Welcome back to the Healing Pain Podcast with Theresa Feola, PT, WCS, PRPC

Pelvic health may not be the first thing that comes to mind when you think of women’s health, yet it is an important issue that deserves attention. In today’s episode, Theresa Feola, PT, WCS, PRPC, of Pelvic Room joins Dr. Joe Tatta. Theresa is a board-certified women’s health therapist. She has served in clinical management roles throughout her career, but her clinical focus has been on the education and treatment of women’s and men’s pelvic health. Today, Theresa discusses the current state of women’s health, the challenges women face in accessing appropriate pelvic health and physical therapy, and her creation and ongoing development of community-based childbirth and postpartum model called the Perinatal Partners Network.

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Development Of A Community Based Comprehensive Childbirth, Postpartum, And Women’s Health Empowerment Model With Theresa Feola, PT, WCS, PRPC

Welcome back. Thanks for joining me for this episode. We’re discussing how to create community-based comprehensive childbirth and postpartum model that improves women’s health literacy as well as access to integrative women’s health care. My guest is physical therapist Theresa Feola. She earned her Physical Therapy degree from the University of Pittsburgh and is a board-certified women’s health specialist.

She has more than 35 years of clinical practice experience with a focus on the education and treatment of women’s as well as men’s pelvic health. She’s the owner of a private practice called the Pelvic Room, which is located in Exton, Pennsylvania. Theresa actively lectures and presents regionally to community groups and healthcare providers on women’s health topics.

If you’re a physical therapist, you can catch her presentation at the Academy of Pelvic Health Physical Therapy Fall Symposium, which is on September 17th, 2022. Make sure to check that out. In this episode, we discuss the current state of women’s health, the challenges that women face in accessing appropriate pelvic health and pelvic physical therapy, as well as Theresa’s creation and ongoing development of community-based childbirth and postpartum model called the Perinatal Partners Network.

The Perinatal Partners Network is an organization focused on providing integrated resources and care during the perinatal period. With many of the changes and challenges that are ongoing in women’s healthcare in the United States as well as abroad, you will find the information that Theresa shares to be impactful for the future state of women’s healthcare, as well as empowering for individual women and community groups. Without further ado, let’s begin and meet Theresa Feola.

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Theresa, welcome. It’s great to have you on the show.

Thank you for having me, Joe.

I’m excited to chat with you. You have been a pelvic health therapist for quite some time. You have a ton of experience in this area. As you and I have gotten to know each other professionally, so much has happened in the world of women’s health, particularly that relates to their pelvic health. We will probably touch on some of those things later on in the episode. A good place to start is to tell me how you became interested in pelvic health. I’m old enough and mature enough to remember when pelvic health didn’t exist in the world of physical therapy. You and I graduated from school around the same time. How did you become interested in this specialty area?

I have been a PT for 35 years. The emphasis on pelvic PT has been in the last 22 years. I’m board-certified for women’s health. I’m also certified in pelvic rehabilitation. I started teaching prenatal and postpartum exercises in the early ’90s. That came about more from an orthopedic and athletic standpoint. A lot of us start in PT from that aspect. My GYN started to mention to me because he knew that I taught the prenatal exercise class. In his medical journals, he was reading about incontinence. I didn’t want to do that. I was young. I hadn’t had children.

I did not see that connection and why I would be interested. He talked to me from about 1994 until 1999. I remember saying to him, “I’ll take a class and see.” At that time, there were very few classes. Even muscle anatomy was never mentioned in my education. I took a class with Hollis Herman around ’99 or so. As soon as I had that class, there was this spark that hit me that said, “There’s so much that we could be doing for women that I had never heard of. No one was talking about it.” I didn’t know any other pelvic PTs. It lit that fire for me.

I always say publicly that women’s health and pelvic health have changed the profession of physical therapy in so many ways because it brought in a different perspective and a whole-person view. As soon as pelvic health therapists entered this specialty, they realized there are biomechanical and biomedical causes and factors you’re seeing here. There’s also the whole psychosocial aspect that’s involved in dealing with that very intimate part of our body. We all have a pelvic floor.

That evolution for me is with experience. You realize they are muscles like anywhere else. I try to convince my patients to make them feel a little easier, “This is like if you pulled your hamstring, I need to touch it.” We would educate, go over how you’re using it, and strengthen it or loosen it. It’s the same thing but in the same breath, it’s completely different. The intimacy factor is a big part and how we hold emotions. The pelvis is a container for that emotion and that automatic protection of the autonomic nervous system. As I get into treating more, the holistic nature and the importance of that are highlighted.

I do treat men. It’s very easy to say women. I certainly see women throughout their lifespan. We’re constantly transitioning. Our needs are constantly changing. They’re very unique and often misdiagnosed and misunderstood because of history. I do certainly treat males as well. It’s not as frequent because males tend to have fewer issues on the pelvic floor but it’s as equally important.

You’ve been practicing and specializing for a long time. What problems do you see in women’s health? There are big systemic problems. What are the problems you’re seeing in your practice and your community?

This goes way back in Ancient Greece and forward. If we can trace it, people would be interested and astounded by how women’s medicine and women’s health have evolved or changed, or the lack of change and understanding. I would have people refer to awesome information. It’s Unwell Women by Elinor Cleghorn. She takes us through history, politics and medicine. You realize that we haven’t gotten very far to some of the things in history that seemed absurd and with no common sense.

We are repeating some of those things, unfortunately. I see a giant call to action to make changes now. My biggest frustration is how slow everything is. In the past, we didn’t have the research. Women and minorities were excluded from research until 1993. That’s not long for us to have information that we can use. We have a ton of research. I would like to share a couple of bits with you.

The gap then in that research getting down to practice and getting into the mindset in our culture of how we’re treated and understood is taking a long time. Some of the aspects boil down to women’s health literacy, which means us having the knowledge to understand our anatomy, accessing reliable information, making informed decisions, and advocating for our quality of care until we ourselves understand, don’t dismiss what we’re feeling, and intuitively know that something is wrong.

Sometimes for PTs, what we’re working on is big and obvious as far as our dysfunction and pain. It’s very acute. Some of the pelvic, women’s health, after birth, and pregnancy issues can be that but they can also be subtle. I like the word unwell sometimes. We do have the obvious but we also have the not-so-obvious. Coming from basic physical therapy, it astounds me and sometimes infuriates me that someone will be sent to me for one small knee ligament that was strained.

They are immediately sent to me. There’s a plan. Try PT. If you don’t get better, then we will do XYZ and we’ll continue up the chain. Screen them. Are they ready to get back to their sport? We have very specific exercises. We run them through. All along, I feel like the person feels heard and at ease because I understand the process. None of that happens for the vast changes.

In pregnancy alone, so often practitioners will say, “You have back pain. You’re pregnant. You have sciatica. You’re pregnant. There’s nothing we can do.” We don’t do that with any other diagnosis. I never say, “You’re a football player. You’re going to have knee pain. There you go. You’re 85 years old. You have knee arthritis. Let it be.” As PTs, that’s our gift. We maximize function. We figure out a way. We modify and change things so that you can function at your highest level despite the diagnosis.

Here are a couple of interesting tidbits then. In first-time vaginal deliveries, 15% to 30% of women will avulse their levator ani. That is our pelvic floor muscle. The base of our entire trunk is being torn. Twenty-five percent of people will have an external anal defect. That’s a pretty significant and concerning issue. Twenty-five percent of us will fear childbirth and 23% to 49% will have some pelvic floor muscle dysfunction. That could be urinary incontinence, fecal incontinence, pelvic organ prolapses, and sexual dysfunction. Only 7% of women are aware that PT was even an option.

If I have a pelvic organ prolapse, the first line of treatment is surgery. Half the items on some of the questionnaires that we fill out about our quality of life with a pelvic floor are over the proper reading level for people to understand. I’m guilty of this. I throw out the perineum or vulvar area. The research shows less than 50% of women could name their external genitalia in a study from 2022 like vagina, anus, urethra, and clitoris. The people who were able to do that were White, already had several children, and in higher socioeconomic. It’s too little too late.

The other thing that occurs after pregnancy is that 20% of women move into a higher body mass index. We know these things. All of this is concerning when we’re thinking of moving forward with our health in general for our lifespan. Mood disorders began four weeks postpartum. They increase 2 to 3 years after that point. Thirty-four percent of women will describe their birth as traumatic. That alone sits in that pelvis and helps in moving forward and healing.

We need to debrief. I describe to my clients after birth, “I need to physically touch the pelvic floor and show that you’re good. That was in the past. That episode is over. Here we go step-by-step. We’re going to help heal you and move you forward.” It’s exactly as if an ankle came out of a cast. There’s a step-by-step reassurance to the body and the client, and a plan to logically move forward.

We then have a very underrepresented group in the research and the literature. Black women are four times more likely to die in childbirth than White women regardless of their socioeconomic status. Ninety-six percent reported a lack of education about the delivery and pelvic floor. What happens is when my expectation going in does not meet my experience, the bigger the gap, the more blindsided, and the more our symptoms create an issue versus if my expectations, my knowledge, and my experience are closer to matching. The US has the highest maternal death and injury rate in all of the developed world.

This is not only a call to action. This is a scream for action. I don’t understand how we can continue to let this happen. Sometimes we have an accident that we weren’t expecting. It takes us by surprise. This is something we can prehab. We prehab some surgeries for clients. We know it’s happening, “You’re pregnant. Let’s prepare you and make the outcome the absolute best.” We’re not going to come out on the other end completely unchanged 100% exactly like we were. Let’s rehab, make sure we maximize and make sure you understand moving forward how to be the healthiest person you can.

It is a long yet very impactful answer. As I sit here and try to absorb all that amazing knowledge and information you have, it points to the fact that we have a women’s health crisis in our country. We know as PTs that women’s health crisis has multiple branches to it. One branch is the pelvic pain crisis. You said something impactful for me as a physical therapist. When I think back to my career, I would see Grade 1 ankle sprains come in.

A Grade 1 sprain is you were walking and you stepped off the curb in the wrong way, or you’re playing a sport and you rolled your ankle. The ligaments there were overstretched and maybe some were torn. A Grade 1 ankle sprain probably heals within two weeks. It’s not a big deal to treat, yet we have women who are going through an entire pregnancy and birthing process. The pelvis has so many thick and strong ligaments that do start to naturally stretch but oftentimes are traumatically injured during pregnancy. We just tell women, “You had a baby. Put your feet up and relax.”

There’s no plan. From a PT standpoint, it’s illogical. We don’t even have long enough for me to go through all the changes that happen like the thoracic spine and the diaphragm. The activator of the pelvic floor is our diaphragm. Our organs are shoved up there. The system is offline for so long in pregnancy. These things don’t automatically go back. We don’t assume after a stroke that you automatically get the function of your arm back. We help it, encourage it, and move it along.

The other aspect of that is this. Six weeks is the only check that we get. At that time, we are told by our medical provider, “You are fine. You are cleared to return to whatever you want to do.” From a musculoskeletal standpoint, that has zero bearing. If they could see from a uterus healing standpoint, you can return but as PTs and pelvic OTs as well, we are the ones who do that screening and that clearing and see. Not only are we not helping but I have treated numerous women who got that word and started to run, jump rope, or lift heavy weights a few weeks postpartum and felt pain or a drop.

They have created a pelvic organ prolapse. We can help strengthen it out but it is what it is. We have overstretched. We have caused a little unnecessary damage to that person. No PT would let a woman change for nine months, go through delivery, whether it be C-section or vaginal delivery, and assume at six weeks without checking anything like glute strength, ab strength, and endurance, “Have you been walking?” They say, “Go ahead. Run, do whatever you want, and CrossFit.” It’s illogical.

The other word you used, which I know you’ve coined this term at this point, is women’s health literacy. You and I both looked in literature. It doesn’t exist. We’re putting this on record that Theresa Feola coined the term women’s health literacy. It’s the impact and the sequela of what that means to women’s health across the lifespan of women’s health but you brought into the conversation the important aspect, which also determines health, and groups that are marginalized who don’t have any information about their human body.

Some of my colleagues are working in rural PT areas and trying to come up with good solutions to this. Pelvic PTs and OTs are hard to find even in urban areas. What is the solution? Luckily, we’re starting to have some telemedicine online. It’s hard to do with any rehab, especially pelvic but they are being creative and getting it done. Something is better than nothing.

Luckily, thanks to the Pregnancy and Fourth Trimester Task Force for the Academy of Pelvic Health or APTA. We have a bill that is introduced to the House of Representatives to make some policy changes finally. I feel like it’s grassroots in the community. Maybe it’s just me and my personal preference. I’m a little frustrated. I can’t wait for policy changes. That’s what happened.

I was frustrated with how women were being treated in the traditional medical model via insurance. In 2020, I branched out and opened my practice so that I could at least feel like the only part I can control of this entire enormous frustrating system is my little area. If I can make sure that the women I come in contact with are getting treated the way I feel that they should be treated, let’s start there.

There’s something else you said too that I want to make sure we touch on before we move forward to the next question. Pregnancy can be traumatic. Some women bounce back from it but you mentioned that a large percentage of women view their pregnancy as a trauma. The word trauma like PTSD or Post-Traumatic Stress Disorder, a lot of people think of that as a psychological problem or challenge. There are psychological and emotional components to it.

However, you said something very succinct. Since the trauma is in your pelvic floor, that’s where the trauma is stored. It’s in that part of your body. We know that to effectively heal trauma 100%, because trauma is an embodied experience, we have to work with the body. I think to myself, “How many women have been traumatized by pregnancy?” Even if they found their way into counseling, they have never found their way to the physical side of it. We know that you have to work with the body to effectively treat trauma.

That’s how I explain it to my clients. The vast majority of them have not even had psychological treatment but some have. A large percentage of what I see too is the number of people who have dealt with abuse or adverse childhood experiences even leading into this. We know that somebody who has been sexually abused in the past has an increased incidence of C-section because of all the muscles in the body, the pelvic floor muscles are the first and foremost to react to a sense of alarm.

Since they have been traumatized, they are going to react. There are so many triggers you can imagine like fear, pain, and the medical community. Often this is not even on the radar and talked about as we are heading in. That is a disservice. It’s hard enough if we have not been abused. If they have been abused, that person needs prehab, physical touch, and in-the-body awareness, “How can I best relax and open that floor when all it wants to do is close, tighten, and protect me?” It’s to have faster and less-interventions delivery for that person.

If someone has polytrauma in their history, the pelvic floor is responding. Even something as simple as a light touch to that area can cause a trauma response and reaction.

We see it. The pelvic floor starts to respond. The pudendal nerves down around the anus and vaginal-clitoral area start to become supersensitized and grow by even the third yeast infection or the third UTI. It makes sense. In the first infection, the body goes, “I didn’t protect you. I’ll be more alert this time.” In the second one, “You got another one. I will protect you and put the walls up.” It doesn’t take much. With one painful sexual encounter, that guarding starts.

I treat puberty and the inability to insert a tampon. Anxiety leads to pelvic floor tension. Our adolescents are going through so much and are so anxious. There is where that learning should begin, “These are your muscles. They’re protecting you.” Make it light and educational. I find it amazing that we can have parts of our body that we don’t even understand and know. Guys would never say that. We’re doing a big disservice.

You’ve started to take all this energy and information you have and channel it into a couple of different places. Being on this show is addressing some of these challenges but you’ve gone a step further to address the gap that you’re seeing in women’s health. Can you tell us about that?

Time and time again. I saw women walking in and saying, “I didn’t know this was a thing.” It’s funny. Among us, that is what we hear, “It’s not a thing. I didn’t know this whole taking care of the pelvic, PT, and OT was a thing.” Among other PTs, they don’t understand the scope of our practice. If anything, maybe they say, “You work with pregnant women and incontinence.” That’s a small segment.

Everybody uses the word core, “I’m doing core.” Nobody knows if you say, “What is a core?” This is what we’re talking about. It’s the diaphragm, the breath, and how the breath is relating to my anxiety and my autonomic nervous system. It’s a key factor in how the pelvic floor moves. The low and deep transverse abdominal muscles and the little multifidi are true core but yet we’re throwing that term around.

Even if we’re working with our athletes, you are working with pelvic and core. If I am a sports medicine PT or an orthopedic PT, it would be important to know what history someone has had in this area. I don’t think we ask that. Even in C-section, do we have that adherence to that scar maybe? I have seen that be an impact after years. It continues to bind for back pain, SI pain, and knee pain. We’re missing a big part of that subjective information.

How have you started to address this on a larger scale?

The frustration was building seeing women coming in. I met with a chiropractor, Shannan Behrens of McCormick Chiropractic. She and I both had similar frustrations. We decided, “We each know practitioners in our community here. Let’s meet, have coffee, and talk.” We were meeting with doulas, midwives, massage therapists, personal trainers, and anybody that we knew that had the same frustration and passion.

As of April of 2022, I’m grateful I stumbled across your innovator program. I had some ideas running through my head. I didn’t know what I was going to do. Thank goodness you help to reel me in. What has stemmed from that is Perinatal Partners Network. There is a website, PerinatalPartnersNetwork.com. This is a directory for women. We tried to keep it a grassroots community. It’s the whole idea, “It takes the village.”

I was seeing that women felt good if I knew your chiropractor or massage therapist. We are all like, “Come on. We have you. We understand you.” We started a website directory. At this point, there are fifteen different specialties represented, between yoga, midwives, chiropractors, doulas, psychological counseling, and complementary medicine. Conventional medicine is the area I’m trying to link and have more practitioners on. That’s a big goal for us in the future.

There are lactation consultants, speech, and beading. I believe I’m forgetting some but at this point, there are 64 different practitioners in three different counties and our immediate area. The goal is so that women can get treatment faster and easier. They feel supported. They don’t have questions. They understand. Under each of those specialties is the person who knows the latest research, “Here’s a great book. Here’s a good website. Check out this Instagram person.” They’re following that specific field.

It amazes me when sometimes medical practitioners will say, “You don’t need pelvic PT or OT.” What do you know? I’m the one to tell you if you need pelvic PT or OT. That’s what we have done for all the specialties. The whole idea is the resolution of an issue. You go to a medical provider and say, “I’m three months postpartum and I’m still having painful intercourse.” It usually ends there if you mentioned that. There’s no resolution.

The hope is if you enter our network at any space, we all understand what each other does. We will point you in the right direction. We are not going to stop until there is a resolution for all of your complaints, big and small. That is going to help the infant, the child, the family, and the community to hopefully make a change in this world. That’s the story. Our directory is helping women and practitioners.

I have learned so much. I’ve been a PT for a long time and didn’t know the scope of chiropractors. I feel at this point in my career, I am tired of us all working in our silos. I have noticed at least in my field and for women that we do better when we have multiple viewpoints. As a woman, I might choose one path and somebody else chooses another based on my ethnicity, my goals, my background, my history, my ethos, and what I believe.

No one should be able to tell me what my path is. I will figure it out after you have given me all the information and laid out my choices. I can make the choice. There’s a benefit to the practitioners. I have seen the look on women’s faces when I hand them the paper that says, “Here’s a QR code. It lists to a directory of 64 other people right here in your town who are dying to help you.”

It relieves me. When I feel a woman is depressed, I don’t have to try to figure it out, “Where should I send you? What should I do?” I hand them that website and say, “Here’s a whole bunch of practitioners that I personally know.” Part of our criteria is that either Shannan or myself meet and greet the practitioners coming on with the same ethos and non-competitive passion for women. We will make sure that we meet. It seems to be a win-win all the way around.

The website is PerinatalPartnersNetwork.com. Everyone can put that into their web browser and check it out. The aim of the Perinatal Partners Network is to create an interdisciplinary pelvic or women’s health community platform. This is a website but that website represents the geographic area where you live. You should tell people where you live.

I’m outside Philly to the West of Philly about 45 minutes in Exton, PA. We have three counties. Our goal is that people are going to start replicating the model near us if we need to talk to each different group and that it spreads. My personal goal is that this will also spread. We will have a network and directory for adolescents and also for the peri and menopausal time period because the same misinformation, misunderstanding, and unnecessary suffering are going on in those areas too.

This is a resource for women and also for clinicians because you’re learning from each other. It’s a resource for women where they can access care. There’s an education component. It targets the women’s health literacy that you mentioned before. and then it optimizes their either prehab or rehab process because you and your partner can streamline the onboarding process for them and connect them with the right people. It’s quite simple, elegant and brilliant. There’s nothing else like that out there.

It’s this whole idea of collaboration. We need more kindness, caring, unity and community. All of this is small and large at the same time when we look at the issues that we are all facing. We can look at it in a very narrow view, or you can expand upon this and enlarge it.

You’ve been doing this for a long time. You’ve seen lots of different facets of the women’s health world. You’ve seen things grow. We have policies that are coming in that are impacting or have the potential to negatively impact women’s health. How would you like to see this initiative grow within the next five years? You’re a big picture person. I know you have big hopes, dreams and visions. I would love to hear what those are.

I would love for it to almost mimic what we do with sports medicine and how we treat our athletes. Let’s prep before we get pregnant, help them all through the process, and immediately have a plan and screen to get back to our activities of daily life, recreation or occupation. If I’m having any little issue, we get you back in the system and figure it all out because this is broader than the physical. When we are disconnected from our pelvis or our core, that has ramifications on confidence and anxiety levels.

This is grounding. It’s very holistic, broad-based, and empowering for women in bringing feminine importance. Sometimes we also are perpetuating this because we have worked so hard to be seen as equal and strong and that we can do it, “I just had a baby. I can get back to work, have a family, do this and that, and get my body back.” There’s the pressure. Believe me. I am one of those women. I want to see that happen too but there is a logical efficient way to go about that.

I’m going to point everyone to that website. It’s PerinatalPartnersNetwork.com. You can all check that out now and take a look at it. You also have another website where people can connect and learn more about you, Theresa. Can you share that?

My business is PelvicRoom.com. I’m outside Philadelphia. I am a sole practitioner there. I tried to make it personalized and holistic. I work out of a collaborative wellness facility. I tried to make it a new safe area for people.

Make sure you check out that website as well. It’s PelvicRoom.com. Theresa, it has been great speaking with you. Thank you so much for all the work that you’re doing and for being a leader and an innovator in pelvic health, physical therapy, and women’s health in general. It has been great speaking with you. Make sure to share this information with your friends and family on Facebook, LinkedIn, Twitter or Instagram. You can tag me as well as Theresa on Instagram. We would love that. On Instagram, I’m @DrJoeTatta and Theresa is @PelvicRoom. If you tag both of us, we would love that. We would love to hear your feedback about this episode. Thanks for joining us.

Important Links

• Pelvic Room
• Academy of Pelvic Health Physical Therapy Fall Symposium
• Perinatal Partners Network
• Unwell Women
• McCormick Chiropractic
• @DrJoeTatta – Instagram
• @PelvicRoom – Instagram

About Theresa Feola, PT, WCS, PRPC

Theresa earned a Bachelor of Science in Physical Therapy degree from The University of Pittsburgh. Theresa is a board-certified Women’s Certified Specialist (WCS). She earned Pelvic Rehabilitation Practitioner Certification (PRPC) from Herman and Wallace Rehabilitation Institute in 2015. Ms. Feola has more than 35 years of clinical practice experience spanning inpatient acute care, inpatient rehabilitation, skilled nursing, and outpatient orthopedics.

She has served in clinical management roles throughout her career, but her clinical focus has been on the education and treatment of women’s and men’s pelvic health. She is the owner of The Pelvic Room in Exton Pa. Theresa is a member of the APTA Academy of Pelvic Health and the IDEA committee. She is a member of the Philadelphia Pelvic PT Alliance and The West Chester Women’s Multisport Club. She presents regionally to community groups and regional healthcare providers on women’s health topics. She is the co-founder of The Perinatal Partners Network, an organization focused on providing integrative resources and care during the perinatal period.