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Incontinence and Bowel Management for Women, Men and Children.
Women’s Health Physiotherapist Brisbane, Australia.
Pelvic Floor Dysfunction Treatment.

Levator Avulsion: It doesn’t have to be the end of the world as you know it!

I am a great believer in empowering women (well everyone) with knowledge. Knowledge is very important- particularly knowledge based on evidence. For example- the world is not flat, climate change is real (just ask any farmer and those living in Greenland) and being kinder to refugees will give us more back than they take.

There is a debate in the obstetric and gynaecology (medical) world and women’s health physio circles that telling women about the extent of their birth injury may be a worry for women and cause more problems than it helps. And I certainly see that when seeing patients for the first time- they are often very anxious from what they have read on the internet in the various forums on Facebook and other sites and sometimes they don’t even have the problems/ injuries they had imagined they had.

Of course sometimes, many times they do have levator avulsion or nerve damage or micro-trauma causing stretching of the vaginal walls or prolapse. Because we tend to glorify the birth process (and it can be very glorious) there is often not a lot said about birth injuries prior to the birth that can happen to a woman with a vaginal delivery and which can ultimately be devastating to the future well-being of a woman.

Image demonstrating levator avulsion taken from the new edition of Pelvic Floor Essentials 2018 

But should we not fully inform women about the current status of their pelvic floor muscles? Shouldn’t we give them an opportunity to receive the information, process it, maybe grieve a bit and then move forward with a plan to maximise their potential of every skerrick of muscle they have left? Enable them to move forward with a plan to support their vaginal walls with a pessary to potentially protect against prolapse (if it will work) and a plan to get them exercising again in a manner that is relevant to their pelvic floor strength and other anatomical changes that have occurred with their vaginal delivery?


I believe that informing women about any birth injury they have is their right.

It is incomprehensible that we should keep the woman in the dark about their changed pelvic floor status. But we have to be there to give them encouragement, motivation and a positive plan of moving forward based on evidence not just dramatically tell them about the damage/changes and leave them dangling and unsupported emotionally, psychologically and physically.

I recently received an article by Alexandre Fornari & Cristiane Carboni which reviewed all the articles referencing pelvic floor physiotherapy as a modality for the treatment of pelvic floor dysfunctions. The aim of this study was to identify and characterize the most frequently cited articles on pelvic floor physiotherapy published in the last 30 years. Between 1983 and 2013 (30 years) there were 1,285 articles published (among them there were 12 randomized clinical trials (RCTs) and 4 reviews). The most common topics among the classic articles were behaviour therapy, pelvic floor muscle training (PFMT), biofeedback-assisted PFMT, and neuromuscular electrical stimulation.

In 2017, the same authors conducted a new search for papers on pelvic floor physiotherapy using the same methods to compare them with the 2013 data and they found 1,745 papers containing the term pelvic floor physiotherapy, indicating an increase of around 35% in 4 years. The authors concluded that ‘pelvic floor physiotherapy is an emergent sub-specialty where scientific knowledge is evolving fast. This is seen not only in numbers, as demonstrated by our quantitative results, but also in quality, as seen in the high-level evidence presented by the classic studies analyzed in our research’.

When I revised and updated both editions of my books Pelvic Floor Recovery: Physiotherapy for Gynaecological and Colorectal Surgery and Pelvic Floor Essentials I wanted to include as much evidence in the books about rehabilitation of the bladder, bowel and pelvic floor as I could, while still making them readable and easily understood by the target audience – which is the lay person in the community. I wanted to translate seemingly complex concepts into easily understood strategies that the woman could begin to implement- particularly if she is a regional area without access to a pelvic health physiotherapist. But if you can access a pelvic health physio, always do so for that individualised, personal assessment and treatment.

If you have concerns about your pelvic floor (or your bladder or bowel function or pelvic pain) then find yourself a pelvic floor physio to mentor you and to assist you to obtain a fantastic recovery from your birth experience in the short-term, medium term and long-term.

A blog about VACTERL: introducing Anja Christoffersen

I recently received an email inviting me to a new book launch for a book called Behind the Smile: An inspirational journey from disability to ability by Anja Christoffersen. The following summary of the book is from the cover of Anja’s book.

Anja Christoffersen learned early on that you can never judge a book by its cover. Born with a congenital disability that deformed her digestive, skeletal, reproductive, circulatory, urinary and respiratory systems; she had her first surgery at five hours old. Despite a grim diagnosis, from the outside you would be unable to tell she was any different.

You would never have known that at birth, the medical fraternity warned that she would never live a normal life. Once Anja grew to an age where she could understand her medical differences, she made the decision that she did not want an ordinary life anyway – she wanted an extraordinary one. As soon as Anja realised happiness is a choice, she made the decision she would be happy despite her circumstances. From surgical theatres to chasing her dreams led her to a career as an international fashion model.

Anja from a young age seemed to chase a dream of not letting her significant disability ruin her life. She says:

I didn’t realise my success was survival and experiencing it with a smile on my face. There was nothing more I had to accomplish in life than just be happy”- Behind the Smile, page xi

When I saw her book cover I was intrigued as it seemed incomprehensible to me that someone with that extent of dysfunction could end up wearing a beautiful white bridal outfit on a catwalk! Reading Anja’s contribution has certainly turned those thoughts on their head. Her words are inspirational and as says in her book she aspires to be, not just a model, but a wonderful role model for anyone with a disability.

“I wanted to be more than just a model. I wanted to be a role model. I wanted to walk on the international catwalks on my own merits, not to have it gifted to me as the token disabled girl. I wanted to make it myself, so I could say that I did it. I wanted to inspire people with my condition and any rare disease or chronic illness that they could follow their dreams regardless of their diagnosis. I wanted to bring hope to the mothers of sick babies that they can get through it and flourish. I wanted to be the positive success story that empowers others to follow their joy and passion, no matter what it is, and no matter the odds that are against them” – Behind the Smile, page 111

Join Anja as she walks the catwalks of Australia and Europe with her hidden medical condition, overcomes challenges and discovers how to keep smiling – no matter what.

I contacted Anja on learning about her book launch and asked her if she could elaborate on her extraordinary life and she kindly sent me the following to help me to understand more about the life-impacts for her. It is a condition which has varying degrees of disability in the continence area and I hope through this blog the word will be spread to others who may have significant issues and that they and their parents may gain hope.

I was born with VACTERL Association in 1998. Barely anyone knows what that is now, so you can imagine the medical fraternity’s experience with it 20 years ago. Growing up, the best way to describe my condition to other 5-year-old’s was, “I was born without a bottom.” In reality, I was born with one main opening where my intestine, urethra and duplicated vaginas drained into.

Immediately, I had to have a colostomy and vesicostomy made so there was a way for anything I ate and drank to leave my body. At 7-months-old I had what is commonly referred to as “Pull Through Surgery” where I was cut from my clitoris to my buttocks to reconstruct everything, just so I could function ‘normally’.

Imperforate anus surgery

What that meant for me was a short-term anal dilatation, vaginal dilatation in my teens and incontinence for life. As none of my openings were natural, I did not have the typical nerve system, muscle complex, anal sphincter or rectum. Dilatation would battle scar tissue and I began rectal enemas to try to forge some routine with my bowels to prevent constant accidents.

Amongst this, I had many other issues associated with VACTERL, all except a limb abnormality. Blessing or a curse; I was graced with a hidden illness that was unknown and unseen to others, and commonly misunderstood by health professionals.

Despite challenge after challenge, and setback after setback, I landed an international modelling contract at the age of 17 and walked Amsterdam Fashion Week the day before my 18th birthday.

Since then, I have been getting involved in the VACTERL and Imperforate Anus community and have become a part of the Resource Development Team of the One in 5000 Foundation started to support those with Anorectal Malformation (ARM).

In July 2018 a few weeks after my 20th Birthday I had the opportunity to present and tell my story to a room of 400 people in the ARM community at the Pull Thru Network Conference in Phoenix, Arizona.

OMG what a story Anja! So inspirational for any young person entering their teens and wondering what their future holds if they have this condition or any other significant congenital disability. And to be so young and to take on roles in education and being an ambassador for VACTERL – such a public position to take. You are simply amazing!

Another common condition with VACTERL is Tracheo-Oesophageal Fistula (TOF). These are variations on TOF and a common complication of a TOF is chest infections which require regular respiratory physiotherapy.

I do think Anja’s book would be so useful as a compulsory read for any medical student to educate them about the heights that people with a disability can reach rather than dispensing gloom and doom to new parents who are facing the diagnosis of something as complex as VACTERL.

Self-belief seems easy when things are going your way, but when life presents challenge after challenge, and obstacle after obstacle, giving up or dismissing a positive story is easy. There were many times I could have given up on myself. The doctors gave up on me ever living a ‘normal life’ before I was even born. It would be celebrated if I could survive, let alone live.” – Behind the Smile, page 2

Luckily Anja had a wonderful, happy nature and obviously a family who fostered this self-belief attitude and this has led to a fulfilled life at such a young age.

“I was a very joyful and flamboyant child, and neither myself or my mother allowed my disability to hold me back in any way. I would always be so excited for different experiences, and despite needing to consider the logistics of how to manage my condition in different environments, it never dulled my enthusiasm.” – Behind the Smile, page 29

I recommend this book to you, your friends and any book clubs and look out for Anja’s Book Launch on Thursday October 11th in the Valley. Contact Anja if you are interested in attending on Ph 0418755691.

Arivederci Studio194 SueCroftPhysioFitness

It has been a sad couple of weeks for me making some hard decisions- but that is life – it is full of hard decisions at times.

I have included below an email that I had to send to all our lovely clients at Studio 194 – the studio I created over 3 years ago to refer patients on for further rehabilitation after their initial assessment and treatment phase. So many times, the answer we get when we ask our patients at their initial consultation to write down 3 or 4 goals they hope to achieve from their consultation with us at Sue Croft Physiotherapy, is for advice regarding exercise which is suitable for THEIR pelvic floor. Many times they have significant prolapse with levator muscle damage that does mean some exercising may make their prolapse worse, particularly if they don’t have a pessary fitted. Sometimes they have pelvic pain which is exacerbated by excessive abdominal work and others have urinary incontinence and they are unsure about what to do to avoid this.

My little studio was my baby which ticked many boxes for those questions, but also in the process a small community was created and this has been the most difficult part about closing down. I know so many of the ladies personally and I know many have made connections and enjoyed the camaraderie of the classes. I know they have benefited from their attendance at Studio194 and I feel like a heel closing it. But you will see in the email below that I had to send all my clients, why it was inevitable that it had to close.


Hi to Studio194 clients,

It is with much sadness and regret that I am writing to let you know that I will be bringing our Gladstone Road Studio 194 PhysioFitness Pilates, Yoga and Dance classes to a close at the end of the year. It has been a heart-wrenching decision as I have loved developing the Studio over the past three and a half years and having the opportunity to progress our patients onto further exercise at the Studio. I have loved the ethos of the Studio and the community that has been established. It has been my little baby and I am terribly sad that I can no longer keep it open.

My physiotherapist Studio instructors – Jane, Martine, Megan and Alex – who all work with me at my Hampstead Road consulting rooms have also enjoyed the opportunity to help women apply the exercise advice they learn in the consulting rooms into the exercise environment at the Gladstone Road Studio.


My other instructors – Marzena (Yoga), Darci (Dance) and Alison (Barre) have all been enthusiastic proponents of their chosen speciality. They have adapted their teachings as necessary to incorporate cueing for the pelvic floor.


To have had a facility to send ladies who have significant prolapse, who have had repair surgery and all types of pelvic floor dysfunction and be able to exercise knowing that their pelvic floor will not be compromised has been such a blessing and one we will all miss.

My Hampstead Road consulting practice will continue unaffected of course.

And some good news is we will still be conducting ‘one-on-ones’ and some small group sessions at the consulting rooms in our downstairs gym area. The ‘Reformer’ will be relocated to the consulting rooms for ‘one-on-one’ and ‘two-on-one’ exercise sessions. These physiotherapy sessions will continue to attract a normal health insurance rebate.

It has always been difficult to make the Studio classes viable and we accepted that for the benefit it bought to our clients, but the final straw for us came when the Federal Government changed the rules which will disallow health insurers paying rebates for Pilates classes as of April 2019.

I wrote a blog about this a few weeks ago when I first learned of this dramatic legislation. The link follows:

We believe this change will significantly impact on the class attendances. So, sadly it is time to close the Gladstone Road Studio and focus entirely on continuing our valuable work at my consulting rooms with our Pelvic Health (and musculo-skeletal) physios Jane, Martine, Megan, Alex and myself at 47 Hampstead Road Highgate Hill.

Some changes will happen before closure: Yoga with Marzena will be only on a Wednesday night from this week. The last Yoga class will be Wednesday 12/12/18; the Pain Relaxation classes with Martine will be held three weekly on Monday 15/10/18, Monday 5/11/18 and the last one will be Monday  26/11/18 all at 6.15pm. (We will be doing small group classes for pain management in the New Year at the Hampstead Rd Rooms.)

The last dance class is Wednesday 21st November – as Darci is travelling overseas from that date. Darci has also been helping with the Thursday PhysioFitness classes when Jane has had difficulty getting to the class – I take the class for the first 15 minutes mat work and then Darci does a 30 minute aerobic session (which is fun and great for your bone density, coordination and your memory/ brain). Jane will mostly be continuing this class until the end of the studio.

All classes at the studio will cease as of Friday 14th December 2018. 

From now, in the lead up to the closure we have reduced the prices of Pilates, Yoga and Barre to a flat $18 and the dance classes are all now a flat $10 so there will be no need to sell the discounted packs as we want everyone to use up their class credits before the Studio closes. Please finalize all requests for health rebate tax invoices by close of business 14th December. There will be no refunds on any class credits.

I would love it if you can continue your support to the end and enjoy the last 3 months of Studio 194.

Warning: There will be tears! (from me anyway)


Thank you for all your support over the past years and I am so sorry that I couldn’t keep the studio going.

Sue Croft

I have had some lovely emails from clients who are also sad about this and I’ve had some angry ones who are upset that there is no insight from the political bureaucrats regarding the enormous value that regular exercise has for health outcomes – that they should be promoting exercise not diminishing its access.

I am pretty sure this piece of legislation slipped by unnoticed from many in the general public and come April 2019 there will be unhappiness. What I am looking forward to is a significant REDUCTION in the cost of my health insurance every year as the Government hoped would be a result of this legislation change.

World Physiotherapy Day- Get active, stay active for good mental health

Between Women’s Health Week and World Physiotherapy Day (September 8th) it is exhausting to keep up with all the spreading the word on these designated days/weeks.

But it is important especially when the theme for World Physiotherapy Day is Physiotherapy and Mental Health. 

Every day we Pelvic Health Physios see plenty of stressed out, anxious women who are coming to terms with their pelvic health issue/ diagnosis. Part of the difficulty with these pelvic health problems is you can’t unburden yourself to just anybody about your newly understood problem. There is shame; there is the fear you are the only thirty-something with these issues; and there is your own revulsion that your life has taken this shocking turn for the worst. The bottling up of these stories continues to place a strain on the mental health of women.

Women are so used to sharing EVERYTHING that is worrying them with their girlfriends, their sisters and mothers. But who can divulge to your mother/sister/husband/friends…even GPs about your faecal urgency that is causing your anxiety to sky rocket or your prolapse that makes you feel extremely unfeminine or your pelvic pain that is causing you to refuse any intimacy post-vaginal delivery? It’s never easy- but the knowledge that the stats are high for many women having pelvic floor dysfunction tells us you are certainly not alone and in these days of social media thankfully the word is getting out. However in my 27 years of just treating pelvic floor dysfunction alone I have seen the messaging change – from barely being able to get a line in an article about urinary incontinence to there now being multiple Facebook groups for every pelvic floor condition there is and lots and lots of conversations in the media for women to access. This is mostly a good thing.

But the down side of this is that so many women who actually don’t have prolapse are convinced they do and there is a certain level of catastrophising about pelvic floor dysfunction.

There are many odd sensations in the nether regions after you have a baby. Drag and ache, bumps and bulges. Sometimes you are right with your diagnosis from Dr Google and sometimes you are not. There can be normal post-natal swelling which is not a prolapse. Also whilst it’s good in theory to understand about your anatomy- looking with a mirror after childbirth can definitely escalate anxiety.

Schedule a 6 week post-natal check-up with a pelvic health physiotherapist who can tell you what is what but also remember prolapse can actually change through the day- it can start off with everything sitting inside the vagina early in the morning and as you have a heavy day on your feet with toddlers and babies and shopping and housework and washing the dog – things can drop by the afternoon. It is always handy for the GP to do an examination in standing to see what you are feeling rather than just in lying where everything is reduced.

You can see there is a common theme from the photos inserted in this blog -that keeping active is important for your mental health. We physiotherapists know and many women know that exercise is wonderful for improving your head-space. And yet so many women believe they can’t do anything after they have had a baby. Even if you have prolapse you can usually exercise with a pessary in – so get along to your pelvic health physio and start the conversation.

What can I do?

When can I do it?

Facilitate my rehab!

Be my pelvic health mentor!

Speaking of mental health for women here is a link to a great article about the mental load that women invariably carry once they become a mother. It is a long post (and a little unfriendly for reading when we are used to things that are fast and iPhone-friendly with reading) but I encourage you all to persevere to the end. It’s the “You should’ve asked” repeating at the end of each little cartoon that really resonates while you are reading it. This is what is exhausting for women. Not just doing the tasks but thinking about what needs to be done, when and by whom (which often ends up being by the woman because it’s just easier than coordinating another to do it) but then the answer comes back when they may crack “But you should’ve asked”.

And finally the mental health of mothers takes a downward plunge if the mental health of their children is not good. This link to an interview on the Today show has the full interview of Hugh van Cuylenburg from the Resilience project with some thoughts on building resilience in children and adolescents.

I encourage you to listen to the whole interview but if you don’t have time, a synopsis follows. Hugh talks about how to develop three key pillars that will help you and your kids develop resilience, which may lead to mental health improvements and you become happier. Hugh stated that recent research that studied 300,000 kids over last 3 years showed statistics that around 40% of high school kids and 24% of primary school kids have a mental health issue with anxiety being the primary one. Anxiety is a condition where obsessive, negative, worrying thoughts can’t switch off.

He commented that he recently heard someone say that with social media and iPhones “We have never been so connected and yet never so lonely”. And it is the omnipresent technology that can be so overwhelming for developing brains. Hugh reminded us that the 2018 adolescent and child brain will receive the same amount of information in a week that we older folk were exposed to in a year. Now that is mind-blowing.

Hugh tells us about how he got interested in resilience training. He was studying teaching in Australia and got access to a classroom when volunteering for a few weeks in India. In this village, there was no running water, no electricity- but these people were so unbelievably happy and so full of joy. One particular child slept on a dirt floor- he was happy, he was full of joy. Hugh couldn’t stop thinking about his own sister who was three years younger than him who was very unhappy, anxious and diagnosed with anorexia. She was desperately unwell and at a dangerously low body weight.

He wondered “How is this possible? This little boy is sleeping on a dirt floor with no running water, no electricity and yet he was so happy and yet his sister was so unhappy. What does this kid do, what do this community do every day that make them so happy?” He observed and watched them for years and he learnt about these 3 pillars- their key to life: Gratitude, Empathy and Mindfulness. He came back to Australia, went to uni and did post-grad studies to provide sound evidence that these strategies will help build resilience and found in fact there is over 30 years of research behind these strategies that if implemented our mental health improves and you become happier.

Pillar 1: Gratitude the ability to pay attention to what you’ve got and not to worry about what you don’t have (we have so much in Australia but we are not very good at paying attention to what we’ve got- we are always wanting for more and searching for a better life without really appreciating what we have got).

Pillar 2: Empathy put yourself in someone else’s shoes. This little boy – who had nothing, who sleeps on a dirt floor- was always exuding kindness and he loved giving compliments to people. Hugh pointed out that we often think nice things about people, but we never say them. He recommended thinking beyond yourself and the happier you are then the more likely you are to be kind to people. There is also strong neuroscience evidence that if you are kind to people your brain releases ocytocine – a feel-good hormone.

Mindfulness is about the ability to be calm and to be present. Mindfulness is not meditating but being in the present moment. Anxiety is the biggest problem- we are on edge and only present for 15% of our day. Screens are our biggest distraction. It is detrimental to children to feel you are not engaged fully with them. The answer is -get off your phone, be there for your kids, leave your device in the car.

To finish this blog I wanted to include more links from the wonderful articles and links that Jean Hailes for Women’s Health created for Women’s Health Week. Mostly this is so I can quickly access them for my patients because there is a wealth of information on the site but I commend them to you.

Here is the link to Day 3 of the Jean Hailes Women’s Health Week.

Here is the link to Day 4 of the Jean Hailes Women’s Health Week.

Here is the link to Day 5 of the Jean Hailes Women’s Health Week.

I hope you find lots of worthwhile information in this special blog celebrating World Physiotherapy Day and to all my Physiotherapy colleagues have a great day, great weekend and a great working year with your patients.

#startmoving #staymoving #bekind #bepresent #begrateful #bemindful #beempathetic

Women’s Health Week Day 2

I get to look at this lady every day in my treatment room

Day 2 of Women’s Health Week is devoted to Happy Hormones – here is the link to Jean Hailes’ articles about hormones.  I thought my contribution would be to post some info about when local oestrogen may be advantageous to improved pelvic floor function.

Local vaginal oestrogen can be helpful through different life-stages for women. One of those stages can be whenever you are breast feeding.


Breastfeeding may suppress your monthly menstrual cycle due to high levels of prolactin (a breastfeeding hormone) competing with oestrogen and progesterone production. As time progresses following the birth, the atrophic vaginal tissues can not only impact on prolapse and incontinence, but also may cause dryness and subsequent pain with intercourse. You cease the local oestrogen as soon as you stop breastfeeding.

Another stage is when you become peri-menopausal and post menopausal. It is useful for plumping up the urethral and vaginal tissues which helps with continence control and with comfort in the vagina with penetration during intercourse. Any changes in the ability of the smooth muscle sphincter mechanisms to provide good urethral closing pressure will contribute significantly to stress incontinence and insidious leakage. The urethral sphincter mechanism also deteriorates with ageing due to decreased vascularity and will benefit from oestrogen supplements locally to help after menopause with maintaining urethral closing pressure. Discuss the use of local oestrogen cream or tablets (inserted into the vagina) with your general practitioner or specialist if you are having continence issues or painful sex.

About nine months ago I received a newsletter from HealthEd with an overview on Vaginal Atrophy and Sexual Function. This highlighted the changes suggested by RANZCOG in the method of application of Ovestin, one of the types of local oestrogen.  If you have been prescribed local oestrogen please take note of the Take Home Messages below. After personally changing from Vagifem to Ovestin a couple of years ago, I became aware of the silly design in the applicator supplied with Ovestin. So I was very pleased to read these guidelines which encourage dispensing a small amount of Ovestin cream on your finger – halve one of the doses every second night as this means you lose less and you can avoid using the applicator (which is impossible to clean) and use a finger to apply. Squeeze the cream on your finger, insert low in the vagina – away from the cervix and be sure its on anterior wall and less deep– the half dose also means you don’t lose as much and this will be easier for any arthritic-fingered patients who were worried they couldn’t reach deep enough.
DR JOHN EDEN MB BS MD FRCOG FRANZCOG CREI wrote the following information. Dr John Eden is a certificated reproductive endocrinologist and gynaecologist. He is a Conjoint Associate Professor at The University of New South Wales in Sydney. He is a visiting medical officer at the Royal Hospital for Women, Sydney, Australia where he is Director of the Sydney Menopause Centre and the Barbara Gross Research Unit.
Take Home Messages
  • There is considerable data to support the use of topical oestrogens in urogenital atrophy.
  • Topical oestrogens should not be deposited deep in the vagina, but rather in the anterior portion, in order to minimise uterine exposure and to maximise the effect on the vulva, urethra and clitoral areas.
  • Oestrogen creams may be best used by abandoning the applicator all together and placed on a finger instead. This is then inserted inside the anterior vagina; some cream should also be smeared onto the vulval skin.
  • Patients who have had breast cancer should use nonhormonal moisturisers first and topical oestrogen as a last-resort.
  • Vulval dryness may respond to soap-free washes, using plain moisturisers on the vulva and intravaginal moisturiser products. Natural oils (such as coconut oil or olive oil) can be effective lubricants.
Post-menopause local oestrogen also helps the vaginal tissues with lubrication and thickening to tolerate any sort of supportive pessary (e.g. a ring, cube, Gelhorn or others) to help maintain any prolapse.

Mona Lisa Touch Therapy laser treatment

Since 2013, a non-surgical, non-hormonal alternative to vaginal atrophy has been available in Australia and around the world. This is a laser treatment (Mona Lisa Touch Therapy) which stimulates the body’s regenerative processes to create more healthy and hydrated cells and to improve the vascularity of the vaginal mucosa. I have written a previous blog on the Mona Lisa. It costs around $2000 in Australia for the 3 treatments necessary  and is not covered at all by Medicare at the moment. This may be a useful option if the patient has vaginal atrophy and has had an oestrogen-dependent cancer and is advised not to use local oestrogen. Discuss this with your specialist or doctor.

I hope these titbits help you start some conversations with your medical practitioners.


Women’s Health Week 2018

This week is Women’s Health Week and Jean Hailes for Women’s Health has a brilliant webpage dedicated to promoting this week. I encourage you to head to this page as it has lots of fantastic information on it- practical advice that will benefit young women, older women, active women and those looking to start the process of improving their health.

Today’s topic is devoted to Silent Issues affecting Women’s Health – and quite frankly there are so many it’s difficult to know where to start? Faecal incontinence? Urinary incontinence? Prolapse? Sexual pain? Constipation? These are all issues which confront women who have had babies (mostly) on a daily basis and ones which have evidence-based treatment strategies to considerably improve their impact on women if not cure them.

Back in 2013, I wrote this blog on All About Bowels because bowel dysfunction is very distressing for many women and it isn’t something that people really want to sit down and have a coffee and chat about. It’s a classic silent problem. So I thought I’d re-post the blog here to summarise all the different issues wrapped up in bowel dysfunction.

Nothing causes more misery in people’s lives than bowel problems. Whether it be constipation, incomplete evacuation, faecal incontinence, sneaky gas, rectal prolapse, haemorrhoids, pain from anal fissures or proctalgia fugax – and sadly, some people can have some or all of these conditions. One of the more famous people who reportedly suffered with major constipation was Elvis – his personal physician writing in his book that he had obviously a huge redundant bowel, that he sometimes soiled when performing and claimed he in fact died of constipation. It’s quite difficult to chat to people about your bowel problems – it’s just too much information even for your closest loved ones. So I thought I’d devote a whole blog to bowels.

I’ve said it before that for many kids, toilet training for ‘poo poos’ means being plonked on a potty with Mum and/or Dad making lots of grunting noises. Not a lot of science. (I have included a new chapter on The Early Years in the new edition of Pelvic Floor Essentials.)

There are 3 key elements to effective evacuation: Firstly the correct position, secondly the correct dynamics for emptying your bowels and thirdly the correct stool consistency. Getting the angles right and the coordination of the abdominal and pelvic floor muscles (external anal sphincter and one of the pelvic floor muscles called puborectalis) to release the stool will make it easier to completely evacuate the bowel motion. In both of my recently updated books in the  Pelvic Floor Recovery series, (Pelvic Floor Essentials Edition 3 and Pelvic Floor Recovery: Physiotherapy for Gynaecological and Colorectal Repair Surgery Edition 4) I go through in detail these three elements to effective, pain-free and more complete evacuation. I have included the diagram for the adult defaecation position below.

Defaecation Position

Copyright Sue Croft 2018

Defecation dynamics means gaining effective coordination between the abdominal muscles and the pelvic floor muscles. Instead of pulling your tummy in and pushing down with your pelvic floor (ie straining), the idea is to gently bulge the abdominal wall which causes an opening and relaxation of puborectalis and the external anal sphincter (ie. creates a funnel to release the stool).

Eating enough dietary fibre is an important first step when managing stool consistency. Seeing a dietitian for assistance with a FODMAPS diet can also successfully manage too loose a stool, too firm a stool, excessive gas production or bloating. Using a product to normalize the bowel motion can be helpful whether you are helping constipation or faecal incontinence. Doing something simple like a corn test to see what the transit time is like is an important first step when assessing the correct potion to take. To do the corn test, have no corn for a week, then a whole cob of corn, making sure you don’t chew it very well (as opposed to advice normally to always chew your food well always) and then no more for another week. You are looking to see when you first see the corn and when you last see it. If it takes longer than 47 hours to see all the corn, then you have some slow transit time happening in your bowel.

Products range from fibres which are good for softening the stool such as Normafibe* (which is also very helpful if your stool is too loose- it acts to bind the stool), Benefibre*, Metamucil* and many others, to osmotic laxatives such as Osmolax* and Movicol* which help bring more water into the bowel to soften the stool through. Adult Glycerol suppositories* are a wonderful help if someone is very constipated, to assist with defaecation and prevent the patient from straining (remember avoiding straining is the best advice particularly if you have rectal or vaginal prolapse, anal fissures, proctalgia fujax, haemorrhoids or have had gynae repair surgery………actually never strain is the best motto). Remember all products have different names in overseas countries so you need to check with your pharmacist going by category – fibre (soluble/insoluble), osmotic laxativestimulant laxative and so on.

Proctalgia fugax can be considered a chronic or persistent pain condition so teaching about the science of pain is very important for the patient. Of course the mechanics of defaecation have to be corrected and this decreases the tractioning of the nerves from straining at stool.  For some patients a  medication like Endep* (prescription item definitely discuss with your doctor) can help with decreasing the constant messages from the pelvic region and most importantly relaxation of the pelvic floor muscles and anal sphincter, general body relaxation and belly breathing will be helpful. 

Poor gas control and faecal incontinence is distressing and can lead to people leaving their chosen employment, becoming very anxious and even agorophobic. I have covered in a previous blog the importance of dietary management, regular pelvic floor exercises (particularly the external anal sphincter) and Imodium to help control the incontinence. Overeating can also cause excess gas production and it may pay to look at portion size as one of the strategies to help excessive gas production.

Simple strategies such as using a flushable wipe (they live in the toilet roll aisle and come in a large size for the home toilet and a purse or pocket-size) to complete the cleaning phase on the toilet (dispose of in the sanitary product bin), often assists when post-defaecation soiling is a constant issue. There are also new types of pads for patients with faecal soiling which have odour control qualities and it is important to use barrier creams to protect the skin (such as Sudocrem) if soiling is a daily problem.

*Please discuss the taking of any preparations/medications with your GP, medical specialist or pharmacist.

I hope some of these hints are helpful and share it with a relative or friend if they have confided in you that they have bowel problems!

Apparently preventative medicine is a waste of money?

In November 2017, there was a decree from the Australian Government that a number of complementary medicine categories would no longer be able to be covered by the Private Health Insurance companies. This is what the Government has decided as part of the linked advice above.

“Rules will be made to remove natural therapies from the definition of general treatment under section 121-10 of the Private Health Insurance Act 2007. Insurers will then not be able to offer benefits for these therapies as part of a complying health insurance policy.”

Three of these natural therapies included Pilates, Yoga and Tai Chi. There are many others but today I am addressing mostly Pilates.

Pilates is one form of exercise.

There are lots of ways to exercise – some are individual- walking, running, swimming.

Others are in a group setting where under an instructor (Pelvic Health Physiotherapists), clients may not only seek supervision, guidance and encouragement about exercise, but they may also have a social experience in the group setting- which has many benefits also. Tai Chi and Yoga are both wonderful ways to come together and exercise in a group setting.  Tai Chi is a great gentle balance exercise which is suitable for many older clientele and there is evidence in fact that Yoga is very useful in treating persistent pain conditions and helping alleviate those who are suffering high levels of stress and anxiety – a mental health condition which is highly prevalent in society at the moment.

I am writing this blog as I have a vested interest in two things.

One is I own an exercise studio and have (Pelvic Floor Friendly) Pilates classes available to my patients as a progression following their initial assessment and treatment programme (where their continence dilemma -and it is a dilemma when you pass wind, faeces or urine in a socially unacceptable way) has been improved and even cured. (Owning this studio and running many classes is purely an altruistic exercise for me as nobody can actually break even let alone earn make a profit when running an exercise studio – I like having the studio to progress the clients).

Secondly I want to get my patients exercising fullstop!

The evidence is strong that exercise is integral to a healthy (happy) life. It has a positive effect on your cardio-vascular system, mental health, bones, muscular system and joints – a total body gig! Many women (and men) have poor balance (so they stop exercising), they feel the exercise gives them pain (usually because they are not used to any form of exercise and they are therefore stiff-so they stop exercising) or they leak urine, gas or faeces when they exercise. Urinary incontinence and anal incontinence are big deterrents for women particularly in continuing with any exercise regime- so they stop exercising.  Then other co-morbidities such as obesity and joint pain set in.

Some examples: I have a patient whose specific goal was: ‘I am worried I might fall and won’t be able to get up off the floor’- this patient started attending the studio and now can do a whole lot more than just get up off the floor.

Another had chronic neck and shoulder pain that interrupted her sleep quality but she was fearful about how to start exercising because she had prolapse. She started at the studio and now feels 10 years younger (she is 78 so now feels 68!) and is confident to exercise and feels stronger, happier and is walking more everywhere.

Unfortunately there is no specific study to prove that she will need less pain killers and sleep medication; that her life expectancy will increase; that she will feel less lonely because once or twice a week she joins fellow class participants at the studio or the important bottom line – that she will cost the Government less money in the future health budgets.

(By the way I would like to do the Maths on the percentage for women versus men who do Pilates in Australia…. is there a hint of patriarchy about this decision?)

I would have thought in 2018 that the former Commonwealth Chief Medical Officer, who was the chair of the National Health and Medical Research Council (NHMRC), would see the benefits of ANY exercise and that an important role of the Private Health Insurance Companies should be to promote preventative health strategies over always waiting for intervention strategies such as a total hip replacement for hip pain (the cost of these ops is massive) or a gastric sleeve to reduce morbid obesity.

The Government states that:

Changing coverage for the listed natural therapies will ensure taxpayer funds are spent appropriately and are not directed to therapies that do not demonstrate evidence of clinical efficacy.

I think the Government is making sure there is no money wasted.

Last week, the week commencing 21st August, 2018 the Australian public graphically saw how taxpayer funds are spent inappropriately -we were exposed to the definition of a gross waste of money!

We will never know just how much last week’s shenanigans cost the Australian taxpayer.

I will highlight just the tip of the iceberg.

When I worked at QE2 Hospital 27 years ago- it went through three (3) changes of board/ region in 4 years. This required three (3) changes in stationary throughout the WHOLE hospital. Even then as a younger woman (meaning less cynical, less scarred with looking at government waste) I thought this a preposterous waste of money.

So if we just examine stationary costs due to the ‘small shuffling of jobs in the Cabinet‘ as a result of “The Spill” letterheads, envelopes, business cards – all in perfect condition but destined for the shredder.

If we look at staffing costs – people losing their jobs in offices like Malcolm Turnbull’s office, Julie Bishop’s office plus all the rest who will no longer be wanted because they know too much (and they just went to work on Monday ready to start another week of work but now may be anxious about their job future).

If we look at all the Special Envoys who are being offered jobs to appease them (to try to keep them from doing more white-anting in a few months time because really they didn’t get the result they were hoping for) Do these new jobs come with a monetary package bonus?

But mostly what about just shutting down Parliament for the afternoon. A second time that this happened to the Parliament of Australia.

I mean we are all encouraged to be Lifters not Leaners; to get up each morning, to go off to work, to turn up on site; to have a go and you’ll get a go – there’s a fair go for those who have a go. Regardless of who we are we are all here to make a contribution, not take one and finally to do something better, it’s not necessary for someone else to do worse.”

I think that all means – the Government doesn’t want us to be slackers, playing wag from work, calling in a sickie.

So who is going to do the Maths to ensure taxpayer funds were spent appropriately last week? 

I reckon when it’s all totalled up the whole of Australia could be funded for some type of exercise class/activity for a year and there still would be some change left over with all the money-wasting of the past few months.

Let your Member of Parliament know you’re unhappy about the decree abandoning Private Health Insurance coverage for any exercise you currently are covered for.


Learned helplessness and some other key words

I sometimes feel like my brain is a bit like my linen cupboard. It’s a bit small for the amount of linen I have acquired over my lifetime and sometimes when I try and squeeze another towel or three into it, the door doesn’t quite shut and it pops open and something falls out. As I read pain articles and books, listen to podcasts on pain science and education and attend new workshops and conferences on pain and absorb more pearls and nuggets of information, I feel my brain has reached its limit and something has to give- my big worry is what? What has now morphed out of my memory and potentially gone for good?

After attending the AGES Conference 2018 in Brisbane over the weekend, it is definitely face and name matching. You see a face and know it well but can’t quite think of the name quickly enough… embarrassing dilemma. I have said it before and will say it again- we should all wear name tags all the time.

What I am writing tonight is a little prompter for some great listening and some key words that I am going to slip into many future conversations- whether they be with pain patients, when doing talks or maybe even a dinner conversation (I will sound very intellectual in the last scenario).

Therapeutic alliance

Control the controllables

Learned helplessness

‘Therapeutic alliance’ and the fabulous statement  ‘Control the controllables’ come from attending a recent workshop on Pudendal Neuralgia conducted by the wonderful Michelle Lyons, an Irish Women’s and Men’s physiotherapist who conducts workshops around the world (and when in America for the Herman and Wallace Institute).

Therapeutic alliance is so important- for me the first part is engaging with the patient from the get-go, listening to their story, assessing and instituting a management programme and then encouraging adherence to the programme from the patient. It is also important to make the programme interesting for the patient, relevant for their needs and one that is achievable. Therefore any goal setting must include relevant goals from the patient – they must be the patient’s goals not the therapist’s.

‘Control the controllables’ – if only everyone approached their day, their week, their life, with that statement frolicking around in their head – it would make the days more productive and more goals would be achieved. It is particularly relevant for pain management (pain cure – start brainwashing yourself -say it over and over again – we want cure not management! This sets a new conversation in your brain.)

First deal with what you can – reduce your work hours if work is high on the stress producing scale; go to bed early if a lack of sleep is contributing to increasing your pain; eat healthily – we know a good diet is an essential platform on which to build a good outcome; discuss with your partner what he/she can do to assist in achieving any set goals. Once those controllables are locked in, then you may have the opportunity to focus on some of the harder issues that seemed insurmountable when you were working ridiculous hours, sleeping 4-5 hours a night and eating lots of inflammatory foods such as sugars and fast foods with a lower nutritional value.

Learned hopelessness – I heard this in Dr Joe Tatta’s podcast Episode 92 with Dr Tim Salomons on the Pain Neuromatrix and it was such a light bulb moment for me. I totally recommend that you try and listen to this podcast in full and I have directly transcribed (it is pretty much word for word from this podcast if it is in italics) some of the salient points that resonated with me.

When you go from provider to provider trying to get help with a persistent pain problem (or any pelvic floor dysfunction for that matter) and you have numerous investigations, assessments and treatment strategies and nothing seems to work, then you begin to have a belief that nothing can help and you get into this state of learned helplessness/ hopelessness and this affects your motivation (essential to exercise), your affect (your emotion, you feel depressed, sad, hopeless) and your ability to learn (and we have said many times that good pain education is a fundamental part of starting on that road to cure).

There are a series of experiments describing learned helplessness- two groups of animals with exactly the same stresses (such as shocks) but one set of animals has the ability to escape the shocks and one doesn’t- what happens is that even though the animals have exactly the same degree of shocks or stresses, the group that has no way to control their outcome stops trying, they become demotivated they show signs of anxiety and depression and most importantly they fail to learn in the next instance so when you put them in a setting when they can control the stress they don’t bother – they stop trying altogether. 

An example of this is when patients are scheduled for back surgery and they have a lot of hope and expectation about the new surgery (or strategy)- so when it fails they are then skeptical about any other new surgery/treatment strategy and they demonstrate features of learned hopelessness. There is a loss of the link between your actions having any effect on what happens to you- a lot of chronic pain patients have tried many different drugs, many physios, psychologists, GPs pain specialists and they have still have pain. They have tried and tried and tried and they have failed and failed and failed and we wonder they are all depressed- why are they not trying at the next treatment with your suggestions. They have become examples of learned helplessness patients. Essentially they believe that nothing they can do is going to lead to a positive outcome and if they get better it is by blind luck.

This is problematic and so Dr Salomons has been studying this at a brain level and across the brain matrix there is far greater activation (central sensitisation) if they perceive their pain as uncontrollable. The people who do well when their pain is uncontrollable seem to switch strategies. There are two kinds of coping strategies – an action strategy (based on taking away the stressor) and an emotion-focussed strategy one where they concentrate on dealing with the stressor at an emotional level. This is relevant because in life- somethings are controllable and some things are uncontrollable and working out what strategy to choose at which time is why some people cope with tumultuous events and others don’t.  This is the ultimate perceived control

Dr Salomons believes it is essential to try and intervene earlier with pain patients- to break this cycle of protracted times between when the patient is first experiencing the pain and finally discovering someone who can effectively treat and cure this pain. So a key point maybe working out through a good assessment tool (maybe the Pain Catastrophising Outcome Measure) who is potentially at more risk and particularly getting those people in and treating their persistent pain early enough. (An example maybe someone who suffers an injury at the same time as losing a partner or parent or even their job- this is a high risk situation which would benefit from early effective intervention to prevent persistent pain developing.)

He talks about the importance of becoming aware of the emotions in the body and their interplay with a persistent pain condition. If a patient has a degenerative condition and the physiotherapist decides they need to do a specific exercise for 45 minutes every day to help slow the  degenerative process, but if they do that exercise it will do nothing (ie except just prevent the degenerative process) but it could make their pain worse, the patient is unlikely to do the exercise. The patient is learning if I do a whole lot of work, nothing is going to happen- in fact my pain may get worse.  People (and animals -google Pavlov’s dogs) learn by being rewarded and managing their expectations. If there is no reward there is unlikely to be continuation of the exercise.

One of the biggest problems in pain management is poor expectation management- patients scheduled for back surgery- invest a lot of hope in the surgery ” Finally this is going to be cured say with back surgery – more often than not the surgery fails- imagine how that feels-they have poured lots of hope and expectation into this surgery that person is now much worse than they were before because they will no longer believe you – they are skeptical they are no longer buying in to what you are saying. 

So what do I see as the take-home messages?

  • Use psychology to get them to exercise and use exercise to help them with the psychology- it helps them feel good.
  • We therapists many times have created this hopelessness by repeatedly doing things to patients and not empowering them with self-help strategies.
  • Discourage learned helplessness with patients -inspire them with good education, positivity and empower them with the belief that they can in fact change the course they are repeatedly traveling along.
  • Reinstate perceived control- the extent to which patients feel that they have control.

And yes my brain has imploded!

Slowly we CAN change our habits!

I write about Change a lot because change is what helps us adapt to life’s challenges and especially those challenges that affect our continence state. My first blog on Change became the closing chapter in both my books because Change in our beliefs, habits and behaviours is often what gets us dry, clean and comfortable should we suffer urinary leakage, faecal incontinence or prolapse.

And lately Change is in the air- what with our need to change and adapt to using reusable green bags. I so love the idea about not getting 100 disposable, non-biodegradable bags a month from the shops – but I am still so bad at remembering to carry bags – not so much to Coles because that is so obvious – but to the fruit shop and the local shops I regularly get to the checkout with an armful of stuff and think “Damn forgot the green bags:-(“

With education (shows like War on Waste on the ABC) and practise (being extremely uncomfortable balancing 10 things on top of the pizza bases and then suffering the humiliation of dropping the yoghurt) we will soon get used to taking the bags everywhere or we may actually buy less groceries (which will also probably mean we may eat less food or waste less food!)

Last week I saw a lady who I had seen over the years for urinary leakage issues. She had followed everything I had asked her to try except for the caffeine part of the story. She had struggled to adjust to less caffeine or 100% decaf. She came back in recently still annoyed with her leakage – it was both stress incontinence with walking but also was insidious – sometimes with no apparent provocation. We revisited everything and I had the decaf conversation again and this time she agreed to try for 4 weeks – to come down slowly so there was less chance of a withdrawal headache and to just see if she felt it made a difference. Then it was entirely up to her whether she continued on the decaf or went back onto normal caffeinated drinks (tea and coffee).

I am very pleased to report that she came in very happy. Her problem had resolved and she had even problem-solved an issue that I hear far too often- the problem of the friends or coffee shop owners JUDGING her for choosing decaf?? I mean really who does that- judges someone for choosing decaf? There are so many reasons why someone could choose to drink decaf coffee or tea. Sleep issues, palpitations, significant anxiety issues- yes caffeine will make some people feel more anxious – and of course the reason we are talking about – urinary and/or faecal incontinence.

I asked her to write me a little paragraph about her success and you will see her clever way of getting around the “indignity” of asking for decaf.

Her blog follows….

I came to my pelvic floor physio to get help with urinary incontinence issues with walking. On my first visit she enthusiastically gave me a spiel on good bladder and bowel habits, pelvic floor exercises and lots more including the suggestion to wean off coffee. This just seemed a step too difficult. I was happy to do pelvic floor exercises, bracing, use continence aids such as a specific pessary to help with leakage, but my morning routine of exercise and coffee with friends was going to remain.

However, with ongoing persistence from her, I decided to take the plunge and go decaf. It really was not a drama at all and with my friends rolling their eyes with my “double shot decaf skim latte” order I took it upon myself to buy an environmentally reusable mug and write my order on the cup and now I just have to hand over the cup and say “the coffee” please. No problem at all(!) -and a double shot is just perfect after exercise and my bladder is also much happier.

I have even begun educating coffee baristas that really there should not be an extra cost for decaf coffee and most agree. I am extremely grateful to all the women’s health physios out there who keep persisting with us patients who are reluctant ‘decaffers’ because now my coffee and exercise mornings so much more enjoyable. J

Thanks J for taking the time to write this for me. I always encourage patients to write of their personal experiences as I find real patient stories are sometimes more powerful because they resonate more with other patients.

Now to getting a quote for a “Take your green bags” tattoo on my hand!


It’s all a matter of #balance


Marzena showing us the wonderful balance poses in yoga

Today Megan had some time between classes so she whipped me up a blog and chose to talk about the importance of balance. Funnily enough in yoga tonight Marzena got us doing lots of balance poses in our yoga class (and I just had to snap her for this blog). This time we are not talking about work-life balance – although that is always critically important – we are talking about the fine line between staying upright and having a fall. I’ve been acutely aware of the importance of good balance over the past three weeks as Mum has been in hospital and is struggling with her balance at the moment.

Mum had a Total Hip Replacement (THR) 3 weeks ago and she won’t mind me saying (I hope) that at a few days shy of 93 that is no mean feat. Of course Prince Philip was the catalyst for a decision that should have been made 10 years ago.

6 weeks post op and Prince Philip walking down the aisle STICK-LESS gave hope to all the oldies contemplating surgery!

Mum has had a painful right hip for a long time but always felt she was too old to go under the knife and so kept saying ‘no’. But when I saw Prince Philip who at 96 had a THR skip down the aisle at Harry and Meghan’s wedding and then watched Mum in absolute agony walking a few days later, I put it to her that perhaps it was time to contemplate the unthinkable- surgery at 93. We went to the Orthopod (I don’t think we can mention his name because of AHPRA) who didn’t even blink at her age. He just said there are 2 alternatives – and the THR will get rid of the pain, the other will give you 18 months pain-free maybe if you’re lucky. I wouldn’t comment and wanted Mum to make the decision, but my aunt Jen kept saying ‘do it, do it, do it’ and next thing she had committed! It was a torrid first 10 days but she was a trooper and now is just pounding the parallel bars at the gym in Rehab daily and home is on the horizon. So this #balance blog is dedicated to you Mum! Megan’s blog follows.

We all expect that our balance will get worse as we get older but should it??  Is this another of those natural processes of ageing that we must roll over and accept and what does it matter if our balance does get worse anyway?  Whilst there are some age-related changes that will impact our balance functions, we must remember the brain is plastic and we can adapt to these changes and find new ways to maintain control and keep our balance function.  This is important in reducing the risk of falls and injury which as we get older has an increasingly significant impact on our lifestyle and ability.

A recent trial conducted in aged care facilities in NSW and Qld had 221 residents perform resistance training and balance exercise for 50 hours over 25 weeks and then a maintenance program for the following 6 months.  The results were a significant drop in falls amongst participants.  (Sunbeam trial 1).  Interestingly, the participants also commented on how much the program improved their general quality of life.

How much do we need to challenge our balance to improve?  How hard should these exercises be?  The reality is that how much balance work you need to do will be individual.  The exercises themselves don’t need to be too hard, just enough to give you a bit of a wobble.  You should start small, maybe a few minutes a day, and as you improve you can progress the challenge.

There’s many easy exercises that you can do to challenge your balance at home.  The main key is to be safe when you are doing them.  Always challenge your balance in a situation where you can grab hold of something if you need to.  You can try with and without footwear, eyes open and closed, and on different (always non-slip) surfaces.  Try to feel how your body balances, the sway is normal and you are trying to control the amount of sway, not stop it completely.  This is our body learning better balance.

Start simply, such as standing on one leg, or standing heel to toe.  You can add eyes closed, or maybe a pillow underfoot.  You can move the leg that is off the floor around, turn your trunk or throw a ball.  It may be tricky at first, but persistence pays off.

How can you tell if your balance is improving? The easiest way is to count how many seconds you can stand on one leg.  Then as this becomes easy, how long can you stand on one leg in more challenging positions such as eyes closed.   

In our Studio 194 Pilates classes we always include at least one element of balance and the class members comment on how much they enjoy the challenge and how they notice their balance improving in daily life.  The key is to do it regularly and do it safely.  You may never want to ride on a stand up paddle board but I have seen plenty 60 plus year olds on the water in my regular paddles so I know it can be done!!  Good balance is animportant life skill, and should be part of everyone’s daily routine.

Thanks Megan for this great blog. And everyone always remember to challenge yourself to do more, move more and not say I can’t I’m too old.
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