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

Women’s Health Week and International Physiotherapy Day (8th September 2020)

Pelvic Health in Regional and Rural Queensland

Small Business Grant Win: Extending the scope of Telehealth in rural and regional Queensland

Today (8th September) is World Physiotherapy Day, plonked right in the middle of Women’s Health Week and it is a good time to chat about an exciting new project that we have undertaken. In the weeks that followed us closing the door on 25th March, 2020 to face-to-face consultations with patients and pivoting (new 2020 Word of the Year, only just pipping unprecedented) to completely Telehealth consults, the Queensland Government encouraged small businesses to apply for Small Business Grants to the value of $10,000.

Not knowing what the future held and having ten staff to continue to employ, I decided to apply for a grant based on trying to extend the reach of Telehealth to rural and remote areas in regional Queensland.

As a background to the choice of our application for rural and regional Queensland Telehealth, we know that incontinence and pelvic floor dysfunction is a silent epidemic with women with severe incontinence experiencing more health issues, restrictions or limitations than women without severe incontinence. For example, 2 in 3 people (76.6%) with severe incontinence were restricted or limited in their physical activity or physical work, compared with 44.8% of people without severe incontinence. We know that incontinence is socially isolating, causes anxiety and depression and limits physical exercise, thus compounding their emotional and psychological burden. If these issues are not addressed it will mean that the problem progresses and ultimately affects our older age with around 77% of nursing home residents in Australia being affected by incontinence. 

And those stats are just about urinary incontinence. They don’t address vaginal or rectal prolapse, faecal incontinence or pelvic pain- the stats of which are also massive.  Childbirth is definitely implicated, but also we know that women who have had Caesarean births or are nulliparous (never had a baby) may eventually have some pelvic floor dysfunction, if they remain uninformed about the science of the bladder, bowel and pelvic floor.

So we know we need to get the message out there about good bladder and bowel habits and the role that pelvic health physiotherapy plays in treating these conditions. At my practice, we had already been doing quite a lot of telephone consults for regional women (men and children) prior to COVID19, but the rapid switch to 100% Telehealth once we temporarily stopped our face-to-face consultations meant that I had to make the process more user-friendly for my staff and the patients and therefore adapted our handouts and information to a user-friendly platform which was well received by both the physios and the patients.

Fortunately, education is the cornerstone of effective pelvic health treatment once a comprehensive assessment has been undertaken. Therefore Telehealth lends itself nicely to the majority of the requirements for effective treatment of our patients. We acknowledge there are some drawbacks when we cannot immediately follow the education with an internal examination, but we have ensured that the patients are asked probing questions by the physio in their assessment regarding:

  • What can they feel when they attempt a pelvic floor contraction?
  • Do they feel lift and squeeze or do they feel descent or bearing down?
  • Are their other pelvic muscles working overtime?
  • Are their abdominals ‘overswitching on’?
  • Are they holding their breath to do the contraction?
  • They are given many cues to check for correct activation of their muscles
  • Do they have a vaginal bulge which may indicate a prolapse which can alter their ability to empty their bladder (meaning any frequency they may be suffering is related to residual urine left in their bladder rather than an overactive bladder).
  • They are asked to fill in a bladder diary and return it to us as soon as possible.

All of this close questioning is to ensure ‘we do no harm’ with our telehealth treatment plans.

We also immediately started streaming our supervised exercise classes also because the patients who attended our classes at Hampstead Road and the studio at 194 Gladstone Road were devastated that we had to stop them so abruptly. This has been a revelation. They work so well that, until there is a vaccine, we will not be having our group classes in the small gym at Hampstead Road, but we will be still having some occasional small dance classes at Gladstone Road – althought the majority are still streamed.

But Telehealth does have its drawbacks. Obviously we are unable to do that very important internal assessment to assess the status of the pelvic floor muscles (are they weak? is there a possible avulsion injury? or are they overactive with tender points? is there a prolapse?) or the ultrasound to see if patients are completely emptying their bladder, but there is so much that we can do that the pluses definitely outweigh the minuses. What has happened is many of the patients have eventually had other reasons to come to Brisbane and have had a face-to-face appointment with their physiotherapist and the necessary examinations and then their consultations have continued back in their own homes via further Telehealth appointments.

What began as a less than suitable substitute, became a fantastic way to reach women (men and children) who live more remotely and who may have had no idea that there was an effective treatment for their very distressing bladder, bowel, pain or pelvic floor problem available.

The wonderful news is that in August, we heard that we had won the grant and so began our journey of offering Telehealth Pelvic Health services to regional and rural Queensland. The grant money cannot be used for wages to provide the Telehealth services. It is designed to set up the infrastructure so to speak, of developing this type of service. Since this news arrived, I have been doing a lot of thinking and researching about how to do this in a way that is inclusive to all the hardworking and fantastic pelvic health physiotherapists in rural and regional areas and also about the opportunity this presents to amplify the value of pelvic health for women, men and children throughout Queensland.

In the beginning we will be offering Telehealth appointments throughout regional and rural Queensland and then trying to link with pelvic health physios who are in the vicinity of the towns where the patients may be located so they can have a face-to-face internal pelvic assessment. Of course if patients are coming to Brisbane for other appointments, we can tee up a face-to-face with them then.

If pelvic health physiotherapists are interested in being on a register of rural and regional contacts please email me on admin@suecroftphysiotherapist.com.au (perhaps with some indication of the courses you have covered).

The evidence is strong that pelvic floor muscle training and education about good bladder and bowel habits should be the first line of treatment for many pelvic health conditions. A study by Doumoulin et al 2018: Compared with no treatment or inactive control treatments, women with stress urinary incontinence (SUI) who were in Pelvic Floor Muscle Training (PFMT) groups in this study were 6 times more likely to report being cured or improved. (PFMT 72% Placebo/Control 11.4%). Another study by Fitz et al in 2017 showed the success rate for PFMT for SUI varies between 60-75% when performed in the outpatient setting under the supervision of a physiotherapist. With the availability of Telehealth, this supervision can also be via the computer and even by streamed classes when the ideal situation of seeing a patient face-to-face is thwarted by the tyrrany of distance such as we see in Australia

We can also recommend some strategies to ensure there is safety around Telehealth appointments.

For example screening for a Urinary Tract Infection (UTI) can be undertaken if there is access to a GP – request a microurine if there is increased urinary urgency and urge incontinence as this can be worsened if there is an infection. It also helps to check for the clarity of the urine (cloudy urine can signal infection) and colour (it should be pale yellow- the more concentrated the urine the more irritating for the bladder). If your urine is clear, a nice pale yellow, there is no odour and no stinging when you void or blood in your urine, then it is unlikely there is infection. 

Another important ‘revealer’ of important data is to undertake a 48 hour bladder diary to see what you can hold in your bladder – measured volumes should preferably be between 350-500mls for the adult bladder. This bladder diary gives us an amazing amount of information – the capacity of the bladder; the degree of urge with each void (from zero urge, mild, moderate, to busting); the spacing of the voids throughout the day; the number of urinary leaks and at what volume of the bladder; the number of voids at night and the amount of fluid voided through the day versus the night; the balance of your fluid input versus your fluid output; the types of fluid that you are drinking; the total volume of your intake; the times you are drinking etc.

Access to getting an ultrasound in a regional centre can also reveal voiding dysfunction – if with questioning symptoms seem to indicate retention of residual urine.

If you are suffering in silence with urinary incontinence, if prolapse is interfering with your farm work, or if constipation is a daily burden – now is an opportunity to seek help. The strategies taught via Telehealth are simple and easier than you think to implement. If you would like to make a booking for Telehealth, contact our secretaries on 0407659357 or (07) 38489601.

If you want to make a headstart on things prior to making an appointment, these things are comprehensively covered in my two books Pelvic Floor Essentials (if you haven’t had or not intending to have surgery) and Pelvic Floor Recovery: Physiotherapy for Gynaecological and Colorectal Repair Surgery(the surgical book). You can check them out on my book website.

Finally, thank you to the Queensland Government for our Small Business Grant and if you are a business struggling as a result of COVID19, check our the Qld Govt website for future small business grants.

The pelvis model – a perfect phone holder for zoom meetings! 

 

 

 

COVID Update for posterity: August 2020

I have to own up to it. I’m suffering from burnout.

It’s not burnout from work, although we are all working very hard lately.

And it’s not burnout from keeping up to date with the necessary reading of research and available professional development that has sprung up left, right and centre since we all moved our ENTIRE lives online.

No- it’s burnout from listening to, participating in and combating futile arguments, discussions and behaviours associated with COVID.

I have wanted to keep writing updates on what has happened in 2020 because quite frankly, I reckon it will end up being like childbirth – you blank out the worst parts of it in order to stay sane. And some of it is so damn ridiculous I can hardly believe it’s actually all happened.

The Battle for the Last Roll of Toilet Paper Circa March 2020

I became aware of this the other day when a patient raised with me one of the ‘discussions’ I wrote about in an earlier blog with a Health Fund representative, who I had to relate what a pelvic floor physio actually did each day when treating patients with prolapse/ pelvic pain / faecal and urinary incontinence.

I had already completely forgotten about that nightmare day when this particular fund made us jump through a few more hoops than we were already jumping through, just to facilitate a patient receiving a $40 refund for their Telehealth appointment. This lady laughingly said she could imagine me red in the face, walking through the Yeronga park, laying down the law about the indignity and discomfort for the patients that they face when they have pelvic floor dysfunction.

That was a horrible day because it was the culmination of a difficult few weeks and a twenty something young guy was trying to tell me he understood about women’s issues and there’s nothing I could tell him that he didn’t already know. He insisted that it was very important that each patient write faecal incontinence or painful sex or whatever their most personal body failing was, on this special extra form they were requiring to be filled out and fax it in before they could get their $40. I had completely blotted that 57 minute conversation from my memory until she reminded me.

But we have had many useless, futile conversations and arguments over the past 6 months. Hundreds (no actual lie or exaggeration here) revolve around the phones and the internet. I know that Australia would become a Superpower of Productiveness if we could raise the bar with our technology providers. The number of hours lost to sorting out the internet and receiving and making phone calls has been insane and it’s a national disgrace. The communication from the employees of all Telcos (being that their primary role is to enhance communication) is appallingly difficult. We are still grappling with a major phone issue that neither Optus or Telstra can fix. So if you ring my landline at work and you get an odd message – definitely ring the mobile (0407659357) and there will be a secretary or the correct message on the other end.

Then there have been the ridiculous arguments from people about wearing a mask or complying with police directions or following rules.

Just wear a mask when you need to!

What is it that people object to? Have they not seen enough people night after night on different news services who have had COVID and telling us – take it seriously, it isn’t the flu?? Have they not been hearing that young people are succumbing to this virus – yesterday a man in his 20s died in Victoria and a 30year old in Queensland earlier in the week.  And then there are the purile political point-scorers – politicians who think it’s ok in the middle of a pandemic to bash on about their opposite number in the Parliament – and that is directed at all politicians regardless of their party.

But there is no point in burning out at this early point in the pandemic because despite today Russia reporting (claiming) they have Won The Race to get the first vaccine up and running, I think we have a long time to go in dealing with COVID. Poor Melbourne is suffering badly at the moment and is in Stage 4 Lockdown – it seems there may have been some shananigans in hotel quarantine. It seems incredible that so much suffering can be traced back to that alleged indiscretion. There is an inquiry tasked with getting to the bottom of that. 

New Zealanders under Jacinda Ardern has had a brilliant success with their Elimination Policy………until they spoke out loud about it and jinxed it. 100 days free of COVID – make a public announcement and back into Lockdown. Now this is increasing daily – started at 4 then up to 14, today 32. It’s more evidence of the contagious-ness of this virus. Jacinda has gone in hard again – particularly after watching Victoria’s experience this may be a good move. Let’s hope that it doesn’t continue to escalate out of control.

Aged care has been a disaster through COVID. There have been many outbreaks in many Aged Care residences and many deaths and it appears that a shortage of PPE and a lack of training has been part of the problem. There is an inquiry drawing to a close soon and the evidence is not looking good. The outcome will be for a future blog.

The final word on burnout is that I have come to realise that holidays are not only a wonderful elixir when they are actually happening, but the months planning them, preparing itineraries for them, thinking about them and imagining them actually contributes to anti-burnout. Those beautiful overseas holidays we have had since 2011 have kept us energised into our 60s – given us a purpose to working very hard so we can explore and have adventures in new and old lands.

Fortunately I have thousands of photos to remember them by. And thankfully Facebook throws up regular ‘Memories’ so I can look back and re-imagine those beautiful days. As we approach the end of August 2020, there will be daily reminders of last year’s very special trip to lots of mountains and of catch-ups with our kids overseas.

One day I hope we can do that again.

I hope we can get on a plane and not be petrified that we will arrive at the other end COVIDed. I hope we can hug our kids – a real bear hug not those elbow bumps. My son has come home, but my daughter and her partner are still in London and if it seemed a long way away before, it seems a million miles away now. I hope we can travel again without allowing two weeks at either end to sit in a hotel room quarantining. I hope we can afford travel insurance or that there is even such a thing as travel insurance.

For this we are relying on scientists. Clever people who are paid a pittance to keep us healthy and safe. If someone can tell me why a footballer or a cricketer are paid a gazillion dollars to play sport and scientists have to burn the midnight oil to put in grant application after grant application to sustain their very existance…….

So until there’s a vaccine, here’s some more mountain spam.

Gornergrat, Switzerland, 2019 -I long to see you again!

 

 

A very short blog on Movement

Today I did a short five minute segment on Katherine Feeney’s show on 612ABC radio – she is having short top tips for COVID from lots of health professionals and she is brave enough to allow me to talk about …………really anything. Today I was going to talk about persistent pain disorders and how all the prolonged sitting in front of computers doing multiple zoom meetings with reduced movement and increased anxiety from COVID was causing a spike in all sorts of pain conditions.

Luckily I came on and listened to Kat’s show about 5 minutes early and heard her play this (fantastically appropriate) song called Movement by Hozier. It truly should be everyone’s anthem. And we should all be moving like Hozier. Give it a go!

And if you want the link to the top tip for this week press on here 

I did also mention that women learning how to Sit Like a Man with their legs relaxed and apart, tummy relaxed and belly breathing regularly through the day can calm their brain, help settle anxiety and help relax overactive pelvic floor muscles. Of course there’s a lot more to treating conditions that come under the umbrella of Genito-pelvic pain/penetration disorder (encompassing previous conditions known as vestibulodynia, vaginismus), PGAD or Peristent Genital Arousal Disorder than just sitting like a man and getting help from a pelvic health physiotherapist is very worthwhile.

The silence around these distressing conditions is deafening and we need to speak about these conditions to help women seek help.

  

The actor who plays Jamie Fraser kindly demonstrating Sitting like a Man 

#movemore #moveoften #movewithgayabandon #movelikeHozier

CPOP pessaries: An observation

This is a CPOP pessary – you can read about its design and how it came about here in this earlier blog. It’s a great pessary which continues to surprise me because sometimes it works when you never think it will on quite significant prolapses. As you can see it’s a different shape and that is one of the keys to it’s success. 

But the new observation about it relates to urinary incontinence. A patient had used a silicone ring pessary for years, but as she was getting older her finger dextirity was declining and she was finding putting the stiffer ring in and out weekly was becoming a chore (stiffer because it was a size 3 and the smaller they are the stiffer they are to manipulate). She had also recently found she had increasing urge incontinence on the way to the toilet – just small amounts, but distressing for her.

Due to increasing difficulty manipulating the ring, I decided to try a CPOP pessary with her – because this particular pessary has TGA approval for leaving it in for 28 days, which means that she would only have to change it 12 times a year instead of 52. 

The interesting thing is that when she returned for followup she not only was ecstatic about the ease of getting the softer silicone pessary in and out, but her leakage on the way to the toilet had almost completely disappeared. I have since offered a change to a number of ladies with similar small amounts of leakage and they are reporting the same effect. The different shape of the pessary at the front may be the reason. 

When you are due for a new pessary, it may be worth considering a change if there is small amounts of urinary incontinence. 

 

 

 

Continence Awareness Week 2020: A Patient’s Journey.

Here is a collage of lots of photos of women. There are some happy smiling photos, but you may be surprised that perhaps 1 in 10 of the younger women may have endometriosis causing painful periods; up to 25% of all the women may have dyspareunia (painful intercourse) and some may have continual pelvic pain or bladder pain.

And yet they continue to act as if everything is normal and they are getting on with working, being in relationships, soldiering on with child rearing or trying to live a ‘normal’ life – but not really having much of a voice or not being listened to and not being heard.

This week is Continence Awareness Week – I have participated in about 30 Continence Awareness Weeks.

Over the years, I have created wrist bands, made videos, stood in shopping centres and handed out leaflets, created banners that string across major streets of Brisbane and had some articles in the newspaper. Thanks to social media – a week that has often ‘Gone through to the Keeper’ (as we like to say in Australia) without much recognition – now has literally thousands of fabulous posts on Facebook and Instagram promoting the value of seeking help for a urinary or faecal continence issue or prolapse problem. The Continence Foundation of Australia is the peak body promoting education for pelvic floor dysfunction (PFD) in Australia and if you are looking for names of doctors, pelvic health physiotherapists or other health professionals with a special interest in PFD then they have a Helpline to guide you to some people close to where you live who can help. Their number is 1800 33 00 66.

But this year I wanted to write about another mega problem in Australia and that is the treatment of persistent pelvic pain or PPP. We have some very articulate patients at our practice and one of them has written a fabulous article about her journey. It is a story of hope, persistence and perserverence. Her story follows:

PPP and Me: An ongoing journey

PPP stands for Persistent Pelvic Pain. Sometimes it’s hard to articulate how Persistent Pelvic Pain (PPP) makes me feel, what it’s like to live with it, and what it’s like to manage it. Without sounding too much like a reality TV star on their quest to find Instagram fame true love, living with PPP is truly a journey (without the teeth whitening and sex toy endorsement deals). So, for want of a better word, here’s my journey.

Side note: While we’re talking about reality TV shows, an endorsement for teeth whitening products would be great but I’ll settle for anyone out there who’ll give me a few tubes of lube!

17 years old

Ahh, my Year 12 Swimming Carnival. A day I’d rather forget. Trying to put a tampon in for the first time was excruciating. It even makes me cringe now just thinking about it. The whole time I kept thinking “All the girls I know wear tampons. Why can’t I? What will others think of me when I say I can’t swim because I’ve got my period?”

And just as I expected, I got many comments throughout the day telling me to “suck it up and just put a tampon in, you have to earn points for the house. It’s not that hard!”. All I could think was they were right. What was wrong with me? I’m a loser who didn’t try hard enough and couldn’t earn points for my house.

19 – 21 years old

Speaking of cringing, let’s look back on my early sex life! Painful, painful, painful. No other words. Lots of “Why are you so tight and why can’t I get it in? I bet it’s because I’m too big” (boys are just so charming, right?).

During this time, I started gaining more knowledge about the pelvic floor by working with a Pelvic Health Physiotherapist. I began to realise that pelvic pain was a real thing and that there’s help and solutions available. And no, the solutions don’t include my old trick of trying to insert a tampon to ‘stretch’ my vagina.

21 years old

I very unexpectedly fell in love with a very understanding man who’s now my husband. One who never commented on the ‘tightness’ or thought he was ‘too big’. This is when I finally decided to get help for my PPP and the urinary incontinence I was experiencing.

Regular dilator use, incontinence management strategies and information on pain theory gave me the confidence to have a normal sex life and it was amazing. I was determined to make it work and was diligent with keeping up everything I’d been taught. I’m still very grateful for the strategies I was taught early on in my journey.

24 years old

I became complacent and slack, so it was back to the Pelvic Health Physiotherapist I went. Admittedly before I went back, I’d put up with my relapse for about a year. I relearned all the strategies and put them into action but got sent away for more tests to rule out STIs or any issues with my cervix. That led me to a pap smear that had me in tears and the doctor telling me the only solution to my pain was to have surgery to open up my vagina. I’m glad I had the background knowledge of pain science and management strategies to ignore the ‘advice’.

My pap smear came back normal with no STI’s, so I kept on working at all the strategies I’d been taught.

26 years old

It was February of this year that I broke down. I couldn’t handle it anymore. It wasn’t just the pelvic pain, it was the period pain, it was the constipation, it was the leakage, and it was the constant state of fatigue (hot tip: drinking 3-4 cups of coffee per day won’t get rid of this, so don’t even try).

I booked in for my first ever gynecologist appointment. One excruciating pap smear and a description of my symptoms later, I was diagnosed with a chronic vaginal pain condition called Vulvodynia. Suddenly everything started to make a bit more sense. I was put on Amitriptyline (better known as Endep) and after 10 days I gave up on that. I was moody and tired and overall someone you wouldn’t want to be around.

So, I rang my gynaecologist and she referred me onto another specialist to look at my next option – Botox for the pain and a laparoscopy to check for Endometriosis. After seeing this specialist, I booked in for my laparoscopy, hysteroscopy, cystoscopy and Botox with great gusto.

The recovery was harder than I thought but was worth it in a way when I was diagnosed with Endometriosis that got excised during the surgery. That explained the painful periods, constipation and fatigue. I can happily report my periods have been virtually pain-free and my fatigue has drastically improved (without coffee as well!). I’ve been able to exercise properly (in a pelvic floor friendly way with lots of relaxation) and have a better outlook on life. In terms of my incontinence, I was diagnosed with Interstitial Cystitis (Painful Bladder Syndrome) and have cut out several foods (zucchini being one of them – what a bonus!) and I’ve improved drastically in that department and am familiar with the triggers in my diet.

I’m happy to report the Botox has worked wonders for my Vulvodynia. Who knew wearing a tampon and having sex could be so easy?

In saying that, Botox isn’t a cure-all and doesn’t last forever. I’m working with my Pelvic Health Physiotherapist on maintaining the good habits she’s taught me over the years, and I find them to be very beneficial. My main issue is perseverance. If I have a relapse, I’m always tempted to throw in the towel but not this time. My determination to keep up the habits is stronger than ever as I know it’ll benefit me, and also people I speak to who experience the same issues who have previously been happy to accept their struggles.

My message this World Continence Week is: Invest your time and energy into your health. Don’t be afraid to speak up and get help. You’re never alone even if it feels like you are. Above all, invest in you.

Thanks so much B for your great story. You are an inspiration to all the women out their who have suffered with their particular pelvic health issue. It takes courage to write about what has happened over so many years and perhaps younger girls at school may think twice before teasing or scoffing if someone says they can’t participate in an acitivity. If you have a ‘private’ issue – make sure you check out your nearest pelvic health physio and get some help. They are used to chatting about anything and give you the time to do so.

Happy Continence Awareness Week!

#Blacklivesmatter

2020 is continuing to unravel and this latest turn of events has seemingly reached rock bottom.

The murder of George Floyd by a policeman while observed by 3 other officers and being filmed for over 8 minutes by onlookers was shocking to witness and has become a catalyst for world wide protests about black deaths in custody and race relations.

It has sparked deep conversations within our own family and my daughter has compiled some resources to help everyone understand issues and values around the hashtag #blacklivesmatter. I commend her resources to you if you are wanting to learn more, to understand how to help and to share with those who feel threatened by commentary about such topics as white privilege and racism. Here is the summary from my daughter.

As promised, here are a few of the articles/pages I’ve read the past weeks to get a deeper understanding of white privilege, racism and related topics. 

 

What does the term white fragility mean?

White Fragility – Robin DiAngelo (very insightful article here:  https://www.google.co.uk/amp/s/amp.theguardian.com/world/2019/feb/16/white-fragility-racism-interview-robin-diangelo)

“Well, when I coined that term, the fragility part was meant to capture how little it takes to upset white people racially. For a lot of white people, the mere suggestion that being white has meaning will cause great umbrage. Certainly generalizing about white people will. Right now, me saying “white people,” as if our race had meaning, and as if I could know anything about somebody just because they’re white, will cause a lot of white people to erupt in defensiveness. And I think of it as a kind of weaponized defensiveness. Weaponized tears. Weaponized hurt feelings. And in that way, I think white fragility actually functions as a kind of white racial bullying.

We white people make it so difficult for people of color to talk to us about our inevitable—but often unaware—racist patterns and assumptions that, most of the time, they don’t. People of color working and living in primarily white environments take home way more daily indignities and slights and microaggressions than they bother talking to us about because their experience consistently is that it’s not going to go well. In fact, they’re going to risk more punishment, not less. They’re going to now have to take care of the white person’s upset feelings. They’re going to be seen as a troublemaker. The white person is going to withdraw, defend, explain, insist it had to have been a misunderstanding. “

I thought this was an interesting summary of the catalyst for the protests/ BLM movement starting in the UShttps://www.youtube.com/watch?v=v4amCfVbA_c&feature=youtu.be

I’m sure you’ve seen the video of George Floyd being killed, but this was the other trigger mentioned in the above video is the Amy Cooper video where she calls the police saying a black man is threatening her when he isn’t – https://www.youtube.com/watch?v=lfVU87y1B60

Also look into the deaths of Ahmaud Arbery and Breonna Taylor and in Australia, Tanya Day and David Dungay.

What is white privilege?

White privilege refers to the concept that people have basic rights and benefits simply because they are white. It doesn’t mean they haven’t suffered hardship or that they don’t have a tough life – just that their colour hasn’t made it harder. JT Flowers (a 26-year-old American rapper, student and activist living in the UK) feels some people get defensive about this term because it’s misunderstood. “You might be a white person and still be poor with a lack of access to education or face a language barrier in the workplace. It doesn’t mean you can’t be disadvantaged in other ways,” he tells Newsbeat. “It just means with respect to that one particular thing – your race and skin colour – you do have the luxury of not being able to think about it. “It means having the luxury of being able to step outside without fearing that you’re going to be discriminated against or oppressed in any way because of the colour of your skin,” he says.

https://www.instagram.com/p/CBDqhlCjLtM/?igshid=uz0fm73fq4us

https://www.instagram.com/p/CAY3zsrHSzf/?igshid=1hlclu2uc1sv1

Black lives matter vs All lives matter ?

This is often used as a response to the phrase “black lives matter’ – the feeling from some people that all lives should be included in the conversation around race. JT Flowers believes people who say it may not understand what the “black lives matter” phrase means. “Imagine your house is on fire and somebody comes up to you and says, ‘Hey all houses matter.’ “Your response would be along the lines of, ‘Yes but your house isn’t on fire, so if all houses matter and your house is fine, then why is it so much to ask you to care when my house is burning down?'” JT believes we live in a society where – at present, “black lives aren’t valued in the same way that white lives are.”

Understanding the impact of the phrase ‘I don’t see colour/race’

https://www.theguardian.com/commentisfree/2015/jan/26/do-not-see-race-ignoring-racism-not-helping

What are microaggressions?

Microaggression is classically defined as, “brief and commonplace daily verbal, behavioural or environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and insults toward people of color.” The term was coined around the late 1960s, early 1970s, after the Civil Rights era, when visible and violent expressions of racism were eclipsed by subtler incarnations. Now broadened to include all marginalized groups and their many intersections, “microaggression” has become something of a buzzword within the social justice arena.

https://www.instagram.com/p/CBGEINMgz93/?igshid=e3irggp2bn5z

How to be an active ally

Learnings and ideas on books to read, accounts to follow, organisations to donate to:

https://www.instagram.com/p/CBCM3skBKn-/?igshid=1l8xmjwqq4dc6

https://www.instagram.com/p/CBEcSV6h4sS/?igshid=116ei9iq6zk5a (Australian specific)

https://www.instagram.com/p/CA04VKDAyjb/?igshid=18w5ujgonvtcn

https://www.instagram.com/p/CA-axYFn2dB/?igshid=gh4skffhz6ou

How to keep going in Australia once the trend passes?

https://www.instagram.com/p/CBHRZqiHpjL/?igshid=q3dfkca5odkc

Here’s a list of further resources 

Books to read:

Films and TV series to watch:

  • 13th (Ava DuVernay) — Netflix
  • American Son (Kenny Leon) — Netflix
  • Black Power Mixtape: 1967-1975 — Available to rent
  • Blindspotting (Carlos López Estrada) — Hulu with Cinemax or available to rent
  • Clemency (Chinonye Chukwu) — Available to rent
  • Dear White People (Justin Simien) — Netflix
  • Fruitvale Station (Ryan Coogler) — Available to rent
  • I Am Not Your Negro (James Baldwin doc) — Available to rent or on Kanopy
  • If Beale Street Could Talk (Barry Jenkins) — Hulu
  • Just Mercy (Destin Daniel Cretton) — Available to rent for free in June in the U.S.
  • King In The Wilderness  — HBO
  • See You Yesterday (Stefon Bristol) — Netflix
  • Selma (Ava DuVernay) — Available to rent
  • The Black Panthers: Vanguard of the Revolution — Available to rent
  • The Hate U Give (George Tillman Jr.) — Hulu with Cinemax
  • When They See Us (Ava DuVernay) — Netflix

Podcasts to subscribe to:

Thanks to my daughter for this extensive list of links, books and podcasts – a great reference for all those endeavouring to understand the #blacklivesmatter cause. Getting terminology, concepts and words right is important as it prolongs the hurt and the injustice felt by black people around the world including Australia. Words matter; actions matters; we need leadership on this matter in our political leaders. I have felt challenged and uncomfortable a number of times over the past weeks, as I have realised what I didn’t understand, but I have learned that the biggest mistake when feeling challenged is to stop reading and learning on this topic. So I’m going to keep reading, learning, donating and taking tangible action. I also commend to you and all the politicians in Australia the Uluru Statement from the Heart (2017) 

Prostatectomy: PF muscle training programme pre-operatively

This is taken directly from The Prostate Foundation of Australia (with permission from Dr Joanne Milios).

It is entitled: A pelvic floor exercise program starting before prostate surgery improves the recovery of urinary continence” Dec 2019. It has been written by Wendy Winnall, a scientific writer for PCFA to summarise the excellent research by Jo to obtain her PHD.

Dr Joanne Milios

Pelvic floor muscles control the bladder and the flow of urine.

Exercising these muscles can help men regain control over urine flow after prostate surgery. New research from Australia has defined an effective pelvic floor exercise program that starts before surgery. Surgery to remove the prostate gland usually leads to temporary incontinence – loss of control of urine flow. For most men this gradually improves over time. But unfortunately, some men suffer long-term incontinence after their prostate is removed.

Leaking of urine after surgery happens because some of the muscles involved in bladder control are removed with the prostate. Before surgery, it is difficult to predict the amount of urine that will leak. Leaking often happens unexpectedly, together with coughing, sneezing or exercise. Some men even leak urine during orgasm. Urinary incontinence is an issue that disrupts everyday life and causes a great deal of distress to these men and their partners.

One way to improve urinary control is by exercising pelvic floor muscles. The pelvic floor is a round layer of muscles at the base of the pelvis. These muscles support organs such as the bladder and large intestines (bowels). They help to control the bladder as well as erections. It’s important to learn how to exercise the pelvic floor muscles correctly. This will give the best results for improving control over urine flow. PCFA has a brochure that describes pelvic floor exercises for men having prostate surgery. However, seeing a physiotherapist who specialises in pelvic floor muscles will be the best way to learn these exercises.

Research into pelvic floor exercises for men having prostate surgery
Many trials have been run to determine effective pelvic floor exercise programs for men having prostate surgery. Even though randomised controlled trials have been done, the results have been mixed. 45 trials testing pelvic floor exercises for prostate surgery were compared in a rigorous review process in 2015. Some studies support the benefits of pelvic floor exercises, whereas others suggest that urinary continence improves over time with no added benefit of exercise. One of the problems with the past research is mixed methodology. There was too much variation in the type of exercise program, the volunteers who joined the trials and the way the programs were assessed. For instance, continence (no leakage) was defined as less than 10g leakage, use of 1 pad or less, or 0 g leakage in different studies. In other words, different studies used different definitions of continence, which probably contributed to different results between studies.

This extensive Cochrane review calls for large, rigorous, randomised controlled trials to test pelvic floor exercise programs. They recommend assessing quality-of-life and pad weights to test the success of these programs. Australian researchers have been using these recommendations to determine the best pelvic floor exercise programs to help men having surgery for prostate cancer.

Australian pelvic floor exercise research
A new Australian study has defined a pelvic floor exercise program specifically for men having surgery to remove their prostate. The trial was led by physiotherapist Dr Jo Milios as part of her PhD studies through the University of Western Australia. Men joining this trial were referred by their urologist before surgery to remove their prostate gland. These men did not have urinary incontinence before surgery and had no previous radiotherapy or hormone therapy.

The Australian trial tested a new pelvic floor muscle training program focused on activating different types of muscles fibres. Both slow-twitch and fast-twitch muscle fibres are specifically targeted. Slow-twitch fibres contract slowly and can be used for long periods of time. Fast-twitch fibres contract quickly. They work at high-speed but tire easily.

The study tested the new training program by comparing it to a similar program performed by a control group. 50 men who volunteered for the study were randomly allocated to the new program. Their results were compared to those from 47 men allocated to the control program. The muscle training programs started five weeks before surgery and continued for 12 weeks afterwards. Both programs started with two sessions of instructions from a physiotherapist for pelvic floor exercises. Men were asked to focus on a muscle called the anterior urinary sphincter, shown in previous studies to promote men’s urinary control. Men were then provided with a daily training program.

Men in the control group were given instructions according to current clinical practice. They performed 3 sets of exercises each day with 10 contractions for each (done in the sitting, standing and lying positions). Men in the new program group performed exercises targeting slow and fast-twitch muscles. They did 6 sets of pelvic floor exercises each day, all in the standing position. Each participant did not know which group they were in.

Men tend to leak in upright postures, especially during actions such as sit-to-stand and walking. So it makes sense to train men in the postures they will need in the recovery process and long-term. I also combined the traditional slow twitch fibre (long hold) training with the fast twitch training of the pelvic floor muscles in times of stress e.g. cough/sneeze/lifting…essentially, what is required for continence in everyday life.” – Dr Jo Milios

To measure urinary continence (bladder control), men were asked to weigh their pads and report any leakage of urine. Continence (no leakage) was defined as having no increase in pad weight due to urine leakage over a 24 hour period. This was measured at 2 weeks, 6 weeks and 12 weeks after surgery. There were more men reporting no leakage in the group who used the new exercise program compared to the group using the old program. At each time interval, the average pad weight was less for men using the new exercise program.

The researchers also used a survey called EPIC-CP to ask the men in the trial how much urinary incontinence was bothering them. At two weeks after surgery the men in the control group reported significantly worse quality-of-life related to urinary issues than the men who used the new exercise program. But at 6 and 12 weeks after surgery the effects on qualityof-life, as measured by this survey, were similar between the two programs.

“For men newly diagnosed with prostate cancer, the research indicates that preparation prior to treatment is the critical difference to minimising the impact of post-operative urinary incontinence. I designed the new protocols based on what I had learnt clinically over 15 years and a cohort of more than 3000 individuals undergoing surgery. By commencing pelvic floor muscle training in a standing position, as soon as possible after a prostate cancer diagnosis, the lead-in time to surgery can be maximised.” Dr Jo Milios.

PCFA recommends men planning surgery for prostate cancer consult with a pelvic floor physiotherapist. The results of this study indicate that doing this before surgery may be beneficial.

Thanks to Jo for permission to share this article via my blog – if you are interested in getting help pre or post op prostatectomy please contact the rooms on (07) 38489601 and Megan Bergman or Amanda Waldock will help you.

Recalibration, reframing valued activities and reconceptualization

Resciesa looking towards The Dolomites, 2019

Recalibration, reframing valued activities and reconceptualization: the title of this blog sounds like I am going to write about our new life post COVID. What will it mean? Where will we be? What will we be doing? What’s going to be our future? (And I am being metaphorical here- I am talking about the bigger picture).

I chose this photo from our last European trip because it aligns with my thinking about the title. That trip to Seceda certainly recalibrated our thinking about overseas holidays. From then on, our trips were always going to involve mountains and we were going to try and avoid cities. And we hadn’t even contemplated in our wildest dreams something like Coronavirus! We made the decision based purely on the beauty, solitude and majesty of mountain scenery. We had decided it was our happy place. (We were also fairly confident our children felt the same and if we chose some place special they would leave the city of almost 9 million and join us in a tiny Italian/Swiss village for a holiday). 

But the phrase I wrote this blog around is actually taken from a recent article called: ‘What influences patient satisfaction after a TKA (which stands for a Total Knee Arthroplasty or what we know as Total Knee Replacement)? A qualitative investigation. (Klem, N et al 2020)

Now I am not going to analyse this article here, but it is defintely worth reading- especially if you are contemplating surgery for your knee or your hip- but when this article was posted on Facebook by a physio in one of the myriad of groups I belong to – it just hit my like a ton of bricks. I love this phrase.

Recalibration, reframing valued activities and reconceptualization.

This is what we pelvic health physios do every day when treating women, men or children with continence issues, prolapse problems or persistent pain. Through education we recalibrate their body functions – the most personal, private bits of their day. We tease out their story, collect data (like from their bladder diary) and then use this to rejig the system. 

We have to change up their thinking about the old ideas, beliefs and habits (some which have persisted since childhood when their mother taught them) and reframe the patients’ thinking into a new direction. We have to drag them (sometimes screaming) out of their comfort zone with their bladder – stopping them from going so often to the toilet to teach their bladder how to store better.

We have to reframe their valued activities when they have persistent pain with intercourse with their partner. This mostly may be temporary, but for some it might be forever and we also may have to reframe the partner’s expectations and bring them along on the journey. We may have to point out the beauty of intimacy without penetration if penetration causes agony and tears. 

The Ohnut – available from Pelvic Floor Exercise (Fiona Rogers online site)

For every single patient we reconceptualize what their new work life, social life and family life will be like in their new post-treatment era. We give them the confidence to set goals they thought were unachievable; to have hope when they thought all hope was lost and the ability to understand that fear mustn’t dominate their thinking. 

And all of that applies directly to what is happening to our lives through COVID19. 

As a society we must recalibrate, reframe valued activities and reconceptualize what the future will be. 

Lots of people feel this time is a wake up call – a chance to very literally stop and smell the roses. Others can’t adapt to the imposts on our freedoms. There is indignation about closed borders to Queensland – but there would be indignation if they opened them and COVID started to spread like wildfire through our community. We have to be patient. Like Nelson Mandella. Like Anna Frank. Like those who have been in detention for SEVEN years.

And those borders aren’t really even that closed. There are exemptions on compassionate grounds. There are exemptions on work grounds and exemptions to seek out health appointments. Ask the authorities if you want to cross the border.

But I have colleagues and family who live in countries who can’t even comprehend how we have done what we have done in Australia. As of today Australia has 7,079 confirmed cases of COVID19 and 100 deaths. The United States 1,501,876 confirmed cases and 90,203 deaths. The United Kingdom has 248,822 confirmed cases and 35,341 deaths.  

Sobering statistics. 

And I for one am grateful that we have strong leaders who are copping the criticism and being cautious as we enter our flu season. We don’t want to look back in horror and wonder why we rushed back from lockdown. 

As you read this, if you haven’t yet downloaded the COVIDSafe app could I ask you to contemplate doing it? If your aunty or grandchild or mother or best friend get a diagnosis of Coronavirus, you’ll be wanting the experts to be able to trace every possible carrier of this insidious virus. That’s what the app can do. Nothing else. 

Stay safe, keep washing your hands and be grateful for our sunshine, our health professionals and our scientists.

And until we can get back to some mountains, here is some more mountain spam. That was a beautiful day. 

Mont Blanc, 2017

(1) Klem, Nardia-Rose BSc (Physio) (Hons); Smith, Anne Postgrad Dip Sports Physio, BAppSci(Physio), MBiostats, PhD; O’Sullivan, Peter Dip Physio, Grad Dip Manip Ther, PhD, FACP; Dowsey, Michelle M. BHealthSci, MEpi, PhD; Schütze, Robert MPsych(Clin), PhD; Kent, Peter BAppSc(Chiro), BAppSc(Physio), Grad Dip Manip Ther, PhD; Choong, Peter F. MBBS, MD, FRACS, FAOrthA, FAAHMS; Bunzli, Samantha BPhty (Hons), GradCert Res Methodology, PhD (May, 2020): What influences patient satisfaction after a TKA (which stands for a Total Knee Repalcement)? A qualitative investigation.  Clinical Orthopaedics and Related Research: May 12, 2020 – Volume Publish Ahead of Print – Issue –doi: 10.1097/CORR.0000000000001284

An Overactive Bladder: Urinary frequency, urgency and urge incontinence

   

Knowing where the next toilet is hiding is the bane of your life if you have an overactive bladder. Especially in our new #Coronvirus life where many public toilets are locked off to the general public – women and men must be really struggling.

I was reminded of this when we went for a giant walk yesterday in my home town, Brisbane, from Somerville House, across the Goodwill Bridge, along a brand new walkway called The Mangrove Walkway, under the freeway where there’s a new exercise area, past Parliament House, through the Botanical Gardens, along another new walkway over the river in front of Riverfront Place, then back through the Botanical Gardens, back over the Goodwill Bridge and to the car.

     

It was a 10,000 stepper walk that took a couple of hours. And what was interesting that in that whole time we were out walking we only walked past one set of toilets.

In the good old days (pre-COVID19), when we were travelling overseas, we often ended up buying a coffee or a spritzer/beer at a cafe just so we could use their toilet, because toilets are as rare as hen’s teeth in Europe and the UK.

You may remember another blog regaling my struggle to maintain continence after a train trip to Brighton where there was no toilet on the train and when we arrived at Brighton, all but two of the toliets were blocked off and the queue to the remaining two was resembling the opening of ticket sales to the Rolling Stones concert. Needless to say I survived and my dignity remained intact – but I remember I was conducting a messenger conversation with some friends back in Australia to keep myself distracted and not thinking about the toilet.

Distraction is just one of the methods that can work well when you have an urgent bladder urge and there is no toilet available. Other ‘urge control’ strategies are toe curling, squeezing your glutes (your butt cheeks), crossing your legs, pulling in your low tummy or strangely relaxing your tummy (try each and see which works better for you), gently engaging your pelvic floor muscles and finally belly breathing.

Toe curling to help turn off the urge (yes I got to go to have a pedicure yesterday for the first time in 3 months)     

These strategies are useful to help you build up your bladder capacity by deferring, but when you are as full as you can tolerate and you sense: “If I take a step I am going to lose it all”, then defer the urge once more and use the time to walk slowly to the toilet, breathing and perhaps counting your steps as you go along.

Doing a bladder diary to check your bladder capacities across two days is helpful in determining how much work you need to do to build up your bladder holding ability.

Other strategies such as pelvic floor exercises (they may help to calm down the smooth muscle pump of the bladder but also sometimes doing too strong a pelvic floor contraction this may make your urgency worse); and even having local oestrogen up the vagina can help overactive bladder symptoms – discuss this with your doctor.

Managing your bowels well is also an important strategy for an overactive bladder. A loaded rectum or even lots of gas and bloating can make it harder to hold onto a decent capacity, so things like sitting with correct postures to empty your bowels and the correct dynamics of defaecation and avoiding foods that give you excessive bloating will be helpful.

Another helpful strategy is using TENS (stands for TransCutaneous Electrical Stimulation) over the tibial nerve (see the application of the electrodes below) to provide some neuromodulation. Your pelvic health physiotherapist will teach you how to use the TENS unit.

It is always important to have a bladder ultrasound before and after you void to make sure you are emptying your bladder completely. If you have a largish residual and you are not aware of this, you may try to wrongly build up your voided capacity when in fact your bladder emptying needs addressing.

An ultrasound can check whether the bladder is emptying properly. Use this position to try to empty completely

Anyway, what is the moral of this blog?

  • The Brisbane City Council needs to install more public toilets around the city.
  • An overactive bladder can be significantly improved by a Pelvic Health Physiotherapist – make sure you get some help.
  • Medications can help also – but discuss with your GP, gynaecologist, urogynaecologist or urologist about the best drug of choice as there is increasing, emerging evidence that long-term use of many of the drugs used to help the urgent bladder are implicated with dementia. (The drugs that cross the blood-brain barrier are the ones to watch out for.)

And finally walking everywhere allows us to stop and ponder life. On our regular walks, we’ve discovered new things that have been built, new outdoor art which is refreshing and beautiful, found things we never knew existed and just observed things.

I wanted to be this bird. He’d had a swim and there he was just sitting on a log in the Brisbane River, drying his wings, oblivious to the pandemic. If you can believe the theories, we should all be doing this to get our daily dose of Vitamen D – which appears to be useful with this damn COVID!

Six Weeks of Telehealth: Update for posterity!

 

Week Six of Telehealth consultations. This is an update for the future to look back on and reflect on these unusual times.

Thursday 7th May, 2020 had some highs and lows.

After 6 weeks of waiting we received our Job Keeper payments. This is a giant high for Bob and myself after weeks of stress and anxiety- farout what a relief! If anyone hasn’t received their Jobkeeper payment and they have applied for it, please be aware it is quite complex to fill out all the forms and you may have missed a step if you haven’t received a payment by now.

The joy was somewhat tempered by the fact that on that same day, I also had a one hour conversation with a representative from HCF – one of the Private Health Insurance (PHI) companies – regarding their requirement that they had a new form for us to fill out if their patients were to receive a rebate on their Telehealth physiotherapy appointments.

This was the proverbial straw to break the camel’s back.

There’s been so many curve balls and hoops to jump through EVERY DAY since COVID19 imploded all around the world. In the beginning I could have easily curled up under the dining room table with my blankey and given up. It all seemed a bit overwhelming.

But gradually each day, with a lot of lists and extremely able staff and husband (who has in fact become an IT guru), we have managed to claw our way back up to peek out from the quick sand and see a future as a practice again. We have classes streaming each day, we are turning peoples’ lives around with Telehealth and even seeing the occasional patient again face-to-face.

We had started to breathe.

And then we get an email from HCF with the news that we have to fill in yet another form if our HCF patients are to be given a rebate from their private health insurance (PHI) – their very expensive health insurance, even though the services anyone can access and receive a rebate from their PHI have been almost non-existent since COVID19 started. Not just give them a Tax Invoice with a special Telehealth code like every other health fund required. No, a two page form had to be filled in by each physio who treated the patients.

I decided when I read this email that I was going to ask HCF to explain to me why all Allied Health Practitioners had this extra burdon placed upon them when no other health fund was doing it. Firstly the number the email gave to ring on just rang and rang and rang- no robot even picked up. After 2 calls totalling 45 minutes each went by with absolutely zilch pick-up, I decided to do what usually gets a swift response from the other major offenders in the category of “Ridiculously Impossible To Get Through To”- Optus and Telstra – I decided to send a Tweet.

Two days later and HCF tweeted back and asked for my phone number.

To cut a long story short – on Thursday 7th May, Kieran from HCF rang me and politely listened to me for about an hour, as I educated him on the complexities of Telehealthing my patients with pelvic health conditions – to say his straight hair may have been curly when I’d finished is an understatement. And I told Kieran that myself and my physios were often physically and emotionally exhausted after an initial consulation with a complex patient and the very last thing any of us need to do or should be required to do is fill in another form.

The patients currently get a detailed Tax Invoice with an Item number, and the cost, their name and address, the physios name and provider number – an extremely detailed invoice. Our patients also get a 14 page set of notes, a specipan for their bladder diary, a copy of one of my books, a specific homework page tailored to their specific problems and then get sent links to videos which I have done to explain the things that they would normally see if they were physically in the room. We are trying very hard to make this Telehealth experience worthwhile and as good almost as being face-to-face. My reaction to this requirement from HCF is they don’t trust us Allied Health Professionals.

It’s funny after all the things that have been testing us all in these strange times, why some things really get your goat.

The internet has been atrocious at times, the mobile phone reception has gone caput, our income has dropped by 60%, the amount of actual change that has had to be enacted to make this all be effective in about 10 seconds flat has been massive…..and yet the meanness of this Health Fund towards the hard working Allied Health Providers who are literally (almost) killing themselves to help HCF clients, beggers belief.

If I were a HCF customer I would ring them to ask them why are you doing this to our caring Allied Health Professionals?

(It would be probs be impossible to get through to anyone though.)

 

 

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