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

Bilbao Precioso – more travel blogging.

Guggenheim Museum, Bilbao by day

The eerie colours and shadows by night of The Guggenheim Museum Bilbao

I have wanted to visit Bilbao for many years, ever since I first saw the first image of The Guggenheim Museum in Bilbao. I followed up this first image with some research into how Frank Gehry, the architect who designed the Guggenheim, came up with the design and I was hooked. I had to see this amazing building which emerged from first crumpling of some alfoil and some free-flowing sketches from this master architect.

The opportunity emerged with this trip and was made even better in the company of two architects – my husband and my son, who can genuinely gain some professional development by exploring the ins and outs of this magnificent building. And it is magnificent. And to think that is it’s 21 years old. How did that concept building which emerged from some crumpled alfoil possibly be designed, engineered and built into a functional, beautiful art museum? Whether you view it by day or by night, in sunshine or overcast weather, the shadows and detail of the building are exquisite.

   

Various views of The Guggenheim

Constructed of titanium‭, ‬limestone‭, ‬and glass‭, ‬the seemingly random curves of the exterior are designed to catch the light and react to the sun and the weather‭.  Fixing clips make a shallow central dent in each of the‭ .‬38mm titanium tiles‭, ‬making the surface appear to ripple in the changing light and giving an extraordinary iridescence to the overall composition‭. Because of their mathematical intricacy‭, ‬the twisting curves were designed using a 3-D design software called CATIA‭, ‬which allows for complex designs and calculations that would not have been possible a few years ago‭. ‬Essentially‭, ‬the software digitizes points on the edges‭, ‬surfaces‭, ‬and intersections of Gehry‮’‬s hand-built models to construct on-screen models that can then be manipulated in the manner of animated cartoons‭. ‬‬(1)

     

The internal views of the beautiful Guggenheim

Try and make add it to your bucket list because having just been to Bilbao, you could just ‘do’ Bilbao for its own culture and beauty without the incredible drawcard that The Guggenheim is.

When you fly into Bilbao you will see it is surrounded by mountains and on the day we went, unfortunately there were gale force winds blowing. As we started to descend it started to get very bumpy…….noticeably so……holding-onto-the-armrest bumpy. When we finally arrived we all looked at each other (strangers) and smiled with relief until the Captain came onto the intercom, rather unnecessarily and said: “Sorry for the rather turbulent landing, but that landing was just within the capability of this aircraft (WTAF did he just say???) Our smiles looked a little wan and green after that admission from the pilot!

When you touch down at Bilbao Airport (designed by another well-known architect Santiago Calatrava), you can get the obvious taxi but the Green Airport Bus is only 3 euros and it drops you very quickly into 4 stops through the town. The first drop off point is the Guggenheim and then the centre of the city and so on- so if organizing accommodation for Bilbao think about close proximity to the airport bus stops. Once you get into Bilbao track down a Tabachi shop (a tobacconist shop) or go to the main Metro station (Consortium of Biscayan Transport -CTB) and Metro Bilbao S.A. located in the historical neighbourhood of Casco Viejo and purchase a Barik card – which is the transport card that you can load with euros and use for up to 10 people (just swipe for each person). The card itself costs 3 euros and then you can load with 5,10,15 euros and use on every type of public transport – the buses (including the return bus ride back to the airport), the light rail, the underground, the funicular and the gondola on the Bilbao Suspension Bridge (or the Puente Colgante -Hanging Bridge) and they are all heavily discounted so well worth the outlay.

  

The view from the top via the Funicular and The Hanging Bridge

We stayed at an Airbnb halfway between the Guggenheim and the old town. It was a really nice unit which slept 5 – which was great for the family, but if I went again I would look for an apartment that overlooked the view of The Guggenheim and just sit at the window and stare at the building. Yes it was that special!

Bilbao has an incredible eating and socializing culture. Everyone sits at the bars (of which there are thousands it seems) and drinks Rijorca (the local red wine) and eats tapas -which are mostly toppings on sliced French bread. The food and wine is very cheap there and it is very pleasant sitting and absorbing the atmosphere, the socializing and the chatter. Children including very young babies in prams are up till very late, included in the outing and there is an incredible number of older men and women who are catching up at their favourite bar. The dreaded smoking is still a big feature and I fear will continue to be a significant health issue as a packet of 20 cigarettes are 4.5 euros (compared to our $30 per packet) so way too cheap for cost to be a deterrent like it is here. It is really the only thing about Bilbao that I didn’t like – apart from the fact that my beautiful new Mimco backpack- my 40th anniversary present as well as this trip- got stolen with all its contents. It was slick, completely unnoticed by the four of us at the table and all the people around us in the outdoor setting and happened in the daylight. So beware, hook any bag you have around your foot and keep your wits about you! Like anywhere that you travel. I won’t hold it against you Bilbao.

Hanging Bridge and Michael soaking up the sun

We went on a metro underground ride out to Algorta and walk to see the tall cliffs and the start of the surfing beaches overlooking the Bay of Biscay. The trees were being pruned by the local council gardeners and they have a very distinct look to them.

  

Long walk to see the tall cliffs overlooking the beaches at Algorta

We then came back on the bus to the old town and had another sit down in the square in the Old Town and tapas experience. Bilbao bars are not well serviced with vegetarian options sadly, but plenty for the meat and seafood eaters. The next day when all the family had finally arrived we went for our Guggenheim experience. The tickets are 13 euros each and that comes with an included audio firstly explaining the wonders of the building and then interpreting each of the exhibits which include Picasso, Leonardo De Vinci and many famous artists. You can go out and come back in for that day pass- just make sure you see an attendant to get a paper bracelet on to allow a re-entry. Personally after checking out quite a few of the artworks, I just sat and absorbed the building. You can honesty look at every aspect of the Guggenheim and there is nothing replicated. It is asymmetrical, with amazing soaring heights, glass, steel, titanium, special installations, special effects (such as fog and fire)…it is brilliant.

 

We next walked over the Zubizuri Bridge (meaning “white bridge” in Basque) which stretches across the Nervion River in Spain, connecting Campo Volantin’s right bank to the left bank of Uribitarte. This footbridge, designed by Santiago Calatrava, opened in 1997 and features a glass deck that lights up at night. Although the glass path can get slippery on a rainy day, many use the bridge to reach the nearby Guggenheim Museum. It is so slippery that it now has a carpet laid on top of it. And yes one of us did slip on the exposed glass to the far side of the bridge (Jimmy….). From a distance the bridge cuts a fine impression. We then caught the Funicular up to the high hill directly behind Bilbao and saw the city view. It was magical but very windy and a bit chilly so returned on the funicular and we headed back for some warming food and drink. With our Barik card the funicular ride was only 0.58 euro but if you didn’t have the card was 3 euros each way!

After seeing off two of our party who had to return to London for a netball game, we went for a walk to the Christmas markets which had opened that night – the 1st December.

    

The crowds were extreme. It seemed like literally every citizen and their children were out promenading and showing the kids the Christmas lights and then heading to the main food street for food Colon de Larreategui Calea. It was almost impossible to make your way through the crowds but we found sanctuary in a restaurant – the Old Shanghai which seems odd in Bilbao, but it was indoors, less busy and the food was delicious.

On our final day in Bilbao the sun was shining and we discovered the Hanging Bridge and then the Gran Hotel Puente Colgante where there was a bar, a verandah in the sun with a DJ playing some cool music and beautiful food (salt and pepper calamari and tapas) very warming and enjoyable. Again across this four days the average number of steps was 25000 per day – it is so damn easy to get your steps up! (Despite this, as I am writing this now that I have been back in Australia for a week – the sad news is despite 25000 steps EVERY day it appears I have put on 3 kilos. Everyone to a person I have told this has said it must be muscle. But it does show calorie intake outweighs exercise).

The final travel blog will be about our two stays in London – one before our visit to Bilbao and one after.

(1) https://www.archdaily.com/422470/ad-classics-the-guggenheim-museum-bilbao-frank-gehry

Ageism in health care

Pair of oldies (over 60s) at Guggenheim Museum Bilbao

Australia’s population is ageing. There is an explosion of people aged over 60 about to present itself to the health care system of Australia. The general consensus if you ask the much older population (my mother, her friends and relatives) is that the health care system doesn’t really have a solution for the problems (pain in joints, difficulty walking etc) that come in the older years. I attended the Explain Pain 3 (EP3) course with Prof Lorimer Moseley, Assoc Prof David Butler and Prof Peter O’Sullivan in Melbourne in early November and Dave’s lecture on the use of metaphors in educating around pain science was fantastic. Using metaphors when teaching patients pain science allows the educational point to ‘stick’ with the patient and makes learning and understanding easier.

Oldies are Goldies is one of the metaphors he used to combat the problem of ageism in health care regarding persistent pain where many health professionals write off pain and different ailments older people suffer with as being a natural part of ageing, when there is plenty of evidence to say that much can be done for persistent pain (AND urinary incontinence and other pelvic floor dysfunction, see later) regardless of the age of the patient. Instead of the usual negative metaphors such as Getting old ain’t for sissies, Oldies are Goldies has a connotation that there’s something to look forward to in the golden years – retired from work, opportunities to travel and spend valuable time with the grandchildren and share wisdom gained with younger friends and family. If you want to learn more about these fabulous metaphors that Dave and Lorimer utilize so effectively in their pain education, I recommend you read any of the Explain Pain books available at the NOI Group website. 

There are different books for different target audiences. The Protectometer is a book written specifically for the general public – the patients in pain- and Explain Pain (2013) and Explain Pain Supercharged (2017) are both targeting health professionals.

As Dave pointed out, we are all living longer – 60 is the new 40, 80 is the new 60…?

This is usually a good thing but ageism is in the air. Ageism is a negative perception of getting older and older people. It’s a really big DIM (Danger In Me) as opposed to a SIM (Safety In Me)and it needs to be challenged. Young and old people can be ageist, older people can be ageist about themselves. This constantly feeds negative messages to the over-vigilant brain. Health professionals and sometimes government departments and companies can be ageist. Let’s challenge it, first by obliterating some myths about pain and ageing.

Myths about pain and ageing

Myth 1: Pain is inevitable with ageing

This is not true but most people including some health professionals think it is. Sure, there may be a few more illnesses and surgical procedures, but people over sixty have no more migraines, no more back pain, no more neck pain than younger people have. In fact, the oldies may have less pain.

Myth 2: If you have pain now, then you will have worse pain later

This is not true either. Pain comes and goes in older people just like it does in younger people. Even though x-rays and scans may show things such as narrowing of joint spaces, this has no relation to increased pain. These are age changes and more age does not equal more pain.

Myth 3: Toughing it out makes it easier to tolerate

Some of us oldies think ‘I can grin and bear it!’ This might be true for a while, but we know that it doesn’t make anything easier in the long run and being stoic can lead to depression, which in turn increases pain more in oldies than it does in younger people. You don’t have to ‘grin and bear it’, ‘suck it up’ or accept it as part of ageing – seek help from an up-to-date health professional, just as you would if you were younger. (1)

But what about pelvic floor dysfunction? Surely there is no hope for people with bladder, bowel and pelvic floor health issues?

The following is taken from my books: Pelvic Floor Essentials (2018) and Pelvic Floor Recovery: Physiotherapy for Gynaecological and Colorectal Repair Surgery(2018).(2)

As we age there are obvious changes that occur to muscles, collagen and the nervous system which can significantly affect bladder, bowel and pelvic floor function. Significantly though, we can hasten or exaggerate these changes, not only through bad habits, but also through inactivity and weight gain. Older people should do some form of physical exercise regardless of age, weight, health problems or abilities and be encouraged to develop habitual physical activity behaviours.(3) While there are substantial physiological changes that do occur with ageing, one of the critical things to remember the old saying:

If you don’t use it, you will lose it”.

We have already seen that if you do not maintain regular training of your pelvic floor throughout your life there will be a 5% to 10% loss of muscle strength per week which is worse in older age groups compared to younger age groups.(4) The more sedentary you are, the more likely you are to hasten the problems that come after the age of 60 – when the ageing process really kicks in!

If you are suffering incontinence (leakage of urine or faeces), it is also important to use proper incontinence pads especially when exercising as they have material in them to ensure good absorption of the urine compared with less adequate menstruation pads. Research has shown that women see urinary incontinence as a barrier to exercise (38% with moderate leakage and 85% with severe incontinence stop exercising due to UI).(5) Therefore it is better to exercise with an appropriate pad (as long as you have had your exercise regime assessed by a pelvic health physiotherapist) than to stop exercising because you are leaking. Also, if you try a device to help reduce leakage such as a pessary or Contiform®, remember to ask your doctor about using local supplemental oestrogen. If you cannot use an oestrogen-based product (due to previous oestrogen-dependent breast cancer), try a vaginal moisturizer twice a week or a medical lubricant to help insert the devices.

As we age, fat is often deposited around the middle waist area. This increases intra-abdominal pressure, especially when exercising. Evidence tells us that if you are overweight, losing 5% to 10% of body weight can significantly help to reduce incontinence episodes and decrease risk of worsening prolapse.(6)  Finding a variety of exercises to do such as walking, dancing, cycling, swimming, Tai Chi, bowls, golf, resistance training plus many more is a prescription for a healthy life.

Dementia is another serious disease process which comes with ageing and has a detrimental effect on continence. There are many types of brain impairment that come under the broad category of dementia but almost all of them result in loss of continence control for both bladder and bowel. This sadly often results in nursing home admission. Some recent research into continence and nursing home admission has demonstrated the staggering statistics that at 6 months after admission, 28% of nursing home residents developed urinary and faecal incontinence (dual incontinence); at 1 year 42% did so; and at 2 years, 61% had dual incontinence. Significant predictors for the length of time to developing dual incontinence were already having urinary incontinence, greater functional or cognitive deficits, more co-morbidities, older age and lesser quality of nursing home care.(7)

An important management strategy can be to institute timed voiding – either nursing staff prompting the client at 2 hours to go to the toilet or by the client using a watch that vibrates to alert them to go to the toilet every two hours to help stay dry. Other neurological conditions such as Parkinson’s Disease or stroke can mean the woman can suffer with slowness of their gait, leading to functional incontinence – where they are just too slow to get to the toilet. The impact of this will be exacerbated by any urinary or faecal urgency. See Chapters 4 and 6 of Pelvic Floor Essentials for management strategies.

Some of the changes that occur with the ageing process

  • A decline in muscle mass, although continuing to exercise regularly throughout your whole life can minimize this.
  • Less elastin in the collagen which results in less strength, plasticity and elasticity of the fascia.
  • Average loss of 2% per year from age 15 to 80 years in the total number of striated muscle fibres in the wall of the urethra leading to decrease in urethral closing pressure.(8)
  • Stiffer smooth muscle (which is found in the bladder and internal anal sphincter).
  • Urodynamic studies show advancing age is associated with a reduced bladder capacity, an increase in uninhibited contractions, decreased urinary flow rate, reduced urethral closing pressure (particularly in women), and increased post-void residual urine volume.(9)
  • Decreased number of motor neurons.
  • Decreased conduction velocity of the nerves.
  • Higher excitability threshold of the nerve therefore making it harder for the muscle to get going.

So as I am looking out the window of my Bilbao apartment and watch the massive crowds, particularly many older men and women walking up and down the pathways (promenading), I say to all our Aussie 60 year olds – keep walking (promenading), keep socializing and keep learning (using your brain) to make the charge towards the Queen’s telegram much more fun and comfortable!

 

  1. Taken directly from the brilliant Explain Pain Supercharged Butler and Moseley, 2017 Page 214
  2. Croft, S (2018) Pelvic Floor Essentials, Pelvic Floor recovery: Physiotherapy for Gynaecological and Colorectal Repair Surgery
  3. Taylor D (2014). Physical activity is medicine for older adults. Postgraduate Medical Journal, 90(1059), 26–32. http://doi.org/10.1136/postgradmedj-2012-131366
  4. Morkved S, & Bo K(2014). Effect of pelvic floor muscle training during pregnancy and after childbirth on prevention and treatment of urinary incontinence: A systematic review. British Journal of Sports Medicine, 48(4), 299-310. 10.1136/bjsports-2012-091758.
  5. Nygaard I, Girts T, Fultz N, Kinchen K, Pohl G, Sternfeld B. (2005) Is urinary incontinence a barrier to exercise in women? Obstetrics & Gynaecology Vol 106 (Issue 2) .
  6. Wing RR, Creasman JM, West DS, et al. (2010) Improving urinary incontinence in overweight and obese women through modest weight loss. Obstet Gynecol; 116(2 Pt 1):284–92 .
  7. Bliss D, Gurvich O, Eberly L, Harms S. (2018)Time to and predictors of dual incontinence in older nursing home admissions. Neurourology and Urodynamics. 37:229–236. https://doi.org/10.1002/nau.23279 .
  8. Bo K, Berghmans B, Van Kampen M, Morkved S. (2007) Evidence-Based Physical Therapy for the Pelvic Floor. Bridging Science and Clinical Practice. Churchill Livingstone Elsevier.
  9. Siroky, M. B. (2004). The aging bladder. Reviews in Urology, 6 Suppl 1(Suppl 1), S3-S7.

 

 

 

 

Venice to Innsbruck

Why Innsbruck? Well I had it in my head that I wanted to travel through some snowy alps in winter so when we looked at Venice and London and train trips and biggish airports, Innsbruck seemed to fit the picture. Whilst it didn’t really end up being lots of surround-view snow-capped mountains, it ended up being quite a picturesque train ride (and the train rides are always so comfortable and easy) and Innsbruck itself was a very pretty destination.

The fast train from Venice to Innsbruck 

This fare was very reasonable. Trains in Italy (and I realise now, Austria) are much cheaper than travelling on trains in Switzerland (they can be prohibitive – but it is cheaper if you book second class in Switzerland and they are still quite roomy seats).

First snow-capped mountains from the train from Venice to Innsbruck

There are lots of amazing engineering feats on this trip with giant suspended roadways everywhere. Europe really does have their infrastructure well organised.

Some of the amazing engineering feats on the trip to Innsbruck

We chose the aDLER Hotel (their branding, their way of writing it) because of its close proximity to the train station carting luggage and the panoramic view from every room – and it didn’t disappoint on both counts. It was a fantastic hotel and I would definitely return to Innsbruck and have another stay there again (but longer this time).

That was our complimentary welcome drink in the bar with the panoramic view in the background. We settled in the room after another reflection on how amazing the view was and then headed out to walk Innsbruck. I know I say it a lot, but truly it is so easy to get your steps up in Europe/UK. The transport system is so well set up and the expectation is there for everyone to get around by walking, cycling, bus, light rail/trams, train or even water or aerial gondolas. This trip has been extraordinary for step accumulation – I am now averaging 25000 steps every day and falling into bed completely exhausted and sleeping like a log every night. I also know the troops (Alexandra, Megan, Martine, Jane, Jose, Roxie, Suse and Ally) are all holding the fort back at work which definitely does help with promoting good sleep also.

The weather (averaging 4 to 8 degrees centigrade) is also much more conducive to walking everywhere also. With our heat wave in Queensland, Australia which I have heard about from those still at home and the dreadful bushfires which have come with it – the intensity of the sun really saps your energy to walk too far and you have to lather up with the sunscreen before poking your nose out the door. Mind you it is actually difficult to warm up when it is as cold as it is over here. We are walking very briskly, long distances and it is still very cold once you have reached your destination and dive into the intensely heated venue. I have invested in yet another essential cold weather apparatus – the neck warmer. I bought it in Bath yesterday and it is my most favourite acquisition over here. It literally blocks out that whistling wind and you heard it here: a warm neck is a happy traveller (my saying, I’m patenting it).

Back to Innsbruck and they really have Christmas Markets nailed – there are plenty of twinkling lights, real Christmas trees, Singing Santas, gluwein everywhere and beautiful Christmas presents and trinkets for sale. I know my grandies would love it here but the thought of rugging them up to combat the cold is very off-putting.

  

  

Wonderful Christmas markets in Innsbruck

One of the other reasons for heading to Innsbruck was to see the Zaha Hadid Architect designed gondola and railway funicular service. For nearly a century, a funicular system offered passage around the hills of Innsbruck. In 2007, the system was retired and replaced with something so architecturally stunning that it became a tourist destination in its own right. The journey is what matters on the Hungerburgbahn, and it happens in futuristic style. Travelers from around the world come not just to travel between four stations – Congress, Löwenhaus, Alpenzoo and Hungerburg – but to marvel at the sheer wildness of the design. Designed by the late Zaha Hadid and built in 2007, the system replaced the previous funicular service in operation between 1906 and 2005. In a country renown for its architectural daring, this new collection of structures seemingly hails from another galaxy. With biomorphic undulations and futuristic curves, they celebrate the gorgeous landscape – while ferrying you over it. Each train carries just 130 people, and the ride lasts less than ten minutes; the physical scale is small, but the artistic vision connects with a great tradition of architectural innovation throughout Austria. (1)

The tragic part about coming to Innsbruck to see the work of Zaha was the fact that it was closed for maintenance and was due to re-open the day we left Innsbruck. Oh well a reason to come back!

The futuristic design of the first entry to the railway tunnel by Zaha Hadid in 2007

We packed up our bags and jetted across the Alps to London to catch up with our children and some WH colleagues – we knew we had arrived in the UK as a dense grey sky greeted us at Dover.

The alps from our plane 

(1) Taken directly from https://www.austria.info/us/austria/stunning-and-surprising-art-architecture/traverse-innsbruck-in-style

Venice Biennale 2018

Look away now if you do not want to see some travel blogging.

The Grand Canal, Venice

As you may be aware my blog is also my diary for trips we take because it is so easy to forget memorable moments as you get older (well it is for me anyway) and I often do some homuncular refreshment and re-read an old blog from years ago when I feel I am need of a mental reboot. So the next few blogs will be about our current trip. We usually head off in the warmer, drier months, but I was very keen to see the lights and Christmas decos in London so delayed the trip until the end of the year.

Our first stop this trip is Venice – it always amazes me that the big A380 passenger jets can deliver us into Venice. This year we were on the wrong side of the plane to see Venice as we were landing, but on our side we were pleasantly surprised to see the snow-capped Italian Alps. Bellissimo! We have come to Venice quite a few times over the years because every two years they have the Biennale Architettura which goes from May to the end of November and with Bob being an architect we go for his Professional Development. It’s a tough gig but he has to do it to keep his PD hours up! The other reason for this trip at this particular time is we have been married for 40 years in a couple of days and I reckon we both deserve a reward for that achievement.

To get from the airport to the main part of Venice you can take a water taxi at 100 euros for two or for 15 euros each catch a Alilaguna, the water buses from the airport to Venice – the boats that are the equivalent of the Brisbane City Council bus – up the Grand Canal and delivered us to pretty close to our destination. (You can have a couple of nice meals in Venice for the 70 euros saved). This year we realised there are actually 3 water bus lines that you can catch – every other time we have come, we literally just jumped on the first boat that arrived and ended up taking the longest route that took well over an hour! So make sure you check where your hotel is and choose the shortest one – which for us this time was the Orange line to Guglie. The excitement of visiting Venice never leaves me and as I write this blog on our train trip through the Alps to our next destination Innsbruck, I feel a little sad to say goodbye to Venice again.

San Simeone Piccolo Church

Oh but I love this landmark in Venice. That striking copper dome roof (La Cupola, which with ageing has achieved a beautiful patina -this beautiful green colour) of San Simeone Piccolo Church greets you when you arrive at Venice Train station or slip past it as you catch the vaporetto. Our hotel for this stay was The Carlton Hotel on the Grand Canal – seeing it was such a short stay I was determined to stay on the canal and as it was the quiet season for Venice, we got a remarkably good price (which we booked directly through the hotel). Our hotel was right next door to the church. Standing at the window or on the tiny balcony in our room, the frenetic pace of the boat life on the Venice canals was there for us to enjoy day and night. The temperature was a marked change also for us for Venice. It has always been super hot 30degrees C every trip we have had before but this time it was 4 degreesC most of the time. An immediate purchase of a woollen scarf and woollen beanie from a street vendor happened about two hours after walking through the streets of Venice as sunset is at 4pm and the chill factor is significant. Note to self and Aussie winter travellers – don’t bother with our acrylic or cotton scarves – they are a waste of time in the real cold.

New woollen beanie (plus pom-pom) and scarf 

Be aware to pack some earplugs also if you stay at any hotel on the canal as there is significant canal noise at night (boats of all kinds including emergency services such as ambulances, police and fire) which for me is part of the fun of Venice.

The best part about coming to Venice in the off-season is the streets are literally devoid of tourists. We could actually walk the streets of Venice and stop and admire the architecture without causing a (pedestrian) pile up behind us. And there was hardly any smoking happening – such a stark difference to every other visit. Often people can’t understand why we love Venice so much – what with the vast crowds and the smoking issue, but truly I am spellbound every time I come here and it is starting to feel like a second home. It is spectacular and around every corner there is a view that every artist would love to paint.

The second day was free of cloud and a bright warm sun warmed us up on the hike to the site of the Biennale – the Giardini – right down the other end of Venice. As we walked toward the Giardini, we saw for the first time the Acqua Alta – the rising tide of Venice flooding St Mark’s Square. The heights of flooding are rising every year and there is a genuine concern that one day Venice will be no more. The elevated platforms which get brought out by the invisible workmen to allow the tourists in Venice to continue to walk around were erected as the centre of the square was flooded.

 

Stark evidence of how Acqua Alta impacts on life in Venice

There is no filter on that photo-that is the true colour of the water

As we were lining up to buy the entry tickets, I became aware of the first of many large groups of students we were to encounter that day. They stood out because each of them was carrying a large Pilates ball. They were architecture students from Spain and we followed them into the Spanish Pavilion to see what they were up to. It must have been “bring your own seat” as they were all just sitting on them listening intently to a panel of architects discussing architecture in Spain.

Spanish architecture students with their Pilates balls

Everywhere we went throughout the Biennale, there were groups of school children listening intently to their teachers who were guiding them through the pavilions. The ages ranged from 6-7 years to University students. I reflected on how amazing it must be to have the opportunity to educate children from a young age on the value of good building design, of opportunities to introduce environmental design to minimize the footprint of a building on our earth and to teach them to look out for the beauty in a building.

Everywhere we turned there were groups of school children of all ages being exposed to the concept of good design

Living in Venice would colour your opinion I am sure. The design concept each country had to work with was ‘free space’. I have to say I was a little disappointed with the Australian entry this year – I do wonder if this is funded at all by the Federal Government because the entry looked like it was starved for money.

We had lunch and then walked to the Arsenale to see the second part of the Biennale. The scale of the buildings housing this section is huge and I marvel each time I come here at the capability of the Venetians in the 1400s to build these giant structures.

One of the displays had some big comfy bean bag lounges so we plonked our weary bodies on them and watched a (terrifying) video on global warming showing the extent of melting ice in Greenland -hit the link to see a shortened version of this ice melting event. I do often despair at our country’s inability to recognize that Climate Policy should be a dire concern for everybody. The extent of climate change we see in the news every day- the drought in Australia with huge dust storms and bush fire season hitting earlier and earlier every year; the savage fires in California; this ice melting event; the worsening flooding in Venice….. I sometimes wonder if it would be better served by taking climate policy away from the politicians and see if it could be decided by a partnership between scientists and business – let the grown-ups decide what we should do not the self-indulgent politicians. They have had their chance and stuffed it up for 10 maybe 20 years. They too would benefit from travelling the world and actually LIVE global warming. This is what is so good about the Architecture Biennale – you see the displays of many countries and get to understand the issues affecting their built environment.

The last stop on our well-planned day was the Peggy Guggenheim museum but as we made our way towards the venue the crowds suddenly began to swell and there suddenly thousands of people heading the same way we were. We found out that 21st November is a very special day on the Venetian calendar – Madonna Della Salute Day .Our plans to go through the museum were thwarted by the fact that on this special day all local Venetians get into the Peggy Guggenheim museum for free so it was very crowded. So we headed out and went to investigate the church associated with the Madonna Della Salute Day. Then the crowds really exploded- you could only go with the flow- you couldn’t say “I’m getting out of this” – there was only one way to go and that was with the throng.

 

These crowds were slightly terrifying – you couldn’t turn around and get away from it

Once we made it through, it felt satisfying that we had rubbed shoulders with the true Venetians – not the usual crowds in Venice that are the tens of thousands of tourists off the cruise ships. We made it safely back to the hotel and at the end of the day 25000 steps had been done. It is so easy to clock up your steps when you are travelling overseas.

The train is heading north towards Innsbruck our next destination…..

Bowel function and pregnancy with a Royal touch

Did you know that even the Queen has to deal with bowel motions? I don’t mean that in a disrespectful way at all- I am reminding us all about that fact because many women (and men) are very reluctant to discuss their bowel problems until they are almost at the Calamity Stage on the Bowel Richter Scale because they are embarrassed or mortified about bowel talk. It’s almost as though they are the only person in the world that may be having this problem when in fact bowel dysfunction is common. Bowels can preoccupy your thoughts when you are suffering with difficult evacuation and we can all relate to the satisfaction felt when you are able to completely evacuate a stool after some period of constipation. I even had a patient exclaim the other day: “Sue I did a bowel motion on a plane toilet!!” and we know that deserves a trophy.

Constipation is a frequent and debilitating problem worldwide. It affects twice as many women as men.

Now I was prompted to write this blog on bowels by the recent visit of the Duchess of Sussex to Australia. Meghan Markel – who (in case you have been living in a bubble devoid of social media or the magazine New Idea) is pregnant and boy (Has Sue been told the sex of the child?) can bowel function change during pregnancy! The good thing it can sometimes change for the better, but it can sometimes also change for the worse. Constipation affects up to 38% of pregnancies with rising progesterone levels in pregnancy contributing to slow gut motility. (1)

As for pregnancy, a prospective study demonstrated that pregnant women are most prone to developing constipation in the first two trimesters. The prevalence of functional constipation in the first and second trimester varies between 35% and 39%, is 21% in the third trimester and 17% peurperium. (1)

But bowel problems are more than constipation and incomplete evacuation. Anal flatus, bloated bellies, sneaky gas, borborygmus (a rumbling noise produced by the movement of gas through the intestines), faecal incontinence, rectal prolapse, posterior wall prolapse and anal pain are all things that may be experienced by women before, during and after pregnancy as well throughout their lifespan. They are not routinely on a GP’s checklist (or in small talk like ‘How are your bowels?’) because it’s literally like opening the proverbial can of worms. The conversation cannot be finished in under half an hour and does not fit in with the 6-minute model that GPs are paid under by the government. Who can blame them? There are many fabulous GPs who do ask about bowels but when it takes a pelvic health physio perhaps an hour to cover the relevant education and pelvic floor/vaginal/rectal examination to find the extent of the problem, how can a GP possibly do much more than say: ‘Here take these laxatives’ if they have 6 minutes?

Hence this blog. I have written a previous blog called All About Bowels years ago and so have reposted some of the content here with a few added nuggets (having just been to another fabulous three-day Explain Pain Course with AssProf Dave Butler, Prof Lorimer Moseley and Prof Peter O’Sullivan where Nuggets <of Information> are chucked around every 5 minutes, I felt it entirely relevent and appropriate(2) to appropriate(3) the word ‘nugget’ for this blog).

The blog on All About Bowels (with some additions) follows:

Nothing causes more misery in people’s lives than bowel problems. Whether it be constipation, incomplete evacuation, faecal incontinence (FI), sneaky gas, rectal prolapse, haemorrhoids, pain from anal fissures or haemorrhoids, solitary rectal ulcer, recto-vaginal fistula or proctalgia fujax – and sadly, some people can have some or almost 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. Who knew!

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 added a short new chapter on The Early Years in the new edition <Edition 3> of Pelvic Floor Essentials with info on toilet training, bed-wetting, FI, daytime wetting and childhood constipation to help).

There are 3 key elements to effective evacuation: Firstly the ideal position, secondly the best dynamics for emptying your bowels and thirdly optimising stool consistency. It’s a lot like Maths and Physics – getting the angles right (maths) and the coordination of the abdominal and pelvic floor muscles (external anal sphincter and pubo-rectalis) to release the stool (the physics bit) will make it easier to completely evacuate the bowel motion. In both my Pelvic Floor Recovery books, I go through in detail these three elements for effective, pain-free and complete evacuation. I have included the diagram for the position below.

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 pubo-rectalis and the external anal sphincter (ie.creates a funnel to release the stool).

One of the obvious problems with pregnancy is that the bowels are getting quite compressed by the end of 40 weeks.

Using a product to obtain a Bristol Stool 3 or 4 bowel motion is critical whether you are helping constipation or faecal incontinence. (Aiming for Bristol Stool 5 for children with constipation and anyone with an anal pain condition or who has had recent gynaecological or colorectal repair surgery). When doing Maths or Physics we often collect data and it is important to do this data collection to crudely see what your transit time is. Doing something simple like a corn test to see what your 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 eat 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) 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 roughly 2 days to see all the corn, then you have some slow transit time happening in your bowel.

Addressing the fibre content of your diet is the first step when looking at how to optimise bowel function. 30 grams per day is the standard recommendation but interestingly many of the fruit and vegetables that would boost your fibre intake may also be the culprits causing excessive gas and bloating. Many people have now read about the FODMAPS diet and sometimes follow the advice on some internet sites by themselves. FODMAPS stands for Fermentable Oligo-saccharides, Di-saccharides, Mono-saccharides and Polyols and they can have a wide range of effects in the gut because they can be incompletely digested in the small intestine. This undigested food continues on to the large intestine (colon) where for some people with IBS they can get: 

  • Fermentation by bacteria which results in gas production and contributes to bloating and abdominal pain or discomfort
  • Gas production (methane and hydrogen) can slow movement through the bowel and contribute to constipation
  • Increased water delivery into the bowel (osmotic effect) may contribute to diarrhoea. (4)

Getting proper supervision from a dietician is important with FODMAPS so you don’t significantly reduce important food groups because you have instituted a blanket ban on all FODMAPS foods. 

If diet doesn’t achieve an adequate texture and volume of stool then added products can be tried.

Remember this is a guide only- please discuss any use of products with your pharmacist, GP or other specialist doctor especially if you are pregnant.

Initially products such as fibres may be used to soften the stool. Some common brands include Normafibe* (which is also very helpful if your stool is too loose (each of the Normafibe pellets swell to 60 times their size and assist with binding the stool which helps with faecal incontinence), Benefibre*, Metamucil* and many others. The next stage if fibres are not working well may be an osmotic laxative such as Osmolax* or Movicol* which help bring more water into the bowel to soften the stool.

Adult Glycerol suppositories* are a wonderful help if the rectum is loaded and difficult to evacuate – 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 or colorectal 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.

Proctalia fujax can be considered a chronic or persistent pain condition so once the mechanics of defaecation have been corrected to especially decrease any tractioning of the pudendal nerve that occurs with straining, then sometimes a medication like Endep* (prescription item definitely discuss with your doctor) can help to decrease the constant messages from the pelvic region. It is also important to give good persistent pain education to help the patient understand why the persistent pain is present and how to decrease or eliminate it.

Poor gas control and faecal incontinence is distressing and can lead to people leaving their chosen employment, becoming very anxious and even agoraphobic. 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 any anal incontinence. Overeating can also cause excess gas production and having just emerged from a notoriously bad time for overeating (a three-day conference at the MCG with amazing food by Epicure) it may pay to look at portion size as one of the strategies to help excessive gas production.

Simple strategies such as using flushable wipes (restricted to a final wipe in these times of environmental concerns-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, 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.

I hope some of these hints are helpful to all those who may have issues and be noted by those who have yet to encounter problems.

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

(1) Verghese T, Futaba K, Latthe P (2015) onstipation in pregnancy https://doi.org/10.1111/tog.12179

(2) Meaning of appropriate: suitable or proper in the circumstances.

(3) Meaning of appropriate: take (something) for one’s own use

(4) Taken from a handout prepared by Dietician Jocelyn Hunter-Clarke 

An Australian Success story: Olive & Bee – A new intimate cream

This week’s blog is about a new intimate cream called Olive and Bee. It has been on the market for over 2 years but I recently attended a conference in Hobart for the Continence Foundation of Australia and Claire Osterstock, an Adelaide based pelvic health physiotherapist and inventor of Olive and Bee, had a space there and I went and had a chat to her and learned more about her product. Soon after I went to an Australian Physiotherapy Association lecture night with the wonderful Dr Susan Evans, a pain doctor who shares her time between Adelaide and Brisbane. Susan was waxing lyrical about Olive and Bee at that lecture night. Fortunately I had asked Claire to write me a blog (when at the conference) and tonight that blog (see below) has popped into my inbox. I started trialling Olive and Bee with patients during this last week and I think it has an important role, particularly for those women suffering with vaginal dryness who are not able to use local oestrogen due to breast cancer concerns. (It is always important to check with your oncologist about using local oestrogen because many times you will be allowed to use it but it is up to the oncologist). Claire’s blog about her journey developing her product follows below.

Claire Osterstock

I am a Physiotherapist in Adelaide, Australia, with a special interest in helping women and men with management of pelvic pain. One part of my roles is to advise on personal lubricants, but I was disappointed with what was currently on the market. Almost all lubricants contain synthetic chemicals and preservatives which sometimes cause irritation. They can interfere with the sensitive vaginal tissues and clients would often report burning and itching after their use.  Most women are also not comfortable buying lubricants, mostly due to their names and packaging. So I teamed up with a compounding pharmacist and went about creating a new all-natural intimate cream.

Simply Olive and Bee was born!

26 recipes later, the perfect product was created! Extra virgin Olive Oil was chosen as a base, as it is naturally antibacterial and anti-fungal and is high in antioxidants and is self-preserving without the need to add chemical preservatives. Olive Oil also has a low comedogenic rating, hence it is less likely to block pores than other oils such as coconut oil. It was formulated with beeswax as this is a natural thickener with anti-inflammatory properties. Both substances are anhydrous, which means they have low water activity and therefore don’t grow nasty bacteria, fungi or mould. The low water content also means that they won’t interfere with vaginal pH as other substances can.

Why an Intimate Cream?

We have decided to use the term “Intimate Cream” as opposed to “Personal Lubricant”. Firstly, this has less of a sexual connotation and we feel it makes the purchase easier. Secondly this product has multiple uses apart from intercourse! Women can experience vaginal dryness or itching from several causes such as menopause, breastfeeding, and skin issues. This product is safe to use as a vaginal moisturiser or for moisturising of sensitive mucosal tissues such as a protruding prolapse. It may be used to help insert a pessary, dilator or even a suppository. In fact it can be used anywhere on the body – we also use it as a body moisturiser and heel cream! Those people who need to keep their skin moist, such as people suffering from eczema will find it moisturises their skin to lock the bad bacteria out. It also makes a great massage oil without leaving a greasy feeling on the skin.

 100% NATURAL.  100% ORGANIC.

ABSOLUTELY NO chemicals, preservatives, flavours, colourings or additives.

100% Australian Made.

I hope you enjoy my new product and find it soothing and helpful for vaginal tissues. 

Thanks Claire for your blog and I hope some women who are suffering with an incompatibility with other lubricants or are after an organic product may be interested in trying Olive and Bee.

It is available from Olive and Bee website.

I am hoping the next blog will have some nuggets from the Melbourne Explain Pain conference (EP3) I am attending at the moment. This is the fourth EP course I have attended and each time there are multiple new gems of information which I hope to share with you.

It has been a sad weekend in Melbourne with the horrific incident in Bourke street.

An incident like this focusses your attention on the importance of saying plenty of “I love you’s” to those who you love when you finish a phone call or leave the house/country and to realise so much about life is luck.

I (foolishly) say to my kids who are overseas travellers “Always keep your wits about you” “Look behind you” “Be aware”…… when they walk around London and other European cities but as I was in the city yesterday to buy some food it was bleeding obvious that when it’s crowded (and it was crowded) there is no opportunity to really see stuff like that coming.

It’s just all about luck.

That restaurant owner of Pellegrini’s (who appears to have just gone out to help someone he thought was in need) was oblivious to the potential horror and was just doing what he’d done hundreds of times before – offered a helping hand to someone.

Unfortunately bad stuff went down and a much-loved man died. Such an abominable waste.

I was amazed at watching the bravery of the police officers and civilians. I hope they are able to keep contributing and don’t suffer too much with the absolute horror of that 10 minutes……….

 

We have no need to be afraid

……..For those who’ve come across the seas
We’ve boundless plains to share……

I met a wonderful nun recently who works with refugees and we were both despairing about the children on Nauru situation and she was telling me some wonderful stories about refugees who she has helped in her work. I asked her to write some down for me. I feel so many Aussies don’t have contact with refugees and so when there is negative diatribe from the papers, the shock jocks and politicians trying to stir up fear and hatred, it is easy for the general public to follow along without questioning the truth of the comments.

I have watched many an ABC show on the wonderful contribution many refugees have made to Australia and particularly outback Australia and have seen whole towns rally together to make representations to Immigration Ministers on behalf of different refugees to prevent their deportation.

Refugee success story in Toowoomba

Here are some of her stories to make you stop and think about how much refugees may have to offer our great big brown land.

  • In the early nineties among those refugees who arrived in Brisbane was an Eritrean woman who had been a guerrilla fighter in her country’s war to gain independence from Ethiopia.

Her close friend here at that time, however, was actually an Ethiopian woman forced to flee her country with her youngest child. For these two, hostilities abroad were not to be entertained here.

This Eritrean woman is an outstanding leader in her community and more widely among women from many African nations. She has shown great resilience, imagination and determination over so many years. From early on she has worked to help immigrants settle into their new home. She heeded a later request to help women find work. In her words: I asked myself what was the one skill that so many of these women bring with them and that could help them succeed? Cooking!”

She set up a restaurant in 2004 called Mu’ooz Restaurant and also provided training in hospitality for such women preparing them for future work. Over 150 women have passed through the course. Her restaurant is a popular meeting place for many groups – the next will be an occasion for refugees and others in the community to meet and to share over a meal through the Welcome Dinner movement. The restaurant also caters for outside events.

She believes that everyone wants the same thing for themselves and their families – to have peace, to be loved and accepted.

Food preparation at Mu’ooz

  • Her friend from Ethiopia had been forced to leave behind her husband and three older children when she fled to a neighbouring country with her baby. This child began school here in suburban Brisbane. The struggle then was how to reunite the family from whom she had been separated for around six years. Her husband had meantime died. When official permission was given for the children to come, the next hurdle was finding the money for the fares. The primary school her son attended was approached and took on the task of helping to raise the funds.  The teenage son had meanwhile taken off at this critical time and had to be found. When the mother who prayed nightly for hours was asked how she found the boy, she replied: I didn’t find him, God did. Finding him happened in part through the help of an Australian religious Sister running a health clinic in their town.

A very excited boy featured on the ABC breakfast programme of the time telling how his school had succeeded in raising the money and announcing the imminent arrival of his fellow pupil’s brothers and sisters. Out to the airport went a welcoming party – mother looking, as someone remarked, like the Queen of Sheba in the stunning white, gold trimmed national dress, along with the youngest child, the school principal and several others. It was a happy, tearful occasion.

  • Poignantly among those welcoming the three children arriving from Ethiopia was another mother with her child from Tigray. As I looked at her, I saw a mixture of emotions – happiness for her friend but pain that her own partner was still far away. Eventually he was able to join her. As an eight year old, their daughter was prone to correcting her mother’s English and when reminded  that her mother spoke two languages (it was actually three) declared very authoritatively : It’s not important to speak the language where you come from but only to speak the language here!

The family now with two boys born in Brisbane, moved to Melbourne where the mother received an award from the top hotel where she works as the best employee over all levels of staff. When reminded many years later of her earlier comment, the daughter immediately conceded: ‘Yeah, sounds like me’ and went on with composing the valedictory address she was chosen to deliver at her High School’s Speech Night. Now with a degree in media,  she is studying international affairs and working in the Immigration Department.

  • Many of those forced to flee Afghanistan are from the persecuted ethnic minority, the Hazara who have been pushed into the least productive parts of their country where living is hard. Several school-age boys came as ‘unaccompanied minors’ sent by their parents to escape the clutches of the Taliban.

An English teacher at their Migrant School in Brisbane decided to form a soccer team to provide these boys, including other Kurdish, Iraqi and Sudanese members, who had no family support here and who often didn’t even know how or where their family members were, with a community. The Tiger 11 Football  team was born. As well as fulfilling their desire to succeed on the field, the boys made wonderful contacts with other young people as well as older citizens, many of whom did not know or even care about refugees and their uncertain situation as temporary visa holders.

As the manager of the nearby sporting club that the English teacher first approached for assistance and who kick-started the team’s endeavours remarked:

‘Well I was of the opinion that the boats should be turned around or even that they should be shot at … but then I had never actually met a refugee.’

In case you are wondering where the verse originates at the beginning of this blog- that is from the second verse of the Australian anthem – Advance Australia Fair.

Click on the image if you want to read the words more clearly.

Thank you to Sister Genevieve who wrote the stories. I wish we could all understand the stories behind the people. We might all feel more compassion.

 

 

A personal story from a pelvic health physio: Nadine Brown

Many physios who go down the pathway of women’s health and pelvic health physiotherapy, do so after the birth of their own child/children.

Some do so because their experience has opened their eyes to the magic of understanding more about the birth process and the changes, many positive to their bodies and to their lives from producing another human being.

Others do so because the experience has been quite traumatic and has had a serious impact on their own well-being, both physical and psychological. One such pelvic health physio is Nadine Brown, who is happy to openly talk about her personal journey and hence there is her name and there are photos. I have chatted with Nadine at a couple of professional development gigs about issues and I asked Nadine would she be happy to share her story and write a blog for me and she has. Nadine’s story follows.

“The world breaks every one and afterward many are strong at the broken places.”
Ernest Hemingway

When Sue asked me to write a blog for her about my birth story, I had two thoughts. The first, “Wow, Sue wants ME to write a blog for HER website!”, and second, “How can I put into words, the emotions I have felt as a result of the physical changes I experienced since having my son nineteen months ago?”

My birth story goes like many others. Vaginal delivery, gas for pain relief, no major tearing or medical issues (small amount of internal stitches), discharged from hospital, healthy big baby, tick tick tick.

But it would seem, as time went on, things just weren’t right “down there”. It was not until many months after the birth, I was told that the birth of my healthy, robust, 9lb “steak n chips” baby boy, left me with anterior wall prolapse and levator avulsion (LA) – a complete detachment of one of the pelvic floor muscles from the pubic bone.

I was devastated.

Being a physiotherapist, with a special interest in pelvic health, I regularly treat women who bear the physical and ultimately, mental health ramifications of birth injuries. I get comments such as “No one told me this would happen”, and “I can’t do the things I used to do, I’m miserable, I had no idea it would be like this”.

They are grieving.

They grieve their pre-baby body.

They grieve their intimate relationships and sexual confidence.

They grieve not being able to just throw on the runners and go for a jog. They’ve lost confidence in their body. And they believe they can never go back. This is grief and it is very real. The realisation that I too had these birth injuries, put me into the cycle of grief.

What are the stages of grief, as we know it in the mainstream? Denial, Anger, Bargaining, Depression and Acceptance.  I know unequivocally, I went through each.

I was in denial. Denial that my baby came so fast, that even my midwives were shocked. Denial that I didn’t get the elective caesarean that I had planned.

There was anger, that despite trying my best to mitigate the risks of a vaginal delivery (because there are many, which are finally being brought to more mainstream attention thanks to social media), I was suffering physically and would for a long time post-birth. Anger that I fought SO. HARD. for an elective caesarean birth but I felt bullied by the midwife when I was vulnerable with horrible scare tactics and I didn’t get the caesar. Anger that I didn’t just bounce back. Anger that some friends didn’t quite understand why I wasn’t the old me.

Bargaining – “Well maybe I can just walk-jog instead of proper running” “Maybe I can just swing a lighter kettlebell?”.

Depression was the worst. It was a black hole, I described it to my girlfriends as quicksand. I could feel myself going down but I couldn’t stop it. I filled out depression questionnaire after questionnaire with medical professionals, they always came up as ‘Severe Postnatal Depression & Anxiety (PNDA)’. I knew it, I felt it, because I was a sleep deprived new mum with no village support and the realisation that my “self” was profoundly different – forever.

I put on 20kgs during my pregnancy, and lost 25 in the months following – I became unwell, and postnatal depression hit me like a freight train. I also lost confidence in being able to offer advice and help to other mums from a professional standpoint. How could I possibly help others if I couldn’t help myself? I had so much healing to do physically and mentally. My social media was that of a doting, yet very tired mum with a beautiful baby boy. Smiling happy faces, pram walks and a squishy sleeping infant. Yet, I was paralysed by PNDA, that had me struggling to even leave the house some days. I finally admitted that I needed help to come to terms with some of what I was feeling, as well as the rage and anger that sometimes comes with being a parent of a baby who never sleeps. I realised I couldn’t process my grief alone anymore. 

Right now, I’m working on acceptance. It is a process, but I’m ok with the healing, however long that takes. I see the purpose in my pain now, purpose in my journey. And like any good Women’s Health Physio, I’m diligently doing my pelvic floor exercises and slowly re-entering the exercise world that I loved so dearly before I had my son. I see hope, I see effective treatments that will give me my confidence and quality of life back. I see intimacy with my partner again. And running around with my son.

I’m sharing my story as a way of reaching out to so many mums who are going through these changes. The 4th trimester – the postnatal period -is not a race, it’s not a competition. It’s not all #fitmum #blessed. It’s not even just about the baby. It’s about the birth of a mother. There can be overwhelming joy, but also polarizing grief.

If you are going through this right now, please know there is help. There is HOPE. Make self-care a priority. Start by talking to your GP. Find a good one who will listen. And most of all, be patient and kind to yourself, Mumma, this is one hell of a tough gig.

Thanks Nadine for this very personal blog. It’s always difficult and somewhat confronting ‘to come out’ with struggles such as PNDA and disclose the pelvic floor issues that you may be personally having, but as one who has had pelvic floor dysfunction for nearly 30 years, I do think it helps patients to understand that there is life after a birth which changes your anatomy and they feel somewhat comforted by the pelvic health physio who is living the symptoms the patient is experiencing.

Good luck on your continuing rehabilitation and remember it’s a life-long committment (your rehab AND your job- once the pelvic health bug gets you, you become passionate about it forever) and keep focussing on what you know you CAN do not what you think you CAN”T do. There is still lots of fun to be had from life -especially one enriched with a (non-sleeping) baby!!

If this blog has raised any issues for you contact Lifeline 131114 or Beyond Blue

The Australasian Birth Trauma Association (ABTA) not only has an active Facebook group which you can join and participate in conversations, but also has recently instituted a Peer2Peer counselling service to help support women who have suffered a birth trauma. Check out the facebook group page for more details.

Benefits of regular exercise

Today’s blog has been written by one of my physios Alexandra (Alex) Schafer who not only sees our pelvic health patients and musculo-skeletal patients but also teaches at my studio- Studio194. Even though we are closing the studio at the end of the year, Alex, Megan, Martine and Jane will still be conducting one-on-ones, two-on-ones and three-on-ones at the rooms at Hampstead Road, Highgate Hill. I asked Alex to write about the benefits of establishing a regular exercise programme – and while it is never too late to begin a regular programme, there are obviously long-term benefits of getting to love exercise early in life. Alex’s blog follows.

We all know that doing exercise regularly is valuable and evidence shows that exercise is very beneficial to living a healthier life. I am passionate about getting everyone to move and enjoy exercise regardless of what they decide to embark on. Starting an exercise regime earlier in life will help you to stay fit, strong, and embrace any physical challenges our life stages such as menopause may present.

From research we know that from around 30 years of age (!- yes that early), muscle mass, muscle strength and physical performance deteriorates. This results in a 10% decrease per decade in aerobic capacity (Gielen et al 2012). Ageing also affects the pelvic floor, which are striated muscles like the rest of our skeletal muscles and can lead to symptoms like urine leakage (Klauser et al 2004).

Decreasing strength overall may also lead to a higher risk of falls, more aches and pains as well as difficulties with everyday tasks. Here is the good news: exercise on a regular basis will help to keep the muscles fit and strong, it will make you feel happy and strengthen your bones. People who start with a higher aerobic capacity and keep up an active lifestyle will maintain a greater fitness level throughout their life (Ades at al 2005).

It is the little things done regularly that will have an impact on your physical health like choosing the stairs over the lift, leaving the car at home and walk or park the car further away from work. Making the effort to do a proper squat or lunge to pick up things from the floor will help to strengthen your legs. What we also know from research is that high intensity exercises, for example resisted upper and lower limb movements, are important to maintain or improve bone and muscle health (Russo 2009).

During Pilates classes at Studio 194 (and when we move the classes to Hampstead Road) we often use weights or other resistance (like theraband or pilates circles) to challenge our muscles in order to achieve muscle growth. If you load your muscles enough then your body will adapt after the workout and as a result the muscles grow bigger and more importantly stronger. Strong muscles, particularly around the trunk and the legs, are important for many everyday tasks and for balance.

Osteoporosis is a common disease that decreases bone density which increases the risk for fractures. Women have a higher risk of developing osteoporosis after menopause. Physical exercise is important for maintaining and improving bone density. Exercise has to be regular and with a certain amount of impact. During childhood and adolescence maximal bone strength is usually achieved and then optimised during early adulthood. Regular exercise reduces the risk of bone loss in older age.

What I am trying to say is that exercise throughout life is important and very beneficial, it is never too late to start but the earlier you start the better.

I would like to encourage everyone to exercise, move and have fun doing it! In my classes I try to challenge everyone and I might give different variations depending on the level of fitness and strength. The most important thing is that you enjoy what you do. This is the key to sticking to any programme which ultimately is the only way to improve and maintain strength, flexibility, healthy bones and joints. Sometimes it can be difficult to get started and initially it might be really hard work. But set yourself goals, like a 3 month plan and see what happens. There is a very good chance that you will love your exercise after doing it for a while and getting the hang of it. See you at Studio194 until early December and then at 47 Hampstead Road Highgate Hill after that.

Thanks Alex. While we will miss the studio, I am looking forward to saying to patients: “Make an appointment with the girls for some sessions downstairs”. I will show some photos once it’s set up in the New Year. Don’t worry- the Running Clinic will still be happening downstairs as well!

I am off to the National Continence Foundation of Australia Conference in Hobart next week, so hopefully I will be doing lots of posting of tit-bits (knowledge bombs sounds better) from the conference – as long as I don’t get too distracted by Fiona Rogers of Pelvic Floor Exercise a fabulous online website for all things pelvic health!

Until next time

Sue Croft

 

“I’m committed but not always compliant”

I saw a delightful patient today who came in full of apologies for not adhering to all the strategies we mapped out at our first meeting a month ago. Now I am totally understanding about time pressures, changes in circumstance, things that unexpectedly crop up to throw a spanner in the works of life. It happens many times to me and I totally get it. But when I questioned this patient more closely – these ‘spanners’ were of great significance. She had lost her darling Mum of 97, another friend from cancer and a younger woman was very ill with a serious cancer and the prognosis had just been spelt out leaving them all devastated.

It’s actually a wonder she could manage any of the strategies we had spoken about.

But in fact she had done her diary; she had started to do her pelvic floor muscle training; she had adopted the new position for voiding and defaecation and she had gone 100% decaf. So she had actually done some really major things but she was still apologising and feeling bad. And then she said it and it’s actually very meaningful!

“I’m committed but not very compliant”

Her honest answer sums a key ingredient in the pelvic health story.

Committing to a programme with a pelvic health physio is a giant step to take. It’s certainly very important, it’s getting the patient in the front door of your rooms. Did you realise that research undertaken via a survey of people in a doctor’s waiting room showed that 57% of people had moderately severe incontinence and yet only 29% of these patients had ever raised it with their doctor. Women and men often take years to raise these private problems with their GP, so if they are brave enough to seek your help you owe it to them to sell the ‘story’ of managing pelvic floor dysfunction in a palatable, encouraging, easy-to-understand way, with lots of reading material and notes to back all that information up.

Thought I’d slip an image of the new updated editions of my books in here

Adherence to conservative strategies by patients is also one of the biggest problems we physios have when ‘selling’ what we do in the medical world. All too often articles in medical journals like to point to the poor adherence by patients to the lifestyle changes and pelvic floor muscle training (PFMT) that embody conservative treatment strategies for some types of pelvic floor dysfunction after a period of say 12 months. This is an argument that a surgeon may put to a patient – have the surgery because you are not continuing to still do your PF exercises and your problem has returned.

But of course PF exercises should be a lifetime habit whether you have surgery or not. (A cautionary note: there are times when pelvic floor exercises may not be the answer such as when there is pelvic pain, or voiding dysfunction or defaecatory problems such as obstructed defaecation due to pelvic floor dyssynergia – when the pubo-rectalis and external anal sphincter muscles contract and tighten when they should relax and open to evacuate the stool/bowel motion. Your pelvic health physio will advise you about this.)

Following all that advice that the pelvic health physio taught you can help protect any surgery you have had and should be continued forever.  This concept of lifetime adherence makes or breaks the success a patient has with what we teach. It is one of the critical selling points we pelvic health physios need to impress on our patients. And we pelvic health physios owe it to our patients to be good at encouraging long-term compliance and adherence and sell the message of good pelvic health throughout the life-stages.

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