Tight Muscles, Loose Joints, Pelvic Pain: The Hypermobility Paradox with Dr. Brooke Winder (Ep 192)

Transcripts are autogenerated and may contain errors

Dr. Brooke Winder: [00:00:00] If you're really treating the pelvic floor and it's like kind of getting narrow and working on pelvic floor strategies, sometimes that's too focused on this region, especially for hypermobile. People don't forget to zoom out because sometimes could be trying to relax their muscles, but if they've got a pots issue or a mast cell issue that's driving the pelvic pain, you can keep teaching them to relax, but really, they actually might make some bigger gains if you help get support for them in those other health considerations that actually might be a bigger driver.

Dr. Linda Bluestein: Welcome back every bendy body to the Bendy Bodies podcast. I'm your host, Dr. Linda Bluestein, the Hypermobility md. A Mayo [00:01:00] Clinic trained expert in Ehlers-Danlos Syndrome dedicated to helping you navigate joint hypermobility and live your best life. I am so excited to have Dr. Brooke Winder on the show today.

Dr. Winder and I have presented together at multiple conferences, and we've gotten to hang out and just chat about all things pelvic floor, joint hypermobility, high level performing athletes, and everything in between. Dr. Brooke Weiner is a pelvic health physical therapist and dance science expert who helps performers optimize movement, manage pain, and navigate hypermobility.

She serves patients through a clinical practice while teaching at California State University Long Beach, and is widely published and sought after for her work at the intersection of pelvic health and performance. This conversation today is so important because joint hypermobility, pelvic health, and sexual health are so interconnected.

As always, this information is for educational purposes only and is not a substitute for personalized medical advice. Stick around until the very end so you don't miss any of our special hypermobility hacks. [00:02:00] Here we go.

Thank you so much for listening to Bendy Bodies. We really appreciate your support. It really helps the podcast when you like, subscribe and comment on YouTube and follow rate and review on all audio platforms. This helps us reach so many more people and spread the information to everyone. Thank you so 

Dr. Brooke Winder: much again, and enjoy the rest of the episode.

Dr. Linda Bluestein: I'm so excited to be here with Dr. Brooke Winder. Dr. Winder and I have had the great pleasure of presenting together a few times and working on some projects together and everything. So, it's high time that we had you on the show. 

Dr. Brooke Winder: Wonderful. Thanks so much for having me. I'm really excited to be here.

Dr. Linda Bluestein: Good, good. well of course you're a pelvic floor physical therapist, you're also a professor. You work a lot with dancers. You do so many different things. We're gonna talk about, all these different fabulous, like interconnected, interwoven topics. but let's [00:03:00] start out by talking about like how you started noticing these patterns of pelvic floor dysfunction in dancers.

'cause of course we see that in hypermobile people. but, you started noticing this in dancers also. 

Dr. Brooke Winder: Yes. part of it was actually my own experience when I was young. so I grew up dancing, but prior to really picking dance as my main activity, I was a competitive gymnast. And, it was actually when I was doing both dance and gymnastics in my early adolescence, kind of through mid adolescence, I.

Noticed, in particular that I would leak, sometimes I would leak urine. I never told anybody, because I found it really embarrassing and I thought I have to be the only person in the world who's experiencing this at my age as a teenager. and I never really understood why that happened. It didn't really have like a particular pattern to it.

and then it got better as I [00:04:00] got older and kind of went finished through puberty. I wasn't doing gymnastics anymore. so it was something that really wasn't on the forefront of my mind, seemed to resolve. but then as I started my physical therapy career and I started working with pelvic floor PTs, 'cause I really started out very much in the ortho side of things.

I saw a lot of people including dancers and other performers, who had low back and hip issues. And then I really realized that there was this whole area in between the pelvic floor region that was, it was very common for people to have symptoms there. And the more dancers I talked to, I realized, oh my gosh, I was not the only one that was going through all of this.

so that really kind of struck my interest once I started working with pelvic floor PTs. And then, I decided to get trained in assessing the pelvic floor as well as working with orthopedic [00:05:00] conditions. 

Dr. Linda Bluestein: And I think it's so terrific what you're doing. And for all the pelvic floor physical therapists out there, I just wanna say thank you, Because as I'm married to a urologist, as I know that, you know, and even though he's operated in that part of the body, in the pelvis, in the male pelvis. You know, I think most physicians do not understand the pelvic floor, like at all. So God bless you, tell all of your pelvic floor physical therapists out there because we need you so desperately.

And we know that hypermobility also impacts the pelvic floor. So tell us about that. 

Dr. Brooke Winder: Yeah, I mean, as, someone who works with dancers and I also work with, aerialists who work in the circus world, I work with a lot of Hypermobile folks. and when we think about sort of that hypermobility pelvic floor connection, generally there's just a higher prevalence of pelvic floor types of symptoms and people who are hypermobile.

so typical [00:06:00] symptoms of pelvic floor dysfunction can be things like. Leaking urine or incontinence can be pelvic pain. and that can include lots of different types of pain that we can talk about. but can include genital pain with sex, painful menstruation, as well as symptoms of pelvic organ prolapse or pelvic pressure, or having to urinate really frequently with a lot of urgency.

So those types of symptoms, if someone's hypermobile, particularly if it's, a genetic hypermobility issue that's affecting all of their connective tissues, they do have a higher, prevalence of these experiences. and there's, lots of reasons that we think that's happening. kind of related to the sequelae that could be associated with hypermobility as well as kind of from a biomechanical standpoint.

potentially people who have [00:07:00] less, Passive stability in their connective tissues, their muscles might need to be working harder or more frequently or more consistently to try to help the body feel stable. and perform with, people I work with perform high level activities. And so that is one of many reasons why there could be, more issues along the pelvic floor.

Dr. Linda Bluestein: So if their ligaments are not able to kind of hold them together with ligaments which connect bone to bone, then maybe the muscles are getting hyperactive in order to kind of try to hold everything together. 

Dr. Brooke Winder: Yeah. So, I mean, I th I think we continue to need more research to really help us demonstrate this, when we think about things like how much tension is in the pelvic floor.

but as an example, let's say you have more, mobility available in the sacred iliac joint, or more mobility available. [00:08:00] Around your pubic synthesis, around your pubic bone or just across the pelvis or even at the hip. 'cause it's so nearby, has so many fascial connections, then it would make sense that the demand on your muscles is ramped up a little bit.

And so the pelvic floor muscles could be, having more difficulty relaxing or maybe they're getting fatigued or just having to work harder or hold more tension in order to compensate for that and help with the stability of the surrounding joints. 

Dr. Linda Bluestein: So does that explain why people can be strong and high functioning, but also have pelvic floor dysfunction?

Dr. Brooke Winder: Yes. Yeah. So it's one of the reasons, it that I think it can confuse someone who is a really high functioning, athlete, let's say like the dancers I work with, where they're strong, they move all the time, their hips are strong, their body is really. con, well conditioned overall. And so it can feel really confusing [00:09:00] if they're experiencing something like leaking because I think we tend to understand that, maybe as being something that is okay, that's a weakness issue.

If I'm leaking, you know, my pelvic floor is somehow become weak. And we see these issues, in hypermobile people, in dancers and lots of high level athletes and performers, not just dancers. we see these issues even before there might be more of a risk of the pelvic floor becoming, you know, strained or having trauma to the pelvic floor, like with pregnancy and birth.

So even people who have never been pregnant, never had a baby, can have these issues as high level athletes. So that potential that maybe it's, a tension issue or a challenge with relaxation can be some reasoning why higher level athletes might have this going on. And then there's a lot of other factors, in terms of their load and demand.

just repetitive impact that can be a factor as well as [00:10:00] nutritional, issues in terms of fueling that could be also kind of overlaying with that. 

Dr. Linda Bluestein: Yeah, that's such a paradox that they can have this, you know, lax connective tissues, but have this increased muscle tension. And I totally agree with you that most of us, when we think about urinary leakage, that we think, oh, the pelvic floor is weak.

Dr. Brooke Winder: Totally. And it's not always the case. Sometimes it's a coordination issue or a tension issue. 

Dr. Linda Bluestein: And we're gonna talk about Kegels. Is that how you pronounce it? Kegels? We're gonna talk Kes 

Dr. Brooke Winder: are Kegels. 

Dr. Linda Bluestein: Yeah, we're gonna talk about that later because I feel like so many people, they think. Pelvic floor equals Kegels.

And it's like, no, there's so much more to it than that. So, yes, 

Dr. Brooke Winder: exactly. 

Dr. Linda Bluestein: Yeah, we're definitely gonna talk about that later. So why do you think hypermobility, issues are so often missed in, well, both dancers and non-dancers? 

Dr. Brooke Winder: I mean, in particular, I think hypermobility in general is still something that's not widely understood.

I mean, hence why you have this podcast. [00:11:00] and so I think a lot of people who have hypermobility and they have all sorts of symptoms that aren't just about, you know, having a bigger range of motion at your joints, they've got si issues that are affecting them throughout all of their body systems. if, it's not really well understood, they.

Might be going to different doctors, different physical therapists, different healthcare practitioners for all of these different issues without realizing that it might be connected. And so I think it can easily be missed in that sense. and then for our dancer and our performing artist population, it's so common to be bendier.

that's part of what, our, you know, our sport demands. in dance is big ranges of motion kind of throughout any type of dance genre you train in from ballet, to breaking to, contemporary dance. [00:12:00] there's so much demand for high mobility that I think a lot of people who end up, in dance and enjoying it can move into those ranges easily.

and so I think because it's so common, we see it all the time, I think that also makes it harder to recognize that yes, that can be an asset for you. But that person who's working at this really high level and doing these amazing things and can move through all this range of motion, might also really be needing a lot of support in other ways with symptoms that they're managing and how they're approaching their, craft.

but, it's very hard to notice when it's just such a common thing 

Dr. Linda Bluestein: and also comparison is so common. Right. So, Jennifer Milner, who of course you know as well, very, well, she and I interviewed Skyler Brandt, who's a principal dancer, of course, with a BT. And she's talking about how she's not hypermobile well, maybe relative to, you know, Chloe Aldeen or some of the other people in the company.

Maybe she's, [00:13:00] you know, but she's, she still has more range of motion than, most people. So they're comparing themselves to each other. 'cause of course, that's who you're looking at all day, every day. So you don't really know what. You know, quote, normal people look like. So I think that's the other challenge that dancers have at that elite level is the, bar has just changed dramatically for them.

Dr. Brooke Winder: Yeah. Especially, yeah. As the years go by, it just kind of, we keep pushing the envelope. and I, think that I see the same with some of the aerialists I work with too, where they see every, a lot of times they're saying like, I'm just not flexible enough because they're maybe working with people who are a lot more mobile.

Than they are, but yeah, exactly. In comparison to the general population. They're, they have high mobility. 

Dr. Linda Bluestein: Yeah. Yeah, exactly. Okay, so let's talk a little bit about your research. You did some very interesting research on dancers, urinary leakage. and I don't know if you covered pelvic pain at all in there or not, but what was some of [00:14:00] the key little bit Okay.

What were some of the key findings from your research? 

Dr. Brooke Winder: Yeah, so, my, colleagues, Carrie Linde gr and Amanda Blackman and I did a study, a couple years ago, came out and, we looked at a little over 200 professional female dancers, and their average age was kind of mid twenties. but the age range did kind of go up to between 18 and 41, but most of them were, mid twenties.

A majority of them had never been pregnant or had a baby before. and around 34% of them said that they experienced urinary incontinence. and a lot of times it was maybe on, on the mild to moderate level of, symptoms for them, but that's, over a third that around a third. That's a lot.

Yeah. which is a pretty, pretty significant finding. and that is, is important to also position in relationship [00:15:00] to other high level, professional level or elite level athletes is that it actually aligns a lot with what's been found in other sports, with female athletes that these really high level athletes, at least around a third of them, sometimes more experience leakage.

we did, our main focus of that study was on incontinence, but we did ask other questions about things like back pain, irregular menstruation, which can kind of maybe be a factor that overlays as well as the only pain, pelvic pain question we did ask was an important one was whether or not they'd had.

history of painful intercourse and around 40% or so, I'd have to look at the exact number, had reported that they'd had an experience of pain with sex. So a huge number. and we couldn't really extrapolate more on that because we didn't have a lot of follow-up questions. but that is something I think definitely is important to pursue.[00:16:00] 

and there's, not enough studies on pelvic pain in athletic populations at all. but the few that are out there, have been on female athletes and kind of aligned with that as well, that pain with sex is a fairly common experience. and we saw something similar. I also worked with. Emily Sheb and, Heather Heinemann on a study on, female aerialists in circus.

And we had over 400 aerialists, both recreational and professional, respond to our survey. I think we had 452, female aerialists and over 40% of them reported leakage. We did have a higher percentage of those, performers who had been pregnant or given birth. and the leakage was definitely associated with things like, you know, pregnancy, history of birth.

But also there was a correlation found between, [00:17:00] those who said they were leaking and those who'd had some type of fall onto the tailbone or some type of fall. associated with training. We don't really, we have theories on why that might be connected. So, so yeah, significant numbers also in our circus population at least so far.

and also very commonly in experience of pain with sex. 

Dr. Linda Bluestein: And I remember seeing a study looking at rhythmic gymnasts and, those da those athletes were quite young and they reported quite high numbers as well. I remember being very surprised by that. 

Dr. Brooke Winder: Yeah. Yeah. We definitely have some data that shows in rhythmic and artistic gymnasts and cheer and cheerleaders, so our ground tumbling folks.

and a lot of that, that was adolescent, each group, having high numbers of urinary incontinent. so something that, that's definitely starting potentially earlier than we think. I'm [00:18:00] currently working with a couple of colleagues to gather information about pelvic floor. types of symptoms in adolescent dancers, but we're still in the data collection phase, so we'll see what we find, because we're very curious about whether we see that same thing in the dance population at those young ages, like what's been seen in rhythmic gymnastics.

Dr. Linda Bluestein: So have, you identified other risk factors besides the fact that there are a dancer or a gymnast or, you know, would, did you associate that with other risk factors when you were, you know, looking at that? 

Dr. Brooke Winder: we did look at some risk factors in our dancer study. and so what we pulled or what we tried to explore, again, it was a survey study, so there were some limitations in what we could test for, because we suspect that hypermobility is a factor.

but that was really not something we could assess through a survey. and, but I definitely think that's something that is really warranting for their ex exploration. [00:19:00] in both the dance and the circus survey study, we did ask, About irregular menstruation. And part of that was actually taken from, questions in the leaf queue to look at energy availability and relative energy deficiency in sport.

And, because there is research that seems to be connecting, low energy availability, fueling issues with an increased chance of pelvic floor dysfunction for athletes. so we think that might also be an overlaying factor. In fact, the International Olympic Committee a couple of years ago, I think it was 2023, but there are updates actually included incontinence as a health, consequence of reds.

so that's something I think, that's kind of this next exploration. We also know that athletes that do repetitive impact activities, there seems to be a correlation. [00:20:00] and certainly dancers do, certainly aerialists do, but they're in the air. So the impact, you know, is, not the same as the ground impact.

but I know that there's some, sports researchers right now, researchers have some studies out that are trying to collect data to kind of create more of a risk profile for the athletic population. And they're including questions that are relevant for dancers and that, so I'm, interested to see what they find.

Dr. Linda Bluestein: and do you think anyone has proposed, you know, possible mechanisms for reds contributing to incontinence? I'm trying to think of what the possible connection is there. 

Dr. Brooke Winder: Yeah. so. So right now it's somewhat, you know, still in the, haven't proved it phase. but when we think about the consequences of reds, particularly on skeletal muscle, that if low fueling is present, then that can just reduce the, strength capabilities of any skeletal muscle.[00:21:00] 

if it's not appropriately fueled and it can cause early fatigue. So, the pelvic floor muscles are skeletal muscles, so if they're under fueled, they're kind of, subject to the same consequences. and, other things like, like, hormonal states are probably a factor we think. So if someone's in that prolonged low fueling, and let's say they're, you know, a female athlete, that low estrogen state that could be induced if they're not getting their period or they're having irregular periods, which is not that uncommon in the dance population, that low estrogen state can affect sort of that continence mechanism, and potentially also affect, the muscle capability.

so that, that's a couple of the potential reasons why. and the other reason which probably could be magnified in people who are [00:22:00] hypermobile is with that low fueling, there might be more constipation and constipation tends to exacerbate leakage or urgency, urinary urgency. and then for our hypermobile folks who might already have something like slow motility or GI issues and then.

I guess that makes me kind of perhaps go on a tangent, but a lot of people with hypermobility have so many gut issues that they're dealing with that they may feel like they are on a very restricted, you know, eating pattern because everything really triggers them. Maybe they haven't gotten a handle on how to help out their GI system.

And so for an athlete that has the potential to lead them to be under fueled as they're trying to navigate getting a handle on their GI issues, and then that under fueling could further slow down their GI sys system or create GI discomfort on top of what they already have. 

Dr. Linda Bluestein: Oh, that's so important.

That's. Constipation, I feel like is so [00:23:00] common. And GI symptoms, like you said, are so, so common in the people that I see. And I see a ton of, I see a ton of dancers, but I also see a ton of non-dancers, you know, and, that is such a problematic sym symptom. And low back pain of course is also problematic.

So many people with pelvic pain, so many people that are having struggling with this. I had a couple follow up questions on incontinence before we move on to the next, section. So, so first of all, I'm wondering if you can let me know when you're talking about like 34% had incontinence or whatever. I'm curious, two things.

One, what's the background percent that you would expect in the general population? So kind of for frame of reference, so we could be like, oh, well the average, you know, population would be 20%. I'm making a number of above obviously. So if, you happen to have that off the top of your head. And then the other is how did you define incontinence?

Dr. Brooke Winder: so, I. Oh gosh, I hope I get it right. But I think some systematic reviews have shown general population, maybe around [00:24:00] a quarter of female populations. So, so athletes sit in some senses higher, but I think it very much depends on the study. because in the general population than, people post, like if you compare people who'd never been pregnant, never had a baby, to people who, have the rates are probably a little bit higher, because, birth, especially vaginal birth is a risk factor for increasing your likelihood of incontinence and also age, per and post menopause.

So, but I think, some studies have shown about a quarter in the general population, so there is thought that, female athletes might be actually at a higher risk. There's some studies that have shown. A one to two times higher risk of incontinence in high level athletes compared to the general population.

But again, I think it depends which studies you're looking at. so that's, kind of interesting to, to try to solve this [00:25:00] question of why are these really highly conditioned folks, experiencing these types of symptoms. And I think you had a another question that, 

Dr. Linda Bluestein: how you defined incontinence.

Dr. Brooke Winder: so we used, in both of those studies, that I was talking about on the dancers and also on our aerialists, we used, the I-C-I-Q-U-I short form, which I think 

Dr. Linda Bluestein: right, 

Dr. Brooke Winder: that's a mouthful. It's a mouthful. so it's a standardized validated questionnaire to look at incontinence. And it's got, you know, it's not super long.

So, we selected that because. Prior, athlete studies on female athletes and incontinence had used that. and so one of the questions basically asked when does leaking happen? And that, person who's filling out the questionnaire could say never, and then they could say sometimes and they can start to list when that happens.

So essentially if [00:26:00] they reported any kind of leaking in response to the I-C-I-Q-U-I short form questions, there's a particular question. And we aligned that with other, other studies that we'd seen. So based on their responses to that questionnaire, we stratified then into leaks and does not leak. And then we further asked questions that are part of the ICIQ UI short form, that gave us information about whether it was stress incontinence, which is.

If you leak when you're coughing, sneezing, exercising, and then urg incontinence, you feel really strong urge to go and then you can't make it to the bathroom. it was much more common for our dancers, similar in our circus artists to have stress incontinence. but in our dancer study we didn't, have a chance though that standard questionnaire doesn't ask specifically for athletes how leaking is [00:27:00] affecting their sport.

so when we did the circus study, we Drew from the model of the dancer study that we had done. but we did ask questions at least about how leakage affected, performance or training for our aerialists to get a little bit more information. and there's certainly lots of other validated questionnaires that are out there.

So I think, some of the newer studies on athletes might start to explore some other. Questionnaires like the Queensland. yeah. 

Dr. Linda Bluestein: And, as you're talking about that, I'm also thinking about, and I should have confirmed this with my husband or looked it up, be myself before we started this conversation, but I didn't.

but I think that there's some data that show that teachers and nurses also have high rates of incontinence. And I think that what my husband had said is because they're, holding it, you know, they're, on their feet all day and they're, you know, not able to just go to the bathroom whenever they want.

And of course, [00:28:00] anesthesiologists also definitely fall into that category. 

Dr. Brooke Winder: Yep. 

Dr. Linda Bluestein: so, so I wonder if, with dancers, you know, if they're, in multi-hour long rehearsals, and athletes are also, maybe once you have all your equipment done and things like that, there's probably some other factors as, as well, that are, at play.

Dr. Brooke Winder: Oh, sure. Yeah. Yeah. And thinking about, Well, that makes me also think about the high pressure environments. you know, you're talking about your husband's job. There's like a high pressure performance environment, for our dancers, for aerialists, for other athletes. not only might they, be on kind of this timing that they can't control, in terms of their bladder habits, but, the pelvic floor region and our, signaling system for the bladder is so dependent on, our autonomic nervous system function.

And so, I think anyone can probably understand that if you are a performer, [00:29:00] and especially in dance, if you're in concert dance and then they say places and all of a sudden you're like, oh, I have to pee. that's kind of a good example of how interconnected that bladder signaling mechanism is with.

Our nervous system. And so if you're in these high stress environments, high pressure environments that a lot of dancers, for example, are, I also wonder how that impacts that signaling system for the bladder, for these athletes, and really for any sport. 

Dr. Linda Bluestein: Yeah, no, definitely. I'm glad you brought that up because of course a lot of people who listen to this podcast, and we do talk a lot about, autonomic dysfunction, so there's a lot of people that have autonomic dysfunction and that could play a role as well.

And it's so funny that you gave that example because I remember sitting in a lecture with my urologist husband about bladder dysfunction, and I, just suddenly felt like I had to pee. I suddenly felt like I had to pee. And I was like, feeling all these sensations, you normally don't feel your bladder at all.

So yeah, I think, that's a very good, isn't 

Dr. Brooke Winder: that 

Dr. Linda Bluestein: interesting point? Yeah. Yeah. It's super [00:30:00] interesting. Okay, so let's move on and just talk a little bit about the core before we're gonna take a break. I feel like, you know, the core like and core engagement and what we're taught about that, I feel like maybe we're getting some messages that maybe are not super helpful.

What, should we know about that? 

Dr. Brooke Winder: Oh, I have lots of thoughts on it because I work with so many dancers. I also work with, I'm Pilates certified. I work with people that have trained a lot in the Pilates world, which is a lot of performers. as well as, I see it a little bit in aerial work too, but since dance is kind of that center, I see so many dancers who are taught that in engaging the core, or at least the impression that they seem to get when they're training, is that engaging.

The core is about pulling up and in, in their belly region. And that should be happening, even if they're just standing there like that, [00:31:00] that, and sometimes I think this also is drawn from how picky we can be in dance, maybe to a fault about people's alignment or how people maybe bring those alignment stories with them.

Like I have dancers like, well, I've told that I arch my back, or I've told that I tuck under. And so I'm trying to correct it all the time. And I'm like, how many years ago were you told that? And they're like, well, probably when I was eight and they're 25 now. Like, oh, well you're probably fine, number one.

And also you're just standing there. You probably don't need that high level of, contraction just to hold your body up. And, I think that pattern kind of then, particularly I know performing artists and a lot of athletes too can be really high achieving. So if you're gonna have the impression that you should hold your core and you're gonna do it 150%.

Dr. Linda Bluestein: Right? Right. 

Dr. Brooke Winder: Right. And to make sure to not let it go. I mean, I still have dancers that are trained with cues that are like, I hold in your lunch, which has also got its own, I take issue with, that. [00:32:00] Oh 

Dr. Linda Bluestein: no. 

Dr. Brooke Winder: Yeah. You know, the belly doesn't always have to be pulled in. But I think what then can happen is when someone's really clenching their abdominal wall and are not taught that can have some play to it.

Right. That during harder things you can lift someone or you're gonna do something more challenging and you need to stabilize your spine. Those muscles should naturally tense. But with lower level activities, you should be able to really breathe through it. So sometimes I think it restricts breathing because if you're really squeezing in, then you're kind of holding your diaphragm in place.

the diaphragm works so much with that pelvic floor that, that you're kind of missing the opportunity. To get that cue of the pelvic floor lengthening. We also know that when people contract their abdominal wall, it usually co contracts with the pelvic floor, which can be a really great thing for stability.

But if the pelvic floor is kind of maybe taught to know how to really pull up an N but it, you just don't practice as much of the [00:33:00] ecentric or the lengthening or the relaxation. Sometimes that can drive things like pelvic pain or urgency in particular even make leaking worse, because it can mess with that coordination function of that system.

So I spend a lot of time telling dancers that it's okay to breathe into their belly sometimes even while they're dancing because for them that feels ridiculous. The ones that feel like they're really good at pulling in, just so that they can use, get used to a different strategy. 

Dr. Linda Bluestein: Okay. We are gonna take a quick break and we come back.

We're gonna talk more about the core. And the pelvic floor and what kind of things we can do if we do have incontinence. So we're gonna take a quick break and we'll be right back with Dr. Brooke Winder.

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We're back with Dr. Brooke Winder, and I really appreciate what you're saying about the pelvic floor and engaging the core. You know, [00:35:00] and, I've taken enough Pilates classes that yes, I know that they're very much like, don't do this, drawing your abdomen in kind of a thing. but it's so interesting because I've noticed dancers and they're standing in the back of the room and you see a.

You see a variety of things. You see people kind of hanging on their ligaments 'cause they have so much hypermobility and they're so tired, you know? so, so they're just exhausted. So if they're not actually dancing and they're just kind of, you know, waiting to go in the center or whatever it might be, or waiting to go across the floor.

so what, whether you're a dancer or not in terms of posture and, you know, cues and things that we should be thinking about so that we are supporting our spine, or is there anything that we should be thinking about there that might be kind of a good tool for people? 

Dr. Brooke Winder: Yeah, I think maybe if, you are a mover who tends to kind of really be good at the drawing in part, or you tend to hold a lot of tension there, then sometimes, a nice [00:36:00] cue can be to actually maybe not be thinking about where the muscles are, but just, you know, stack your ribs on top of your pelvis.

What does that feel like? So a, the imagery of where. Where your bones are, rather than the amount of muscle tension. And I find that sometimes that can be helpful, especially, I think performing artists, we get so perfectionistic 'cause that's how we're trained in terms of the movement that if you give a muscle cue and someone's like, wait, am I doing it right?

How much? And really analyzing that, and they're like, oh, just stack. You know, maybe just more of, and sometimes that like an external cue or an image can be helpful. or if they are supposed to be keeping their spine still and we're doing, you know, core stability exercises, I really just kind of try to give them simple rules or set up the environment and kind of tell them your core is gonna turn on, it will, it's gonna respond to what you're doing.

So, you know, if they're on hands and knees and I'm wanting them to keep their spine pretty [00:37:00] straight, like, can you balance this yoga block on your back and keep breathing and now move your limbs? And hopefully their, core systems should respond to that by turning on. So sometimes I like to give them the, experience of what does that feel like when maybe you're just aligning your bones or you're thinking about one simple image or thinking about, more tasks specific rather than exactly where your alignment needs to be.

And sometimes then that needs maybe some more information for people who are hypermobile and might need more exacting to feel really good in their joints. Certainly. but I find that sometimes that can be an interesting exploration for dancers who haven't had the opportunity to train that way to see if there's other cues that help them out.

Dr. Linda Bluestein: Yeah. And I love that explanation that you, or that example I should say, that you just gave. And I know Jennifer has a lot of like great little things that she would ha at I Adams, [00:38:00] for example, the International Association of Dance Medicine and Science, when she would do workshops. And I've done some of those and she would have, people do, and I would try these like small little things that could be really challenging.

So I think those kinds of exercises are really great because, you know, it's, I think it's confusing sometimes 'cause we can do so many great things with our levers, but yet it, that doesn't necessarily mean that we are having the optimal function of our pelvic floor, our diaphragm, our core. is that accurate to say?

Dr. Brooke Winder: Yeah, I think so. And I, would say likely, maybe more accurate for people who have hypermobile joints, hypermobile bodies, because there's just more, more movement options. There's more options for positioning and, Typically, maybe also some reduced proprioception or feeling of where they are in space, especially through those end ranges.

And so that's where, for someone who's more hypermobile [00:39:00] in particular, it can feel really nicely challenging or, maybe not nicely challenging if it's really hard exercise. But some of those tiny adjustments or tiny little tasks to help, you know, that dancer find a new alignment or a new stacking, can be harder than you might imagine.

but also can be really nice because it can give some, information into your system that I think is really helpful from proprioceptive point of view that, that hopefully is easy for that dancer to then take into their class or their performance. 

Dr. Linda Bluestein: And what about the nervous system? what the nervous system and the pelvic floor, the tone of the pelvic floor, how are those connected and why is that important for people with hypermobility?

Dr. Brooke Winder: Yeah. so the region of the pelvic floor, essentially, in a lot of ways the muscles, they're skeletal muscles just like your biceps. but what is unique about that whole [00:40:00] region is that because we have our bladder and bowel function or sexual function in that region as well, is that there's a lot of, neural information or input coming in that is from our autonomic nervous system.

So our fight flight freeze, and our rest digest system really signals that region as it should to control our organ function. and the, you know, part of the tensioning and the relaxation of the pelvic floor is, driven, by those systems because when we. have to have a bowel movement when we need to pee.

We need that coordination of the appropriate relaxation to happen. and then, you know, we need the, muscles to react really, automatically. So I think because, because that's so closely intertwined with how our pelvic floor functions. And then if we have someone who's hypermobile and [00:41:00] they're dealing with autonomic nervous system dysregulation, they've got something like pots going on, that can be a big factor in how their pelvic floor region is responding.

or maybe responding in a way that is not helpful if their, system is dysregulated with pots. 'cause even some of the symptoms of something like POTS could be feeling more urgency in the bladder region, feeling kind of, like that continence mechanism is a little thrown off. So, So for anyone, whether they're hypermobile or not, any, interventions that can help improve nervous system regulation can really help with the pelvic floor, with bladder function, with bowel function, with sexual function.

but with someone, with hypermobility who may be struggling with that kind of overlap with something like pots, then man helping them with strategies that [00:42:00] manage the POTS symptoms can be AKI way to help them with pelvic floor symptoms. maybe even more so than like some bladder training program that I might give to someone where it's not that, where they don't have that complexity of what's going on with their autonomic nervous system.

Dr. Linda Bluestein: No, that makes sense. And, let's move on to sexual function. We've presented together on sexual and pelvic health, and how does pelvic floor dysfunction show up in sexual function? 

Dr. Brooke Winder: can show up in a lot of ways. in particular, I think on the, pain side of things. so if there is dysfunction to the pelvic floor region, then that can show up as, genital pain, vulvar pain, penile pain, vaginal pain, testicular pain.

and, [00:43:00] that can be due to a lot of different factors. There can be, irritated nerves that can cause that the pelvic floor muscle tension or non relaxation can also contribute. And then some of the other things I think we're gonna talk about from that hypermobile standpoint, and so pain with sex and then pain with sexual activities that are non penetrative can be common.

also, can contribute to issues with arousal. So low arousal, also low libido can be very common as a factor when that system is not well-regulated or is having trouble. and then on the, maybe a related end that can be, can have to do with things like mast cell issues, can have to do with things.

Related to neural compression, but things like PGAD where you have persistent gen genital arousal disorder dysfunction, or that could even be due to, [00:44:00] other sacral issues that are contributing. but that can be a really distressing symptom that people can deal with as well. and then, issues like incontinence or pelvic organ prolapse or bladder urgency and frequency can also interfere with sexual function as well, and contribute to people having lower desire contribute to people having lots of different discomfort.

related to sexual dysfunction, and also just stress surrounding, or maybe even shame surrounding that because they're dealing with pelvic floor symptoms that's affecting their sex life. 

Dr. Linda Bluestein: Yeah, and I'm glad you mentioned about, PGAD and mast cell and there's, so, there's so much of this that, you know, you and I, when we've done presentations, it's nice when, most of the time we've had 90 minutes together, so we each have 45 minutes because it's, a lot to talk about.

And of course we then, we have slides and everything, so it's really, helpful to be able to, you know, show, with [00:45:00] diagrams and studies and things. Yeah. The PGAD piece is really interesting 'cause I know that there have been studies that have shown that PGAD, persistent genital arousal disorder is more common in people with hypermobility.

So I'm glad that you brought that up as well. So what should rehab clinicians focus on when they're working with hypermobile patients to help them manage sexual dysfunction? I 

Dr. Brooke Winder: think there's a, few big areas when it comes to, working with people who are hypermobile. certainly assessing the pelvic floor itself, if you're a pelvic floor physio, is something that's gonna be a given no matter what, person you're working with.

whether that's external and or internal assessment. but I, with people, well, through any patient, particularly for people who are hypermobile, I really kind of think about zooming out to some big themes that can help them out. so one piece is really looking at [00:46:00] their pelvic floor symptoms, you know, as this, like why is their pelvic floor so angry?

Why is their per pelvic floor needing to, to, hold tension or why is it responding in this way? And then in that zoom out, one of the pieces I think is really important in rehab is then looking at all. Potential other orthopedic issues that someone with hypermobility could be dealing with. So people who are hypermobile are gonna have potentially issues with if we think nearby regions, maybe more issues with hip instability or femoral acetabular impingement, or other, joint issues within the hip, that could be, a place where they need some stability and strength and support in treating that hip.

And that allows the pelvic floor just one of those little pieces that can allow their pelvic floor to function better. similarly with low back issues, that are common in people who are hypermobile, [00:47:00] there's a little higher incidence in things like, if you think of low back sacral tarlo cyst disc herniations.

so is there pelvic floor actually having trouble because, of something more proximal that needs assessment? Or just even giving them the idea of stability elsewhere can be helpful. and even kind of zooming further out issues in the cervical region. So people who are hypermobile might be dealing with things like upper cervical instability or just a lot of neck hypermobility that can be really distressing for their nervous system, kind of proprioceptively and also cause a lot of tension to be held up here.

And I know my, pelvic floor physical therapist will know that a lot of times this tension and issues up here and clenching up here seems to correspond with the pelvic floor having a lot of tension. very similarly, making sure to screen [00:48:00] and, help support things like jaw issues, with TMJ, gum issues, dental issues, anything in kind of that oral facial region that's calm more common in people with hypermobility that can cause a lot of tension up here that then can.

Be one piece that's also driving tension that already exists at the pelvic floor. so I think that's a really big piece is like that zoom out and thinking about all the different, I mean, it's kind of nice. There's lots of inroads that could help actually even indirectly that pelvic floor find a little bit better balance.

and then kind of on this other big piece, I think, looking at lots of coping strategies and like things like pacing for patients with hypermobility and sexual dysfunction or hypermobility and pelvic floor dysfunction. because, you know, people who are hypermobile might be dealing with a lot more fatigue or challenges in recovering after daily [00:49:00] activity.

we're, and that, or sport, right? So, I think helping them figure out how to work through patterns of when they might. Plan ahead for a time where they're gonna be more fatigued or they know they get really wiped out of these things. 'cause if you're really tired and you just don't feel well and you can't recover, that certainly can affect libido.

and so I think, helping those patients really try to suss out some patterns, which can be hard 'cause it's hypermobility. I think I have a lot of patients where they're like, there's no pattern. I can't quite predict what's gonna happen. But maybe setting up the things that they know they go to, to, calm their system down, whether that's meditation or a heating pad or a brace.

You know, like if they're gonna be doing a more difficult activity and they know, they sh they feel better if they put a neck brace on or they feel better if they have those support. Some of that planning, I think can help them figure out [00:50:00] then how to navigate coping strategies when it comes to sexual function.

With themselves, with a partner. so that can be a big piece too. because some people who are hypermobile, I think we've talked about this before, might, manage symptoms by actually kind of overdoing it. Like, like if their sensory system feels better when they just go, or they actually feel worse when they sit too long or stand too long, sometimes that might be driving people to do too much and they don't realize that's part of their, kind of behavioral patterning and trying to find a balance with that.

Or if they're really, you know, having a lot of symptoms through movement, maybe they're not moving enough and, need to really find an inroad to get, moving just so that their body can feel more confident or feel more positive with movement. because that's, an important piece with, sexual function and, pelvic is [00:51:00] pelvic symptoms.

And then in terms of sexual function too, for people who are hypermobile, if you're thinking about strengthening programs, think about sexual positions that they feel nervous about getting into. Like maybe they might feel like, oh, I feel like my hip's gonna dislocate. or I feel like my shoulder or my finger or my wrist.

So, you know, asking questions about that and trying to work with them in terms of like those exercise positions that might help them build more strength and stability and more confidence so that they don't, have to sit with as much fear about having a flare up with sexual activity, even not totally directly related to their pelvic floor, but related to their surrounding joints.

Dr. Linda Bluestein: Yeah, there's so many things with hypermobility and I mean, even just people who aren't hypermobile. The pelvic floor is so co I feel like it's so complicated and, you know, like we hear this, oh, just, do more Kegels. But you're talking about the relaxation piece and how you know that you need to balance the stability.[00:52:00] 

and, the ability to activate the muscles with the ability to relax the muscles, it sounds like too. So how do you know where you are on that spectrum? And do I need more Kegels or do I need to learn to relax my pelvic floor? 

Dr. Brooke Winder: Sometimes we can, tell most easily with something like an internal pelvic floor assessment where we can really palpate a painful region or feel that we can feel that the muscle or see that the muscle is having trouble relaxing, and that can kind of give us a clue.

but for someone like, you know, if you are dealing with a pelvic floor issue, things that are more commonly associated with more tension or non relaxation or difficulty relaxing, can be things like pain, pain with inserting a tampon, painful sex. Frequent urinary frequency or urgency or painful [00:53:00] menstruation.

those tend to have more correlation with more tension in the pelvic floor and also incontinence. But kind of look at like, are you dealing with these other things? as I mentioned, with whether it's kind of more of a weakness driver, you know, are you, pregnant or early postpartum or postpartum?

If you've given birth that's especially vaginal birth. Maybe you've had a very big stretching of that pelvic floor and that strengthening piece is probably a, maybe a bigger first step after something like that, or a pelvic surgery, that's where we're gonna see. Or maybe you've had, like a nerve dysfunction that has caused weakness, then that makes sense that might be the first inroad.

What's kind of interesting that I think we're gonna, of course, because it keeps getting more complicated, but also we get more [00:54:00] information out there that there is, I, think we kind of swung the pendulum in this way where if someone has too much pelvic floor tone, then we kind of went in this direction of like, okay, well stop kaling.

I think you can know if you're doing pelvic floor contractions, it's making your symptoms worse, that's probably a good clue that you need to try a different route to start to manage your symptoms. And I know that seems maybe too simple, but, a lot of people find that're like, that doesn't make any sense.

I'm doing pelvic floor contractions. I thought it was weak, but I actually am leaking more. so sometimes you could start with going, okay, well now if I try some things that, that foster relaxation, maybe learning some internal external stretching or self massage or yoga breathing or positions that give me relaxation, does that start to calm my symptoms?

But what's interesting is we are seeing some newer papers, I think come out in the last couple of years that are showing that we don't have to totally avoid strengthening with people who have [00:55:00] pelvic pain, that it, that kaling can be a piece of the puzzle. but it's about, trying to make sure that we're assessing someone's strength and length and ability to relax and then finding maybe the first inroad to help them get their symptoms under control.

And then as we are working, sometimes strengthening can help to decrease pain. but I think it's about what you're finding clinically when you assess someone and how they're responding to initial treatment to kind of help figure out that balance of strength and length. 

Dr. Linda Bluestein: Yeah. 'cause the pelvic floor can be overactive or underactive.

Right. And can a person have. Overactive sometimes and underactive other times. Is that possible? 

Dr. Brooke Winder: I mean, it seems to be the case, and that's kind of like with what I was just kind of mentioning with, you know, some people with pelvic pain are maybe benefiting from certain types of contraction and [00:56:00] strengthening.

even if they're already holding and maybe they're sitting in a tightened pos like an overly tightened position, that somehow that strengthening actually helps them learn to relax the muscle. so yeah, I, it seems to be that they're, maybe it's just not as simple, which kind of makes sense, right? Us as humans and the way our bodies move, it's never so, you know, you're in one lane or the other.

So I think that some, people are kind of dealing with a combination of, both. And if, your muscles already so like holding so much. Then it's hard to really, like, you're not starting at a great length, tension relationship to get a good contraction. So in that sense, it can actually maybe sort of seem like it's presenting as under activity because you're, already, you already shut the door, so you can't, it's hard to just shut it more so to speak.

Dr. Linda Bluestein: Yeah. No, that makes sense. And are there certain things that people [00:57:00] should stop doing that they might be doing that are making things worse? 

Dr. Brooke Winder: Oh, that's such a good question. I think going back maybe to the simplicity side, that if you have kind of start you, you're noticing you've had pelvic floor symptoms and you had maybe assumed or just thought, okay, maybe I should start contracting my pelvic floor, and you're noticing that it's either not helping or it's making things worse.

try something else. Try either strengthening the rest of your body or what we call down training and relaxing it. I think. I think just because it sounds like it's supposed to work. If it's not working for you, it maybe it's actually just not the treatment that you need. And maybe that's too simple of a, thought, but I think sometimes you can think, well, like, this is so frustrating, it should work for me.

I'm leaking, I'm probably weak if I'm working on contracting these muscles, why isn't that helping? and [00:58:00] sometimes it's about treating and helping every other aspect of the body to support the pelvic floor so that it can work more efficiently. Or sometimes it's about relaxing the pelvic floor or learning different types of coordination.

so I would say that's probably a big one. and then I, think maybe this is maybe more on the clinician side and I don't, I, think we were gonna head there. But if, you're really treating the pelvic floor and, it's like kind of getting narrow and working on pelvic floor strategies, sometimes that's too focused on this region, especially for hypermobile.

People don't forget to zoom out because sometimes you could be trying to relax their muscles, but if they've got, a pots issue or a mast cell issue that's driving the pelvic pain, you can keep teaching them to relax. But really, they actually might make [00:59:00] some bigger gains if you help get support for them in those, other health considerations that actually might be a bigger driver.

Dr. Linda Bluestein: So you're saying that sometimes we can get overly focused on something like the pelvic floor when really there's other contributing factors and we need to zoom out and be looking at those other factors as well? 

Dr. Brooke Winder: Yeah. Yeah. Particularly. like I mentioned with the hypermobile population, there's, inflammatory drivers.

There's, a lot of GI system issues that, a lot of times with things like leakage or urinary urgency, managing constipation can have a huge positive impact on reducing bladder symptoms. and so that can be another piece that, that just can be super helpful, ma And also managing kind of, with a registered dietician or looking at, [01:00:00] you know, all the different supports that maybe are needed from a nutritional and nourishment side that might help the constipation and also help energy levels when it comes to athletes.

I think that's just another, window to, make sure you're thinking about, you know, to see if that can really help that person. 

Dr. Linda Bluestein: And for people who are listening to this and saying, well, they just kind of sound like me. What's the first step they should take? 

Dr. Brooke Winder: oh boy. I mean, I think if, they maybe haven't started to find a support system for, these issues, so if, you're thinking, this sounds like, man, this is a pelvic floor issue, and you've never really connected with like a pelvic floor physical therapist, maybe start exploring what could that look like?

because a lot of times pelvic floor PTs, are gonna be looking at the systems surrounding that and can be really [01:01:00] helpful, particularly, and I think if you're an athlete, like a dancer, a performer who is kind of resonating with this. working with someone who understands high level athletes that will look at the whole picture, I think is really helpful.

That kind of can hear the mobility piece, the pelvic piece, and the fact that it's, that your whole body needs to really function at a high level can be a really helpful thing. So start kind of reaching out in your community, kind of looking at resources, even people that have been on your podcast and other places.

asking around within the performing arts community, you know, and you know what's interesting on the dance side, I know lots of performing arts PTs now that are pelvic PTs. There's something about where we've kind of headed in, into that performing arts care. [01:02:00] so for dancers, I'm seeing more and more kind of every conference we go to, there's more and more.

At least on the PT side, where yep, they treat orthopedic issues, high level dancers, and are also trained in pelvic floor, which I think is so cool and exciting. so just know that we're out there. Hopefully more of us are multiplying every year. 

Dr. Linda Bluestein: Yeah, I, hope so too, because, you know, it's the whole hammer nail thing.

So you, only have the tools that you have, so the more tools you have, the more you can help somebody. So if you're trained in orthopedic physical therapy and also pelvic floor or physical therapy, you're gonna be able to offer, you know, such a wider range of, things and, you know, don't get me started on insurance.

Mm-hmm. And how, oh, but you're treating the left ankle. God forbid you look at the right ankle, or God forbid you look at the left knee, you know, or something. It's just drives me insane. because I 

Dr. Brooke Winder: know [01:03:00] 

Dr. Linda Bluestein: for the insurance companies that are listening, everything in the body is connected.

So, so true. You know, number, one, everything in the body is connected. And number two, if there are any insurance people listening, please, pay more for these other ancillary things that people desperately need. Like, you'll pay for surgeries, you'll pay for outrageously expensive surgeries, but people need things like this.

They need to be able to go to Pilates and, you know, ideally have their insurance pay for it because it's for their health and it's gonna help them function better. And, you know, it might save you a lot of money in the long run, but I know insurance companies are, don't, not looking at things that way.

They're not preventative or, anything. But yeah, that, that's something that obviously is one of my soapbox. before we wrap up, can you tell me what you think is a big misconception about pelvic floor physical therapy that you want to take this opportunity to clear up? If there is any? [01:04:00] 

Dr. Brooke Winder: I, would say for.

Maybe potential patients. So people who are having pelvic floor issues and kind of thinking about what pelvic floor physical therapy is. I think one of the misconceptions that people can get is that it only or has to involve an internal exam of that region, which can feel really scary and intimidating for people, or it might not be what someone really wants to ever pursue.

and I think that can hold people back sometimes from getting an assessment from a pelvic floor physical therapist or physio. and so I think it's important for people to know that it. Is a method of assessing the pelvic floor muscles, but it is not the only way that we are assessing muscles.

I treat lots of people virtually. and I obviously don't do internal exams. I'm not seeing the patient right in front of me. and we [01:05:00] figure out lots of strategies to help the pelvic floor. And so, you know, you are, you have agency, you are the person who gets to kind of decide what is important to you in your care and what you feel comfortable with.

and you don't have to have an internal exam. There's a lot of ways that we can figure out what's going on, and a lot of times we're looking at whole body function, and there's, ultrasound, there's external modes of assessment. I think technology is continuing to help us with that, that give people lots of options.

So just know that pelvic four BC is not just about the pelvis, not just about internal exam. It really is. Looking at a lens very similar to I would call orthopedic pt. so I think if more people can know that, and that you can find many pelvic physios who will work with you. And if you're not comfortable doing an internal [01:06:00] exam, there's lots of ways to figure out what's going on.

Dr. Linda Bluestein: And that's great that you can actually do it virtually. Like, like we're doing right now. I'm in my home office. I don't know if you're in your home office. Yeah. But I'm, yeah. So, yeah. Okay. Well, this was such a great conversation and I know that you know, that we like to end every episode with a hypermobility hack.

Do you have one to share with us? 

Dr. Brooke Winder: Yeah. I would say, if you are hypermobile, just know that even if you have a ton more mobility and maybe some connective tissues that. don't respond the same way as other people that you can. You can get strong, you can perform at a high level if that's something that you want.

I think it's about finding, sort of the right recipe for you and figuring out how you feel best supported in how you navigate movement. and that sometimes can be about slowly building a team, that supports you, [01:07:00] and figuring out little bits of something here and something there that can help you feel like you can take your movement to the next level, no matter where your level is to start with.

Dr. Linda Bluestein: And I think I've told you that it was listening to you in one of our talks together and you were saying something about sometimes having weights actually helps with proprioception. And I, kept thinking that I had to be like, really good at doing. My weight training class with just arm weight before I could hold any weights in my hands.

And then after listening to you say that, I thought, I think I'm gonna try to start using, you know, light weights. And it did seem like it helped my proprioception and of course helped me get stronger faster. So I really have you to thank for my, you know, actually making some progress in that direction and actually building some muscle recently.

So thank you. 

Dr. Brooke Winder: Yeah, that's so awesome. and I think it's important to know that even if maybe there's these other factors [01:08:00] that, tissues respond to loads, so load can help improve resilience of our tissues, we just might have to tweak kind of how fast that happens or how we recover. but it's often helpful and like you said, helpful on the proprioceptive end.

Sometimes I can be giving a million cues to someone about their alignment, particularly if they're hyper mobile. And then. I'm like, oh, this isn't helping. I'm not, giving them helpful feedback and by hand them a weight, their body figures it out because they've got that kind of maybe axial or compressive lobe that just helps their, body figure out what feels good to them.

Dr. Linda Bluestein: And this is where it's so tricky because, you know, it's so common to have kinesia phobia when we are, when we're hypermobile, right? So we're afraid to move and we could get injured doing small little things. And it's, so, it's ironic. I mean, I've injured myself doing small little things, but now I'm going to this weight training class three times a week, and I've, knock on wood, been doing, you know, well with that.

So it can be so [01:09:00] tricky to figure that out. But I think no matter what you, need to have a certain amount of load, right? On your tissues, whether you have a genetic connective tissue disorder, or if your connective tissue isn't functioning as well as you would like it to, because your immune system isn't functioning optimally.

But either way, right? We need, we keep needing to do some challenges. On our bodies, right? Because otherwise we will get weaker. is that correct? 

Dr. Brooke Winder: Yeah. I mean, I, one of the biggest things that seems to, you know, if we're really distilled down exercise as an intervention is really helpful in so many ways.

And the, magnitude or the intensity of that can be scaled obviously. But, but our tissues need some type of stress. Not all stress is bad stress. and we need some type of stress to keep that stimulus for our bone health, for our muscle health, for and for our connective [01:10:00] tissue health. and, it is like I find with the dancers that I work with that are hypermobile sometimes, you know, they can be doing these really high level things in their class and their performance and then they're like.

You know what really threw me off was sleeping. 'cause they were in a passive position and that felt actually more uncomfortable than when they are getting that stimulus for all their muscles to contract around their joints and support them. and that feedback from moving and also the joy of movement, if you can, find something that gives you a little bit of joy or it's kind of fun, and it can feel good to, to make that little leap or that little accomplishment and feeling a little bit stronger.

Dr. Linda Bluestein: Yeah. And I, I realize as I'm saying that, I also want to acknowledge that people who have postex exertional malaise, that can be very, tricky to figure out, like, what can I do? And I'm not saying that everyone should go do a graded exercise program because I know that can really set some people back.

But those are often [01:11:00] like, you know, prescriptive, right? They're like, do you do this, then you do this, then you do this. And we really need to individualize things and make sure that we're meeting people where they're at. And, helping them to move as much as they can because it just, otherwise it seems like it just, you know, turns into sarcopenia, muscle loss and, you know, other, suboptimal things like, you know, dysfunction of the autonomic nervous system.

Not to throw that in at the very end, but I just realized after I said that it could be misinterpreted by some people. 

Dr. Brooke Winder: Yeah. Yeah, 100%. And I'll kind of put the lens on that, that I, my, I work with a lot of hypermobile folks that are high level athletes, and I acknowledge that is definitely not everyone's experience.

if you're dealing with a hypermobile issue. and maybe it's, maybe your goal is like, I've, I need to get outta bed today. so, so you know that moving more like is so scaled so differently depending on where you're at and what your needs are and what your symptoms are and your conditions [01:12:00] are.

so yeah, I definitely agree. I think that's such a good point. 

Dr. Linda Bluestein: Yeah. And thank you for saying that because Yeah, it's, so true. That's why I really. Bendy bodies. I've, every, so often I've thought about, oh, should I change the name? But really I want this to be for anyone who has hypermobility, whether they are a high level performing athlete, or if there's somebody who, yeah, they can't get out of bed.

They have so many things going on. And of course there's massive differences between these people and science hasn't really caught up yet, but hopefully we're making some progress to figure out like, why do people look so vastly different from each other, yet they also have some similar similarities.

Right. So, well this has been a fascinating conversation as always. I love getting to hang out with you and it was fun to, to get to do this. 

Dr. Brooke Winder: Yes. Thank you so much. It's so great talking with you.

Dr. Linda Bluestein: I am super excited to tell you about the Bendy Bodies boutique. I'm so proud of our fierce styles and [01:13:00] flexible designs. These are created by hypermobile artists. For hypermobile shoppers, there are so many fun items from clothing, accessories, home goods, and my favorite are the bags. I especially love the weak weekender tote with one of the EDS tough designs.

Whether you're shopping for yourself or someone you love, there's so many options to choose from. A portion of the proceeds goes to support EDS nonprofit organizations. For more information, please visit bendy bodies boutique.com. Thank you so much for listening to this week's episode of the Bendy Bodies Podcast.

If you'd like to go deeper, I share additional education, clinical insights, and resources in my newsletter, the Bendy Bulletin, which you can find on substack@hypermobilitymd.substack.com. You can also help us spread the word about connective tissue disorders by leaving a review, sharing this episode, or sending it to someone who needs it.

These small actions truly make a difference in raising awareness about conditions that are still widely misunderstood. And don't forget, full video episodes are available every week on YouTube at Bendy Bodies Podcast. As many of you [01:14:00] know, I offer one-on-one coaching and mentorship for both individuals living with connective tissue disorders and people caring for them.

You can learn more about these options on the servicesPage@hypermobilitymd.com. You can find me, Dr. Linda Bluestein on Instagram, Facebook, TikTok X and LinkedIn, all at hypermobility md. As part of our collaboration with the UVA Ehlers-Danlos Syndrome Center, we also wanna share some of their helpful resources.

For questions or appointment inquiries, you can contact the UVA EDS center at R Uva EDS center@uvahealth.org. Again, that's the letter R as in Robert uva, EDS center@uvahealth.org. You can find answers to common questions at uva health.com/support/ EDS slash faq. Our incredible production team is human content.

You can find them on TikTok and Instagram at Human Content Pods. As you know, we love bringing on guests with unique perspectives to share. However, these unscripted discussions do not necessarily [01:15:00] reflect the views or opinions held by me or the Bendy bodies team. Although we may share healthcare perspectives on the podcast, no statements made on bendy bodies should be considered medical advice.

Please always consult a qualified healthcare provider regarding your own care. For more information about the Bendy Bodies program, disclaimer and ethics policy submission verification, licensing terms, HIPAA release terms, or to get in touch with us, please visit bendy bodies podcast.com. Bendy Bodies podcast is a.

Human content production. Thank you for being a part of our community, and we'll catch you next time on the Bendy Bodies podcast.

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