This is an interview between Georgie Kovacs, founder and CEO of Fempower Health and Corey Hazama, PT, DPT, OCS, CFMT, PRPC, WCS from Beyond Basics. Corey is a member of the American Physical Therapy Association (APTA) and Women’s Health Section, Interstitial Cystitis Association, and International Pelvic Pain Society (IPPS), serving as co-chair for the medical research committee. Corey is a pelvic floor therapist and founder of Beyond Basics, which is a physical therapy practice in New York City.
Georgie: tell us about yourself and why you started Beyond Basics.
Corey: I went to college in Boston. When I first was trying to figure out what career I wanted to go into, someone mentioned physical therapy. I had no idea what it was but knew I didn’t want to sit in an office. I discovered a love for the field. I graduated from college in Boston and moved to New York, where I started doing sports and orthopedic physical therapy. That addresses things like back and neck pain and post-surgical rehab. I was introduced to the Institute of Physical Art, which is a continuing education program with classes that teach hands-on and manual skills.
Manual physical therapy uses hands to mobilize joints, retrain body movements and facilitate muscles to work correctly. I started working with more complex injuries and chronic pain syndromes. I found that patients with back pain and hip pain weren’t recovering. I did all of the tools in my kit to rehab them without seeing improvement.
This is when I started to look more closely at the pelvis and the pelvic floor. I noticed the intricate nature of how the pelvis works in relation to the hips and spines and realized I was missing a huge component. This recognition motivated me to get into a clinic where I could practice in this area. I met Amy Stein and decided to completely switch my career path into pelvic floor work. I love working with this population of people. We see men and women. I really started to see the things that I was doing having remarkable changes in symptoms.
Our patient load necessitated opening a second location. We now have a second Beyond Basics location downtown.
Georgie: “downtown” refers to downtown Manhattan and they also have a midtown base. All of this info is relevant to people in any location.
What is pelvic floor PT?
Corey: pelvic floor PT is an orthopedic designation of physical therapy. PT can treat cardiopulmonary conditions, pediatric conditions, etc. Orthopedic therapy treats musculoskeletal injuries. Pelvic floor specifically addresses the pelvic region, including muscles inside the pelvis. There is a large component of education and pelvic health awareness that we teach in regards to sexual function, balance and bladder function and maintaining optimal function of those systems.
Georgie: give me some examples of conditions that can be treated with pelvic floor PT.
Corey: tailbone pain, hip pain, groin pain, lower back pain. We also treat other conditions that may be less familiar, including vaginismus, which is an involuntary contraction during penetration. We treat pain with intercourse. When the pelvic floor muscles aren’t coordinated or strong enough, it can result in urinary or even fecal incontinence. There are a wide range of things that we can treat.
Georgie: how does someone come to a pelvic floor PT? You may have these conditions but there is a spectrum of specialists. Given the nature of the healthcare system, not everyone is aware of what is available. Let’s say I’m a woman at my OBGYN and have certain symptoms that aren’t getting better. How do I know that I should seek pelvic floor PT treatment?
Corey: awareness is improving. However, many women have no idea that having pain during a gynecological exam is abnormal but it really shouldn’t be painful. I’m hoping that more and more gynecologists with standard routine PAPs and using a speculum, if a woman is flexing or cringing or saying it’s painful would be aware of potential issues. Some specific doctors have moved more into a specialty of sexual medicine, which cover things like pain with intercourse. This awareness may not be part of a typical examination.
Women need to ask their gynecologists if something is painful.
Georgie: sure. For example, endometriosis isn’t always accurately diagnosed. Pain can be a symptom. Can PT specifically help?
Corey: pain, specifically with endometriosis, is more a symptom but there can be a lot of conditions that do result in having weak pelvic floor muscles. The pelvic floor is underneath all of your abdominal muscles. Any condition that has irritation to any structure, including the rectum and vagina, could be offset by pelvic floor treatment. Muscles spasm and go into protection mode when they’re threatened. This is a reflexive reaction to something not being right in the area.
Conditions like IBS or Crohn's disease can indicate the need for pelvic floor physical therapy.
Endometriosis is a condition where cells that are similar to the lining of the uterus exist in other places. These can be in the pelvis, on the ovaries, in the abdomen, on the rectum, on the intestines. It causes irritation and inflammation because it’s tissue that’s not supposed to be there. That, in turn, irritates organs and can irritate the pelvic floor, resulting in spasms, tension and pain.
Georgie: when you’re facing any of these conditions or symptoms you get in tune with how much of a machine the body is.
I recently interviewed Dr. Allyson Shrikhande and she does pelvic floor rehabilitation. I thought it would be helpful to break down the difference between that treatment and your treatment.
Corey: pelvic floor physical therapy doesn’t offer the same interventions as pelvic floor rehabilitations. They are medical doctors. We are not. We work on hands-on, soft tissue mobilization techniques, joint mobilization and exercises. This relaxes or retrains the muscles. We’re usually the first line of attack. You want things to be as minimally invasive as possible. You want to start with physical therapy. If that doesn’t work, you may need a little more help, when you’ll be referred to pelvic floor rehabilitation or another specialist.
If women don’t respond to our techniques, they may benefit from an injection or even a medication.
Georgie: I’ve heard a lot about vagina massages. How do they help women?
Corey: we’re looking for the dysfunction within the muscles themselves. I like to call it soft tissue mobilization. In regards to the vagina, we do work inter-vaginally and inter-rectally, with one gloved finger. It is the only way that we can get to these pelvic floor muscles. It really has been, in my learning process, a transition from working outside the body to accessing internal muscles. It has been enlightening for me.
I was finding patients where the pain didn’t go away. After receiving specialized training in the pelvic floor field, I learned how to use the right level of sensitivity to access these muscles. From being able to palpate muscles on the outside of the body, I know what it feels like when a muscle is restricted or tight. Women identified immediately the pain that was unbearable. These muscles are so important and can really cause pain anywhere in the body.
Accessing these muscles can illuminate issues with abdominal pain or pain down the legs. There is an interplay. It’s been a huge learning process for me. If women are skeptical or embarrassed I’d say: just like the muscles outside the body, with any pain, if you want to release tension or increase mobility, you have to access those. These muscles just happen to be inside the body. It’s never something you have to do: it’s always an option or choice. Experts in this field have excellent training and can thoroughly explain the process.
Georgie: have you ever had women who show up and refuse this treatment?
Corey: some women come in scared or skeptical, especially if they are having a lot of pain. For instance, if they can never use a tampon because it is too painful. In those cases, we would never start with an internal examination. If anyone is anxious or fearful of the pain, there are plenty of things we can do external to the pelvic floor muscles. There are also muscles that are closer to the skin that we can palpate from outside the body. We’re careful to educate each of our clients on their anatomy and the treatments we’re performing.
Georgie: you’ve mentioned dealing with pain during an annual gynecology exam. We as women aren’t taught a lot about our bodies. Most women can’t even draw their anatomical parts. Let’s talk about what shouldn’t be there. Besides when you’re having pain during an exam, what are other things that women just “grin and bear it” about because they don’t know better?
Corey: in regards to gynecological exams, I can remember back to my mom describing it as “uncomfortable.” When it was really painful for me, I thought that was what she was talking about. The same thing happens with painful periods. We all sit around and complain about cramps, normalizing that pain. For one out of ten women in that circle, though, the pain could be debilitating but she thinks it’s normal.
Women write it off themselves and are written off by medical providers, which can be damaging to their mental state.
With intercourse, women tend to just allow penetration even if it’s painful. Having an understanding that nothing should be painful or put up with is important. Women have a right to have good pelvic health and a right to good care: there is help out there.
Georgie: what if I live in a very small town, hundreds of miles from a major city: would my access to pelvic floor PT be limited? What can women do if they can’t find this kind of treatment?
Corey: we are very aware of this. In New York City, we do have access to some of the best doctors in this field. There is a lack of knowledge and awareness in other parts of the country. We’ve always had, at our Beyond Basics locations, an “out of town” program. Women and men can come, stay in the city and get treatment for a week. Usually this is for more than an hour a day. It’s almost like boot camp for treating yourself. You get a thorough assessment and an exercise program.
If you have the knowledge, there is a lot that you can do at home. You need the initial guidance of a physical therapist to get you started in self-treatment. It’s a fascinating experience. With COVID-19, all physical therapists have been pushed into doing more telehealth and online treatments with our patients. Going forward, these consultations via the internet will be immensely helpful for people who don’t have access to specialists.
Georgie: I didn’t know you offered something like that and I do think it’s important to have these options. COVID-19 is forcing everyone to think differently about our lives. I’m glad that you’re getting creative.
Are there any misconceptions about pelvic floor PT that you would like to clear up?
Corey: within our own medical community, a lot of pelvic floor therapists are being perceived as treating an isolated element of the body. I’ll have doctors that refer patients to me specifically for a pelvic floor condition but being sent to another physical therapist for another, orthopedic condition. I work at a clinic with some of the strongest orthopedic therapists that I’ve ever met. We see the body in its entirety. There are things that go on in the neck that could be related to pelvic pain. The misconception that we’re “just pelvic PTs” needs to change. We are whole body PTs.
In regards to orthopedic physical therapists, we’re probably more whole body than they are because we treat in an area that most other specialists don’t have the training to treat.
Georgie: part of how I got in touch with Corey was at an endometriosis summit. All of a sudden I heard about Beyond Basics, and my son goes there. I emailed his physical therapist to get in touch with the head of the center. I’ve been educated by you around these different aspects.
I have hypermobility syndrome. Now that I look back I realize that I’ve been at physical therapists quite a lot in my life. How does someone determine what a good physical therapist is?
I’ve been to some PTs where they show up, give you exercises, hang out in the corner and watch you do the work. The exercises don’t change. Then I’ve been to physical therapists where they sit next to you the whole time, manipulate you, give you heat and touch you constantly. That’s the spectrum I know. How do you make the decision for treatment?
Corey: there are some conditions where the PT needs to interact minimally. In regards to choosing a physical therapist, you need to understand your own body as well as you possibly can. If you have underlying conditions, like hypermobility, going to your standard PT who’s doing high volume and low supervision could be detrimental. People who are hypermobile compensate and do things differently, which could lead to hyperextensions and injuries. If you aren’t being watched, that could result in a bad injury.
So, you need to understand your own situation. Do you have underlying conditions? How extensive is this pain or issue? Our patients are fairly complex. They may have pain, bladder dysfunction, may have a history of broken bones without full recovery, history of migraines, etc. In our understanding, there are more components that need to be considered. A good physical therapist will take that all into account.
If you tore your meniscus, you just need some good exercises and some heat. That could be a very basic, fairly hands-off physical therapist. In contrast, if you have long-term pain or had hip pain and haven’t seen improvement, you need to take the steps to find a physical therapist who has more background and experience in those conditions.
Georgie: that’s a good, full perspective. There is a spectrum and matching your needs with a provider’s abilities.
There isn’t a lot of information but a lot of great changes are happening. What is your greatest hope for women's health?
Corey: I really, truly believe that every single woman deserves the best attention and treatment. No woman should have their pain overlooked or dismissed. The whole medical community needs to take women’s conditions seriously. I’ve been floored before hearing about all-male clinical trials for drugs that are then prescribed in the same dosage for women with the expectation of results. Moving in the direction of taking women’s health more seriously and providing the research and care they deserve is what I hope to see in my lifetime.
Georgie: at Fertility4Me, we've built a survey to crowdsource from women what their experiences are. I think women’s own experiences are where we identify the gaps, whether that be treatment, knowledge, research or other areas. The goal then is to go to companies that do research, run pharmaceutical trials and develop new drugs with this large-scale data.
What inspires you as you treat patients?
Corey: In so many cases, pelvic floor treatment hasn’t been looked at or addressed. Typically, I’m the first person to provide this to a patient. The changes can be profound. In many instances, it’s like we give people their lives back. Sexual health, bladder function and other issues completely transform someone’s lives.
I get inspiration every day from my coworkers and patients. I work with a group of women who are constantly challenging themselves and pushing themselves. We all stay on top of our game and continue to teach ourselves and learn new things every single day.
I’ve benefited from some of the most capable and innovative physical therapists in the world. That is a major component in wanting to continuously self-improve.
Georgie: thank you for making time. I’m grateful to have connected with you and see all of the wonderful things that you do for patients. This will be a great asset for women who are struggling and can’t find their way forward.