The Whole Organism Approach with Dr. Nicole Cozean

In this episode of the Unreal Results podcast, I have an amazing conversation with my friend, Dr. Nicole Cozean.  We talk about the significance of a comprehensive assessment & treatment strategy for pelvic floor patients, but really this approach is for every patient.   Some highlights of our conversation include treating the whole organism vs whole body, understanding the interconnectedness of the body’s systems, and utilizing systemic treatments over isolated exercises.

Resources Mentioned In This Episode:
Nicole's Instagram
Pelvic Sanity Instagram
The Pelvic PT Rising Podcast
Pelvic PT Rising Website
Finding Pelvic Sanity Podcast
Pelvic Sanity Website (Nicole's Clinic)
Sign Up For LTAP in Washington D.C. (June 15-16)
Sign Up For LTAP in San Diego (Nov 2-3)

Considering the viscera as a source of musculoskeletal pain and dysfunction is a great way to ensure a more true whole body approach to care, however it can be a bit overwhelming on where to start, which is exactly why I created the Visceral Referral Cheat Sheet. This FREE download will help you to learn the most common visceral referral patterns affecting the musculoskeletal system. Download it at www.unrealresultspod.com

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• Episode Transcript

  Anna Hartman: Hey there, and welcome. I'm Anna Hartman, and this is Unreal Results, a podcast where I help you get better outcomes and gain the confidence that you can help anyone, even the most complex cases. Join me as I teach about the influence of the visceral organs and the nervous system on movement, pain, and injuries, all while shifting the paradigm of what whole body assessment and treatment really looks like.

  I'm glad you're here. Let's dive in.

  Hello, hello! Welcome to another episode of the Unreal Results podcast. It's a special one. I have a guest. Many of you know I don't do a whole lot of guest episodes, so when I'm bringing on a guest, it's usually someone I'm like, feel very comfortable with, and I'm friends with, as well as someone I know that is worth sharing, and also is going to give you a perspective of how the viscera and the nervous system can relate to musculoskeletal pain dysfunction.

  So my guest today is Nicole Cozean. Uh, she's a pelvic physical therapist, um, up in Orange County, San Clemente area and, um, That is like the very small part of what she does. So I'm going to let you let her introduce herself and tell you about all of her things. And then we're going to just kind of riff and just chit chat.

  Um, and, and let you all hear our conversation.

  Nicole Cozean: Yes, this is awesome. Hi everyone. And, um, Anna, thanks so much for having me. I really appreciate, um, you, Ask me to be on the podcast. I'm super excited for our conversation. We've had many conversations offline. Um, and I'm super excited for people to hear, um, sort of where we align on a lot of areas.

  So like she said, my name is Dr. Nicole Cozean. I'm a pelvic floor physical therapist. Um, I have been a public floor physical therapist. Most of my physical therapy career, I got roped into, um, do B doing pelvic floor therapy at a time when it was. still considered very weird. I think most of the people coming into it now are so excited about the pelvic floor.

  Most patients or potential patients have heard about the pelvic floor, but that was not always the case. Um, I remember getting made fun of in my ortho practice quite a bit for taking everyone's pants off and why is she always going back into that room What are you doing back there? And I was like getting my patients better.

  Keep up people keep up. Um, and so, so I have been a public physical therapist for about 20 years. Now I worked for and started a hospital based public floor practice. I'm in orange County, California. Um, at a big hospital based, uh, place. I did that for five years, worked for another outpatient, uh, pelvic floor therapy clinic for another five years.

  And I've had my, my clinic for almost over eight years now. And pelvic sanity. So. started, um, back then. It was at a time, too, where I just had written a book called The Interstitial Cystitis Solution. Um, and interstitial cystitis, for those of you who don't know, is a bladder pain condition that I was treating very much orthopedically, fascially, viscerally pelvic floor wise.

  And now we know a lot more about that condition and it makes sense why. So I'm excited to talk to you about those visceral visceral type symptoms, um, and how we can treat those orthopedically. Hello. Um, but so I wrote a book called the interstitial cystitis solution started pelvic sanity. Pelvic sanity is named very strategically.

  Everybody thought that, um, it was a dumb name at first. Everyone told me not to name my clinic that, uh, But I was coming home so many times from treating really in depth chronic pelvic pain patients. And I would come home to Jesse, who's my husband and now business partner. And he, and I would always say to him, man, this is just so insane.

  This is insane that this person had to live with these conditions for so long. This is insane that how, like how much progress we're making in a short period of time. And, and when we were deciding to name the clinic, we were just like, well, let's just bring some sanity back into the process for patients.

  And we called the clinic pelvic sanity. And since then, um, we have treated patients from all over Orange County, California, but also all over the world. We have a pretty extensive out of town program. We've seen patients from, um, over like all six, six continents. So if you know anybody from Antarctica that has fell in Florida's function, uh, let them know that we have an out of town program.

  Um, and over like 120 people have come from all over the world. And so really excited to just be able to expand the reach. On that note, I've also created a company, second company, called Pelvic PT Rising. One of the, the goals of my work at doing the book, which is a patient centered book on interstitial cystitis, was to help patients to find pelvic floor therapy.

  And Go see folks that are doing this and I got hundreds of emails and Communications after people read that book and said well I went to pelvic floor therapy and it wasn't like anything like how you were describing it should be and so I took a mission then to not only educate patients on the benefits of pelvic floor therapy, but pelvic PT rising is essentially the clinical arm of where I do a lot of teaching, um, have online courses for pelvic rehab practitioners and also do business coaching for people that want to start clinics like Pelvic Sanity.

  Um, so that's me in a nutshell. We've also started a, a pelvic rehab conference called Pelvic Con with my good friend, Jessica Real, uh, which is an in-person conference for pelvic rehab providers. So we're just on a mission to, to change the way pelvic rehab providers treat the pelvic floor. And I think that, Anna, to your point with all of your work, I feel like.

  When we say we treat from head to toe and we treat the whole person, we actually really mean it.

  Anna Hartman: I love that. You treat the whole organism. And that's why I switched to like saying it that way because so many, so many practitioners would be like, Oh, I treat the whole body because they think, well, Oh yeah, if somebody comes with knee pain, I'm looking at their hip and their core and their breathing.

  And I'm like, that's still not the whole body. That's the whole musculoskeletal system. Like, so I was like, this is why when I, like I, I, I, I would say that though I don't have the biggest vocabulary, I am very smart. Like, particular about the words I use. And so that's why I don't say whole body because of, you know, just like your people were reaching out to you.

  Like I've gone to a pelvic floor physical therapist and it's not what you describe. And, and unfortunately that's not just pelvic floor physical therapy. That's like all physical therapy. I get so many messages from people that are like. I went to a physical therapist or I went to an outside trainer and they're like with my knee and they only touched my knee and I'm like, yeah, and like, I see this across the board at every level, like my, my, my athletes go to go to other practitioners sometimes that are like well known practitioners and it's such a disappointment when I hear what they do.

  Because I'm like, gosh, like you're even going right to their knee. Like you didn't. And I'm always asking the athlete, I'm like, did, did they look at anything else? Like, did they even evaluate you? Did they even look at anything? Or they're just like, Oh yeah, your knee hurts. Let's do your knee and your hip.

  And they're like, yeah, not really. And they're like, definitely not like you, but they didn't really even do anything other than where I told them I heard it. And it's like, damn, like sometimes I feel like we've come so far and then sometimes I'm like, how are we still here?

  Nicole Cozean: Totally.

  Anna Hartman: So anyways, yes. This is why I call it a whole organism approach as opposed to whole body because I don't want people to think like, Oh, I already do that.

  I don't need this information. And then I also want people to be like, why is she saying organism over body? Because it has so much more to do with the. Organisms like fundamental, like drive for survival and finding safety in their body and safety in their environment, like that drives so much a drive so much, as you know, like, I mean, and again, like, this is like, I, you know, part of the reason I wanted Nicole to come and, and why Nicole and I have tried to like, get to know each other, each other better since we met a while back ago is like, because pelvic floor.

  Like, I end up getting a lot of them in my ecosphere, even though I am not one, because you all, like, understand that the viscera influences things. And most of the time when somebody's coming to see you, not only do they have like just general musculoskeletal pain in their pelvic area, but they also have very visceral symptoms of stuff.

  And so it's like, you're already seeing that crossover. So I don't have to spend any time convincing you that it matters. And then, but the other thing, and sort of like, like, what's my point with this is, uh, um, I don't even know where I'm going with it based on what we were talking about but it's like Yeah, you already get it.

  You already understand how, Oh, I know how I thought of this is like, so the other thing that you end up dealing with a lot, I would assume as pelvic floor physical therapist is trauma around this area of the body and trauma from not just a physical mechanical trauma, but like an emotional, um, trauma, like people who have had been, you know, sexually assaulted or people who have had, um, miscarriages or loss around like births or not being able to get pregnant.

  Like there's a lot of emotions and, um, fundamental, like safety versus survival mode that you deal with on a regular basis where, whether, whether the therapist really realized that or not, right? Like, and I'm sure you talk about that, especially. Well, at least the industry talks about that when you're talking about an internal exam, and I, I know we've talked about a little bit about your training and what your training does, and unfortunately, I know it's probably not as like trauma informed and as I would think it would should be, um, but it's like, you know, hopefully it's getting talked to.

  And I, I at least know, probably practitioners are aware that when they go in to touch that region, Even externally, people who with trauma, like you start seeing it in their body. And so this is to like, this is to what I mean, whole organism, whole organism approach is that understanding that sometimes even just to do a good evaluation on someone you like, it's not about the questions you ask.

  It's not about like anything other than like setting the tone to have the environment in the treatment room, or in them, the. The co regulation already starting just when you're talking to them, just when you're walking them in the door, how you sit next to them, like paying attention to their body language and understanding that you could do, you could literally be the best pelvic floor physical therapist of all time, do the best internal work, like learn from the best, do the best, like have the best hands on.

  And if you're not paying attention to what their nervous system cues are giving you, you're not going to have a good time. Treatment outcome period because they're never gonna feel safe enough to elicit a healing response because healing happens in a, in a safe nervous system. And so if they spend their whole appointment with you is still in this like fight or flight survival mode, then it doesn't matter how good of a technique you did, whether, you know, because you're not doing it where the body needed it.

  And the body needed the first technique, not to be in the pelvis, but the first technique to maybe be up in their cranium, um, away from them to really like tap into their. Parasympathetic response to decrease overall central nervous system tension from feeling threatened Before you can go in there. So anyways, that's that's a little bit too of like why I say whole organism.

  Yes Versus whole body and and I know you appreciate that too, right and I know that when when you're teaching practitioners with your you know, how to, how to have a practice like pelvic sanity, sanity when you're talking about whole body, you're talking about whole organism.

  Nicole Cozean: I am talking about whole organism and I love that distinction.

  And, and there is a difference, um, with talking about it like that. And so a couple of things I want to pull out from there too is, so I love when you say like, we have to take the whole patient experience and make it safe from the bad And we'll go into why that even matters even more from a pelvic floor perspective, but, um, but it matters for everybody as well.

  And so, and I, I think that, so we are very specific of, you know, what people, what pictures people show on the website, like how we're interacting with them on the phone, what the waiting. Environment is like, you know, even something so as simple as teaching our front desk staff to say, you can either have a seat or stand over here because if you tell somebody that they.

  have to sit down socially that can create anxiety if somebody is literally coming for pain with sitting. And so, you know, it's like now all of a sudden they're thinking, well, if they don't, why are they going to make me sit? I don't want to sit. I don't want to get worse. Like, do they even, then they go immediately to the catastrophization of that, which like, am I even in the right place?

  Are they even going to know what's going on? Yeah. And so I feel like The empathy that we have to have for peep for folks that are actually walking into our, our doors needs to extend into every aspect of our being, how are we walking them down the hallway? Where are we telling them to sit? Can we give them a moment?

  Um, and pretend to go get a pen just so that they can scan the environment without you being in there, you know? Um, and you know, it. Somebody, one of my mentors talked to me and said, like, pretend you're, don't know anything about pelvic floor or what's going on. You go into a treatment room, you walk in and there's literally at least three, probably if not four places to sit.

  There's the chair that we all assume that they're going to sit in. There's the stool that we sit on. If you have a desk in there or another chair somewhere, there's that. And then there's the treatment table. So even just that, even just helping them to know. Like telling them what to do, having them take a half a beat by telling them to sit not on the table.

  Now all of a sudden they know we're not going to start with the internal stuff. We're going to talk first. You have, you can do all that stuff without saying a word, right? And so that's where I really feel like the patient experience helps to create safety from the very beginning. And that's something that we take.

  a ton of, of, of importance in, and we place a lot of importance on that at pelvic sanity and everybody that we teach. And then the other thing that I wanted to point out too, from your, just what you were saying about the whole organism is that I really, you know, I always tell people that I'm teaching and training.

  We have to remember that at the point when somebody in this case specifically has a pelvic floor problem, they have a pelvic floor symptom. That means they have something that your body is now no longer able to compensate for. We can go a lot and a lot of time, a lot of things can happen where our body is innately prioritizing.

  Peeing, pooping, sexual activity, and protecting that region at all costs. And because those are such fundamental bodily functions for our physical survival. And so at the point when our patients come in and they have something that is going awry with one of those things that your body is innately neurologically designed to protect, shit's more jacked up than we realized.

  You know what I mean? And because of the compensatory strategies are now also no longer working. And so I think that to understand that, even though Something like stress incontinence is quote unquote simple, and I'm using air quotes. Um, it's a relatively simple thing that's happening, right? There's a pressure that is greater in the bladder than the pressure of your, your urethral sphincters can, can connect.

  And and prevent like it's literally can be whittled down to that anatomically. That's what's happening. But the reason why that's happening is so much more complex than that. And it means that there has been a loss of protection, a loss of that compensatory strategy to. To protect the very region that we're neurologically designed to protect at all costs.

  And so I feel like if we think about that, then we have to have a lot bigger, better, a bigger reverence for the patient sitting in front of us. Um, Because even the symptom that they're describing may seem benign or not that big of a deal to us as practitioners, but it's a freaking big deal to the patient and it's a really big deal that the body has now come to this place where it's not able to compensate anymore.

  Anna Hartman: So good. And actually listen to you. I'm like, you know what? Maybe I should reorganize a little bit of the steps of the LTAP. So it's like one of the, in the LTAP and you've taken it so you know, like one of the things is like it's set up based on an organ hierarchy that is kind of made up. Like I didn't, it's not like they teach that in the Barral Institute.

  It's like made up for me because I had to organize things in my brain of like proving that. My listening skills that I learned with the Barral Institute, like I was seeing a pattern of them. And so it made me kind of go back and be like, can I, can I kind of mimic this pattern when I'm choosing these orthopedic tests to get us at the, arrive us at the same spot where the body is protecting and the organ hierarchy was like basically like look at the structure of the body and And the organs that it protects in hard frames are most, more important than the organs it doesn't.

  And I kind of, I've always lumped the pelvic organs with the abdominal organs because it was just convenient. But I kind of like, from listening to that, I'm like, God damn, you're, you're right. Like, eliminating our wastes is like, you can't survive without that. You can only go so long Without being able to eliminate your waist.

  And so it's like, Hmm, perhaps the pelvic, I mean, and I say that too, when I teach it, I'm like, yeah, and the organs and the pelvis, they're more important probably than the organs exposed in the thing. But yet my L TAP doesn't reflect that. So I'm like, maybe

  Nicole Cozean: it's a little sub, a sub category, for instance,

  Anna Hartman: I might be reorganizing things and be like, no, we should probably check the bladder.

  And the, um, reproductive organs and the rectum first,

  Nicole Cozean: potentially, you

  Anna Hartman: know, like maybe include them a subset of like, because like the thoracic cavity first is the cranium. Second is thoracic cavities above the diaphragm, actual thoracic cavity. Third is, uh, thoracic, abdominal organs. So like, uh, liver, pancreas, spleen, stomach.

  And then, then I'm like, Oh, and the abdominal pelvic organs. But I think that the bladder, the uterus, ovaries and Um,

  Nicole Cozean: rectum

  Anna Hartman: rectum, seminal vesicle, they all need to probably go with the, um, abdominal thoracic organs. Yeah. Yeah. Yeah. Also in a hard frame.

  Nicole Cozean: Yeah, totally. And, um, and procreation. I mean, if you really think to what the, the, the species survival based on, like, so if you even go more meta, then it's that too.

  Um, so yeah, and I, so again, I, I just really think that we have to have reverence for our patients too, of people that have this. this stuff, even if they're not acting like it's as big of a deal, they can be super excited to see us, you know? And, but then when we actually get down to, and I love when you're talking about, like when we're actually touching people's bodies in, even in the abdomen, right?

  Yeah. Even in the abdomen. I always, I don't know. Tell my staff to when, when we're doing some training, I'm like, pay attention, not to what they say necessarily, but what their body's doing. So even something as simple as if your patient is supine on the table and they have their legs crossed, that's a very closed posture.

  It's, and you might be sitting, you might ask them, are you comfortable? Do you need a wedge underneath your. underneath your knees and they'll be like, no, I'm fine because they're people pleasing. They may be in a sympathetic state that is actually, or vent, ventral vagal state that is like more of like, just, Oh, it's okay.

  Everything's fine. Right. But like, Just instead, could we not say like, Hey, I'm just going to put a pillow underneath your legs because I need symmetry when I'm as close to symmetry as we're starting when I'm doing evaluation, because them crossing their legs, number one means that they're closed off.

  They might not be as comfortable as they're saying, but that also that can change. My exam, if their right legs crossed over their left or their left legs crossed over their right, like that matters. And so I really love that you're that specific because this is why I love you. It's like, yes, we're that specific.

  Yes. We think about this stuff. And

  Anna Hartman: we're always observing and for, we're observing for cues of safety or threat. And I'm like, yeah, when you go right before you go to put your hands on somebody, or even after you put your hands on somebody, you should be looking at their face.

  Nicole Cozean: As

  Anna Hartman: well as their whole body, but definitely their face.

  Yes. You want to make eye contact with them, but also not even eye contact, you want to be observing their face to make sure that they feel safe. Totally. Because like the first place they're going to show you they don't feel safe is their face. Whether you really recognize it or not. Yeah, and their

  Nicole Cozean: eyes and like, and then I, even if I know that I'm going to, I don't know, assess the Uracus first as an example or something like, uh, I still am not going to go right to that area as excited as I am as a practitioner to see, does this, is this going to elicit a bladder response if we go up near their belly button?

  Ooh, um, you know, I feel like we can get so excited and I, sometimes it's just a hand. Um, resting on the outside of their, you know, of the, of the towel or the gown or whatever you got going on with your situation, a hand resting on their pelvis for a second, as I'm talking, as I'm going to explain what I'm going to do, then I ask a question, may I lift up this area?

  I'm going to put my hands, place my hands on your abdomen. Like you're, you're narrating what you're going to do, um, because even your words can, can elicit a threat response, your, your touch, like all of that. And so. Yeah, and sometimes we can, we can listen to the body and wait for it to settle for a second to see like Cause it does do a little bit of an assessment too.

  It might be initially like, Oh, and then be like, no, she's okay. She's safe, you know? So it takes, it gives it, give them a half a beat to figure out what's going on. And, and then that can become your, and I always too, I go. Even if I'm going to work on a different area of the body, I will sometimes always create that, what people can expect.

  So, every single time someone lays supine, I'm going to do that same thing, and then we can go wherever we need to go. But now it's like, it starts to be a treatment pattern that the body learns to expect, so it's not so surprising if we do something different.

  Anna Hartman: Yeah, exactly. Yeah, I was just this past weekend, I was teaching an LTAP course and I was like telling, you know, after you watch everybody in a breakout lab, you're like, Oh, okay, I need to emphasize this.

  And so I was like, one of the things I emphasize, especially when you like as a practitioner, when you don't feel super comfortable about a new technique you're trying, I'm like, don't be in such a hurry. Like, be patient. Like, just be patient. You have, you, you, I mean, it's like that with any sort of relationship with somebody, right?

  Like, nobody likes franticness. Right. Especially when it comes to touch, it feels very uncomfortable. And so it's like, just be patient, be soft with your hands, like let them be there for a second and let them get used to that

  Nicole Cozean: and

  Anna Hartman: let their body respond and then go into the test.

  Nicole Cozean: Yeah. I always talk.

  Anna Hartman: Go in like all fast and quick and like, I'm not sure what I'm supposed to feel and you have all this tension.

  It's like, they're going to feel it too.

  Nicole Cozean: Yeah.

  Anna Hartman: And the thing too, with the pillows that I like, I, this is, I talk to people about this all the time. Like, yeah, I don't. When I am looking for an answer, I'm not looking for words. I'm looking for your body to tell me. And so it's like, if I feel that maybe you would be more comfortable with a pillow, instead of even asking you, I'm just sliding a pillow under your legs and looking at your response.

  Most of the time, I'm right. You needed a pillow. And then I don't even, I don't even have to worry then about them trying to be like a people pleaser and be like, I'm fine. And I'm like, no, your body's telling me you're not fine. Like I appreciate that you don't want to be an inconvenience, but right. But also Right.

  And so I'm like, I'm just going to put some pillows until I see your body do a certain thing. And then I'm going to point it out. See how much more relaxed your body is. Isn't that nice? Like, like, let's just make sure that we always have these sort of little props for you so your body always feels comfortable.

  Totally.

  Nicole Cozean: Absolutely.

  Anna Hartman: These are, these are specific for your body only. Not, this is not, everybody gets it and then they feel like, wow, this is kind of special. So yeah, I know me and you could probably write an entire, like do a whole weekend workshop on like this.

  Nicole Cozean: Just on that. Yes. 

  Anna Hartman: Yeah. 

  Nicole Cozean: Thousand percent like 

  Anna Hartman: crazy because it's so needed.

  But I feel like nobody would take it. 'cause they think 

  Nicole Cozean: I know because no one thinks that they need it, which is why this podcast is gonna be . Right. We got a rep. Give 'em what they, what is that phrase? Give them what they, 

  Anna Hartman: yeah. Meet what they want. With what they need. What they need. Yeah. Marry the two. Um, 

  Nicole Cozean: and I, you know, I also wanted to point out that you also said something really interesting about, you know, being in the pelvic floor space and, and trauma, and I'm reading, um.

  I've read a couple different books, um, a lot of books on this actually, but what I'm reading right now talks about the, we all say it in like big T and little t trauma. I feel like the, the overt, obvious traumas to the pelvic region or things like sexual assault, or even just being in an accident or some sort of a major blow to that region, fall on a tailbone even can be considered that.

  Um, so I feel like those are like direct traumas to that region. Some more emotionally involved than others, but, but there's also the, the little t trauma essentially that where, cause it's where you hold your anxieties as well. And so something, an event that, you know, wouldn't be quote unquote traumatic to anybody else.

  Um, even something like it from your childhood, like getting made fun of or something like that. Like where was that held? Yeah. And I do believe that there is, that people, different people hold stuff in different areas of their body. Mm-Hmm. And I think that as a pelvic floor therapist, we tend to see a lot of people that hold tension in their pelvis, but not everybody holds their tension there.

  And, and sometimes, like if you're getting. scared during a movie, you know, what happens? There's actually an article that looks at, uh, looked at public floor muscle activity with, um, with scary movies. And a lot of times people with public floor dysfunction would have that, um, greater, uh, reaction at their pelvis, but some people can do it in their throat, in their chest.

  Um, and I feel like whether you're someone that doesn't treat into the pelvis that much at all, or someone you're listening as public floor therapist that does, I, I do feel like. We have to understand that that our patients may have a greater tendency to hold tension in the pelvic region than we might realize, or that they might realize, and that's the thing they can say, Oh, I'm fine.

  I'm really high achiever. I don't really get anxious that much. And even the. Stress their stress response on a day to day basis when they have three kids and they're running around and doing all the things and they're a lawyer also. And now all of a sudden it's like, well, right, but you're holding tension there still out of a protect zone for that, that region.

  And so. Yes, that doesn't count as like trauma as it's defined in like the textbooks, but it can be a repetitive holding pattern, um, that's meant to protect. And I feel like that's something else to realize that a lot of our people that are having these issues at the visceral level when they see us also have that, those tension patterns that are being held, um, from other areas of their life.

  Anna Hartman: Absolutely. Absolutely. 

  Nicole Cozean: Yeah, 

  Anna Hartman: I, I see it too. 

  Nicole Cozean: So, let's talk to, because, so I did take the LTAP, Anna, um, as you know, it's one of my most favorite courses I've ever taken. You know what, I'll say this too. 

  Anna Hartman: I didn't even pay her to say that. I love that. 

  Nicole Cozean: I know. But here's the thing, I feel like when I told some of my colleagues that I was taking it, they're like, oh, who is this chick?

  I'm like, Oh, she's just an athletic trainer. I'm sure you get that a ton. So how do, what do you, what do you say to that? I'll tell you what I said to that, but.

  Anna Hartman: Well, so yeah, so I guess I get it more from, um, people who are, I probably hear it the most, obviously people who come to my classes, like they think I'm amazing. Like this, this is the funny thing about like, somebody was like, are you nervous for teaching this weekend? I was like, no. No, these are my people.

  Yeah, they're my people. Like, there's probably nothing I could say this weekend that would make these people not like me. I was like, there's like maybe two people in the class that don't really know me. And maybe you won't like me by the end. I was like, but I'm pretty sure they'll like me. I'm pretty sure there'll be on board, like the rest of the people.

  And they're just the people who were like free spots for hosting the course. Right. But I was like, yeah, no, everybody else is like my biggest fan. They're like, This is of all the things that I do in the world. This is should come with the least amount of fear because they already are bought in. I was like, so the, just an athletic trainer, I get that mostly when I'm attending other continuing education courses and, um, or I get that when somebody has heard me speak or heard me describe something and they're like, wait.

  But you're just an athletic trainer or, or I'll get like, wow, you're, you know, a lot for an athletic trainer. And, um, I always laugh cause I'm always, cause it depends on how like confident I'm feeling in that day. Cause sometimes I'll be like, actually, I know a lot for everyone. I'm really smart. I'm actually really sorry.

  Right. And obviously, as I've gotten older, my response to that comment has changed over the years. At the beginning, I tried not to be offended by it, and then there was a little while that I was offended by it. And didn't say anything and now I'm not offended by it, but I also will be like, yeah, yeah, I'm really smart.

  It's not, I'm like, you know, I could be a bitch and be like, you're just a physical therapist. Yeah, I know. You're a physical therapist and you don't know this. Like, you know what I mean? 

  Nicole Cozean: Totally. 

  Anna Hartman: There is a, and this too, probably is why I let, All practitioners come to my courses, not just PTs, not just athletic trainers, because I 100 percent Have seen in my whole career in con ed classes in In places that my, my athletes have gone for physical therapy or athletic training, like it doesn't matter what your credentials are.

  There's a lot of shitty practitioners out there, period, both physical therapists, athletic trainers, chiropractors, doctors, Pilates instructors, like there's a lot of fucking shit out there. 

  Nicole Cozean: Yes. 

  Anna Hartman: A lot of shit. And. Also, there's a, there's a handful of great people in all of those fields. And, um, the thing that makes them great is not their credential.

  Nicole Cozean: Totally. 

  Anna Hartman: And so I'm like, you know, for a while, you know, we get really like, I think people get really attached to their credentials because they worked hard to get them and earn them. And I can appreciate that. But also like. When somebody is so, so attached to that, or like is threatened by that. I'm like, you have a lot of work to do.

  Like there's a bigger block become between you getting better and doing better for your patients than you probably realize, because the fact that you even think that it's a problem that I'm just an athletic trainer and have nothing to teach you means that you're not open to learning things and you're not open to learning things outside of.

  Like traditional ways of doing things and so this is probably not the right course for you anyways, right? You know, so I'm like, you know Nowadays, I don't take offense to it. I just take a mental note of like you're pretty closed off. Yeah, holy 

  Nicole Cozean: but I mean I Absolutely, so for those of you who are thinking about maybe taking I feel like definitely like do it But here's the thing what one of the amazing things about The course that I really loved that I think that everybody should, should think about is, and it really like leveled the playing field with everybody is when you went over those core beliefs and like, kind of like the things that we are going to go into this weekend, assuming at first, and then basically proving by the end of the weekend.

  Yeah. And. I've actually stolen that in my thought process a little bit, like in, in some of my teaching because I feel like it's so awesome to think about what are all the things that we're going to agree on if this stuff is going to have its optimal, um, You know, optimally go into your brain, right?

  Because I feel like, and I usually call this, yeah, butting, um, where people they're like, well, yeah, but where you people get defensive, uh, regardless of what, um, you know, what their credentials are or whatever it's, I feel like it's a little bit of a human nature and it's a fricking pet peeve of mine of people that do.

  Butting. I think I did a whole, a whole podcast episode on my podcast about people that, yeah, but it gets me back and annoyed. But I really, but I feel like, I feel like this amazing thing that you did really helped everybody to sort of be on the same page going into what you were teaching and how you were teaching it.

  Um, and, and one of those core beliefs was this thing that we were talking about at the beginning was this, that there is in fact a hierarchy to what your body is protecting. Period. And, and we, I feel like we all understand this innately as human beings, but I feel like sometimes we forget it when we, when we put ourselves into the practitioner role and we're just so.

  obsessed about fixing the thing that the patient is saying is wrong. And I, I say this in my teaching is like, Oh, find the wife and keep asking the question. Well, why is that like that? Well, why is that like that? And why is that like that? But I really loved how you sort of laid out at the beginning, the core beliefs, things that were all of us in this room are essentially making a pact to, to support.

  Yeah. And then now we're going to move into the weekend with these core beliefs at the core of what we're doing today. And then we can now work off of that. And that, I feel like that was a really great thing, especially when you have multiple different people from multiple different backgrounds in your courses.

  Um, Cause I think that, that can enhance the experience and I feel like you helped everybody to really get on the same page. And I, I really appreciated that. 

  Anna Hartman: Yeah, no, it is. I have liked adding that in. I actually got it from Jill Coleman. It's like a sales, it's like a sales strategy. Really is to like identify the core belief of each offer.

  And like, basically that's what you're trying to prove to them, like that you have the answers for, but it, but also, so what it is to me when I heard it and when I, why I'm like, Oh, I love this. And I'm going to, you know, because a little bit of a, from a sales strategy, you don't like necessarily call it a core belief right at the beginning, but you like, basically like that's how it's set up.

  Um, But I was like, I'm actually going to just call it out and be like, these are the core beliefs of each one of these courses. One to organize my brain, but then also because I'm like going back to like fifth grade science project, right? Like it's, it's the scientific. 

  Nicole Cozean: method. Yes, 

  Anna Hartman: it is the scientific method to have a hypothesis and then spend your whole time trying to prove or disprove the hypothesis.

  Like that is the whole scientific model that all sciences are based off of. And so, um, that's why I think it's so important to, to identify like, This is the scientific model that we're going like that we're basing everything off of and then you're the scientist It's your job to just really the way the scientific method is set up is like you're supposed to disprove it, 

  Nicole Cozean: right?

  Anna Hartman: You can't disprove it. Then it's like a valid method, 

  Nicole Cozean: right? Yeah, it was so funny And this is like convergent evolution as it at its finest. So I have a course called Pelvic PT Essentials and essentially it's the, it's the how to like when they, when people take their first pelvic floor course, then they're left kind of like, ah, I'm supposed to actually treat a patient.

  Like what the hell? I just learned how to stick someone with my finger in someone's vagina. And now I don't know what to do. Right. And I teach, we call it in, in the essentials, we call it having a prior, like you have to have a, a prior assumption of what you're looking for to happen when you do said intervention.

  And then if it doesn't happen, then it's like, Hmm, it should create pause or what else am I missing? Or what, what else would make sense when that's the outcome? What else could be? Behind what are the steps up there? 

  Anna Hartman: Happen. And this is the whole thing is like somehow, somehow our industry got so hooked on being the expert, got so hooked on the credentials, got so hooked on like solving everyone's problem that they forgot their main hat was a curious scientist and the curiosity is then completely lost.

  And what, what happens when we lose curiosity is we stop reassessing and we stop looking at even how our intervention. Changed things in the body not an intervention from like they came in week one and by week eight They are better. No, no, no, no like in terms of like This was my assessment. I did this thing and then I instantly reassessed and what changed and did what change did I expect it?

  Based on my hypothesis. Does that make sense based on the the like hypothesis? I'm going from that like it's gonna make sense of their pain or does it not make sense and whether it does or doesn't That nothing It is nothing to do with being right or wrong. It's more information. Yes. And more information should breed more curiosity, should breed more possibilities.

  To help someone fully as opposed, you know, and, and this is a thing, like so many times, well, and we're doing this, whether we realize it or not, like we're basing our, all the information we're gathering, we're trying to prove our points. Right. And so it's like, but it's always proving whatever bias you have.

  And so this is, again, goes back to why it's nice to list out those core beliefs, because it's like, we're believing that. You know, like the, we're believing that the breath hold is influencing things from a neurological standpoint, a sensory standpoint, not a pressure, well, yes, a pressure standpoint, but pressure as a sensory experience that the organs are having, which is better information to the brain, which means better output from an output standpoint, and the outputs we're looking at are mobility, strength, Right.

  Range of motion. Uh, I don't know. Like motor performance. Yes. 

  Nicole Cozean: Yes. A thousand percent. So that is frigging brilliant. And I, I just loved that whole thing. The other thing that I feel like I get a ton, um, and has gone into my teaching, but that when I was in the course, I was like, yes, like, you know, someone could be sitting in In your class or even some of my courses and being like, but what, but what's the evidence for that?

  Right? What's, but what's the evidence for that? So, you know, is 

  Anna Hartman: practice trolls. 

  Nicole Cozean: Yes. The I call them the evidence police. All right. So, and I understand the need and the want to quote, unquote, practice evidence based medicine. The one of the wonderful things I loved about having the core beliefs and then having.

  You know, your brain help us to process stuff and what we're seeing in the body and all that kind of stuff. Really at the end of the day, comes back to something that I truly believe and that I put in my teaching too, is that like anatomy is evidence, physiology 

  Anna Hartman: is evidence. 

  Nicole Cozean: Patient in front of you is evidence.

  And 

  Anna Hartman: like, that's what I think like makes me so frustrated is because I'm like at the evidence based police people, I want to know how many times they're actually reevaluating their patients within their session. Cause I don't think they are at all. 

  Nicole Cozean: No, I mean, it's no, I would challenge that too. It's just 

  Anna Hartman: like, that's the evidence.

  There's evidence right there. There's evidence right there. 

  Nicole Cozean: And, and for instance, even for something like the bladder, right. It's like, yeah. Why? Well, why are you working there? What's the evidence for that? It's like, it's, it's fucking anatomy. It's that, it's that the, the autonomic innervation of the bladder comes from T10 to L1 and S2 to S4.

  Like you have evidence to be working at the sacrum and the lumbo, uh, the thoracic, thoracolumbar junction. For your people with bladder pain, you have it. You also have it for the peripheral nerves that go there. You have it for the dura that, yeah. Goes right through there. You have it to be there. You have going all the way up the, you know, 

  Anna Hartman: the more evidence you have.

  Yes. And that, and that to me too is like when people are like, where the evidence? I'm like, oh, tell me you don't know anatomy. Without telling me, right, right. If you're asking me for evidence, you're clearly telling me you don't understand all of the layers of anatomy. 

  Nicole Cozean: Yes. And then also the physiological system.

  It's like, well, why are you working at the groin to help with, you know, prolapse symptoms? It's like because pressure like the organs don't By, by def by design, they don't give, they give a ton of information, but stuff that doesn't always reach our consciousness. Right. And so if there's something in our organ systems that like pressure in the pelvis.

  It can also be from things like inflammation. And do I want to work on the lymphatic system? Hell yeah. And it's like it just because the person's feeling pressure doesn't mean they have a prolapse. Even if they do have a prolapse, does it mean that that's the. Problem is that why they're sensing pressure?

  No. And so there's physiological systems that we need to consider that can create that those inputs to the organ that's going up to the brain. And that is your evidence to treat that region or that body system. Um, it doesn't have to be that somebody has. Researched this exact groin technique or even lymphatic drainage for prolapse symptoms.

  It doesn't, it doesn't have to be like that. It can just be that we know that major lymphatic drainage happens at that region. And it can be disrupted and that can create pressure, like, period, end of story. 

  Anna Hartman: And then like, too, like, those organs in the pelvis are endocrine organs. And so they mean that, that means they work in a system with all of the endocrine organs.

  So you can have something affecting the thyroid in your neck, pressure, like, you can have like shit going on in your neck that is affecting the thyroid mechanically that is going to influence the uterus. And the ovaries 

  Nicole Cozean: and the hormone system and all of that. 

  Anna Hartman: Come on. Come on. Again, like show me someone who's like, tell me that evidence is means somebody doesn't understand anatomy and physiology as well as you would hope they would.

  You would 

  Nicole Cozean: hope they would. Right. Totally. But that's, that's, I feel like that was one of my biggest. Just again, like solidifying moments that, that not only, I mean, it was a huge challenge for me to be like, gosh, I feel like I know anatomy a lot and you still fricking blew me away with some of this. I'm like, well, you did that goes where I need to like, look at it, pull out my netter and be like, what the hell 

  Anna Hartman: I knew I had a lot of pelvic floor people on the class.

  So I, you know, studied up a little bit before class to be like, how can I, how can I point out? And it wasn't necessarily to impress you all, but it was to show it's, it's a demonstration sometimes to show people that if you think, you know, the anatomy, there's still more to learn. 

  Nicole Cozean: Absolutely. And then the other thing is, is like for anyone listening to like, When I treat patients, I keep a fricking anatomy book right there.

  Like.

  Anna Hartman: I am constantly Googling pictures. Or I have them involved. I say, Hey, will you grab your phone and will you Google. Look up. The ovary suspensory ligament for me. Yeah. So I can see a picture of it and they're like, sure. And then, then, you know, then they're participating. 

  Nicole Cozean: Yeah, totally. And then I feel like that is so it's powerful for the patient.

  They start to look at stuff, then you're. Our brains, our clinician brain can start to go be like, where is that? Yes, all of it. And so I just really feel like for anybody thinking like, Oh my gosh, they, they, you know, they know so much stuff, especially Anna and all the things. It's like, I still have cheat sheets everywhere all over the place.

  I mean, Of, of all of the visceral somatic reflex connections and the innervations of all of the different things like it's okay to have that because we can't be expected to remember and know every single thing, but what we can be expected to do is make sure that we are treating in a way that makes.

  sense for how the patient is presenting in front of you. And so sometimes we need a little refresher on what else is, could be a pain generator in that region, or why else is that pain not going away? Because I thought that this intervention was going to be the key and it's not. So what does that mean?

  Where else can it be coming from? And sometimes you can like look at, look at stuff and just be like, Oh, I didn't remember that. The broad ligament goes right over the Iliacus and like, where does that get intonated from? And all of those different things, like we got to make sure that we're, we're looking at the totality of the area in front of us as well.

  Anna Hartman: Yeah, I agree. And I was, we're, as we're like talking about this, one of the things too, that, um, I say at the beginning of the course in this month, this might, um, this even goes back to your question about like, what do I say when people are like, Oh, you're just an athletic trainer. And I'm like, When you're, when people are saying like, saying things like that, it's actually them being offended and, and I, so I tell people at the beginning of the class, like I tell this story about how my first Barral class, like they said, how Jean Pierre Barral says that the muscles are the garbage can of the body because they're like basically just like, protecting everything else.

  Right. And they absorb a lot of tension and adhesions and stuff because of that. And so there's a lot of junk in the muscles because they're being a bodyguard. And, um, but it was also like interpreted in my brain that bodies are the garbage can, meaning they don't matter. Cause I think of garbage as being wasteful.

  They don't really matter. And it took me a couple of weeks after that course to realize like, How deeply offended I was by that comment, because that comment in like one fun, you know, the teacher, I'm sure it was trying to be funny too. Right? Like he was like, Oh, Jean Pierre says the muscles of the garbage can of the body.

  And everybody kind of laughed. And I laughed, you know, like, I was like, Oh, yeah, it was, it was funny. But like, weeks later, I was like, fuck, that really offended me. Because my whole life career up until that point was centered around the musculoskeletal system being like, this is the thing I've been studying for, at the time it was like 10, 12 years, right?

  And so I was like, I didn't realize how much it offended, it offended me. And, but that I was smart enough to realize that, that being offended like that, was challenging some deeply held beliefs I had about the body and was challenging this hypothesis I had about the body. And so I was starting to then have an experience to prove their, prove my hypothesis was wrong.

  And, um, so that's the most important thing. So it's like sometimes too fundamentally, like, like people thinking she's just an athletic trainer, it's like challenging a deeply held belief they have about how they know more than athletic trainers. Yeah, athletic trainers shouldn't know that. Right. But then too, like, it's also when I do the core beliefs at the beginning of the class to sort of set the tone and, um, Put us all in a scientific inquiry process and to like let everybody know that we're all in the same playing field now Regardless of our credentials.

  I also say hey disclaimer this weekend. I'm going to offend you In fact, not only am I going like not not even disclaimer In case it happens, like, I didn't do my job correctly as a teacher if I didn't offend you, and didn't challenge deeply held beliefs you had about the body. And if I don't offend you, and I don't challenge those deeply held beliefs, then you're probably not going to walk away from this weekend, like, actually making a change.

  Nicole Cozean: Totally. 

  Anna Hartman: And which is fine because sometimes you're not ready for that. And like, but also like that means when I challenged deeply, I believe there's going to be a lot of cognitive dissonance that comes up and it feels icky. I was like, and I saw it this weekend. Like everybody's all super excited Saturday morning.

  And then by lunchtime, people are like, Either they're like, fuck this, right? Or questioning. I don't believe they're like, I don't belong here. I'm so lost. Like, this is all new to me. And then by the end of the day, they're like, brains are fried. They're questioning everything I've ever done. They're like beginning to see like, They're beginning to feel that cognitive dissonance of me challenging the deeply held belief that everything they've done up until this point was with the wrong lens of view.

  Nicole Cozean: Right. 

  Anna Hartman: Or not, I don't want to say wrong, wrong's a harsh word and incomplete. Incomplete. 

  Nicole Cozean: I like, that's a better way to put it, but also wrong. I'm just kidding. 

  Anna Hartman: But also wrong and incomplete and wrong. Because it's incomplete is wrong. But, um, And so it's like, yeah, by the end of the day, like I can see it.

  People are like, just having that internal battle with themselves. And, you know, luckily by the end of Sunday, everybody feels much better and like capable and like inspired by it. But I'm like, I warn people Saturday morning. Cause I'm like, it's. And maybe you've never felt that in a course before, because honestly, I used to, I took like 10 con ed courses a year leading up until, until I started taking Barral Institute classes.

  And I never once felt offended. 

  Nicole Cozean: Yes, absolutely. And I feel like too, I feel like that's a sign of learning and growth. And when, There are, were things, even when I was in your class and I was like, well, of course she's going to say that because she's done so many other brawl things. Well, of course, you know, and be like, well, how am I going to ever be able to do that?

  You know, when she's looking at it through a lens that also includes blah, blah, blah, blah, blah, you know? Um, and I've only taken, you know, three visceral courses, you know? And so I just. I feel like, but that was a good feeling for me. Cause it was like, no, wait a second. Can't I can do this. And it's good for me to feel like that as well.

  And I loved being the participant because I'm. So often, I mean, you can drink your own Kool Aid for a long time. So it's like, you always have to challenge yourself to, to get challenged. You know what I mean? And especially as like a course creator and stuff, like, I feel like that's really important, um, to take other people's stuff and, and challenge your own things.

  And like, where do I agree? Where have I, You know, disagreed at any point where, you know, where do I need to shift? Like you're even just talking about shifting potentially a little bit of subtype of the LTAP. It's like, 

  Anna Hartman: I'm going to, I'm going to have to, 

  Nicole Cozean: yeah. 

  Anna Hartman: I'm like, well, I can't keep going on the way I've been going.

  Nicole Cozean: Right, right, right. So, and I feel like I love, I just love that type of growth mentality too. Um, and I think that, you know, for anyone listening to, it's just like, where can you be seeking out that growth? That growth from somebody else and challenging something. And I hope that I do that for people too. I hope that I, someone sat in one of my courses and been like, I don't think that that's going to work, or I don't think that I can give a supplement recommendation because blah, blah, blah.

  And it's like, you're challenging those things about, um, the way that you practice and that's the only way that we get better. 

  Anna Hartman: Yeah, 100%. Well, and I think too, so one of the things you said is like, how can this be true for you when I have, you know, like I've taken 20 brawl courses, so yeah, I've got a lot of techniques and information.

  And one of the core beliefs that we did lay, that we do lay out in the LTAP, which is a Big core belief is that it doesn't matter what tool you use as long as you're in the right spot. Yeah, you're in there in that that's a another quote actually from Jean Pierre is like, you know, you can use the best you can, you can perform the best technique on the operator, externus or internus that you want, like you can literally could have written a book on it.

  But if it's not where the body needs the treatment, if it's not where the body is protecting, Not that great. It's not, you're going to not going to have a very good outcome. And I could do if the body is like actually taking me to somewhere in the thoracic spine and I do a technique around the thoracic spine first, and it can be a general, and it can be a movement.

  It doesn't even have to be a manual therapy technique. It can be like laying on the quarters while breathing, or it can be like just seated rotation and the like, like very specific to the right segment. If I start there. And that's where the body's protecting, then I'm going to have a better outcome for my patient.

  Right. Because, because I'm following the body. I'm meeting the body where it's at. I'm not forcing the body. And so that's too, and it's, it's, it kind of makes me laugh with the Barral, Barral Institute. Obviously I love them and I love their classes, but they're, you know, you're always like thinking about like what people are saying and then what their actions are.

  Right. And in any, not even Barral Institute, just in general, like it's sort of like, I always go back to relationships. We've all probably been in a relationship where the guy or the girl says all the right things, but if you really look at their actions, they're not 

  Nicole Cozean: calling you back. They're ghosting you on text.

  Anna Hartman: Your friends are like, they don't really like you, but you're like, well, they tell me how great I am. They tell me they like me, but they don't show me they like me. Right. And so this is actually the funny thing with the Barral Institute. They tell us from the very beginning how important assessment is, but then the, all of their courses are.

  actually focused around techniques, treatment techniques, very specific techniques on very specific pieces of anatomy. Well, I'd say the other thing it's focused around is learning the anatomy. And they do say that's a priority. So that matches up. They talk about how important knowing the anatomy is. They teach a lot of really great anatomy, but then they talk about how important the assessment is.

  And they teach it once, and they reiterate it, but then they never really go back to it. And um, they assess the individual organs, and the mobility of the organ, and that's important, but less important than the actual general assessment of like figuring out where to go. And that's like, they're always, even the teachers, when you ask them a clinical question, Most of the teachers will be like, well, where was their general listening taking you?

  Where was their local listening taking you? Right? They'll, they'll ask, like, did you do that general assessment? And, but they, since they don't ever revisit it from an action standpoint throughout the classes, it loses its emphasis on actually being important because the action doesn't match the word.

  Nicole Cozean: Interesting. That's it. 

  Anna Hartman: So for me, this is actually, you know, part of the reason for the LTAP is because I realized and I, I actually listened to their words and I did take the time to get really good at my general listening and my, my assessment pieces and tune in my hands. And I actually did witness that that is where the magic happens.

  Like that is what gets good results is actually not the technique I was using, not. Not the treatment tool, right? Not the intervention, but being in the right spot. It was, it was in following the body. When I learned how to listen to the body and follow its lead and where to start treatment, that's when I could finally fly across the country, treat an athlete once and leave and not see him again for a week to two weeks and have, and know and see his body hold on to whatever I did.

  That never happened before I, before I learned how to, like, figure out where the body was acting. Access, right. And so that's too, that's what, you know, and when I was, when I was going to all the courses and people, I would hear and people are like, oh, I don't really do dreadnought listening. And I'm like, are you getting good results?

  And they're like, nah, I mean, kind of. I'm like, do you know when to use the techniques? And they're like, well, I kind of base it off of like the symptoms. And I'm like, yeah. Like, how would you ever know to lift their liver if they don't have a way to, like, direct you to the liver? Right. Um, and, uh, so that's when I realized, like, man, it's not just people, it's not just people that don't have the brawl work that don't know how to find out where the body is.

  Is leading them. It's everyone. And I'm like, if I could like, if I could help people do that. And so what I was also at the same time, people were wanting to learn from me. And I was like, well, I can't teach them general listening because it's so difficult. General listening takes a long time of practice and a whole journey.

  a whole nother podcast episode about trusting yourself and how to gain trust back into your own body and trusting what you feel. And so I'm like, how can I get to the same results orthopedically? And that's when I just started like looking for patterns within my orthopedic assessments. And my journey, you know, and that's when I came up with the LTAP.

  And so that's like, so that, like going back to what you said, like, how can this work for me when I haven't taken 20 Barral courses? And I'm like, because it's actually not about the 20 Barral classes. It's about the first couple that they teach. They don't even emphasize it very well in the rest of the courses.

  And so that's like why I'm like, this is why it works because as much as I love learning within their system and I'll continue to take a bunch of their courses because I love. Why I take their courses now is because I love learning the anatomy. When I take a course, it's not the technique. I might come away from that weekend with like three new techniques, but the growth of the anatomy in my brain and in my hands is exponentially improved.

  And so that's why I take the advanced courses, not for the techniques, but for the anatomy, because I also know that the techniques don't matter. In fact, this weekend when I demoed on somebody, It led me to their kidney, and I looked at Veronica Campbell, who's a PT that took my course. She's my mentor in the Barral Institute, and I was like, I hope you're not disappointed.

  I'm actually not gonna treat, I'm not gonna use a Barral technique for the kidney, because I think cupping works better. And I did the dynamic cupping and the skin lift, and that was my treatment. And then later she's like, don't feel bad about that. She's like, if, if it works, like, she's like, if you found that it works just as well, she's like, why wouldn't you do that?

  Like, she's like, cause it doesn't, cause again, like I'm not trying to pass a techniques exam. I'm not trying to impress the teachers that I know their techniques. I just want the results for my patient. 

  Nicole Cozean: And it's that ego. It's the, it's the lack of ego there. Right. 

  Anna Hartman: Right. Right. That is the key. So I'm like, I'm, so I'm like.

  Also, that just means I have a lot of more techniques to pick from. So if the cupping doesn't work for the kidney, then you better, well, no, I'm going to pick a different technique and it might be a visceral technique, but it's like, sometimes a general technique is just easier and more accessible for both me and the patient.

  And so why not start there? 

  Nicole Cozean: Yes. Like, 

  Anna Hartman: why are we trying to make things so fucking difficult? 

  Nicole Cozean: So hard. It's like, stop. Just pick the easy, pick the easy thing. Do it. 

  Anna Hartman: So anyways, that, that, I think that's like an important. thing. And even this weekend with people, I'm like, yeah. And, and also the reason why I like having other, like a mix of practitioners in the course, because when your only tool is visceral manipulation, of course, you would do visceral manipulation.

  If your only tool is movement, you're going to have to figure out how to move these areas of the body. But what makes us a better tool is clinician is to have more, more to pick from and to see it from a bigger 30, 000 view foot. So 30, 000 foot view. So it's like, even for me and you, like, how am I going to treat the operator?

  You might pick an internal technique. I'm going to pick an external technique and you might have never even thought about that external technique. 

  Nicole Cozean: Totally. 

  Anna Hartman: And so that means, okay, now you've just like opened your brain up to a new possibility. So like next time you do treatment on someone and an internal technique doesn't work, instead of being like, well, now what the heck am I supposed to do?

  You're like, well, I've got these four other external ones that let's try these. 

  Nicole Cozean: Totally. Yeah, that's I feel like and for somebody to like me who preaches and whose I hope actions match what I've talked about. Um, but, but to that's where it's like pelvic floor internal is very important. And also we have to treat outside of this if we're going to.

  really address the underlying why. Because like I said from the beginning, people that have pelvic floor dysfunction as an output or an organ dysfunction as an output of pelvic floor dysfunction, like that has to come from somewhere. And there is a disruption in their nervous system and there is a disruption in the way that they're, Processing safety.

  And there there has to be. Otherwise, that wouldn't be the area that would had the problem. And so it's like, we have to look outside. And I know before we were talking before we started pressing record, I know you're talking about like, Oh, you know, sometimes you get questions from public for pt saying, you know, Oh, well, how I get how this relates to pain.

  But does this also relate to things like incontinence and prolapse? Um, did I get that right? Yeah. And it's like, right. But if you think about the why behind somebody that might have incontinence or the why behind somebody that might have prolapse, then you're going to be able to adapt. these techniques and really any technique external to the pelvis to optimize the nervous system and the nerves that go to the pelvis and the nerves that go to the pelvic floor.

  Right? So a good example of this to and this was also at when we were doing. So I've been teaching this as well, and then, um, a really awesome physio from Australia who has a ton of courses on prolapse and, um, incontinence, talked about, you know, the innervation of the bladder neck and the rhabdo sphincter is the pedendal nerve, and so, um, If someone doesn't have to have pain to have dysfunction in their pudendal nerve, and that's where, you know, you know, everybody always thinks, Oh, if you have pudendal nerve issues, then you automatically will have pudendal neuralgia and pain.

  And that's, that's not true. It's no, actually not at all. And so it's the pudendal nerve is something that I clear for. Every single person that has any problem with, uh, bowel, bladder, or sexual dysfunction, because it innervates the pelvic floor, and it innervates a lot of the organs in that area, and it innervates the external vulvar skin, and so a part of it.

  And so it's like that nerve still has to have blood flow. It still has to have the lack of, of an inflammatory response going on there. It has to have good mobility, um, to To stretch and glide, right? And, and so. That's where we can start to really expand our view of where we're treating both externally at the nervous system, the lymphatic system, but then also treating, let's say for, for pelvic floor people listening like the Alcox canal and at the ischial spine where it comes back in the pelvis for somebody that does have prolapse or incontinence because you're, you're enhancing the entire health of the system, um, and it's nervous system response tools to go up back up to the brain.

  And like, that's what we're also intervening on. It's not just about the muscle. It's not just about the obturator internus. It is also about the health of the blood flow and the nervous, the nervous system input and the peripheral nerve and the top down central nervous system, autonomic response to that region.

  And it's all of it. And, and we have to intervene at all of it, um, or at least check off the boxes that The, that it's cleared as okay, if we're going to expect the output down the chain to be improved. Right? And so that's where I really feel like the answer to that question is absolutely these, this way of thinking, this, um, this way of thinking both, you know, the whole organism is actually applicable to any symptom, right?

  Including things like that you wouldn't think are related to that area. 

  Anna Hartman: Yeah, and it's one of those things too that I'm always like, well, yeah, so that's like, you know, so I teach, you start with the LTAP, you figure out where the body is protecting and then you pause before you treat that area. Then you like ask the patient, like, what's going on, like, what are we?

  dealing with today. And so if their answer is low, you know, low back pain, then you do all of your assessments that you would on low back pain because you still have, you still want to gather like, what's going on? Like, why do you have like, let me, let me get my best clinical judgment of why you have low back pain.

  But same thing if they're like coming in because they have incontinence or prolapse, then you're like, okay, well, I'm like, this is when you put on your pelvic floor physical therapist hat, what would you normally evaluate with someone with incontinence or prolapse? Like me, not being a pelvic floor physical therapist, but like understanding sort of the mechanics of like where the anatomy is and the pressure.

  I'm like, okay, if somebody came in with me. with prolapse. I'm assessing their SI area. I'm assessing their, like, I'm assessing their whole pelvis. Basically, I'm assessing their hip range of motion. I'm assessing their thoracic spine and their rib mobility. Like I'm accessing, I'm actually probably also going to assess their ankle mobilities to make sure they can shift their weight forward on their feet to get their pelvis Good position from a pressurization standpoint, right?

  So it's like, yeah, I'm going to assess the nervous system I want to see what kind of neural tension they have Because even though put like I mean pudendal nerve is like I love the pudendal nerve. I treat it up all the time Yes, right. And so even the even the pudendal nerve, it's so it's so short and it's so close to the spine but like In a general lower limb neural tension test, you'll still pick it up.

  Like you'll pick up. If they've got general lower neural tension, they've got, I'm like, it's probably not gliding very well either. Right. So I use my neurodynamic tests to be like, is this peripheral or is this central? And all of this information becomes like the orthopedic stuff that I'm wanting to change.

  And then I'm like, okay, I've got my list of orthopedic stuff I'd like to change that I think is influencing your, Prolapse or your incontinence and then I'm going to go back to where the LTAP directed me and maybe the LTAP Directed me to the central nervous system So I treat whatever is going on in the cranium and then I retest all those things because I want to see What was that central nervous system tension?

  How was that influencing the mobility of their pelvis? How was that influencing the mobility of their thorax? How was it influencing the Older and older the general lower limb nerve tension, right? Yeah, and then like okay now It's now I've taken gotten this laundry list of orthopedic things that I know is involved in their problems prolapse.

  And now I've narrowed it from 25 things to five things. And so it's like now let's do the whole top again. What's next? And it's like, each layer, I'm taking off a protection pattern, and I'm actually narrowing in on the actual mechanical orthopedic thing that I think is related to their prolapse that I that is like, is it truly?

  Need work on it. Right. Right. So to me, it's just doing it this way too, is just like, ideally it should make things like prolapse and incontinence and things like a little easier to treat. 

  Nicole Cozean: Right. Because, right. Cause the, and to your point, if we start to, and this is where I get all annoyed at this isolationist approach to pelvic floor strengthening a lot of the times, because it's like, if someone came in with prolapse and all we're doing is strengthening the pelvic floor, As an isolationist approach.

  It's like, it doesn't work that way. Cause, and even if it was going to work in a, in a small sense, it's still not functioning in the system, like how we want. And so we have to take that. So we have to take the broader view. I call it the adaptive, the adaptive strengthening approach where we, we basically take all of the other things so that if we do end up having to strengthen at the end of the day, it's, Only up to the decreased demand that we were able to create by treating the whole system.

  And so that's where, yeah, I feel like our whole, this is where I was like, in that course, I was like, yes, like we're, we aligned and now we're best friends. 

  Anna Hartman: And did we just become best friends? Totally. I mean, it's so true. I mean, and that's the thing too, is like, this is, Going like why I'm like so passionate about introducing a visceral and neural lens of view to practitioners because it's like yeah Okay, if you really truly think that a stronger pelvic floor is going to be the key And you want to do all the pelvic floor exercises.

  Well, I Exercise movement is still an output. So what are all the things that we can do to change the input to make the output come easier and make sure it sticks? Because if, if you're trying to get people to contract their pelvic floor through a, through a, um, concentric and cognitive experience of squeezing a muscle, then you're never, this is never going to work.

  This is like trying to tell somebody how to like, do a, like. bicep curl, right? And be like, okay, just. Get stronger by just holding that contraction and relaxing it, holding it and relaxing it. I'm like, no, like we know that an eccentric contraction is like just as important as the concentric, but we don't, our brain cognitively, like in order to like create an eccentric contraction of the pelvic floor, you actually have to tell them to contract the tricep.

  Because that's the only way our brain understands muscle contractions because this is, our brain is not supposed to control muscle contractions, 

  Nicole Cozean: right? Especially not those ones, right? Especially the ones that are, that are meant to function automatically. Like they're controlling things like peeing, pooping, orgasm, like all of that.

  Like if we had to think every time about each of those things. 

  Anna Hartman: We would be so slow. 

  Nicole Cozean: We would be, we would be so slow. We would be annoyed. We would be, it wouldn't work well. 

  Anna Hartman: It wouldn't work. It wouldn't work. We literally couldn't think about anything else. Right. 

  Nicole Cozean: Right. Because there'd be too much input.

  Right. Just like, just like, that's why we don't, we attenuate to like tags on our clothes. Right. It's like, we're wired for that. So yeah, all of, all of that is to say is that we have to look at the, especially when we're looking at the pelvic floor. And I'm so passionate about this is that You have to look at what it's baseline, normal, optimal level of functioning is, and I'm telling you, it is not anything conscious, right?

  It's all automatic. It's all reactive. It's all anticipatory postural. Um, with a smidgen of voluntary contraction in the most crazy of circumstances. My bladder is about to burst. Like I cannot do, you know, I mean, obviously, but like, that's the, so if we look at it through that lens, then we have to, to treat it.

  Through that lens as well. And we're not needing to introduce like don't make it harder than it needs to be. We don't need to introduce any like conscious stuff if we don't have to. Um, 

  Anna Hartman: nobody wants to like have to think before like before they move. 

  Nicole Cozean: No, it's just not right. 

  Anna Hartman: You just ensure that the nerves are communicating that muscle great and All the things it is protecting don't need to be protected and then you have them just do a squat.

  Nicole Cozean: Right. And then it'll just work. And then for the same reason why, like it was old school back in the day when we were in PT school and stuff, it was like, we were taught to brace the abdominals and like, and to have them contract all the time during things. It's like, well, that was never a thing. It was never going to work that way.

  It was all supposed to be automatic and we need to train it to be automatic. Just like, and I, this is what the analogy is. analogy also used to is that just like if somebody had a balance problem, we wouldn't give them only calf raises. We would be like, what do you do? You start to just train balance. You train the automaticity of getting a better balance.

  And you might have to control the environment a little bit to be able to adapt and make sure that they can be successful and stuff like that. It's not always a strength problem. And so I feel like it's one of the biggest like pet peeves of mine in the pelvic floor world. It's like, it's not all about this damn fucking Kegel situation.

  And like practitioners sometimes fall into that thing too. And so I feel like that's why I love. thinking about it from a hierarchy perspective, from a neuromuscular perspective, from a viscerosomatic perspective, from a somato visceral perspective, and really making sure that we're addressing each of those in the order that makes the most sense for the body, um, so that the patient can have the best outcome.

  Anna Hartman: Yeah. 

  Nicole Cozean: Love it. 

  Anna Hartman: It's funny, like. Whenever somebody is like, well, I went to pelvic floor physical therapy for this issue, and so I don't know if that's what I need. I'm like, what did they tell you to do? What, like, what was their, what did they do? And they're like, oh, well, they gave me like some Kegels. I was like, no, no, no, that wasn't the right person.

  Yeah. I'm like, don't give up on pelvic floor physical therapist. Yes. You just need a different one. 

  Nicole Cozean: Yes, totally. 

  Anna Hartman: Or you don't even need somebody as a pelvic floor physical therapist. You just need somebody that's like looking at the whole organ. Yes. 

  Nicole Cozean: A thousand percent. 

  Anna Hartman: But so that's funny. All right. I know.

  I don't want to like go crazy long. I know we could literally talk all 

  Nicole Cozean: day. 

  Anna Hartman: Um, So please share where the people can find you to your podcast. Yes. 

  Nicole Cozean: So I have a clinician based podcast. Um, similar to yours, the clinician based, um, that is called, uh, pelvic PT rising podcast. So I do that with my husband. You can find me on Instagram at Nicole Cozean DPT.

  Um, I also, if you, um, have need a reference for your patients, I also have a, patient centered podcast called Finding Pelvic Sanity, um, and our clinic page on Instagram is at Pelvic Sanity. So those are the two places you can find me. If you're a clinician though, for sure on Nicole Cozean DPT. And thank you, Anna, for having me.

  I really appreciate you having me on your podcast. I love, um, our nerded out brains in this conversation. 

  Anna Hartman: Yes, me too. Uh, yes, I will definitely link all those things in the show notes for everyone. Definitely check it out. I've listened to a couple, I'm not a big podcast listener, uh, but I have listened to a couple of your episodes and I'm like, Oh my gosh, me, like the whole time I'm like, yes, yes, I treat here too.

  Like, yes, yes. Like the one I did, I can think it was on like, um, um, some sort of like fascia related to the rectum. And I was like, Oh my gosh, I treat this all the time. Yes. athletes. 

  Nicole Cozean: Yes. Yes. 

  Anna Hartman: I was like, yeah, nerding out for sure. Cool. So great podcast. Definitely. If you like my podcast, I'm sure you will like that podcast.

  So cool. Um, cool. Well, thank you for being here. Um, I'm so grateful that we have connected and Get to nerd out and everybody who follows both of us is always like when are you gonna do a course together? I am sure one day. We just need to find the time to like 

  Nicole Cozean: one day though But reach out to us if you if that excites you make sure you DM Anna and or myself so we can with ideas 

  Anna Hartman: Yeah, through the ideas, what would you want us to do?

  Nicole Cozean: Yes, what would you want to do? How 

  Anna Hartman: would it go? 

  Nicole Cozean: Cool. 

  Anna Hartman: All right. Well, thank you very much, my dear. Thank you everyone for listening and we'll see you next time.