#146 Prenatal Therapy with Marissa Ruhl

Only in this past year did it come on my radar that some therapy clinics are offering prenatal therapy. While I can personally relate to the desire to have a therapist guide you through such a complex stage of health, I thought that because it isn't offered widely, the evidence base would probably be weak.

I couldn't have been more wrong. The evidence for prenatal prevention therapy is robust for improving:

Pelvic health. Pelvic floor muscle training during pregnancy reduces urinary incontinence by 28% and cuts the risk of severe perineal tears in half (Zhang et al., 2024).

Pregnancy outcomes. Prenatal exercise programs lower the risk of gestational diabetes by 25%, hypertensive disorders by 33%, and cesarean delivery by 14% (Xiang et al., 2026).

Mental health. Mind-body interventions like yoga, mindfulness, and cognitive behavioral therapy significantly reduce prenatal anxiety, depression, and stress — while also improving pain management and self-efficacy (Miao et al., 2026).

Maternal role and quality of life. OT-specific prenatal interventions improve maternal quality of life, emotional regulation, and coping — with benefits that persist into the postpartum period (Karakus & Akyurek, 2026).

Despite this evidence, prenatal therapy remains vastly underutilized. The gap between what the research supports and what is actually available to pregnant individuals represents one of the biggest opportunities in our profession right now.

In this course, we'll welcome Marissa Ruhl from Thrive OT, who is paving the way in offering these services and will share what she has learned about helping to build a thriving practice around this massive need.

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Transcript

SPEAKER_00 0:00

Only in this past year did it come on my radar that some therapy clinics are offering prenatal therapy as a pillar service. While I can personally relate to the desire to have a therapist guide you through such a complex stage of health, I thought that because prenatal therapy isn't offered widely, the evidence base would probably be weak. And I just could not have been more wrong. The evidence for prenatal prevention therapy is robust for improving pelvic health, pregnancy outcomes, mental health, and maternal role in quality of life metrics. But despite this evidence, prenatal therapy remains vastly underutilized. The gap between what the research supports and what is actually available to pregnant individuals represents one of the biggest opportunities in our profession right now. In today's episode, we'll welcome Marissa Rule, an OT from Thrive OT, who is paving the way in offering these services. She will share what she has learned about helping to build a thriving practice around meeting this massive need. We have a lot to cover today, so let's dive in. Welcome to the OT Potential Podcast. I'm your host, Sarah Lyon, OTRL, and I wanted to let you know that this podcast may qualify as continuing education for you. You are probably listening to this podcast on a free podcast platform. But to gain CEU credit, you will need to be a member of the OT Potential Club, our OT Continuing Education platform. You can go to OTpotential.com to learn more. Okay, here we go. As I mentioned at the top, joining us today is Marissa Rule, M-O-T-R-L, C L T-LANA, and CPAM. Marissa is an occupational therapist and the director of operations at Thrive Occupational Therapy Health and Wellness in Omaha, Nebraska. She specializes in lymphedema, oncology, and pelvic floor therapy. Marissa obtained her master's degree in occupational therapy from the College of St. Mary and has been practicing since 2016. Marissa has advanced pelvic floor training and provides top quality services to male and female clients in all stages of life. Marissa also has advanced specialty breast cancer rehab and male pelvic oncology certifications. Marissa prides herself in focusing on quality of life and helping clients thrive. So without further ado, I will patch Marissa into our live studio. Welcome, Marissa. It's so great to have you today. Hi, Sarah. Thanks for having me. How are you? I'm so good. I'm fired up about this topic for a twofold reason. One, in my own pregnancies, I would have paid anything, gone anywhere to talk to a health professional about how I was feeling for myself. I was vomiting constantly all nine months, both pregnancies. And it just like wasn't enough to trigger concern in my doctors, but it totally tanked my quality of life. And I would say now a decade later, I'm like something fundamentally changed in my health. Like my autonomic nervous system like never recovered from that. So I would have loved these services. And two, like with my research brain, I was so surprised when I started to look at the research that's been done for this time period. And the evidence base is so strong. I would say it is stronger than most of the rehab evidence that we rely on. There's so many randomized controlled trials. Like if you are interested in an evidence-based practice area, get yourself to prenatal therapy because there is so much to draw on and there's so much being written about it currently. So I'm so excited to talk about the services that OT can offer, what those can look like, and the logistics behind it. But before we get to all the details, I would just love to hear a little bit about your story. You found prenatal OT and maternal OT. And that wasn't on my radar in school. I feel like it's still kind of a niche offering. How did you get to where you are today?

SPEAKER_02 4:17

Thank you so much for bringing up like this topic. And you mentioned, you know, there's so much research going on right now. Like it's about time. Women have been having babies forever. And it feels like we're just expected to just endure this change. And, you know, I truly do believe OT is like a pillar of the village that is needed for that transformation. And it's a mind-body thing that women have to go through. So I love that now science is supporting it. Now we need to get that moved over to practice. But yes, so I found prenatal OT um actually as a client. So um our the owner of our clinic, her name is Erica Stevens, and she started this in small town Harlan, Iowa back in 2017. She and I went to OT school together. We were in the same class and we were very close friends. And I remember she started her practice. And then I had a very uh, well, I found prenatal OT when I got pregnant with my daughter back in about seven years ago. And I um was going to a different OT at the time who was starting to dabble into pelvic floor. And then I had a traumatic delivery, and I remember calling Erica as a friend and being like, I don't know what to do now. I'm having all these symptoms. My OB isn't really doing anything to help me. This doesn't feel normal. And so she at the time was serving clients in their homes in Omaha a little bit, like one day every couple of weeks, while also serving in the clinic that she created in Harlan. And so I became her client out of pocket, out of insurance, and found so much benefit myself. Um, so then as a practicing clinician, I was working at a cancer center and they needed uh, they wanted to introduce pelvic floor therapy as an offering for clients who had ovarian or uterine cancer. Um, we saw a lot of men with prostate cancer, and I got my formal certification at that time and had more training in the oncology side of it, but brought that uh prenatal training into my pelvic floor stuff.

SPEAKER_00 6:25

Very cool. And now you work at Thrive OT, like you said with Erica. When I look around the country, I think of Thrive OT as like one of the, I want to say, most successful OT clinics. I feel like you have grown a lot since 2017 with these multiple locations. It feels like you've stayed really focused on this like holistic OT offering. I have like a billion questions I want to ask you about Thrive OT. I'm just going to say some of them out loud and then you can take it from there. One, what has made you successful? Two, thinking about prenatal OT specifically, like what percentage of your population is that? And three, we had a um question in the comments. How do your services differ from um a PT clinic that's offering pelvic floor therapy? I'm going to stop myself there. Those are clinics. And share anything else about Thrive.

SPEAKER_02 7:24

Yeah, those are great questions. Um, I joined Erica with Thrive about four years ago. So I saw her as a client for a couple of years and obviously experienced the benefits. Um, I had no idea if she was ever going to look to expand or bring people on. She was just a solo therapist, just in the trenches on her own, figuring it out, carving out a little pocket for herself with our very loyal Harlan clients. We love them. And I remember she called me one day and asked, I kind of want to expand this and come back into Omaha and provide services. Like, I don't know who could help me with that. And I just was like, uh, yeah, I would love to do that. I don't want to commute to Lincoln every day. I want to be part of this, you know. I refer to Thrive as her baby because it felt like she was like handing me her baby. And I have been so privileged to be able to be part of the growth now that we've uh been able to have. We have now four locations and about 14 people on our team, and we're all women and we're all OT and uh very excited to be here. So, what makes us successful? I think there is uh so much depth to that answer. I think some of the secret sauce is to look at the stuff that is hard, especially as an entrepreneur and a practice um owner. And I'll speak for Erica on this. She doesn't turn away when um situations come up, or we do take some insurances that adds a whole nother layer of complexity to treating clients. And she really wants to be as compliant as possible while also honoring the full OT scope and um being able to just take that tiny step forward every day while knowing I have the next five years in mind and I'm going to keep chipping away and not turn away when things do feel like very challenging. And then um, I will also say energy is everything. Um, and just her mindset of as a business owner, her mindset about OT and just really that passion, I think, is so ingrained in our team. And we feel very passionate about just being able to expand the OT bubble and really reaching all the corners where in previous settings where I've been in, I've been put in a box, and she does not believe in the box. So I think that has served us all very well. And now, as a more of a business owner than a practicing clinician, she's really focused on having a great place to work. So we're um I'm very grateful to that she allowed me to come on the team and help get us this far. Uh, for our clientele, we do see a traditional OT clientele. So any male, female, children, um, all ages, for our prenatal population, it really ebbs and flows. Um, if one client comes in and says, I'm pregnant, you're gonna have like eight more within the next two weeks, and then they all deliver at the same time and they all go through postpartum together. So um, that is fun. And I would say right now we're probably around a third. Um, when she originally started, she really focused her marketing efforts on the pelvic floor in Harlan with more of that prenatal population. But now I'd say it really ebbs and flows, but I'd say probably around a third at all times.

SPEAKER_00 10:50

And then the PT question. Yeah, what makes you different than the PT clinics? I Googled like what's available in Omaha specifically, and I'm like, there's a lot of therapy offerings when you look at pelvic floor therapy in Omaha. What sets you all apart?

SPEAKER_02 11:08

Yeah, that's a great question. You know, I feel I can answer this in a couple of different ways. Um, my brother is a PT and he also practices pelvic floor. And I feel like I've gotten to know his perspective just personally, also on when we talk about client cases, we really do come at it from different lenses. But you're right. I'm really glad that Omaha and even Inda Harlan and Gretna does have pelvic floor PT available. The name is out there, people are kind of starting to understand what it is. I think where OT stands differently and where our clinic specifically stands differently, is we try not to limit the pelvic floor to a structure of muscles. We view the pelvic floor as so much more, I think, a little bit well more rounded and it's connected to the nervous system, it's connected to the lymphatic system, the fascial system. We house a lot of emotions and trauma in our pelvic floor, and all of that is OT. And so I believe PTs are doing a great job. I think um we can be really harmonious and complement PT really well. And patients will come to us after receiving pelvic floor PT and say, Oh, I this is this is just so different. This is um, I'm learning so much more about my body. I may be releasing some trauma I had stored. I'm learning how to elongate and use those muscles. And then for prenatal specifically, um, I think with OT, we do a really great job also looking beyond the patient. So bringing in their birth partner, having their babies come into sessions for feeding, looking at more than just birth and looking at that transformation of do you have stress management tools? Are you setting yourself up for success at home with that transition? Um, and we're we're expanding, I think, what someone sees when they see a prenatal client.

SPEAKER_00 13:01

This already subverts my expectations because I think I was stereotyping Nebraska and being like, I bet they're successful because there's not that much competition in the space. But that's really not true. There's a lot of therapy offerings. So it sounds like you're standing out for a different reason. Uh, for our listeners, I just like highly encourage you to Google Thrive OT and look at your the website. Like you can just tell you're doing something right. I love how easy it is to book. I love how you showcase your therapists and just how uh you've been successful in meeting this need. I can't help but I'm gonna ask one more logistical question. This is super nerdy. I'm just curious about your private paypayer mix. Like, are most people private pay, are most people coming to you through insurance? Sorry, this is so nerdy. And if you can't answer it off the top of your head, that's okay.

SPEAKER_02 13:51

Oh no, as the director of operations, this is this is that part where I think the payer mix is one of those things. It's like you have to pay attention to that, right? To stay uh a forward-moving clinic. And so we have about, I would say around a third, a third and a third, depending on the payer source. We're hoping we want to go more of that private pay because we have so much less boundaries. Um, but our clients who are pregnant, they really, if they have blue cross, we can use that. So that's been really helpful for them. And I think it's easy to justify depending on their symptoms and presentation, and especially postpartum. We can transition really well with blue cross over to that. For our prenatal population specifically, though, I would say we're probably closer to half and half. I was including Medicare and wellness in there. But for prenatal, we get about half and half. And we've um, I think really that barrier of affordability has been there from the beginning. And where we have been able to find success is getting the um referral sources on board that the client already has an expectation of an out-of-pocket cost and but understands the benefit of it on the other side. And having that kind of tried and true over and over again has have served really well.

SPEAKER_00 15:14

Good question. It's that's it's a hard topic. I could ask so many logistical questions about this, but okay. I want to say out loud some of the awesome research that's out there. Yes. Um, and I'm going to lead you into why isn't prenatal therapy being offered everywhere given this research. But I just want to say this out loud and tell people that on our course page, um, I'm going to link to all these articles so they can go find them and read the stats for themselves. But some of the things that stood out to me is that pelvic floor muscle training during pregnancy reduces urinary incontinence by 28% and cuts the risk of perineal tears in half. Cutting the risk of tearing in halfing or cutting the risk of tearing in half like I'm sold right there. Um, sign me up. That's from one of the 2024 articles in a 2026 article. Prenatal exercise programs lower the risk of just gestational diabetes by 25%, hypertensive disorders by 33%, and cesarean delivery by 14%. Again, sign me up for this therapy. Another article focused on mental health outcomes was that mindfulness uh protocols significantly reduce prenatal anxiety, depression, and stress, and prenatal yoga yield to robust improvements in physical pain management and maternal self-efficacy. These are all big systematic reviews. Uh, some of them had like 7,000 patients, like these ton of numbers, ton of evidence. Uh, and then the last one I'll say is we have a 2026 article uh linked on there that looked at OT-specific prenatal interventions that improve maternal quality of life, emotional regulation, and coping. And what stood out to me there was that these benefits like persisted after therapy into the postpartum period, which again is kind of unique actually among rehab offerings. Like sometimes we do not, we see the benefits drop off. So it was really interesting in that study to see the benefits uh persist until after baby. Um, so awesome things that lowering that risk of tearing, lowering like those improving health outcomes, improving mental health, these benefits go on. With such a strong evidence base, why isn't this in every town? Like, what are the barriers? I like I truly don't understand why. Don't I have a prenatal therapy little office in Aurora?

SPEAKER_02 17:55

I think that's that's a very systematic question that I, if I could I could get on my rooftop and shout about women's health in general all day long. So I think this definitely obviously falls under that umbrella. And what I think um has happened over time is I think women don't know that it's available. It's like a lack, then the studies are there. I think it's a lack of understanding um within that field of medicine, how that should be prioritized. And I think we're in such a reactive state of healthcare that to them, they'd rather do the, you know, the big system would rather do the stitches or the C-section. And the the focus gets shifted to baby instead of mom. And I think, and maybe you remember this, I felt very like, well, it's not my body anymore. I'm just a vessel. And I, you know, felt like my doctor, I'm just doing everything I can to take care of my baby. They're constantly checking on the baby, but who checks on the mom? And that's actually one of the reasons why Erica started Thrive is uh she was going through her own fertility journey and she felt like she was just another patient, just another chart, but no one really stopped to listen to her story of what was going on and what she's tried and taking her seriously. And she's like, you know what? An OT can do this. I'm just gonna start doing it. I I needed this. And so um I think it's not offered because we're too reactive instead of proactive. And that's just the way, the way that insurance in the big systems um are. I think the lack of reimbursement around preventative care is very limiting. I do think that it's it's trickling in. I think the coasts are much more common. I have one positive shout out. I have a friend who was a first-time mom and she went to mom school out in California. Like, um, I don't know if an OT was involved, and of course, I always advocate for us, but I I'm glad the evidence is there. I think we also need more therapists to feel confident in treating those clients and practicing the evidence as well.

SPEAKER_00 20:01

Yeah, when I was in school, I used to believe that like the best evidence drives practice. And now that I'm older, I'm like, oh, unfortunately that is not the case. Our systems of payment, our historical biases, those have created where we're at. And in our fee-for-service world, if you're in a hospital system, you make more money when there's a surgery, you make more money, um, unfortunately. And that's why so many shifts are needed in healthcare right now. And it feels like prenatal therapy is kind of at the heart of it and like showcases why so many of these shifts are needed. Those were kind of my like big picture intro questions to the topic. And now I just want to get pretty logistical about what this practice looks like. And I want to start with attracting prenatal clients. Like you mentioned that that was a focus of Erica's at the beginning. Um, I want to tack on to this question. You kind of alluded to it, but I'm not in full understanding. For people looking for insurance reimbursement, is being pregnant enough for a therapy referral, or does there have to be a documented complication? That's a great question.

SPEAKER_02 21:18

So, most of the time when you're pregnant, you're going to have pelvic floor or issues or pain. And so you still have to have something you're treating. Um, yes, that's a good question. But the way that we can support a client, a pregnant client can be let's treat what's going on. But then my OT brain is always adding my checklist of I know these other things are gonna help prevent an increased burden of care, you know, with a potential need for gestational diabetes treatment or C section or increased pushing time. Our doula groups, they invite us to speak every year. Which we love, um, and they really support OT. And they share every time they they introduce us, they say, our clients who go to prenatal therapy reduce their pushing time by like two hours. Whoa. I don't know and I pushed for four with my first. So I was like, yeah. Sign me up. Exactly. Um I think when you get out of the OB office, we do have some very supportive providers in our area as well. But I think for the traditional person that's going in and their doctor doesn't even know what they're talking about, you have to start looking at where is their you know, pregnancy yoga offer. Maybe they have a connection to somebody kind of outside that traditional referral source. And then uh, sorry, you asked me how we attract prenatal clients. Yes, yes, yes. Uh, when Erica started Thrive, she would go talk to anyone who would listen about the pelvic floor. And of course, that always kind of attracts um maybe some pregnant clients. For us specifically, word of mouth has been uh just a game changer. So as soon as you help one pregnant mom feel better or have the birth that they want, or at least feel like they can ask for the birth that they want, they're gonna go tell all of their friends who are getting pregnant or trying to get pregnant, because we see clients for their fertility journey also, that, hey, you got to go to this person because she helped me with this, this, and this. And for our prenatal clients, that has really supported that population. We have some doula groups, like I said, in the area that we've connected with that just have really put us on the top of their list, which we really value and appreciate. I had them at my birth, Erica had them at her birth as well. Um, we have a midwife group here who has seen the value in us. And it's funny because a lot of these groups have maybe had a connection to a pelvic floor PT. And maybe when we first called, they said, I already have someone I send people to. I'm not worried about it. And if you can get in front of that person and explain why OT is different and pull in that mental health piece that we know is not happening with PT, then that is where over time we've been able to get that buy-in of where does OT fit in at the table? Because we do fit, and I think we can fit right next to PT. And we have groups that kind of decide how much mental health does this person need. I would advocate everybody does, but I would say our clients come with someone who's likely pregnant and stressed out, as I was, and and just needing someone to advocate for them and educate them. So we've had some really great groups. Chiropractors also, especially if they have the Webster training, have been supportive and understanding that someone treating the fascia and the muscles and these other symptoms going on will help the chiropractic adjustments go farther and we can support the body from both sides.

SPEAKER_00 24:54

That's super interesting to hear the multiple avenues for referral. And I think is making my brain work about like, oh, I see where the success is coming from because there's these multiple channels of entry. Okay, so now I'm an OT or I'm you. I'm sitting in my office at Thrive and a pregnant client walks in. What's on your checklist of things that you're probably going to assess? It's like one of my longest checklists.

SPEAKER_02 25:26

Um I want to know. I usually start with what is the what's the biggest symptom that they are struggling with? Usually it's sleep. They can't they're so uncomfortable they can't sleep, or it's incontinence. Um, so I'm looking at what are you, what are you experiencing right now that is out of the norm? Um, we obviously do a full occupational profile, medical history. We do have objective measures we use that are more pelvic floor specific. And we always try to tie it based on function, um, sorry, based on the symptom back to function. So if it's incontinence, it's a toileting goal or a pelvic floor symptom. If it's a core issue or they look like they've got that diastasis going on in the stomach, which all pregnant people will experience, that would be tied into some weakness that we can work on. But I usually give them the floor because women, they know like what's wrong. My ankles are swollen, or I, my back really hurts, or I just I don't know if this is normal. We do some mental health screenings in our clinic, depending on what people need. So we've got kind of a toolbox, but I always start with the patient sharing their story. Tell me about getting pregnant, you know, if they've given birth before, tell me what that birth was like, tell me what postpartum was like. And a lot of people don't even realize, oh, I I hear this all the time. I didn't know pain with inner course was a problem. I just thought that was normal. Because they do sometimes go to their OB and their OB just, yeah, you've given birth, or yeah, you've, you know, well, you tore really bad. So of course you're gonna be sore. And so for me to just validate, I think that is like one of the biggest things that we do assessment-wise, is just what are you experiencing? Because likely it's something that we can help with.

SPEAKER_00 27:11

Yeah, when I looked at, I can't say these percentages off the top of my head, but the percentage of people that experience like urinary incontinence around pregnancy is pretty high. It's like 30 or 40 percent. And so I can see how those things get like normalized, but that does just because a lot of people experience them doesn't mean they're normal and there's not things we can do to help. I want to uh ask about the objective measures. I think is it the Australian public floor questionnaire? Is that one that you use? Um and that's a self-report, isn't it?

SPEAKER_02 27:52

Yes, I do it guided. Um so we do therapist guided with all of those. Um, and because some people, a, it's kind of like lays the foundation for you of more detailed questions on things that people because people do find it normalized, right? So I'm like, well, do you get up at night to pee how many times? When you have to get the urge, can you hold it or are you rushing? And some people are like, well, I rush, but I always have. And it's like, okay, well, that's a sign of you know urgency and we can do something about that. Um, so the questionnaire helps guide someone to see, oh, maybe I'm not as typical as I thought I was. So the APFQ is one, I believe there's also a that we have some pelvic pain ones um that are like pelvic specific. And I think there's a pelvic floor like function questionnaire. I really like the APFQ. I brought that over from I um started using that in a different clinic, and it just feels very everything in that is very relative and it paints a picture for me as the clinician.

SPEAKER_00 28:51

I love doing a guided patient-reported outcome measure because it helps me like remember to ask the different areas. And yes. Do you know off the top of your head um like mental health screens that you might use? And do you do those guided as well, too? I've never done that in the clinic.

SPEAKER_02 29:09

Yes, we do do those guided. We have, I believe, um it starts with an O. I'd have to look up, but we have a depression scale, um, we have an anxiety scale. And then um actually our wonderful, I would give her the shout-out on the website, Julia. She was one of our, she's one of our therapists. She started as my capstone student and now she um is our director of marketing. But during her capstone, she created a tool that we still use not only with prenatal clients, but anyone with some mental health things that we need to support called the RAP Wellness Readiness Um Action Plan. And that was modified from a group who was treating clients after sex trafficking. And this was one of the tools that they used for their mental health. And it really helps the client be empowered with identifying what ramps them up, what brings them down. And then it has a section where we write out who are my support systems for what need and kind of helping the client start to anticipate okay, when you do get really tired, what do you need to feel better? Who can come over and help you? What are some who's really good at maybe cooking a meal versus helping with laundry? And having that actually written out, I mean, if I had had that after my first, I would have felt so much easier about calling for help. And um, I can't say, you know, if there's direct evidence yet to using the wrap and seeing a reduction in um PMAD's scores, but I've seen it live in our clinic where that has really set people up for success. And we do invite birth partners to come in as well. And so if there were any um concerns, I always offer like I can communicate this need to your birth partner and I can coach the birth partner how to stay calm, what is helpful, what is not helpful when this person is preparing to deliver.

SPEAKER_00 31:03

I can already tell I want these services. That's just the assessment part. I know from there, treatment probably goes in all kinds of places based on what people's primary needs are. But thinking overall about treatment, what are some of those high-impact things that are typical with prenatal clients?

SPEAKER_02 31:24

Yeah. So prenatal clients, I would say the kind of big hitters are breathwork and you know, really working on that diaphragmatic breathing, checking their core and glutes. I don't know if you noticed this. Actually, Erica had to point it out for me. Your glutes and hamstrings like go to sleep when you're pregnant. And I could not engage or isolate them. And she tried to get me to do this exercise postpartum. And I was like, I've been lifting, I've been back at the gym. Like, why can't I not do this glute isolation? And she's like, It's because you haven't rehabbed them. And I've noticed in my own practice, as I've gotten clients to engage muscles in the body that typically the body shifts out of during pregnancy. If I can get them to focus on those, it helps that postpartum recovery is so much better. So I would say obviously, like overall stability in the low back and the glutes, the post posterior chain, core, pain management, so joint pain, carpal tunnel. I mean, there's you know, Dequervens is flared in pregnancy, carpal tunnel, um, swelling. So any like lymph work you can do to support a patient with um pregnancy swelling. And then we do what I say is like the OTPF has just a rainbow of colors and we include all of them in our palette. So, you know, if it's digestion and nutrition goals, um, medication management support, and I would argue I would put gestational diabetes underneath that, you know, educating people if you eat a fat and a protein with your carb, like monitoring the sugars, what do you do with that data? How do you respond to what is your body responding well to? Exercise prescription, and then definitely getting into the spiritual holistic parts of OT is just acknowledging that this is a transformation and how do you set yourself up and taking that pressure off too? So we just do a lot of rapport building with our clients and then trying to help them with whether maybe they're having body dysmorphia or you know, maybe they are having a flare of a mental health issue or something underlying trauma that comes back up during pregnancy and being able to also talk about that and give them tools and be a safe place to treat that as well.

SPEAKER_00 33:45

Do you have a typical like arc of your session that you follow or maybe like begin with breath work, education, exercise, manual?

SPEAKER_02 33:58

Yeah, that's a great question. So every client who comes in will end up getting some manual work done um on the table. And we don't have a typical therapy gym, we have independent treatment rooms. Our goal is to make the client feel safe. And so um it's one-to-one, closed door with your OC the whole time. And the arc of the session really looks at consultative first, kind of really trying to hear their story, make eye contact, and then I might have a plan of okay, they're at 25 weeks, maybe the baby's breach. I should start to teach them about some spinning baby strategies, or I should start to help stretching out the round ligaments because the tight pelvis could be impacting that. But they might come in and say, I, you know, threw up this morning, or I got a migraine, or my TMJ is flared, and I'm shifting into what is bothering you the most today, knowing I also have, I would say it's an arc of the pregnancy. So I kind of have the trimesters in my head of where we need to get to. And um, we found, you know, right ramping up before delivery is really helpful. So seeing them closer to weekly around that time. Uh, and then yeah, whether we're on the floor doing stretches and exercises or breath work or on the table, I always want them to leave feeling better than when they came in, um, especially our pregnant people who are they just don't feel good. And I don't blame them. Yeah. Yes.

SPEAKER_00 35:28

You kind of alluded to this. I want to ask about it explicitly is patient education. Are there like nuggets that you feel like you teach on a regular basis that resonate with people? So many amazing things happen during pregnancy, and I don't even, I feel like I don't even know most of them. Uh, what are the patient education things you like doing?

SPEAKER_02 35:49

So, one thing that I like to point out to people is research shows your metabolic rate is that of an Olympic athlete just by being pregnant. Did not know that. Yeah. When you're walking down the hall or you are going up the stairs and you feel like you're climbing a mountain, it's because your body like logistically is. Yeah. Um and your blood volume doubles. And so just giving people facts of this validating what they're going through. And the other thing that people I don't think realize is typical is because your blood volume doubles and your iron is so high, you get really constipated. Constipation is a sign of a pelvic floor issue, and but it could be related to just the natural progress of pregnancy. And there are some really natural ways we can help get the bowels moving. So those are some big ones. And then we always educate everyone on the pelvic floor. I do think that's just a foundational thing to have when you have a prenatal client in is what is the pelvic floor? And I will say, I mean, for therapists listening, that generalist, there is so much out there available that is accessible training to at least be able to speak to the pelvic floor as a system and how that coordinates with breath. Um, and then another, you know, heavy hitter is we we practice. Um you're making me think of all the handouts I've created over the years, but we practice birth positions. So, like let's get, let's simulate it. Let's get your body into what you kind of how you think you want to push. And is that comfortable for you? Can your partner support you in that position? I was pregnant with my second um when I was here at Thrive. And Julia at the time and I took photos with my belly of us doing birth positions together and yoga ball stuff. And um, we use that uh as for some patient education handouts. So I've used my own experience time and time again of pulling out what I think what the client needs based on what I experienced and then what I've seen through other people coming in.

SPEAKER_00 37:58

I've definitely noticed that great therapists do have tend to have their own like trove of handouts that they've created. It's just such a great opportunity to like interface with your client to like I don't know, just opens conversations.

SPEAKER_02 38:12

Um does, and I people are visual, humans are visual, and you can be talking at someone and then especially pregnant. I don't know if you knew this parts of the brain actually grow and change, like the hippocampus changes size and the prefrontal. Yes, yes, it's it's insane. So your primal part of your brain literally grows, and the logic part of your brain shrinks, which is why we have pregnancy brain. Yes, it's so normal because wow, when we were delivering babies in the woods, we had to be primal and protect them, and we didn't care about the logistical things, and that's still present today. And so there's brain fog. I mean, people come in with so many, like, I just don't feel right. And it's like, okay, if you know about your body, I think giving women the education is is the key to getting this rehab to be outstandard.

SPEAKER_00 39:09

Prenatal therapy is so unique because and pregnancy is so unique because you're kind of building to this event of giving birth, but then it sets off this whole nother mountains beyond mountains of ups and downs to navigate with being a new mom or a new parent. And what that's making me wonder is when you're thinking of discharge, like do patients tend to just come for prenatal therapy? Do they tend to come back? What's the insurance limitation if it's tied to a complication during their prenatal stage? How does uh birth factor into the course of therapy?

SPEAKER_02 39:57

It's funny because most pregnant women think, well, I'll save my investment for after for when I actively have issues. And again, the reactive side of medicine. And I say, if you do it before, you're less likely to have issues where we need to fix. There's always going to be probably something. Birth is unpredictable. And I wish we still treated it that way. Feels like we're trying more and more to get women just to be predictable with inductions and you know, taking away, I think, birth women's rights in the hospital room. But um, besides that point, um, a typical follow-up session and discharge. So, birth, in our opinion, it is a discharge because now we have new medical things to work on because the body has changed. You're not treating the same thing. It's not even really relevant anymore what you were treating pregnant. Now we need to see what it looks like post-part. It was kind of like a post-op. And I suggest we see try to see everyone two weeks after delivery. And sometimes that's via telehealth if they are not comfortable coming out of the house yet. And I think that's super important because it's before we get to that six-week point. And most of my people, especially with um pain with urination, pain with bowel movements, like you're so swollen and you're sore and you're tired, and your body just I describe it, I describe that first couple of weeks as my body is like oatmeal and my brain is like jello. Like I just don't know what's going on. And if I can get to them, then I can set them up for more success um when they come in at six weeks. So I've had some private pay clients even opt to do telehealth postpartum, and and sharing that birth story is treatment, in my opinion. And insurance-wise, you know, we're assessing again, we're looking at what has changed in the body, what do we need to do? I mean, weakness is very prominent, swelling most likely. Maybe there's um some medical things that happened, and we need to treat scar tissue or, you know, incontinence, things like that. But, and then within OT, uh, we have some really great therapists on our team who have come from feeding clinics and take on some of those breastfeeding clients if they need support. Um, and then we also have some really great lactation uh referrals in the community that we can send out to as well. And just being able to assess at least, and then guide mom of, you know, looks like we you might need to go um see lactation or go ask about this to the pediatrician. Um, we're also bridging that gap of it's called maturescence, the transition into motherhood. And so approaching the prenatal population with that mindset of this this is an active transformation of mind, body, spirit. It just is, it has to be. And your body, the societal expectation that it just bounces back, there's this arbitrary six-week mark, and all of a sudden you're back to pre-baby is just unrealistic. It's not right. And I think if you can see your client right after a delivery and just build up their confidence, give them some tools, that goes a long way with that success and that rehab outcome.

SPEAKER_00 43:11

I'm hearing the need out there is massive. I mean, basically every pregnant person could probably benefit from some level of therapy. There's a lot we can do. There's a lot of research that supports multiple kinds of interventions. My next question is what can a generalist do versus what special training would you recommend? Like for me personally, I just wanted to go to someone and cry and help have them help me brainstorm how to eat and drink. Like, I think a generalist probably could have helped me, or I would have benefited from that just because there wasn't a specialist in my area. Um, but do you have like a basic bucket? Of what would be in a generalist wheelhouse and then what special training you would recommend people go get.

SPEAKER_02 44:07

Yeah. So I'll just give a small story. Even with my pelvic floor training and the cancer center I came from and treating pelvic floor for a couple of years and then coming over to Erica, I looked at her and I said, I've never treated a pregnant client. I don't know. I feel like I'm out of my wheelhouse. I don't know what to do. And she um, you know, we we are not gonna know everything about everything, but we know something about a lot, and we can always help someone. And my first ever client here at Thrive showed up. We did not know when she booked, but she was pregnant with twins. And I think that was the universe telling me you're gonna be just fine. Um and so I'd say go into it confidently and pull and use the toolkit that you have. And I mean, obviously follow recommendations and if there's any restrictions and things for your client, but otherwise, many of us are treating diagnoses we've never had: ALS, memory loss, strokes, and we can still find ways to help people. So if you've never been pregnant or you've never taken a class, I think the generalist OT can really focus on okay, is there pain management, sleep hygiene? Can I at least be a safe space for this person and validate, which we do every day with our we all know that in the hospital? Who are the ones that are sitting there holding the family's hand? Like it's usually the OT. And so um bringing that same nurturing energy into a session with a pregnant person, and then thinking, okay, what if I took the pregnant part out, what would this body be showing me they might need? And is that something that I feel confident treating? And then knowing just some general uh pregnancy precautions. We do have direct access in Iowa and Nebraska where we practice, but we do fax out our planes of care on all client, uh pregnant clients to the OB just to have that extra layer and that the OB is aware and educated on what our goals are and what we're working on. And so I think that would just be something that a generalist could easily add in. For the specialty training, and this is where I think, you know, as we know, Lindsay Vessels paving the way for CEUs. I do think we need more access to pelvic floor CEUs as OTs, but I recommend going and getting some level of at least pelvic floor training. In my opinion, every pregnant person should receive internal as long as it is safe medically and as long as the client is consensual after that rapport is built. There are other areas of prenatal therapy practices where that is the only tool. And I don't believe in that. I believe it is a tool. There's a lot of other tools we have that don't involve internal at all. And breath work, again, for the generalist on that side. Uh, specialty, I would say just if you don't know anything about pregnancy, even looking beyond rehab CEUs, I think there's some really great resources out there, like the fourth trimester, woman code, um, about pregnancy and like female hormones and like how does the body all coordinate together. That knowledge, I think I've learned more picking tools up on the way outside of a formal pregnant CEU, just by just asking questions and experiencing and then thinking of it through my OT lens. I think one of OT's secret tools that we don't acknowledge is curiosity. We are so curious and we are not arrogant, an arrogant profession. Um, and that serves us poorly in some areas. Don't get me wrong. I think we need to have a little bit more um, you know, I think we need to be a little more pushy sometimes. But I do feel we are very nurturing and very curious. And if you lean into your client with curiosity of what they're experiencing and how they got to you and what do they even want for their birth? Have they even thought about it? How are they sleeping? Let me let me see, lay on the bed, let's see what we can adjust here. And it's sometimes it's like the tiniest thing. And someone's like, oh, I I could have thought of that, but I'm pregnant and I didn't. And thank you for it. You know, I mean, I would I I truly valued having my prenatal team here at Thrive for my second birth and that and my doula team and my chiropractors and my midwives, and that was a much different experience. The my first birth was very traditional. And I feel like if women don't know they have a choice, that's another piece of the puzzle.

SPEAKER_00 48:49

But and as you said at the beginning, like OT is one part of the village. And when you're thinking about what's in your scope and what's out, like as in all practice areas, when something feels off, you call the right person. Um, and that is part of our role. Whether you're a specialist or a generalist, um, there are times to call, make the call to the doctor. And that is like every other practice, we have to do that here.

SPEAKER_02 49:18

Right. And that's health promotion. That's in our OTPF, is in my opinion, that's medic medicine management and health promotion. And we're the ones that are curious and care enough to make that call or to get that list or to figure it out. And I think traditional healthcare is just getting, they're getting so overscheduled. And the way that that's going is that personal relationship is not there. Nobody has the time or the energy to look into something for a client. The client doesn't know where to go because there's so much online, there's so much out there, it's so overwhelming. And to have like a coach to be like, okay, this is what I would do. I might not know how to help you with this, but here's where I would go. That's I think completely appropriate and valuable.

SPEAKER_00 50:02

We're going to zoom out big picture in just a moment, but I have one question in the comments, which comes back to a business model question and also kind of makes me uh smile because the question is do you see patients on telehealth from out of state? Which I hope means someone's like, Can Marissa see me? What's your telehealth offerings? And um do you see patients in multiple states? Do people come to uh drive in? Uh, how do you address the out-of-state need?

SPEAKER_02 50:31

Yeah, that's a great question. So we have um all of our therapists are licensed in Nebraska and Iowa. So we can do telehealth in either of those states. And then we have a couple that are licensed in Kansas. So if we needed to do a telehealth there, until the OT Pact goes through, we have Doug and Doug and Doug into I've tried I've had clients call from California, Colorado, Texas. I think we added it up one time and we had clients from like eight different states. But in order to do telehealth, even outside of insurance, it's the licensure piece where it gets tricky. So until that pact is passed, currently clients would have to then travel into a state where we could see them. And so we've had clients come from Arizona, Colorado, South Dakota in for treatment. We've had clients locally who say, My so-and-so might actually had this happen. My daughter's traveling in to visit me from Florida. I want to pay for her session. That's my Christmas gift to her. And um, this client was able to come in. And then I was able to try to help find something in her area. I have not been very successful in finding comparable clinics. So if anyone out there is listening and it sounds like what you do in your state, please let me know because we're always getting people asking where they can go outside of those states that we are able to serve right now.

SPEAKER_00 51:55

That ended up being a great segue question because clearly the industry needs to change. If someone's driving to you from Arizona or Colorado, like that to me means like there are not enough local offerings. If you could wave a magic wand and change this prenatal care industry, what are some of the big things you would change?

SPEAKER_02 52:19

One of the big systemic things outs in and outside of OT is like giving the power back to the client. I think as a pregnant person, I didn't realize I had choice at the time. I thought I, well, I just I don't know, I'm just doing what my what they said. Isn't I just have to do this glucose at this time in this way, or I have to, you know, um take these types of vitamins, or I have to birth on my back because they told me to. And I think giving if in general with prenatal clients, if the power was given back of, well, what do you want? And what how here's here's some educated choices you choose from this menu on what sounds best for you and your body and your baby. I think that is becoming more common. I'm having more clients coming in with a better idea of what they want. And I mean, you need to have plan A, B, and C because pregnancy and birth is unpredictable. But if you can find a provider who listens to you and supports, and then the other part would be treating the pregnant person, not the baby, just the baby, especially during pregnancy and postpartum. It's like everyone's over to visit the baby. Like, no, like who's there to visit me? I want to share my story. I I also changed. I I'm a mom now. So I and then in general with the therapy and the rehab industry with this, I think we need to have people who treat the whole picture. I think that's where I'm glad pelvic floor is getting really popular and it's getting really understood. But if you go and you only maybe get a 10% of a treatment compared to another clinic that could do 100% because they're looking at all the layers, I think we're gonna see um swings of was this really effective or not. And I wish that insurance provide, I wish that you know, coverage was there to do the entire OTPF with every single patient every single time. So um, if anyone listening is pregnant or has looked into coverage, I would say if you have to go out of network, it's worth the investment. It's just such a it's very um such a transition to your body. And if you can have someone who can preemptively support you, just like if wouldn't it be great if we had a patient where like, we know you're gonna have a stroke, let's really get this arm work, like let's get things ready. I mean, we know it's coming, so why not do the rehab ahead of time?

SPEAKER_00 54:52

I'm feeling so inspired by the work that you're doing. I'm just like really in awe of balancing the business model. I know it's hard to run a successful business, and then thinking about uh pregnancy during or rehab during pregnancy, there is just so much to learn, so much that it sounds like you've taken in and you're offering your clients. And I'm just yeah, impressed by your offerings. I'm curious as we wrap up our conversation today, we've touched on all kinds of parts of prenatal therapy. What's the final thought you want to leave us on today?

SPEAKER_02 55:31

Oh, I love that. Thank you. Um, and by the way, super happy to be here. I've been like fangirling for OTN show for so long. And um, I remember when we first met it, I was not even treating prenatal at the time. Um, I was going down to the cancer center. So thank you for having us on and for giving Thrive praise and compliments. I know Erica really looks up to you, and um, we just feel really honored to be here. But I think what I would want people to take away from this is that OT belongs in the prenatal space. And I think arguably we can be just as valuable as the standard providers for that population. And so obviously, I OBs are definitely needed, but I've had clients who have had home births with just a midwife or a doula, and they have continued to praise how much value they got out of OT, specifically in getting ready for one birth or multiple births. And I think, you know, just recognizing that people are looking for relief and comfort, and OT can provide both, we can problem solve and also validate. And um, I think we're really special in that and acknowledging the mind-body transformation, OT does, we already are doing this. I think we need to, I think people get intimidated, and I understand why. Um, the idea of I don't want to hurt someone or I don't want to say the wrong thing, it's a pregnant client. This is like so out of my wheelhouse. I do feel if we showed up with that integrity and that confidence ethically like we do with everybody else, uh, that we could really carve out our seat at the table even more um more clearly.

SPEAKER_00 57:16

Yes, it feels just emotional to think about being able to provide more support to people during pregnancy. We know how lacking that is. And I'm so thankful to learn about what's possible to be inspired by your practice today and just for everything you've shared with us. Marissa, thank you so much for being here and um just teaching about your practice.

SPEAKER_02 57:37

Thanks for having us. And as we wrap up, there's a fun tradition at Thrive that we do on every virtual call. Um, whether it's one-to-one or a group, we all high five. So if you wouldn't mind and oh, let's do it. Thank you for that. Thanks for having me. This has been so fun.

SPEAKER_00 58:01

Oh, thank you, Marissa. This has been just really helpful. I really appreciate your time today. Thank you for joining us on the OT Potential podcast. To earn one hour of AOTA approved continuing education for your time today, you will need to sign in or sign up at OTPotential.com. Once you're in the OT Potential Club, you will find a five questions post-course quiz connected to this episode. When you pass the quiz with a score of 75% or higher, you will be able to download a PDF certificate that certifies your completion of this course. Okay, I want to thank you for joining us today, and we'll see you next time.