people think, but it's not common does not mean normal. And she went, she started experiencing severe urgency and bladder pain and she went to the urologist and she was one who thought, oh, she got referred to see Me and she thought, oh that's, that's not going to work and, but I'll just go and I'll appease my urologist. And she came and she, I put together the pieces that her losing her fiance caused her to tense her muscles in a way that created like an alarm system within her bladder. So she got a diagnosis of interstitial cystitis, but within two sessions she was probably 90% relief with her bladder. And we started working through her back pain and she's now able to have penetrative penetration without pain. And so she was, she was one that is relatively a low number of sessions. Sometimes it takes people a very long time to work through some of these deep rooted issues. But I, it's an honor to work with her the processing of, of her grief and losing her fiance and kind of finding, helping her connect and not dissociate from her body. Because she was so dismissive of her back pain, her period pain, her pain with penetration, she was ignoring these things. And she explained that she had a high pain tolerance. She thought because she had a facial trauma and has had a lot of different surgeries including dental and nose and to her, to her face. And so, and she experienced severe migraines and so nothing compared to these migraines. And so all her other pains were kind of what she felt like were non significant or didn't know she could get help for them. And so now she's, she feels like this therapy has helped her work through her grief but also her physical symptoms. And so yeah, for somebody like listening [00:39:31] Speaker A: at home and wondering, you know, should they see a pelvic floor physical therapist, what are some recommendations you would make if yes you should and if so, what's the best way to find the right person? [00:39:50] Speaker C: That's a great question. I think many of us pelvic floor therapists can be found on pelvicrehab.com and there's bios there. But typically you can call a pelvic floor therapist and ask for a consult. Many of us do free phone consults and see if you feel comfortable with that person. I think feeling like you would be in safe hands is really important. And I think the environment in which the facility, the environment the facility provides is also really important. We use things like table warmers and aromatherapy to help ease the challenges of this facility type of assessment. We don't use stirrups or speculums in any way. And so I think inquiring with your. If you feel like you might need it or might be A good candidate. Calling your nearby pelvic floor therapist and see if you feel comfortable with them. [00:41:01] Speaker B: And for those that are listening and thinking about it, any closing golden nuggets that you'd like to leave with our audience. Any advice or tips for good pelvic floor health? [00:41:19] Speaker C: I would say so often it comes down to breath. Improving your breath mechanics will improve your pelvic floor, no matter what the condition or diagnosis, and slowing down and really listening to your body, connecting with it and not being dismissive. So many of these symptoms are dismissed and people are embarrassed. And so I, I would encourage you to share your symptoms, of course, and find someone some help. But connecting with yourself will be of value and connecting with your breath will be of value in the long run. [00:42:09] Speaker A: Jackie, thank you so much for sharing your insight, your wisdom, your passion for what you do. It's so appreciated and it's so needed. I think in, in healthcare right now and I think there's so many people that would benefit from not only what you had to say, but, but what you had to offer. And I think for folks who are wondering, Dr. Jackie Kroll is a pelvic floor physical therapist with 15 years of experience. She's based in Atlanta, Georgia and she is the owner of Progressive Pelvis Physical Therapy. And she's a mentor to all kinds of folks and is a coach and she specializes really in chronic pelvic pain, pregnancy issues as we talked about, and postpartum care, as well as bowel, bladder and sexual dysfunction for all age groups, all genders, all sizes, big and small. And she takes really, as you can tell, a whole person approach that combines pelvic health with the nervous system, regulation, lifestyle, you name it, seeing the big picture, putting it all together to help people change their lives in meaningful ways, heal and recover. And Jackie, such a pleasure talking with you today. [00:43:41] Speaker C: Thank you so much for having me and for the opportunity. I really appreciate it. [00:43:46] Speaker B: Jackie, it was a pleasure having you here. And to all our listeners at home, thank you for joining us today on the Comeback with Boomerang Healthcare. We're grateful to have you here. If you've enjoyed today's episode, be sure to subscribe so you never miss an update. You can follow us on social media for more tips, information and inspiration. Until next time, Keep moving forward. Your comeback is just getting started. [00:44:16] Speaker C: Ha.