My New Abdominal Distention Protocol

How posture, deep breathing, pelvic floor therapy, and a healthy mindset can improve gut health with Jandra Muellerading in sentence case.

Jandra Mueller–pelvic health physical therapist at The Pelvic Health and Rehabilitation Center–is back on the podcast to discuss the surprising connections between pelvic floor health and gut health. This time, she weighs in on the three-step protocol I’ve developed to improve abdominal distension and how posture, breathwork, and emotions all tie into healing the gut and feeling better. Listen in to learn more.

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Intro:

Welcome to Dr. Ruscio, DC Radio, providing practical and science-based solutions to feeling your best. To stay up to date on the latest topics, as well as all of our prior episodes, make sure to subscribe in your podcast player. For weekly updates, visit DrRuscio.com. The following discussion is for educational purposes only, and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking with your doctor. Now, let’s head to the show.

Why does abdominal distension linger for some patients?

Dr. Ruscio, DC:

Hey, everyone. Today I spoke with Jandra Mueller. She is a pelvic floor PT and she’s back for round two, where together, we unpack and expand upon this abdominal distension protocol I’ve been working on for a while. It’s essentially a three phase therapeutic protocol, and there have been a number of insights over the last six months or so that have really helped me to appreciate that while gastrointestinal health, including SIBO, dysbiosis, regularity, addressing of food triggers, things like this are, a crucial component of resolving abdominal distension, there is more to it than that. And Jandra and I have been going back and forth on this, because she kind of overlaps with a few of the other facets of this protocol I’ve been putting together regarding those areas, which are the areas that she focuses on chiefly as a pelvic floor PT. So I wanted to share this because there are patients in the clinic for whom, I guess as a sort of common issue to contend with in healthcare, we (people and also healthcare providers) can have this tendency to want to go deeper and deeper and deeper into a certain realm of therapy that may have helped us previously.

Dr. Ruscio, DC:

Knowing when you’ve exhausted everything from a given lane or avenue, if you will, and when it’s time to make a lateral move, can be very important. It can, of course, help you obtain the improvements (in this case in distension) that you’re looking to get more quickly, save you time, and save you money. So with that, we’ll go here to the conversation with Jandra in a moment. And I also just want to remind you that if you are struggling with distension and you need some help, my clinical practice is more than happy to assist you. So just keep that in mind, again, if you’re in need of some assistance or guidance along your path. And with that, we’ll go to a conversation with Jandra Mueller and myself. Again, Jandra is a pelvic floor PT, she’s been on the podcast in the past, and this is a part two convo, again, on the topic of distension. Alrighty, here we go.

Dr. Ruscio, DC:

Hey everyone. Welcome back to Dr. Ruscio, DC Radio. This is Dr. Ruscio, DC back again with Jandra Mueller, and we are going to be going into abdominal distension. And Jandra, this is something that I’m really appreciative of a lot of the work that you’ve been doing. In fact, you connected me with the pelvic floor therapist I saw in San Francisco who helped me identify my lack of hip mobility. People may have seen my Instagram post where I was doing this, 90/90 sort of stretch assessment. And that, combined with a few other things, has been very helpful. Not that I had distension, but I had some tightness and a little bit of low back… I don’t want to say pain, but low back discomfort. I just felt like something was off. And so that was a big referral. So let me thank you for that, and then welcome you back to the show to expand upon the expanding topic of distension.

Jandra Mueller:

Yes, thank you for having me, and always glad to have these conversations with you.

Dr. Ruscio, DC:

Yeah, you know, this is one where… over the past maybe six months, I’ve been developing this protocol, because there’s clearly this population that has distension for whom it’s not just SIBO, FODMAP intolerance, food reactivity, or something of this sort. And I’m able to make that discernment because those things are the primary focus of our clinic, or one of the primary foci of our clinic. And as I’ve been sensing, something there does not track with the typical response curve for patients for whom their distension (plus or minus also having bloating) is caused by something else. And you know, I’ve been having that sense, because some people will come in, we’ll go through the personalization and algorithm in GI that we’ve been developing now for nearly 10 years. And not everyone responds right out of the gate, but typically by the third month, we’re making some notable traction with their symptoms.

Dr. Ruscio, DC:

And this includes this distension, this, you know, “looking like I’m pregnant”, abdominal wall pushed out. The distension does not always come with a feeling of bloating and pressure and discomfort. And in fact, what I was noticing was there was this cohort for whom they really didn’t have any other complaints other than this distension that was lingering. And oftentimes they were female, and there was some sense of a skewing toward those who either had hypochondriac tendencies or limbic imbalances. And none of these things, by the way, are disparagements. They’re just trying to identify what are the characteristics, and then how can we help them. You know, these boxes are always used to then say, “well, what can we do for this person?” So, the more I’ve been thinking about this, I’ve been developing this protocol. And I’ll go into the protocol in a moment.

Dr. Ruscio, DC:

But anything there you want to add, Jandra? Because I know that you and I have had correspondence back and forth on this, and it was nice, you know, you focusing more on muscular function than I do of course. We definitely have some overlap, but you’re kind of on the opposite side of the spectrum where the musculoskeletal function is more of a primary area, and it’s really, for me, kind of a tertiary area. So as I was bouncing this off of you, you were saying, “yep, this makes sense.” So is there anything you’d add to kind of this preface, this picture that we’re painting?

Jandra Mueller:

No, I think you really captured it. And you’re right, for some, the abdominal bloating or distension or the discomfort that they have can be in isolation of gut regularity or diarrhea, constipation, or any other symptoms. And it’s really interesting, and I think their history has huge implications to that. And what you’re dealing with now, 15 years into it, might not be the same mediating factors as it was when it started. And I think you’ll talk about this when you introduce your protocol, but there’s this concept of visceral hypersensitivity, shortening of tissues. We now are in an environment where we are sitting or driving a lot, versus out and about running around like we were when we were teenagers. And given other comorbid conditions or injuries, we really can’t dismiss the musculoskeletal system, whether it’s a primary driver or a mediator of some other condition, or developed because of 15 years of feeling bloated, distended, and sucking in your gut, and then developing pelvic floor dysfunction or a number of other things.

Jandra Mueller:

And I think… I feel lucky that I get to spend so much time with my patients where I can really ask detailed questions and learn about their history and be curious, where the person that they may first go to for this has 15 minutes with them to give a diagnosis and a treatment plan, and maybe a couple of follow ups. Which I think is not their fault, it’s the way our system is, but I think it leaves people thinking it’s in their head or, you know, “well it’s not this, so what else could it be?” And it’s really confusing and it’s frustrating for these people experiencing this.

Dr. Ruscio’s, DC abdominal distension protocol

Dr. Ruscio, DC:

Absolutely. And a lot there I want to unpack. But let me go into the model first, or the protocol if you will. And this is a loose protocol, it’s not meant to be something, just to clarify for people, that you follow with no modification. But, like any framework, it’s a basis for decision making. Phase one would be gastrointestinal. Is there SIBO? Is there dysbiosis? Is there an issue with regularity, meaning constipation, or mixed type IBS, or diarrhea? Is there pain and discomfort? Dyspepsia, indigestion, the feeling of bloating, gas, and pressure. Phase two is where we look more at posture.

Dr. Ruscio, DC:

And this is something that in the past couple podcasts, it’s become more apparent that if someone’s not, I guess, in a habit of healthy posture– and I went back and tried to find it, I think this may have been in the SIBO SOS Facebook group. And this lady is taking a picture. And you can see so much, you know, the old saying that a picture’s worth a thousand words really had merit here because, you know, the text of the post was, “argh, I’ve been distended for so long, I can’t figure out why I’ve been here, I’ve been there, done this, done that.” And then you look at the photo of her, and there’s a frown on her face, her shoulders are slumped so far forward, almost if you were going to kind of sarcastically make a depressed mannerism, you’d frown your face and slump your shoulders forward. But when you do that, your stomach also protrudes outward. And there’s this really interesting recommendation often in breathwork and in yogic practices, they’ll say, “pretend that someone’s pulling a string from the top of your head.” Almost like you’re grabbing a little cusp of hair on your crown and pulling yourself upward by the top of your head.

Dr. Ruscio, DC:

And that tends to pull your shoulders back. And, indirectly, it seems to correct the posture of the hips. But if you slouch your shoulders forward, your abdominal wall relaxes. And if the muscles in the abdominal wall relax, then all those organs, you know, there’s a natural tension there, they’re going to push forward and out. And so I looked at her, and that was one of the key insights if you will, where I said, “hmm, this person… you can just see in their posture and their facial expression that there’s more to this than just the distention.” And it almost seems like this, you know, reading into that– and I think this is part of what a good clinician does, is they can kind of read the picture behind the presentation– and in this case, I’m assuming this person may be barely exercising, they’re probably on a very restrictive diet, they’re under a lot of stress, they clearly have bad posture.

Dr. Ruscio, DC:

And that got me thinking, boy, just a few changes with this person’s posture, and postural queuing, and exercise, and maybe expanding their diet, improving their breath, may go a long way. And so this is the phase two, which is postural, making sure there’s no thoracic kyphosis (or said more simply, their shoulders aren’t slumped forward), and they have healthy breathing. Another concept that came up in the podcast in the past is if people fall into this pattern of overly diaphragmatically breathing, even though I don’t like that term because you always use your diaphragm to breathe, but it just means, I guess a translation would be, if you’re breathing and just kind of pushing your belly outward, you’re kind of losing the other facets of respiration that should be moving (namely your ribs).

Dr. Ruscio, DC:

So again, phase two is postural, and also respiratory. And then phase three, and again, these don’t have to necessarily be followed in this order, this is just how I’m thinking about it, at least at this point in time. Phase three is muscular, meaning abdominal wall strength, inflammatory, and limbic. And I put those together because… well, I’ll explain that in a moment. So let me just run through that one more time. Phase one: gastrointestinal. All this stuff that we talk about on the podcast quite frequently. SIBO, dysbiosis, regularity, food triggers, what have you. Phase two: postural and respiratory. Phase three: muscular (namely abdominal wall but not necessarily limited to that), and then inflammatory and limbic as one kind of interwoven pairing. And I’ll explain some of the rationale further in a second, but let me pause there for a minute, Jandra, in case you want to add anything.

Jandra Mueller:

Yeah, I think it’s a great way to start to break down all of the things that are interconnected and affect each other, which is why you state that this isn’t a one-size or “you just do this”, it is all interconnected. Whether it’s a secondary response, the postural stuff, it’s primary, it’s mediating everything. But you’ll probably find that there are components of each of these phases, especially with the length of time that you are experiencing this discomfort without resolution. And one way I think about this is, you know, maybe your distension or bloating is primarily a GI-driven issue, and finally after 10 years you’ve gotten that under control, but you still have it here and there, or it’s less, but it’s still there. Can you do postural improvement and have some improvement? Absolutely.

Are we overdoing it with belly breathing?

Jandra Mueller:

Even in clinic, you know, I have these people that probably have a more GI underlying component, but we can also change in that treatment session the feeling of discomfort, just by doing postural changes. Does that fix the GI issue? No, not necessarily. But do you have a tool that’s, one, going to help you prevent injuries later on, and also help that discomfort immediately go down? Yes. And so it’s very related, even if it might not be the primary reason. And I like that you mentioned about, in phase two, the thoracic kyphosis, and just posture and rib mobility in general. I think a lot of people use belly breathing and diaphragmatic breathing interchangeably. And there is… yes, you have abdominal expansion during diaphragmatic breathing, but you can also, like you mentioned, have lack of ribcage, like in a lateral direction, or even in the back, and you’re not getting this 360 degree expansion, which really is the diaphragm coming down, belly is going to come outwards. But you can also have just that belly rising up and it’s much more prominent when you’re doing belly breathing than diaphragmatic breathing when you’re having this whole abdomen-ribcage-back kind of protrusion happening. And that’s really important to distinguish, because some people get really stuck on the belly breathing thinking they’re doing diaphragmatic breathing, when they’re actually not.

Dr. Ruscio, DC:

That’s what happened to me. I mean, you know, way back in college when I was learning this stuff, there was this– and maybe it was my misperception of the education, but it seemed to me this obsession with– “breathe into your belly, breathe into your belly, breathe into your belly, breathe into your belly, don’t breathe into your chest. If your chest is moving, you’re doing it the wrong way.” And, you know, I remember Mike Nelson when he was going through an assessment, I think it was one of his initial assessments on me, maybe three years ago. He said, “you know, you don’t really have adequate ribcage mobility, and I think it’s because you’re not breathing into your chest at all”. And I was like, “breathe into your chest?! What do you mean <laugh>?” So again, maybe part of this was my misinterpretation of the teaching, but I still hear that sometimes now, you know, make sure you’re breathing into your belly.

Dr. Ruscio, DC:

And I think like many things in healthcare education, we may overcorrect. Some people can have a problem with gluten, let’s say 6% of the population. So we convince everyone that they have a problem with gluten and they should avoid it all the time. Well, that’s going too far, right? That’s disservicing to 94% of the population and it’s helping the 6%. So for, you know, maybe that parallel analogy for what I’m assuming is a subset, not the majority, of people who are super stressed and don’t move and are very disconnected from their body. Maybe they are overly breathing into their chest. But I think we’ve gone too far the other way, where I’m assuming I’m not the only one who was doing this, and that was one of the reasons– my own personal experience– and it may have been what led to part of my issues with hip mobility in that, and this may tie in with the pelvic floor and, you know, not having enough, I guess, mobility with breath, because you’re going have some pressure downward as well as upward if you have a good kind of scope of your breath. But blah, blah, blah, all that to say, that’s part of the reason why I put this in here as step two, is just making sure people have good, I guess, respiratory posture if you will.

Exercise & posture

Jandra Mueller:

Yeah, absolutely. And it’s probably a combination of the way people teach it, the cues that are given without the full understanding. But it’s all about pressure management. You want the pressure to be managed all throughout the throat, the chest, the abdomen, the pelvic floor. And if you have it going too far in one direction, there’s going to be problems. And so you see that, and that may present differently in different people, but looking at not just also the chest and ribcage, it’s, you’re right, the hip mobility, and how you are standing, and the joint alignment and joint stacking. Your body actually can be more efficient if it’s stacked correctly, because we don’t feel gravity because it’s a constant for us, but I’ll push down on somebody’s shoulders when they’re standing in their correct posture and if it kind of goes to their back and you see this kind of kinking or folding right there, you know that there’s some issues because it’s not going all the way down into their feet in the ground. I correct them, I do it again. And they’re like, “oh, whoa”. Because now their joints stack, their muscles that are supposed to turn on sort of just turn on, and they no longer have to feel like they’re sucking their stomach in because they feel their belly’s protruding or whatever. It just happens.

Dr. Ruscio, DC:

And this is where I feel exercise to be so important. If I’m doing everything right from an exercise perspective, and I do think this involves a touch of pushing yourself, and maybe for me that works, maybe I’m an exception but, you know, glute activation seems to be something that I need to work on. And at least in my experience, the glutes don’t turn on super easily. I mean sure, you can do some exercises that will activate glute med that don’t require a lot of effort. But just as one quick aside, I’ve been doing… kind of a little bit of a bastardized attempt at VO2 max training. I don’t know what my VO2 max is. The data I have from my Garmin Fenix watch I don’t think is very useful, because if you do trail running, apparently it throws off how the watch calculates your VO2 max.

Dr. Ruscio, DC:

And so I don’t know what pace to run at. So what I’ve been doing is using a tabata timer, and I’ll essentially run as fast as I can for 30 seconds, recover for 30 seconds, and then repeat. So it’s 30 on, 30 off, and I’ll do 10 rounds of that. And it’s gut wrenching. I mean before I do it I get kind of nervous thinking about it, and apprehensive, but I can say that later that day and the next day, my posture feels better, because, almost like a dancer, if you’ve watched a dancer, they’re just so erect, right? Their posture is so good, and you see their back is on, their glutes are on, and I’ll feel that carryover the next day and a couple other days. Because when you’re running at a pace that you can only sustain for 30 seconds, you’re getting glute, you’re getting hamstring, you’re getting back. So one component of this I think is exercise. In fact I think I’m going to build into the model here during step two, probably just a checkpoint for making sure someone’s exercising, right, because that really does fit in with both breathing and with posture.

Jandra Mueller:

Absolutely.

Dr. Ruscio, DC:

Okay. So step two, posture. Some of this, and I can say this, you know, from my own experience, is just simple cues, like you said. Just simple things of… when you’re going to go do a deadlift, think about that person pulling a string up from your head. Or when you’re breathing, think about not just breathing into your belly, but rather I’ve heard something of a balloon that expands in 360, you know, outward, backward, up and down. So that’s the respiratory, and a lot of that may really take care of rib mobility, I would assume, not, you know, making it more complicated, and I’m assuming just good queuing will take care of a lot of posture, of a lot of breathing, of a decent amount of mobility, and then making sure someone’s exercising. Because I do think that will help, along with posture, probably through some indirect mechanisms that are related to, you know, kinesthetic feedback.

Jandra Mueller:

Yeah.

Dr. Ruscio, DC:

Any other thoughts you want to add here? I mean I’m sure you have a lot of thoughts to add, but, you know, anything pressing you want to add, kind of into the phase two?

Jandra Mueller:

Always lots of thoughts. <laugh>. Just another cue that I find really helpful that is easy to do at home, because it is… a lot of my patients will say, “gosh, why is this so hard? I don’t know how to breathe”. And, you know, it’s just we’re used to different cues and we go off of what we think we’re being told and, you know, we just develop these patterns. And so if you have a yoga strap or a belt or something, I’ve had people wrap that kind of snug around the bottom of their ribcage, like just under the breast line. You don’t want it too tight because you want that expansion, but you want it tight enough where it won’t just drop down. And I encourage people in different situations or positions– sitting, lying down, driving in the car when you’re getting really stressed out because of traffic– and breathing into that, and feeling the strap kind of compress in all directions around your entire ribcage.

Jandra Mueller:

And it’s really good biofeedback for the person, because when you breathe, let’s say just belly-dominant, right, you’re not getting that expansion outwards or laterally from the ribcage, you’re going to feel the strap slacking on the sides or in the back and kind of drop, but expand a lot in the front. And so you can retrain, just by using a simple belt or strap, okay, where do I need to breathe into? And it gives you that tactile cue of, okay, breathe more into the back, or breathe more into the sides. So I encourage people to try different positions, because that may change it. For some of my patients, lying on their back is actually really hard. But when I put them in child’s pose or face down, they get that feedback from the ground on their belly and even outwards. And so that’s a simple, easy thing to try to explore, if you just have a yoga strap laying around, or a belt, and see where you are breathing, and see what happens with the belt.

Dr. Ruscio, DC:

Love it. And to clarify for our audience, we’re usually making phase two where we will refer to Jandra, or someone in her clinic, or another therapist to help with this. We don’t put it all upon the person. But thankfully it’s also not super complicated, meaning, you know, you don’t have to go do 30 visits with a therapist. And doing this via Zoom is also very possible. I mean, for me, I did two visits with the pelvic floor therapist, maybe I’ll do a third. I think I’m probably a pretty quick study due to having an athletic background, so maybe for someone that is a little less cued into your body, maybe you need six visits, right? But just trying to impress the point that it’s not this, you know, arduous undertaking.

Jandra Mueller:

Correct. And you know, if you find like simple things, okay, let me look, and you do it, then great, and it’s practice. But sometimes, especially if there’s a lot of structural issues or you have other ongoing musculoskeletal conditions or things like endometriosis, where you’re really stuck and you have been that way for a long time, there are some really good ribcage and diaphragmatic releases that a physical therapist can offer, or other body workers as well, to really get the ribcage opened up. And even with that, one or two sessions can really make a huge difference in helping you expand. But then you’ve got to use it and practice that, because now you have the mobility to allow that to take. But some people are so restricted for so long they don’t know until we do the releases, and they’re like “oh my gosh, I feel like I can breathe so much better.” There are some techniques that you can do with asthma, not that you’re taking away the underlying condition, but you can really minimize the attacks just from training your breath.

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Helpful cues for correcting your posture

Dr. Ruscio, DC:

Back to queuing just for one second, I’m just reminded of another cue that Molly had given me. That’s the therapist that you had referred me to in San Francisco last time I was back in California. I dropped in and saw her at her office there in SF, and she felt I was putting too much weight on my heels, and not enough weight in the balls of my feet. And that was also huge for me. I think I had over time, and maybe this was because I kind of fell into this habit at my standing desk, and I kind of pictured myself putting all my weight on my right foot, leaning on my desk and also just kind of letting my weight slough, partially supported by my desk and then, you know, leaning to my right side and with my weight a little bit back on my heels.

Dr. Ruscio, DC:

I think that’s what ended up happening. And she used the analogy, to bring back in the dancer analogy, she said– I think she had said this, I happened to befriend someone who was a dancer around the same time, so everything kind of clicked <laugh>– but when you watch a dancer move, they are not on their heels. And just for the manly men out there, I’m sure you’ve heard the stories about professional football players taking dance classes. Well, I finally understood why that was. When I started noticing and paying attention to the cue of moving my weight ever so slightly from being on my heels to the balls of my feet, that seemed to open up my hip flexors, and it kind of opened up, I think some of what was tightness in the pelvic floor. Because if you’re kind of on your heels, almost picture like a little kid who has to go to the bathroom who is like scrunching his butt in <laugh>, right?

Dr. Ruscio, DC:

That’s kind of the posture that you assume when you’re on your heels. But if you bring your body weight forward just a little bit into the balls of your feet, it extends and opens everything up. And that’s kind of where the dancer posture comes in. They have good posture, their chest is open, their back’s contracted, their glutes are contracted, and it’s a much more balanced position. You know, what do they say, don’t get caught on your heels? Well that’s for a reason. So that one little cue for me was also very, very helpful, to your earlier point Jandra, which is, you know, these things can be very helpful even though they’re simple and subtle, just to help someone correct a postural habit they may have drifted into.

Jandra Mueller:

Yeah, that one is huge. And to bring it back to the bloating, distension, and the thoracic and diaphragm and ribcage… when we stand further back on our heels, maybe we have tight calves, but what we don’t realize is up the chain, what’s happening is you’re actually having more of an anterior pelvic tilt, so that, like, kind of sway back where you’re just more tilted, your lower back muscles are scrunched, especially if you’re trying to stand up tall, right? But you haven’t fixed the feet, and where your weight is, you’re actually more… you’re hyperlordotic in your lumbar spine, but then you’re lifting your chest up, expecting to stand in good posture, when it really starts where your weight is in your feet, because you’re bringing your entire center of mass or center of gravity over your base of support.

Jandra Mueller:

And when you do that, and then you feel like you’re going to fall forward, but what you do is you kind of relax your lower back, your pelvis kind of shifts back into that neutral position, your hips now lock in and are more externally rotated, so you’re not having the knees rotating in or the flat feet essentially, and then you feel your abdomen just kick in and turn on. Because now everything’s joint stacked properly, and you can actually engage, without having to overdo or suck in your stomach when you’re having this distension or bloating.

Dr. Ruscio, DC:

Yep, yep. And another thing I noticed from this, just a simple cue, well it was partially a derivative of her assessment. And this is where ,<laugh> man, some of these things will just knock your ego. She said, you know, can you stand on one leg, and then push up, but put most of the pressure on your second and third toes. And that for me was incredibly hard, because I drifted into this habit of pressing off through my big toe. And I think what that was doing was it was causing this whole kind of kinetic chain effect where I was not engaging my glutes or my hamstrings in gait as much as I could. And that also reduces pelvic, I guess, rotation, if you’re walking in that, you know, it’s almost like classical type A, right? Just like everything is straight and linear.

Dr. Ruscio, DC:

And another thing that ties in with watching dancers is, this sounds weird, but they tend to have very strong toes. Like, all of their toes, because they’re always gripping in the ground. And this is one of the things that the minimal soled shoes and barefoot running gurus will say, you know, you really want to grip the ground, use your feet muscles. And I had also drifted away from that. And just that one thing, day over day, I started feeling all of that sort of wake back up. I was using my other toes, that was leading to more of that kind of claw through during gait that engages the glutes, engages the hamstrings, gave me better, I guess, rotational movement of the hips. So a lot just cascaded from that one change. And the feet are big, right? So I would expect a lot to cascade from the feet, but that was a great insight on her part and really helped me.

Jandra Mueller:

Yeah. Simple things can make huge changes. And I love Molly’s creative brain, and she really nails it when it comes to the biomechanics. So I’m so glad you noticed those things. But it really is those simple little cues and then paying attention, and whatever your daily activities are, if it’s running, if it’s working out, if it’s standing at your desk, at your work-from-home station that you kind of rigged up. Because those are the activities that we do the large majority. It might not be the three hours a week total that you’re at the gym, but that could be a component. It’s probably more of those day-to-day activities, standing in line at the grocery store, washing dishes, standing at your desk or sitting at your desk, that really are probably the areas to pay attention to that are kind of driving this, because that’s where we are most of the time.

How a pelvic floor therapist can help you find the missing link

Dr. Ruscio, DC:

Yep. Just to share one other somewhat related observation. So I train with Mike Nelson, or at least I had been, I’m not training with him anymore. I felt the need to kind of go out on my own, and we’ll have a number of podcasts coming dedicated to exercise in the future, some of which I think is going to be hopefully jaw-droppingly insightful and helpful for our audience. There’s been a few realizations there that have been pretty remarkable, but yeah, I’m excited about that, definitely. But, you know, all that to say, I am a former athlete, my undergraduate was in exercise kinesiology, I was working with Mike, I’m pretty mindful about this stuff, I do sometimes sitting on the floor, I have a pull-up bar I hang from, I do, again, a whole array of different exercises. So driving to this appointment to see Molly and kind of, you know, taking a moment not to be listening to a podcast or just, you know, having a moment for some stillness and reflection.

Dr. Ruscio, DC:

I’m thinking to myself, I don’t know, I don’t think there’s anything else that can be done. And I was kind of worried, right? Just like many of the patients and many of the lifelines I try to extend our audience about mindset. I found this one voice in my head saying, I don’t know, I think you’re just going to have this annoying low back pain and feeling of hip tightness and instability forever. I mean, what else can you do? Maybe there’s some sort of major issue wrong where, you know, you’ve got a growth of some sort in your hip, or dysplasia, or you know, going to that fearful place. And then the other voice inside my head said, “dude, like, what do you mean?” Like, of course you haven’t done everything, you’re not an expert in this area, and there’s a very high likelihood that exactly what you see in your area of GI, this therapist sees in her area of, you know, pelvic and hip health.

Dr. Ruscio, DC:

So, for our audience, I fall prey to these same things, which is why I continually try to voice the optimistic perspective. And, what do you know, I’m now maybe a month out from my first visit with Molly, and it’s been like a 180. I mean, I’m not fully out of the woods, but I feel way, way better. I have pretty much none of those symptoms. I feel like I have further to go and still have some imbalances to try to fully rectify. But already, I mean, you know, the improvement I’d say from zero to 100, 100 being totally resolved, I’m probably at 70%. So, you know, just to share that regarding the psychology piece. And you’re not alone if you feel like “I’ve done everything <laugh>.” I felt like I had done everything and I really had barely even scratched the surface. And oh, by the way, she had said that half of her clientele are stressed out executives. So there you go.

Jandra Mueller:

Yep. And I’m so glad you shared that, because I think especially with the population we see, this is our population. “I’ve done everything. What else is there?” And when you’re curious as a practitioner, I mean, we can’t say we have all the answers, but I think that being curious and working with somebody who’s curious enough to help you figure it out. Whoever’s coming in with the problem, you have the body, you have the symptoms, you can tell everything to me and I can help you put this all together and make sense of it. But I’m not in your body, and I kind of think, you know, the large majority, probably 95% of the people, these symptoms, they’re there for a reason. And just because the 10 providers they’ve seen so far can’t find anything wrong doesn’t mean there’s not something wrong.

Jandra Mueller:

Our bodies innately don’t want to be in pain, right? And so I think it’s really good for you to keep looking and searching for answers. You know, people take breaks because it can get frustrating or they hit dead ends. But I think that… don’t stop looking for answers if you feel like you’ve hit the end. Because you might find that person at the right time that can help you put those pieces together. And a recent patient I saw that came, she was really hesitant to come in at first, and she was diagnosed with abdominal phrenic dyssynergia. And I think this really ties into the abdominal distension and bloating in all of the phases you’re putting together. And we talked for a little bit, and I kind of gave her my process and how I look at things, and at the end she said, “you know, I just really want somebody to be curious enough to help me figure this out.”

Curiosity is key (but be mindful of excess testing)

Jandra Mueller:

And I think that’s really telling because I think as healthcare providers we sort of lose that sometimes in the grind or, you know, the system’s not always set up. But I think it’s a really good mindset to have as either a patient or a provider, and just be curious. You don’t have to have all the answers, but we’re here for a reason. And if you’re experiencing these symptoms, you know, Google, yes, you can go down bad rabbit holes, but also you can find helpful information that maybe you didn’t think of before. You have another piece to the puzzle along your journey from seeing different providers. And I just think keep looking for the answers.

Dr. Ruscio, DC:

Yeah, well said. I’ll also add one caveat to this, for both patients and providers. Be careful not to fall into the satisfying your curiosity via new lab tests trap.

Jandra Mueller:

Yes.

Dr. Ruscio, DC:

Because this is where I think unfortunately some of the benevolent curiosity that providers do have is really just bastardized, and it’s put into these tests that, again, the majority of tests in functional GI care are crap. And they lead people to be treated as numbers, and unfortunately what ends up happening is it can be so hard to look for correlation between these ever-changing numbers and symptoms that clinicians never figure out the labs aren’t really helping them, and then that curiosity just continues to kind of flounder in this sea of testing and repeat testing. I mean, imagine if you were treating someone’s uBiome results as the basis of your care. Now that we know that that test was complete bunk and partially based upon dog shit to establish the normative ranges. So some tests, yes, I would argue that you have about a 75% chance if you’re saying to yourself, “well Dr. Ruscio, DC what about test X?” 75% chance that test is garbage. So keep that in mind, especially providers, because I think, and I’m becoming progressively concerned, that the field is being ruined by these tests that are just making claims that they can’t support.

Jandra Mueller:

I 100% agree with that. And yes, I should clarify the curiosity. You can learn so much from symptoms alone. And I’ll use the Nutrition Assessment Questionnaire just as a screening tool because it breaks down lifestyle, diet, medications, and then upper GI, liver, gallbladder. And some of it I kind of take with a grain of salt, but I only use it in context with what’s going on. If we go back to bloating in your phase one of the abdominal distension and bloating, and we’re thinking GI, and we’re thinking maybe a SIBO issue or food related, is their actual presence of gas, versus this feeling of bloating? And the way that I think about that is, you know, there’s going to be a difference where I might think maybe more postural or something like endometriosis when maybe there’s a low level all the time. You wake up with it, it gets worse when you eat, but that’s going to be a little bit different in assessing somebody or kind of treating when you have somebody who specifically states that, no, my bloating is only after I eat and it’s only after I eat certain foods.

Jandra Mueller:

And what’s the timing? Is it immediately, is it 30 minutes? Is it two hours? What else goes along? Is there diarrhea followed by that? Or constipation? And, okay, let’s get consistent, what types of foods? And let’s gather some data and see if we can find some patterns here. Especially in those people that come back and say, “my SIBO test was negative, I don’t have SIBO”. I don’t trust that all the time. And I always look at them. Can you show me your results? And we go back to that, okay, is this a false positive? Is it a false negative? What’s going on, is there consistency with the food you’re eating? Whereas my patients with 15 years, they’ve done all the tests, probably way more than they needed to, and it’s like, no, I have this underlying, always bloated, and you see them super kyphotic, I’m not going to go down the GI route as a priority. I might go into phase two kind of with more emphasis, and consider phase one. So I think that’s important, like you said, with the testing. You can gain a lot from somebody’s history and asking the right questions.

The limbic system component

Dr. Ruscio, DC:

And you know, one of the things about the testing is, and especially with that sort of avatar patient that you portrayed, you know, 10 or 15 years, seen a whole bunch of doctors, had all the testing, that’s when you can come into phase three, one of the components, which is limbic.

Jandra Mueller:

Yes.

New Speaker:

Because they’ve been told they have all these things wrong with them. And you know, one of the cases here that also helped me put together this protocol was the case study that we released, a video conversation with Danielle. And Danielle, if you guys remember back to her story, she saw some nice improvements with our work together a few years back, was in pretty good shape, and then her GP said, “you should really follow up with a local doctor instead of this telehealth guy because it’s so much better to have it in person, blah, blah, blah.”

Dr. Ruscio, DC:

And, okay. I think there’s something to be said for that for conventional follow ups. But for more of a functional health consultant as we function as in the clinic, this is where I really see this as a complement to the conventional medical analyses you hope never find anything, but also don’t tell you everything that you need to know. Anyway, she went and she saw one of these kind of half-conventional, half-alternative providers. And this person did something like a GI-MAP sort of test and said “you’re really sick” because of, like, a mild finding of dysbiosis, which I think is egregiously bad handling of the conversation, and proceeded to pump her full of supplements, and she got no better. When she came back to see me, it took a number of visits for me to convince her to actually try the limbic retraining.

Dr. Ruscio, DC:

And she said in the video, I was patient with her, and we had this kind of dance we were in for a little while where I was like, “I really think you should do limbic retraining,” and she was like, “well what about this other thing?” Right? And I was like, “okay, we can try immunoglobulins, but let’s also have you try limbic retraining.” And then we’d follow up four weeks later. “How are the immunoglobulins?” “Eh, I think they help a little bit.” “Did you try the limbic retraining?” “Nah, I didn’t try it.” “Okay, well I really think you should try limbic retraining”. “Well, what about biofilms?” So, you know, we went around for a little while in this dance. She finally tried limbic retraining, and what do you know, when she followed up, she had gone back to CrossFit, she had expanded her diet, and she was no longer complaining of distension.

Dr. Ruscio, DC:

And I said, hmm, isn’t this interesting? I think the limbic piece here was so powerful that not only was it driving food reactivity, but it was also driving her distension that was not distension… you know, when I say food reactivity, it was not, I eat, I get gas, and I’m distended. It was, I’m always distended. And I think part of what happened, and this is where phase three really comes in– now I’m speculating on this, but I think it’s a reasonable speculation, because Gupta has shown in two clinical trials that he can reduce symptoms. And part of those symptoms seem to be immune-mediated, via the brain-gut connection in this case and how the amygdala controls many functions, but clearly the amygdala retraining that you do in limbic retraining can dampen reactivity to the environment and to foods.

Dr. Ruscio, DC:

Now my speculation is, we know that inflammation upregulates this substance called substance P. It’s essentially a pain signaling molecule. So, if you’re inflamed due to amygdala over-function, and you do something like Gupta limbic retraining, and you become less inflamed, it stands to reason that you have, or you’re less sensitive to substance P, which is a pain signaling molecule. And we know that some people, they are hypersensitive to normal levels of gas pressure. And it could be that this, I guess psychosomatically driven inflammation, makes you distended, because it upregulates your sensitivity to normal levels of gas pressure. And therefore this is how I account for Danielle seeing remarkable improvements in her distension by doing, you know, not a SIBO treatment, but by doing the great work of limbic retraining. And I think this correlates with some of your experience, Jandra. So I’d love to hear what you’ve seen in this regard.

Jandra Mueller:

Yeah, I think that’s really great to bring up, because what you demonstrated was great patient selection <laugh>, right? So this patient had this chronic low level… it wasn’t really induced specifically to eating. And of course, if you take somebody that specifically says every time I eat, you know, pizza or garlic and onions and all of the FODMAPs, and they have this reaction, that’s going be very different than that chronic low level bloating, which, you know, there’s no rhyme or reason for foods. All food or no food, whatever. And/or the visceral inflammation piece and the hypersensitivity can come as a result of having the food reactions for a long time. So it could be part of it, but I think your patient selection is really important. Are you going to do gut healing protocols and SIBO, or are you going to do more mindfulness because that’s what’s going on?

Jandra Mueller:

And I think what I want to add to this is that it sounds like we’re talking about neurogenic inflammation. What’s interesting is, when we’re dealing with neurogenic inflammation, it’s not just the structures creating the substance P that’s going to the brain, your nervous system starts actually pumping it to the end target, and it creates this cycle of hypersensitivity and reaction, especially in chronic conditions. And aside from that, if there is something else going on, so the enteric nervous system is gonna be what’s involved with many of the hollow organs.

The endometriosis connection

Jandra Mueller:

So this kind of relates very perfectly into the population with endometriosis, because there are lesions that are actually creating different inflammatory markers. They have nerve growth, and they are on structures within the abdominal pelvic cavity that are generating these inflammatory markers that are being given to the brain. IBS, it’s no surprise that 90% of women or of those with endometriosis also have symptoms and or are diagnosed with IBS. And now there’s this visceral, visceral reflex going on, where you’re having an issue in different organ structures, but because it’s the same nervous system, when it goes to the brain, it’s sort of mixed messaging. And now you have this response because those with endo, especially with the IBS symptoms confirmed with endo– there was a great study that was done– they did a questionnaire, and 90% of them that have these symptoms, and bloating is the number one symptom of endo–

Dr. Ruscio, DC:

And Jandra, are they clarifying in this assessment between distension and bloating, or distension plus or minus bloating?

Jandra Mueller:

So in this particular study, which is good, and I think that’s important to note, bloating is the feeling of gas. Distension is the visible objective finding, right? And so you can have both, but the sensation that’s very uncomfortable may or may not be related to actual distension. So bloating is that feeling, distension is the visible sign of distension. And in this particular study, it was just a questionnaire that was given asking bloating, diarrhea, constipation, etc.

Dr. Ruscio, DC:

So we could presume that some people had the feeling of bloating, some people had the appearance of distension, and some people probably had both. Do you think that’s a fair assumption?

Jandra Mueller:

Yeah, in this particular study. However, there was a different study that was done in 2009 which was really good, and it’s called Abdominal Bloating: An Under-Recognized Symptom of Endometriosis. And that study, there’s not a huge number, I think it’s 25 people confirmed with endometriosis compared to 25 controls that did not have endometriosis. And they actually do a really good job really differentiating bloating versus distension with measurements throughout an entire menstrual cycle for all of the women. And they actually made some really interesting associations that are pretty consistent with what I see in the population, where they talked about the different subgroups that had distension versus bloating, both, where in the menstrual cycle was it in comparison to those with endo and to those without endo. And surprisingly enough, in the subgroup of patients who also were on birth control or medicated endometriosis, I think they used that term, they actually had more severe discomfort associated with the bloating than the non-medicated, or those not on birth control of endometriosis or controls. And so that study actually really does dive into the distension versus bloating or both.

Dr. Ruscio, DC:

Hmm, interesting. Okay. And how are you accounting for that, or how did the researchers account for that? Is that some sort of long term hormonal imbalance makes one more prone to endometriosis or more moderate-to-severe endometriosis?

Jandra Mueller:

So with endometriosis, they looked at the people that were in the study that just had a diagnosis confirmed with laparoscopic surgery. So this is really just known among those with endometriosis. It’s the number one GI symptom, followed by constipation and diarrhea, abdominal pain, nausea. But it’s driven because these endometrial-like lesions, so cells that are similar to the endometrium, are found outside of the uterus. And there’s a lot of mechanisms and we’re starting to see some subtyping, which is really interesting as it relates to pain. But the severity of the disease does not have any correlation with symptoms. So you could have very minimal endometriosis, but have very severe symptoms, and vice versa. You could have severe endometriosis, and really no symptoms at all. So it’s a very interesting disease. And the way that they measured in this study is they took these women throughout an entire menstrual cycle.

Jandra Mueller:

So day one to day one, and they did girth measurements of their abdomen, plus a symptom questionnaire. And they looked at all this data to compare the controls with those with endometriosis. And there was a significant difference between the two groups as far as the feeling of bloating or distension. And I think it’s common to a degree for a lot of people right before their menstrual cycle to maybe have some level of bloating. We know progesterone can kind of influence that a little bit, but not to the degree that people with endometriosis experience. Plus, the longer that that disease continues, which there’s a 7-10 year average delay in diagnosis (not because they’re not trying to get one, but because they’re not thinking of this). And then you think about, okay, the visceral hypersensitivity there, the ongoing problems that just add up together because it’s an inflammatory condition, and with the GI overlap, it gets really tricky in this population. Is it GI driven? Is it endometriosis driven? Has it become a visceral hypersensitivity because you have a lot of mechanisms underlying that could be going on, if that makes sense.

Dr. Ruscio, DC:

It does. Actually, and you know I’m realizing that the initial intent of this podcast was to do a deep dive on endometriosis, and I think you and I had just had so many kind of sidebar conversations about distension that that ended up being the predominance of the discussion today.

Jandra Mueller:

But it’s great, yeah.

Dr. Ruscio, DC:

Yeah. But what I’ll do is I’ll circle up with you once we end the recording, and then we’ll put a time in the books to do a follow up on endometriosis. Because I do want to give people some sort of simple checklist. And I’m also of course going to use this to help refine when we make a referral for endometriosis so that myself and our clinical team can really be good about pegging that. You know, hopefully we can do that, let’s say three or four months in when things just don’t look right, we’ve tried multiple things in the GI, we haven’t gotten the response. We cross reference our paperwork wherein we have a short checklist of factors that flag endometriosis, and then we make a referral promptly. So hopefully we can put a little dent in that seven year average, and at least in our population, we can get them there in less than six months, which I think would be a huge win of course.

Jandra Mueller:

Yeah, no, that would be great. But I mean I loved the conversation of the distension and bloating, because it opens it up to so many other people that are not just endometriosis, but it’s a huge piece of endometriosis. So I loved this, I loved the talk about musculoskeletal and the influences there, but yeah, I think it was great. And per our conversations back and forth over the last few months, I think this was great.

An app for gut-focused hypnotherapy

Dr. Ruscio, DC:

Is there anything else, you know, regarding limbic that you’re doing, that you’re seeing… I know it resonates with a certain, I guess, subset of individuals that you work with, but anything further there that you want to comment on or encourage people regarding?

Jandra Mueller:

I think just to kind of highlight that the gut is a huge part of our immune system. There’s that major gut-brain connection, and I think there’s no harm in doing this type of retraining. And I will recommend things like the Nerva app or Happy Inside, specifically because it targets the vagus nerve and parasympathetic nervous system. And if we think about our gut, rest and digest, right, parasympathetic nervous system, versus sympathetic. And I think that calming all of that, whether it’s… there’s different ways to do that. Limbic retraining is one of them. One, there’s no downside. Maybe it doesn’t work for you, but I would be very surprised if there was no change. Everybody that I’ve done Nerva app with, which is not the exact same that you’re talking about, has loved it. And there’s no harm. You know, there’s no downside to helping do this and seeing if that’s a piece of the puzzle for you. And the best case, it really is the driving factor. And we want our gut to be healthy, and we want it to function properly. We need our nervous system to be in the right state if we’re expecting it to do its job and digest and absorb our nutrients properly.

Dr. Ruscio, DC:

Right. And Nerva is… I’m thinking of Neuvana, I think, which is a VNS stimulation. You know, I’m looking up Nerva and this is…

Jandra Mueller:

Mindset Health, and it’s a gut-focused hypnotherapy. So it’s a visualization. It’s a six week program, 15 minutes a day, really to highlight… I mean they call it gut-focused hypnotherapy, but they’re doing a study right now that actually I believe it’s comparing to the low FODMAP diet, and it’s being used kind of in comparison with Monash’s low FODMAP, but I believe they’re running a specific study now. And so it’s been really helpful, because it kind of killed two birds with one stone, at least in my patients. We’re talking about mindfulness and meditation. But you do a 15 minute gut-focused app, you also hit the nervous system. So that’s one that I’ve just used and had a lot of success with, but there are many others out there as well.

Dr. Ruscio, DC:

No, I love this. This is great. I’m looking it up right now. I think this came up in our FFMR research feed, and we did, you know, a mention of it, maybe in our podcast, I believe. But I like this, because this could be something that, for someone who doesn’t want to go to the Gupta program, it may feel a little bit too much, or they may have more mild symptoms and maybe they just need to, I mean, said a bit candidly, they need to chill out a little bit regarding their diet. This might be sufficient and they may not need Gupta, because Gupta I think is probably going to be a bit more robust than this. But it may be what someone needs who has a bit more going on. So this is great. Yeah, Thank you for this. I’m going to look into this and we might start recommending this at the office.

Jandra Mueller:

Yeah. And every patient, they’ve loved it.

Closing thoughts & where to find Jandra

Dr. Ruscio, DC:

Yeah. No, this is awesome. Cool. Anything else that you want to kind of mention or leave people with in close?

Jandra Mueller:

No, I think we’ve covered a lot.

Dr. Ruscio, DC:

Pretty good run, yeah.

Jandra Mueller:

We’ll talk more about endometriosis, have some exciting things coming up, but I think this covers a lot of bloating, distension, and a really great place to start from for the majority of people.

Dr. Ruscio, DC:

And will you tell people about where they can connect with you, and maybe remind them that your clinic does offer telehealth? Because I think that’s something that people mistakenly believe that they must see a pelvic floor therapist in person. So tell us a little bit more about that.

Jandra Mueller:

So I work at the Pelvic Health and Rehabilitation Center. I am in Encinitas, California, but we do have clinics throughout the Bay Area and in Southern California, and on the East coast in Lexington, Massachusetts, and New England. And we do offer telehealth. So a lot of people, you know, want some answers, they want to discuss their case, and we do all of that, and we can provide resources for finding local providers. I would say not all PTs or pelvic PTs are the exact same, and we all have different training and backgrounds. So even if you’re seeing a public floor PT but you’re not quite getting the answers, we’ll always help connect or kind of bring to light some new ideas or thoughts to think about. And of course we would love to see you in person as well, if you are local to one of our clinics. We are on Instagram at @PelvicHealth, you can follow us. We have a blog, weekly, all things pelvic health related, including specialists that sometimes kind of write in about different topics, all regarding pelvic health. We have a YouTube channel, to check us out there, we create some videos. And our website is PelvicPainRehab.com, and you can find all the information there as far as making telehealth appointments or calling us directly.

Dr. Ruscio, DC:

Awesome. And just to echo, like so many things, you have a range of kind of skillsets within PT, and even within pelvic PT. Some are more kind of conventional, medically based, which is not necessarily a bad thing, right? Just depends on kind of what your needs are. And then some are a bit more holistic in scope. So there have been a few people who’ve been working with PTs and we refer them over to your outfit, Jandra, because I felt like they needed a little bit more of a holistic approach. If someone was, let’s say fresh post-surgical, that’s when I think some of the more kind of conventionally minded in-the-box pelvic PTs would’ve been a better fit. And then in a case like this where we want to make sure that you’re not maybe missing the fact that their GI complaints of distension are coming from something like SIBO, that’s where I think it’s nice that you have a little bit more of a broad perspective.

Jandra Mueller:

Yeah, absolutely. We are always here to help.

Dr. Ruscio, DC:

Sweet, alright, so round three will be on endometriosis to come soon, guys. And Jandra, thank you again, really enjoyed our chat per the usual.

Jandra Mueller:

Awesome. Thank you for having me again. Looking forward to talking more.

Dr. Ruscio, DC:

Yeah, same here.

Outro:

Thank you for listening to Dr. Ruscio, DC Radio today. Check us out on iTunes and leave a review. Visit DrRuscio.com to ask a question for an upcoming podcast, post comments for today’s show, and sign up to receive weekly updates. That’s DrRuscio.com