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

Metaphors that ruin your life.

This is another one of those blogs where my close family members need to look away, if me talking frankly about sex is embarrassing for them. But I want them to remember that the silence around sexual dysfunction is massive and it is important that, as a health professional working with women and men with problems in this area, I need to cover this topic in my blog.

I have written previously about orgasm and sexual function in this blog here. Most importantly, it is imperative that if anyone out in the stratosphere is reading this and you have pain, uncertainty or questions about sexual function, then your local Pelvic Health Physiotherapist will be able to help you or refer you on to someone who can. Google for your nearest pelvic health physiotherapist.

Over the nearly 30 years I’ve been treating (mostly) women but some men for sexual dysfunction, one of the most destructive phrases or beliefs that keeps cropping up over and over is a common one which patients report from their Catholic (church or school) upbringing and probably from many other religions also and it is: “Masturbation is a sin”. 

That simple phrase has caused much angst for many women and men and their sexuality. This phrase must have been said and reiterated to these patients when they were young, vulnerable and impressionable because for many, it has caused them to deny themselves a lifetime of autonomy over their bodies. It has encouraged them to repress sexual feelings they have had and to feel guilty if they don’t ignore those sensations and feelings and actually decide to acknowledge them and do something about them by doing self-stimulation.

What it also has done is create mystery around how women can actually achieve orgasm and made women afraid to actually explore their own bodies with the view to learning what feels pleasurable and what doesn’t. This is an important skill for women to learn as they need to be able to tell their partner what feels comfortable and what feels uncomfortable or just plain hurts. This is another life-area where there is very little proper instruction – a lot like having a baby. I mean is anyone else absolutely incredulous (if you truly think about it) how little instruction is given to mothers and fathers about the most important task they will ever be given – here take this baby home and look after it……. FAROUT.

So in the ranking of important information we should talk much more about – how to orgasm and what is involved in having pleasurable pain-free sex is right up there because sexual dysfunction is a common cause of marital disharmony. If women (or men) can’t have pain-free sex and are too afraid/ embarrassed/ ashamed (yes shame is a common emotion women feel if they can’t have sexual penetration with their partner) to openly talk about it, seek help or counselling for it – then it sometimes causes relationships to fail, which then causes untold grief to families and particularly children.

Professor Helen O’Connell

Back to women learning about their clitoris (‘their’ being the operative word – it is an important part of every woman’s anatomy and belongs to her). The clitoris exists purely for pleasure. But sadly the clitoris is a mystery to many women and most men – and I am including some doctors in that broad statement. The interesting thing about the clitoris is that it wasn’t until 1998 that a female Australian Urologist, the now Professor Helen O’Connell, actually did detailed dissections and discovered the previous-held views on the true anatomy of the clitoris were completely misleading. A big fail in Grey’s Anatomy for many years! I’m not sure if all health professionals have caught up with this fact and still believe the clitoris is merely that (magic) button just above the urethra. Here is a great article about the anatomy of the clitoris by Dr Mark Blechner. 

Most of the components of the clitoris are buried under the skin and connective tissues of the vulva. It comprises an external glans and hood, and an internal body, root, crura, and bulbs; its overall size is 9-11 cm. (1) Therefore the clitoris is huge! Clitoral somatic innervation is via the dorsal nerve of the clitoris, a branch of the pudendal nerve, while other neuronal networks within the structure are complex. (1)

Image from an article by Mark Blechner (see full article linked above and at the reference below) 

Understanding about the power of the clitoris is important because when we are teaching women about how to manage persistent pelvic pain, we talk about the body’s own ability to administer some pretty powerful drugs of its own. This relates to the “The Drug Cabinet in the Body” and Dave Butler explains this very well in the linked 5 minute video. General exercise (walking, running, gym, netball, rowing, swimming, in fact, anything) releases some of the ‘drugs’ (such as serotonin, oxytocin and dopamine) in our bodies that helps with persistent pain management. But another excellent way to access the ‘drug cabinet’ in the body is via the clitoris and particularly apt if one has female sexual dysfunction (FSD).

Quite often women have pain with penetration – pain at the vulva or internally generated by their over-protective pelvic floor muscles, but have no pain around the region of the clitoris. This means that with a good lubricant, they are able to gently touch the clitoris for short periods of time and build up tolerance to the touch, release warm, fuzzy feelings and gain arousal to assist with dilator work or with penile penetration. This graded exposure to clitoral self-stimulation will also help with any feelings of guilt or shame that may be present. This can be used in conjunction with dilators (or trainers as they are sometimes called) and as progress is made, then with adding a gentle vibrator which can be purchased from here and here (from Pelvic Floor Exercise an online store for all things Pelvic Health)

For your interest, there has been a change in definition of Female Sexual Dysfunction (FSD) and the International Continence Society (ICS) went with the definitions from the DSM 5 (The Diagnostic and Statistical Manual of Mental Disorders fifth edition). The DSM 5 has combined disorders that overlap in presentation and reduced the number of disorders from six to three.

  • Hypoactive sexual desire disorder (HSDD) and female sexual arousal disorders (FSAD) have been combined into one disorder, now called Female Sexual Interest/Arousal Disorder (FSIAD)
  • The DSM-IV categories of vaginismus and dyspareunia have been combined to create Genito-Pelvic Pain/Penetration Disorder (GPPPD).
  • Female Orgasmic Disorder remains its own diagnosis
  • All diagnoses now require a minimum duration of approximately 6 months and are further specified by severity. (3)

There it is – Female Orgasmic Disorder all on a line by itself. Orgasmic dysfunction in women is the inability to achieve an orgasm, markedly diminished intensity of orgasmic sensations, or marked delay of orgasm during any kind of sexual stimulation. They report (high) sexual arousal/excitement. (Prevalence 16–25% in 18–74‐year‐old women in US, Canada, Australia, Sweden but in 2 other studies from Nordic countries 80% of all sexually active women age 18–74, independent of age, report some degree of orgasmic dysfunction). (4)

One of the reasons there could be such high rates of female orgasmic disorder is women wracked with guilt. When girls and women are actively told by their church or their peers or their mothers/fathers that masturbation is a sin? It sounds so wrong. This statement makes it difficult for them to explore their bodies, to chat to someone about it – even their friends, because the knowledgable ones might be skiting about having three orgasms every night and that in itself is intimidating for someone who may barely know where their clitoris is.

Context matters with pain also.

Many women are able to wipe their perineum after they have urinated with no pain experienced at all around the vulva, but when they (or their partners) are attempting to touch this area to explore in a sexual way, it is then that they experience pain. This is an example of the brain believing there is a potential for danger associated with sexual intimacy. The evidence has been accumulated by the brain over the years and much cortisol and adrenaline has been released with every attempt at penetration or really any sexual intimacy. Even thinking about having sex can trigger off this sympathetic nervous system response (the fight- flight response). The brain perceives the threat even without any physical contact. And the response of the pelvic floor muscles is to become over-protective and women experience levator myalgia – the muscle tissues become sensitive and tender points are palpated in the muscles. History matters to the brain! Good and bad experiences leave their indelible impression in the brain. Memories are important and laying down new memories with positive experiences will be useful when moving forward with persistent sexual pain.

Finally after lots of explanations about the anatomy, persistent pain and the like, some resources to help you are important.

OMGYES (the link is here) is a website where you pay a one-off $49 for a lifetime subscription. It teaches about the art of orgasm. Warning: It is very graphic.

I have another blog which has many links within in it called: Persistent Pain Resources in One Area

I hope this frank blog will give you some strategies and the confidence to pursue some help from a pelvic health physiotherapist.

Below is a link to a TED talk on ‘The unknown greatness of the clitoris’ with Maria Røsok

. Enjoy……

 

 

(1) Pauls R 2015 Anatomy of the clitoris and the female sexual response Clinical Anatomy 376-384

(2) Blechner M 2017 The Clitoris: Anatomical and Psychological Issues, Studies in Gender and Sexuality, 190-200

(3) ICS Terminology Website: Rogers R, Thakar R, Petri E, Fatton B, Pauls RN, Morin M, Lee J, Kuhn A, Whitmore K. International Urogynecological Association (IUGA) / International Continence Society (ICS) Joint Report on the Terminology for the Sexual Health in Women with Pelvic Floor Dysfunction. Int Urogynecol J,2018; Neurourol Urodyn,2018
(4) McCool et al (2016) Sexual Medicine Review Prevalence of Female Sexual Dysfunction Among Pre-menopausal Women: A Systematic Review and Meta-analysis of Observational Studies

 

DRAM Part 2: Exercises to do post-partum

Who are those two cutie-pies with me? (No Dior for me, that’s my mother’s top I’ve borrowed!)

I feel so sorry for Meghan at this stage of her pregnancy. I remember that in the last few weeks of my pregnancies, I was definitely not up for one or two photos of me and my (massive) pregnant belly, let alone one or two thousand! And I certainly never mastered walking in pencil thin stilettos in ordinary life, let alone pregnant life.

Nice sensible flats for me (action shot of Snoopy, the dog who was never still)

I would love to be a fly on the wall every morning as she gets out of bed and faces yet another round of engagements – there must be the occasional day when she’d love to say “Not today Harry- I just can’t do it!” But the time is fast approaching when there is going to be a fanfare and pronouncement of another Royal Baby arriving and another round of aghast amazement or outright belittling condemnation of however Meghan presents herself on the steps of the place where she’s just had the baby. It’s usually a lose-lose situation if you’re a young female Royal. I just for once wish everyone would give these women a break and just say Congratulations! instead of the usual negative palava.

When you look at the photos of us (the royal ‘we’) pregnant, you can see there is quite a strain placed on the abdominal muscles as the weeks close towards the end of pregnancy. We know the abdominal muscles are important for trunk movement, pelvic stabilization, and restraint of the abdominal contents (1)  – what an amazing adaptation to be able to stretch to such an extent and yet for many women, return to mostly what they were like originally. But sadly for some women there is significant separation and also micro-tearing of the fascia and skin which also contributes to a tummy which causes grief for the woman. The research is certainly pointing to the fact that ante-partum activity level may have a protective effect on DRAM and we know that exercise improves post-partum symptoms of abdominal separation. (1) Interestingly, research from Mota also highlights that women with DRAM were not more likely to report lumbopelvic pain than women without DRAM. (1)

The reason for this blog and pregnancy talk is that I promised a second follow-up blog to the DRAM blog that Martine wrote a few months ago and so I asked my Megan (Megan Bergman who works with me at Sue Croft Physiotherapy) to write Part 2.

Megan’s blog follows…

In a previous blog Martine explained diastasis or separation of the rectus abdominus muscles and some lifestyle tips for helping to manage this.  In clinic we have many women asking ‘what are the exercises I can do to flatten my tummy and can I get rid of the separation’?

When looking at these 2 questions it is important to understand a couple of concepts.

Firstly, separation is a normal adaptation of the abdomen to allow for the growth of a baby.  Every woman has a different pregnancy experience and different background which means that everyone’s restoration of function is different, and post pregnancy ‘normal’ may look quite different from pre-pregnancy. So we individualise treatment based on what we find at assessment. 

Secondly, you can achieve good strength and control through your abdominal canister even though the muscles may remain (slightly to moderately) separated. Many women have residual separation that you cannot see. What we are interested in is function

What do we mean by this?

If you imagine the two rectus abdominus muscles with a stretched piece of stiff tissue between them (the linea alba) that allows the muscles to sit out to the sides away from the midline of the tummy creating the separation.  If you contract the rectus muscles and draw them closer together that stretched piece of tissue will bunch up and become loose.  So, although your muscles are closer together, there is now loose tissue in between. This can be a point of weakness in the abdominal canister, and the rectus abdominal muscles do not contract as well as they should.  Additionally what many women will demonstrate is a doming effect in the abdomen (the two rectus muscles popping up in the middle). 

There is a deeper muscle called transversus abdominus (TA) which runs like a corset and pulls perpendicularly to the other abdominal muscles. The research is somewhat conflicting about the importance of TA with some studies reporting that a pre-contraction of the transversus muscle can generate tension in the linea alba which visually prevents the doming effect and functionally prevents looseness in the tissue (2). And yet other studies show that the inter-rectus distance (IRD) widens compared to rest along the length of the linea alba with the pre contraction of TA. Abdominal crunch has been considered a ‘risk exercise’ for development of diastasis recti but other studies have shown that the IRD narrows with a small abdominal crunch.

So what do we do?  We individualise the treatment. When we prescribe the early exercises we assess what does an exercise do to that patients tummy and say “Yay” or “Nay” to that exercise and then progress as the strength/IRD narrows/ function improves. This therefore means some may do a small crunch with a good positive effect and others may not. Some may activate TA and others won’t. 

How do we activate the transversus?

Imagine you are putting on a pair of jeans and you’ve forgotten to out your undies on.  As you do the zip up you are gently drawing in around the pubic hairline (to keep the hair away from the zip). In doing this contraction you notice a very gentle tightening in your lower abdomen but you can still breathe and your upper tummy is still relaxed.

In all exercises ensure you just keep breathing, (don’t breath hold) draw in the transversus and pelvic floor and then perform the movement (this allows the diaphragm to move up and the pelvic floor and abdominals to contract well). If you can do this and continue to breathe while exercising you can perform a wide variety of exercises.

The following exercises are gentle and slow in the early days but need to increase in speed, intensity and difficulty as you get stronger. These are for the early days.

Leg slides

Progress from TA activation to adding in alternate leg slides. 

Gentle head lifts

Lie on your back, gently tighten your low tummy, vagina, anus and gently in at belly button and bend one knee up at a time, so that both knees are bent. Then lift your head up and hold for 3 seconds and lower your head back down.

Pelvic rocking

Lie on your back, gently tighten your low tummy, vagina, anus and gently in at the belly button and bend one knee up at a time, so that both knees are bent. Slowly flatten your back into the bed by rocking your pelvis back, allowing your tummy to gently draw in. Repeat 3 to 5 times. Breathe and relax after this set.

Modified straight leg raise

Lie on your back, knees bent up, gently tighten your low tummy, vagina, anus and gently in at the belly button. Keeping your pelvis steady, draw your right leg to the chest and then straighten your leg out, holding the straight leg about 8cms (3 inches) off the bed/floor for a count of 3 and then go back to starting position. Repeat 5 to 10 times. As this becomes easier, do this exercise as described above but increase the number of straight leg raises to firstly 3 and then 5 if no discomfort. Remember always concentrate on the gentle tightening of your tummy and pelvic floor. Breathe and relax your muscles after this set. Look in a mirror for doming if you have that issue. Control it gently while continuing to breathe. 

Bent knee fall out

Lie on your back, with both knees bent up; gently tighten your low tummy, vagina, anus and gently in at the belly button; slowly lower your bent right leg to the side and slowly bring back upright again. Aim to stop your pelvis from rocking from side to side and check for doming as before. Repeat with the other leg. Do for 5 to 10 times. Breathe and relax after this set.

Modified clam

Lie on your side, with your knees bent and feet together, gently tighten your low tummy, vagina, anus and gently in at the belly button. Keeping your feet together, lift your top leg 8 cm (3 inches) off the other leg. Do not roll your pelvis backwards as you lift. Hold for 3 seconds and slowly lower down. Repeat with the other leg. Do 5 to 10 times. Your focus is on the abdominal muscles and pelvic floor in the beginning. Breathe and relax your muscles after this set.

 

Pelvic rocking in 4 point kneeling

Make sure you have enough tone in your abdominal wall before you go onto this gravity-dependent exercise. This is also a great postural stretch and is known as a ‘cat curl’. On all fours, hands under shoulders, knees under hips, maintain your lumbar curve, gently contract your low tummy, pelvic floor tension at the umbilicus and then stretch your back up, while dropping your head down – hold for 5 seconds then return back to the start position. Breathe and relax after this set. Repeat 5 to 10 times. 

Wall squat

Standing with your back against a wall, your feet are approximately 30 cm (12 inches) away from the wall. Most importantly, your heels should be under your knees so your lower legs are vertical. Gently tighten your low tummy, vagina, anus and gently in at the belly button and slowly slide your back down the wall 8cm (3 inches) and hold the position for about 5 to 10 seconds and then slide back up again. As the weeks go by you can increase the length of hold to strengthen your central muscles and your thighs. Do not go down to 90°. Do not do this exercise if you have knee pain. You can use a Swiss ball behind your back as well. Breathe and relax after this set.

Mini squat 

Stand tall with feet straight ahead and hands on hips. Gently tighten your low tummy, vagina, anus and gently in at the belly button and slowly bend to 45 to 60 degrees at hips / knee. Incline your trunk slightly forward, maintaining a gentle curve in the lower back. Squeeze gluts to come up – pushing through heels. Bring your trunk to upright and relax gluts and pelvic floor. Repeat 5 to 10 times. Once you are feeling stronger with this you can add some rotation and also weights.

There are many more exercises and progressions of these early ones to be performed when rehabbing your DRAM. If you aren’t sure and would like help finding your transversus muscle we have ultrasound at our clinic which allows you to see the muscle working and ensure you are doing the correct contraction. We also conduct one-on-one sessions in our small gym down stairs and then we have small group, Pelvic Health Physio-led strengthening sessions where your individual problems are assessed and then a programme prescribed. 

(1) Mota P, Pascoala A, Bo K (2015) Diastasis Recti Abdominis in Pregnancy and Post Partum period. Risk factors, functional implications and resolution. Current Women’s Health Reviews 11,59-67. Sourced 17/02/19 https://www.researchgate.net/publication/282271189_Diastasis_Recti_Abdominis_in

(2) Lee D, Hodges PW (2016) Behaviour of the Linea Alba During a Curl-up task in Diastasis Rectus Abdominus: An Observational Study. JOSPT 46(7): 580-589

Thanks Megan for this blog. These early exercises are designed to establish a response by the muscles to different pressures and movements through motor training. Initially you have to think carefully about switching the muscles on and give yourself biofeedback via a mirror, but eventually the muscles will respond in a more coordinated, background way.

You can see there is still some research to be done to clarify ‘which exercises actually do what’ to DRAM. Mota, in her comprehensive article, has summarised the situation: “There is an urgent need for more basic and experimental studies to understand the mechanisms of different abdominal exercises. In addition, high quality randomized controlled trials on the effect of different abdominal exercises to prevent and treat diastasis recti abdominis are warranted”. (1)

In the third part we will progress the exercises to harder, stronger, more functional exercises.

Ring the rooms on (07) 38489601 or 0407659357 if you would like an appointment with any of the physios who make coming to work such a pleasure for me. (Megan Bergman, Martine Lange, Jane Cannan, and Alexandra Schafer). Or if you have issues in another suburb or city, check out your local Pelvic Health or Women’s Health physiotherapist for help. You can search the Australian Physiotherapy Association’s website Find-a-Physio for names.

Please note all the illustrations for the exercises come from my books Pelvic Floor Essentials (2018) and Pelvic Floor Recovery: Physiotherapy for Gynaecological and Colorectal Repair Surgery. (2018)

And here are those two cuties all grown up and a new generation of cuties produced.

 

 

 

Some strategies to help deal with grief

Grief is something we all have to deal with at different times of our lives. Sometimes it starts with a pet dying or of course worse, a grandfather. If we are young, it’s difficult to understand what has happened and the people around us often have trouble talking about death and dying.

But grief can arrive when loved ones are lost if they break off relations with family members such between a mother and daughter/son or between sisters and brothers, sometimes with no real understanding of why the rift happened.

Another source of grief can be of a brilliant mind lost to dementia. What has gone before – the mind, the words, the relationships, the abilities – all become a blur as the identity of that person fades away to just become someone who is being cared for – that someone becomes a dementia sufferer, their previous life lost and sadly forgotten by so many.

Grief is a normal and natural response to loss. Grief allows you to gradually adjust to your loss and find a way of going on with your life without the person who has died/ broken off contact/ is unable to communicate or interact as before due to dementia.

The following is taken from two sources: On Grief and Grieving: Finding the Meaning of Grief Through the Five Stages by Elisabeth Kübler-Ross and David Kessler (2014) and Bereavement support in your time of grief from The Royal Melbourne Hospital.

Elizabeth Kubler-Ross described the five stages of grief as:

  • Denial
  • Anger
  • Bargaining
  • Depression
  • Acceptance

DENIAL

Denial is the first of the five stages of grief. It helps us to survive the loss. In this stage, the world becomes meaningless and overwhelming. Life makes no sense. We are in a state of shock and denial. We go numb. We wonder how we can go on, if we can go on, why we should go on. We try to find a way to simply get through each day. Denial and shock help us to cope and make survival possible. Denial helps us to pace our feelings of grief. There is a grace in denial. It is nature’s way of letting in only as much as we can handle. As you accept the reality of the loss and start to ask yourself questions, you are unknowingly beginning the healing process. You are becoming stronger, and the denial is beginning to fade. But as you proceed, all the feelings you were denying begin to surface.

ANGER

Anger is a necessary stage of the healing process. Be willing to feel your anger, even though it may seem endless. The more you truly feel it, the more it will begin to dissipate and the more you will heal. There are many other emotions under the anger and you will get to them in time, but anger is the emotion we are most used to managing. The truth is that anger has no limits. It can extend not only to your friends, the doctors, your family, yourself and your loved one who died, but also to God. You may ask, “Where is God in this? Underneath anger is pain, your pain. It is natural to feel deserted and abandoned, but we live in a society that fears anger. Anger is strength and it can be an anchor, giving temporary structure to the nothingness of loss. At first grief feels like being lost at sea: no connection to anything. Then you get angry at someone, maybe a person who didn’t attend the funeral, maybe a person who isn’t around, maybe a person who is different now that your loved one has died. Suddenly you have a structure – your anger toward them. The anger becomes a bridge over the open sea, a connection from you to them. It is something to hold onto; and a connection made from the strength of anger feels better than nothing. We usually know more about suppressing anger than feeling it. The anger is just another indication of the intensity of your love.

BARGAINING

Before a loss, it seems like you will do anything if only your loved one would be spared. “Please God,” you bargain, “I will never be angry at my wife again if you’ll just let her live.” After a loss, bargaining may take the form of a temporary truce. “What if I devote the rest of my life to helping others. Then can I wake up and realize this has all been a bad dream?” We become lost in a maze of “If only…” or “What if…” statements. We want life returned to what is was; we want our loved one restored. We want to go back in time: find the tumour sooner, recognize the illness more quickly, stop the accident from happening…if only, if only, if only. Guilt is often bargaining’s companion. The “if onlys” cause us to find fault in ourselves and what we “think” we could have done differently. We may even bargain with the pain. We will do anything not to feel the pain of this loss. We remain in the past, trying to negotiate our way out of the hurt. People often think of the stages as lasting weeks or months. They forget that the stages are responses to feelings that can last for minutes or hours as we flip in and out of one and then another. We do not enter and leave each individual stage in a linear fashion. We may feel one, then another and back again to the first one.

DEPRESSION

After bargaining, our attention moves squarely into the present. Empty feelings present themselves, and grief enters our lives on a deeper level, deeper than we ever imagined. This depressive stage feels as though it will last forever. It’s important to understand that this depression is not a sign of mental illness. It is the appropriate response to a great loss. We withdraw from life, left in a fog of intense sadness, wondering, perhaps, if there is any point in going on alone? Why go on at all? Depression after a loss is too often seen as unnatural: a state to be fixed, something to snap out of. The first question to ask yourself is whether or not the situation you’re in is actually depressing. The loss of a loved one is a very depressing situation, and depression is a normal and appropriate response. To not experience depression after a loved one dies would be unusual. When a loss fully settles in your soul, the realization that your loved one didn’t get better this time and is not coming back is understandably depressing. If grief is a process of healing, then depression is one of the many necessary steps along the way.

ACCEPTANCE

Acceptance is often confused with the notion of being “all right” or “OK” with what has happened. This is not the case. Most people don’t ever feel OK or all right about the loss of a loved one. This stage is about accepting the reality that our loved one is physically gone and recognizing that this new reality is the permanent reality. We will never like this reality or make it OK, but eventually we accept it. We learn to live with it. It is the new norm with which we must learn to live. We must try to live now in a world where our loved one is missing. In resisting this new norm, at first many people want to maintain life as it was before a loved one died. In time, through bits and pieces of acceptance, however, we see that we cannot maintain the past intact. It has been forever changed and we must readjust. We must learn to reorganize roles, re-assign them to others or take them on ourselves. Finding acceptance may be just having more good days than bad ones. As we begin to live again and enjoy our life, we often feel that in doing so, we are betraying our loved one. We can never replace what has been lost, but we can make new connections, new meaningful relationships, new inter-dependencies. Instead of denying our feelings, we listen to our needs; we move, we change, we grow, we evolve. We may start to reach out to others and become involved in their lives. We invest in our friendships and in our relationship with ourselves. We begin to live again, but we cannot do so until we have given grief its time.

Another way to assess the impact of grief is to examine:

  • Feelings – shock, sadness, anger, guilt, loneliness, you may feel numb.
  • Thoughts- confusion and disbelief. You may dream about them or feel their presence. You may feel you’ll never get over their loss/their illness/ the changes in their mental state.
  • Physical reactions –sleep is affected, loss of appetite, tiredness, nausea or even chronic pain.
  • Behaviours- you may have no energy at all or feel like you need to do everything at once.

Suggestions to help:

  • Give time and be patient with yourself
  • Don’t make big life decisions
  • Don’t isolate yourself from family and friends
  • Allow people to help you
  • Self-care is important – eat well and exercise
  • Seek help if grief becomes overwhelming

This blog was prompted by the sad passing of Bernie – a father, grandfather and much-loved friend to many. Much love to Brenda, Kush and Barney and all their families. Everyone says that Bernie was a clever, thoughtful and generous soul who will be sadly missed by everyone.

Vale Bern.

 

 

International Women’s Day: The Whole Woman

This year’s theme for International Women’s Day (March 8th) is #BalanceforBetter and I can’t think of a better hashtag to represent what we pelvic health physiotherapists face every day, when in clinic treating patients who have pelvic floor dysfunction.

We have to assess the patient and use critical thinking, in conjunction with the patients’ wishes and desires, to work out what the patient can do every day, without over-thinking her every move and what the patient maybe should modify to prevent their problem worsening.

This is the dilemma.

We need to assess and treat – the Whole Woman.

Not just her pelvic floor. Not just her bladder. Not just her bowel. Not just any one part, but the whole of that woman who sits before us, pouring out her most vulnerable self; allowing us into her most personal corners of her being and giving us the privilege of hearing her story and giving us an insight into her personal nightmare. And let me reassure you – pelvic floor dysfunction for women can be a real living nightmare.

We have to treat her brain – her happiness, her thoughts, her anxieties, her beliefs to name a few.

We have to treat her cardio-vascular system and we do this by getting her back to exercise so her heart is strong and her blood vessels are pumping efficiently.

We have to treat her bones, her joints and her muscles in her body – again by encouraging her to exercise despite any changes that may have happened following pregnancy and childbirth.

And we have to treat her psyche – the very essence of her being a woman because a traumatic vaginal delivery may turn her female-world upside down affecting her sexuality, her confidence and her ability to do very basic things without feeling fearful and anxious.

We need to get the woman back in balance after the changes that pregnancy and childbirth bring to her.

Every day in our pelvic health practice we see patients who have a myriad of issues that arise as a result of a pregnancy, a vaginal delivery or a caesarean birth. Nowadays patients can easily access the same information about these issues as their physiotherapist or doctor. Many research articles are freely available on the internet and modern patients are very often good researchers.

Many are also very active on Social Media- they are members of many Facebook Groups that discuss childbirth issues and mothering problems – including all the joys, successes, heartaches and failures and can be very well-informed, but also absolutely terrified by what they have read.

Happy and oblivious! I was untrained in both baby caring and my bodily changes and I was a physio! And worse still, Facebook was not a thing

The patients arrive armed with pre-knowledge, primed with anxiety and fears and already have diagnosed many problems (that may not be even accurate, but the fears are difficult to let go of). Don’t get me wrong though, many of these Facebook support groups have been a lifesaver for women and brought them back from the brink.

Many arrive with complex problems that have completely trashed their former lives and because we focus on the ‘one day of labour’ instead of informing women about potential changes that can happen – women are completely unaware and not expecting these serious complications that have come out of left field for them. These patients can be sad….and bewildered………and angry at the same time.

Then because we see having the baby as the line drawn in the sand, rather than the beginning of the fourth trimester (more on that in a moment), women are handed this baby and sent home without due respect being given to any changes that have happened to their bodies.

Some women feel abandoned by the health system.

(The fourth trimester is a period described by expert Dr. Harvey Karp, an American pediatrician and children’s environmental health advocate, as the first three months of a baby’s life- a time when a newborn is adjusting to life outside of the womb. Many writers and commentators are now viewing the fourth trimester as a period of time for the mother to be ‘rehabilitated’ and as such are lobbying governments to fund regular visits to a pelvic health physiotherapist as a routine like they do in France).

 

Some of these women have played competitive sport.

Some are recreational joggers.

Some had hoped they would eventually kick a ball in the park with their child as they got to toddler status, without leaking urine (or gas or faeces).

Others had hoped to get back to sexual intimacy sometime before the child headed off to school.

Call me biased but I just don’t think governments and health funds take women’s health seriously.

Because if they did there would be serious attention and funding given to prioritizing the immediate period after having a baby like there is in France.

The evidence is clear. Pelvic floor dysfunction costs our economy a lot of money. Incontinence alone was estimated to cost the Australian economy $40 billion back in 2010. (Access Economics Report)

So if we want to indeed strive for #BalanceforBetter for women, we should become more vocal about financial support for mandatory assessment and treatment for every woman who has had a baby – regardless of the mode of delivery.

And if we want to indeed strive for #BalanceforBetter for women as they age, we should also become more vocal about incentivizing women to attend a pelvic health physiotherapist regularly every year through all the life-stages to encourage long-term adherence to pelvic health programmes. 

Today, while waiting on the phone to my health fund to enquire about the new (whiz-bang) changes to the name of my level of private health coverage (all $6025 per year for two of us) – now called Gold Level (I wanted to see if Silver, Bronze or Wood … would still keep me alive and kicking and cost substantially less) there was a pre-recorded message to lull me into a stupor (and thus rendering me oblivious to the length of the wait).

Instead the pre-recorded message made me angry.

My health fund was telling me that I was entitled to two visits to the dentist per year for a fully funded visit (absolutely nothing out-of-pocket) for an inspection, clean and scale – BECAUSE WE ALL KNOW HOW IMPORTANT DENTAL HEALTH IS TO OUR GENERAL HEALTH AND WELL-BEING! said the recording. This equates to $225 twice a year for every member on the coverage. No out-of-pocket expenses.

I was shouting back at the pre-recorded message: YOU KNOW WHAT? PELVIC HEALTH PHYSIOTHERAPY- GETTING YOUR BLADDER, BOWEL AND PELVIC FLOOR IN ORDER – IS PRETTY DAMN IMPORTANT TO YOUR GENERAL HEALTH AND WELL-BEING ALSO!!

Shouting at the pre-recorded message on the phone won’t get us anywhere.

What might help is to write to your parliamentarian (they are always all ears when there’s an election looming), ring your private health fund and ask them to record your complaint about this inequity (dental rebates versus physio rebates) and perhaps share this blog on Social Media.

Enough of expecting women to shut up and put up with pelvic floor dysfunction!

Here is the link to another blog I have written about this inequity.

#BalanceforBetter #pelvichealthphysiotherapy #treatthewholewoman #InternationalWomen’sDay #IWD2019

 

 

 

DRAM: Diastasis of the Rectus Abdominus Muscles

This week’s blog contribution has come from Martine Lange, one of the excellent Women’s Health (and musculo-skeletal) physiotherapists who work with me at Sue Croft Physiotherapy. Women are always distressed about the changes that occur to their bodies with pregnancy and this is important to acknowledge and respect because it can play with their sense of well-being and happiness. If a woman has a large abdominal separation and/or stretch marks and loose skin and she is miserable with her ‘changed look’ of her body, this can lead to significant anxiety and depression for her. Martine’s blog follows.

“I still look pregnant!”, “Look at all this flabby stuff!” (as she grabs at her belly), “Why hasn’t my tummy gone back to normal?” These lamentations are commonplace within the walls of a physiotherapy clinic for women from 2 months to 20 years post-baby. Sometimes the problem can be attributed to DRAM or Diastasis of Rectus Abdominus Muscle, otherwise known as abdominal separation, rectus diastasis or diastasis recti.

Image from Pelvic Floor Essentials 2018 (Sue Croft)

What is DRAM? 

It is the excessive separation between both bellies of the rectus abdominus muscles and can occur anywhere along the linea alba from the xiphoid process (tip of the breast bone) to the pubic bone. Most of the separation often occurs at the belly button (the umbilicus). It is measured by something called the inter-recti distance (IRD). (1) A strong, intact abdominal muscle is important for abdominal organ support as well as postural support.

If we think of our rectus abdominus or six-pack muscles, (yes we all have them even if we’ve never seen them!) – as your belly expands during pregnancy (or with abdominal weight gain), the rectus abdominus muscle needs to stretch to accommodate the growing baby and the increasing weight and dimensions of the expanding uterus (from 40 to 1000 grams and the capacity from 4 ml to 4000 mls) (1)

Muscles, however, can only stretch so far, so when they have stretched to their maximal capacity, something else has to happen to make room for the abdomen. So, the muscles separate sideways. They remain joined centrally by the fibrous structure -the linea alba -which is made up of collagen fibres (called an aponeuroses) from the deeper abdominal muscles such as transversus abdominus and the external and internal obliques (1). The linea alba is one of the important structures for good strength and function of the anterior abdominal wall but it can increase in length when the mechanical stress is prolonged such as with sustained increased intra-abdominal pressure (as in pregnancy). (2) 

Abdominal separation is very common- in fact some researchers believe some degree of separation is found in up to 100% of women during pregnancy (Mota et al 2015), but it commonly affects between 30-70% of pregnant women and in studies has been coincidentally found in 39% of women undergoing abdominal hysterectomy (3) and 52% of menopausal urogynaecological patients.(4,1)

After the baby is born and suddenly there is much less stretch on the muscles, then everything should just bounce back… right?

For some, with great genetics (meaning great collagen elasticity) this does happen and within six to twelve weeks after giving birth, their separation may be minimal and not symptomatic for the woman. For the rest of us, the process is a little slower or never seem to completely resolve.

Imagine that you are wearing a corset, it holds the abdominal contents up and in. Now imagine you loosen the corset down the middle, everything  sits a little lower and a little further out. This is somewhat analogous to what happens with an abdominal separation, we no longer have that taut fibrous band down the centre of the muscles, instead the band (linea alba) is more stretched or loosened so things can tend to “pooch” out a bit more.

Functionally, if you are getting bulging in the belly with exercises or getting out of bed or a chair, this is not a good thing, because it means there is not enough tension across the linea alba to hold the abdominal contents. If a person can increase the tension (i.e. take out the slack) in the linea alba whilst they are doing exercises that may otherwise cause bulging, then they are preventing worsening of DRAM. This tensioning is done by contracting the transversus abdominus and pelvic floor muscles. This co-activation of muscles can be performed to protect against increases in intra-abdominal pressure (such as during cough, sneeze, lift, bending etc) and is called “bracing” or “the knack”.

For women who worry about the appearance of their tummies (and let’s face it that’s most of us at one time or another), often we are holding / sucking the belly in for significant periods of the day. When these muscles are “turned on” for long periods, they tend to fatigue, and then are no longer able to assist in the support of the pelvic organs effectively and it may increase the risk of pelvic floor dysfunction such as stress urinary incontinence or worsening of prolapse. These muscles should be contracting (and relaxing) regularly throughout the day to protect the pelvic organs from excessive descent or from bladder leakage which can occur with increases in abdominal pressure (such as with cough/ sneeze / lift etc).

What strategies can we use to help improve / prevent DRAM?

  • Bracing with the pelvic floor and low abdominal muscles for strong movements (sit to stand, lifting, sneezing, coughing etc) and relaxing the muscles afterwards when the task or activity is finished
  • Ensure good bladder and bowel habits to maintain good pelvic floor health
  • Move well – for example log-rolling to get out of bed rather than doing a sit up
  • Sleep with a thin pillow under the belly when on side to minimise drag on the separation
  • Use of abdominal supports in the early post-partum period such as tubigrip, SRC recovery shorts and other brands of support
  • Using your hands to support the abdomen with coughing / sneezing etc

For some women, especially those with poor collagen elasticity and who have had multiple pregnancies their DRAM may not recover to a point that they are happy with, and this is completely understandable! Who wants to be asked how many weeks along they are when they aren’t even pregnant? For these patients there are surgical options:

  • Plication-based repair – these can be done either open or laproscopically or a hybrid repair (both laproscopic and open), usually the linea alba is brought closer together and then stitched, (and may be reinforced with mesh).
  • Hernia-based repairs
  • Abdominoplasty – In this case a plastic surgeon may also be repairing other things such as excess skin, performing liposuction. (Here is a link to another blog on a patient’s story about her Abdominoplasty)

There is no robust evidence regarding recurrence rates, cosmetic outcomes, quality of life or complications following surgical repair. It is also worth noting that these are fairly invasive surgeries, so for optimal recovery it is important to minimise lifting / housework etc afterwards, which is not always easy if you have a couple of toddlers! Having said that, for many women having these surgeries can significantly improve their quality of life and body image.

All the changes that happen to our bodies after babies can be intense, mortifying, painful and sometimes wonderful, but for each of us it is a different and unique experience and our management is therefore going to be different for every individual. With guidance from an experienced caring pelvic health physiotherapist and healthcare team you can get a satisfying outcome

(1) Mota P, Pascoala A, Bo K (2015) Diastasis Recti Abdominis in Pregnancy and Post Partum period. Risk factors, functional implications and resolution. Current Women’s Health Reviews 11,59-67. Sourced 17/02/19 https://www.researchgate.net/publication/282271189_Diastasis_Recti_Abdominis_in_Pregnancy_and_Postpartum_Period_Risk_Factors_Functional_Implications_and_Resolution

(2) HernándezGascón B, Mena A, Peña E, Pascual G, Bellón JM, Calvo B. (2012) Understanding the Passive Mechanical Behavior of the Human Abdominal Wall. Ann Biomed Eng 2012 13; 41(2): 43344

(3) Ranney B. (1990) Diastasis recti and umbilical hernia causes, recognition and repair. S D J Med; 43(10): 58

(4) Spitznagle T, Leong F, Van Dillen L Prevalence of diastasis recti abdominis in a urogynaecological patient population.  Int Urogynecol J pelvic Floor Dysfunction 

Thanks Martine and we will follow up with some exercises in the next blog that you can do at home to help with improving any abdominal separation you may have. We are conducting one-on-ones in our new space downstairs so if you would like to have an individualised programme set by Martine or Megan or Jane or Alexandra, contact the rooms.

Celeste Barber: Author of the best self-help book for teenagers

Strong language (in this week’s blog) warning (Mum)!

I have just finished Celeste Barber’s first book Challenge Accepted and I can’t recommend it enough – yes it’s a good laugh but mostly it’s a prophetic look at handling growing up and surviving living in a SoMe* saturated life. Her insights into why we all shouldn’t GAF** about SO MANY THINGS are a revelation and this book should be mandatory reading for all teenagers currently suffering with a sensitive tummy (my new go-too phrase instead of anxiety) and angst with school, social life and life in general.

The interesting thing about Celeste is she suffers with dyslexia and the task of writing a book must have been very daunting for her.*** She is also quite young to have so much to write about but she draws on her own significant health / life events to keep the reader entertained and laughing even when the topic is quite serious. #inspiring. Celeste also writes about her own difficult times at school when the Mean Bitches**** made one of her school years lonely and probably sad, on many occasions.

She writes: “I couldn’t think of what I could’ve done to warrant such anger and hostility from the whole school year (Gr8). So in that moment down by the buses, I took a deep breath, pulled myself together and made a decision. I just decided I didn’t care. I didn’t care to investigate, I didn’t care about begging for forgiveness for something that no one was going to help me understand. I realised all people wanted was to make me feel shit, and I didn’t care. I had bigger stuff going on. I had drama monologues to learn, ‘Friends’ episodes to watch and re-watch, dancing concerts to show off at. These bitches were the least of my worries. This continues for an entire year. Bitches 1 and 2 had used their mean-girl power to persuade everyone in Year 8 into thinking I was a loser who wasn’t worth talking to.”(1)

To do this in Grade 8, Celeste had amazing resilience and strength of conviction in her sense of self and her thoughts on how to navigate life. And her theories on dealing with negatives also now extends to her later life when she is now an Instagram star (5.4 million followers and counting) and obviously cops some dubious trolling on SoMe*. This book needs to be part of any school curriculum.

When I first heard about Celeste, I thought she just started doing her ChallengesAccepted with no background or ‘training’. But of course she is a trained actor and comedian and has been preparing for this ‘stardom’ for her whole life and she deserves it. You need to read her book to understand what I mean.

Helping teens cope with the trials and tribulations of school life and growing up with raging hormones and confusing relationships needs serious attention. The statistics for sensitive tummies (anxiety) and sadness (depression) are mind-blowing. More than 40% of Year 12 students report symptoms of depression, anxiety and stress that fall outside what is considered the normal range for this age group. The teenage years are also seen as a crucial period for intervention as 75% of mental health problems emerge before the age of 25 years.(2)

Not only is mental health a concern in this age group, but if teenage girls have their bodies infused with chronic cortisol and adrenaline release from ‘friend’ bullying AND have regular significant pain with their periods, they are at risk of developing persistent pain that will go on to affect their working life, their sexual experiences and their sense of well-being. So learning strategies to break the cycle of bullying and cope with ‘poxy’ peer behaviour early in adolescence may have a larger impact than we can even imagine.

What is best about this book is, it’s written in #kidsspeak with a smattering of #badlanguage and a huge number of laughs. Better than any formal book on strategies to manage a sensitive tummy (anxiety). So I commend this book to you and recommend you follow @celestebarber on Instagram to get a regular laugh in this crazy serious (#climatechangeisreal) world of ours.

(1) Book by Celeste Barber Challenge Accepted! 

(2) Black Dog Institute https://www.blackdoginstitute.org.au/

Other resources:
My blog with lots of links to persistent pain resources within in it: https://suecroftphysiotherapistblog.com/2014/10/30/persistent-pelvic-pain-information-in-one-location-at-last/

Beyond Blue is an organisation which provides information and support to help everyone in Australia achieve their best possible mental health, whatever their age and wherever they live.

The Black Dog Institute is dedicated to understanding, preventing and treating mental illness. We are about creating a world where mental illness is treated with the same level of concern, immediacy and seriousness as physical illness; where scientists work to discover the causes of illness and new treatments, and where discoveries are immediately put into practice through health services, technology and community education.

*SoMe stands for Social Media- the world of Twitter, Instagram, Facebook, SnapChat and the like.

**GAF stands for Give a fuck

*** Writing a book is hard with no learning/language difficulties – I wrote my first book Pelvic Floor Recovery: Physiotherapy for Gynaecological Repair Surgery in 2011 and Pelvic Floor Essentials in 2012 and have revised and updated them every couple of years, being up to Edition 4 and Edition 3 respectively of both books. It does become overwhelming at times- the research, the constancy of having to sit at the computer every weekend writing (when others are having fun), as I see patients throughout the week and then there’s the Imposter Sydrome***** that comes with deciding that you have something actually worthy to say. I have actually learnt from Celeste’s book – I no longer GAAF******about Imposter Syndrome!

****Mean Bitches you can get an insight into who Mean Bitches actually are by watching a MUST SEE movie called Mean Girls even if it is 15 years old now. It is all about girls and how mean they can be to each other at school.

*****Impostor syndrome is a psychological pattern in which an individual doubts their accomplishments and has a persistent internalized fear of being exposed as a “fraud”.

****** GAAF means Give an actual fuck 

Continence – no its not two very large areas of land

We take continence for granted until we don’t have it any more.

Many people don’t even know what we mean by the word ‘continence’. I was reminded of this the other day when I went into a restaurant and I asked could we hire their restaurant for a meeting for the Continence Foundation of Australia – the peak body for continence promotion – and the waitress wrote down the word Continents. When I corrected her spelling she had no idea what the word Continence meant.

What does it mean?

It means confidence with laughing at the Melbourne Comedy Festival.

It means exercising with gay abandon with your children.

It means you aren’t really thinking about where is the next toilet, therefore freedom to enjoy your holiday, travel on public transport, hike in open fields with no trees (to hide behind).

Continence is expected by the age of 2 or 3 and if you don’t achieve it, your parents get judged.

There are no formal instructions given, yet it is way more complicated than putting together an Ikea wardrobe.

And when you lose continence after a baby, you are sometimes told by your doctor, you are too young to do so and it’s all because you didn’t pay attention at the birth classes when they mentioned pelvic floor exercises.

But when you are a woman and post-menopausal the same health professional may almost write you off because there is an expectation that it is a ‘given’ that you will leak now you are old.

So what are some hints to achieve continence?

If it’s sudden and out of the blue – think infection. See your doctor for a micro-urine because all bladder infections don’t necessarily present with burning, pain or a feeling of passing razor blades.

If it’s immediately after childbirth, take it seriously and be assessed by a pelvic health physiotherapist to see what might be the cause. It may well be that learning about those pelvic floor muscles may in fact get you dry.

But do seek help – don’t just hope it will get better with time, even though there may be some improvement as swelling decreases, as nerves start to do their thing after the tractioning or compression they may have received at the vaginal birth. There can be urethral sphincter damage (Intrinsic Sphincter Deficiency ISD); there can be smooth muscle (the detrusor) irritation making it seem like the bladder is the boss not your brain (the overactive bladder OAB); it may be that the vagina (the labia) seems to be trapping the urine causing an annoying dribble post void (called a post micturition dribble); it can be due to constipation – who’d have thought?

The pelvic health physio is going to teach you to be a detective – what does your bladder hold? Normal is 350-500mls per void (wee). So she will ask you to do a 48 hour bladder diary and check out volumes, triggers to void, what you drink in (type of fluid and volume), episodes of leakage, frequency during the day and night and assess how you need to respond to the findings.

She* will give you lots of education about what is normal and what goes wrong and reassure you that leaking urine is common (30% of women in their lifetime will suffer urinary leakage) but never normal and may even tell you she got into her job because she has had it also.

A pelvic health physio should help you feel unburdened once you have fessed up to your secret. You should feel lighter for seeking help and more hopeful that this isn’t the future forever. And once you have commenced your new strategies you should feel renewed vigor in your step and reinvigorated to go back to exercise, to playing with your grandchildren and laughing out loud with confidence!

The saddest thing is that as you read this, in many doctors’ surgeries around the world there will be many women (and men) too embarrassed to mention their problem to their doctor and their doctor is too time-poor to ask them “How is your continence?”

Well at least after this blog you will know if your doctor asks you, he is not enquiring after any large land masses!

If you have any continence issues we have five delightful pelvic health physios who can help you; Megan, Jane, Alexandra, Martine and myself, Sue. Give my caring and discreet secretaries a ring on (07) 38489601 if you are in Brisbane or check out the APA Find a Physio site or the CFA Helpline 1800 33 00 66 and they have a list of Pelvic Health Physios to help you around Australia.

*My pelvic health physio is a she in my blog but there are he(s) that can be pelvic health physios also.

 

 

Jane Cannan: The Pain Revolution Ride: Training for Tassie

I have written another previous blog about one of my lovely, smart, compassionate pelvic health physios – Jane Cannan – who got herself a gig on the #painrevolutionride around Tasmania with Lorimer Moseley and David Butler this coming March, 2019. I am so pleased for Jane because this is a highly sought-after ride to spread the word through regional Australia about how best to manage persistant pain. It’s a hard ride and is especially amazing because Jane is certainly the athlete – but a runner not a cyclist. But she is showing that she has hidden talents as a cyclist because she is ‘killing’ the training. She slips into work each week looking like SHE is doing LitenEasy (not me) and looking stronger and fitter every day. She has written this blog and kindly allowed me to post it as well. I love it because she reminds us about the training required to teach the brain how to not go into the usual fear-driven response when pain is felt with a movement and also how innately strong and resilient the spine and our bodies really are.

Jane’s blog follows:

I recently read a quote by Wayne Gretzky that said “you miss100% of the shots you don’t take”. I’m reminded of it this morning after coming home from another ride in preparation for the Pain Revolution Rural Outreach Tour which is only just over 7 weeks away. Since applying for this Tasmanian adventure in September 2018 I have ridden over 4150km to prepare for the 8 day, 700km ride from Devonport to Hobart.

Hello, I said 4150km, in 4 months!! This is NOT normal behaviour for me. I absolutely loved this morning’s session because it was hard – it asked me to give more than I knew I had and 10 hours beforehand I was horribly afraid of showing up for it and needed a friend’s encouragement to be brave. More than the physical gains I’ve made, the most meaningful change has been in how I cope with fear; an achievement that I have learnt doesn’t happen through hope or good intention alone, and coincidentally, neither does recovering from persistent pain.

One of the goals of the Pain Revolution is to prepare people to rethink what their pain means and in doing so give them the opportunity to try and take the shot. The shot they have probably taken unsuccessfully for quite some time. That activity or movement that has caused them an increase in pain and reinforced the belief that they are fragile, broken, limited and should never expect to be free. This feeling is crushing to a person’s sense of self and is responsible for killing many a joy.

Wayne Gretzky was an ice hockey player and coach, but I watched a game once and couldn’t understand it, so I’m sure he won’t mind if I think about his quote in terms of basketball instead. 

Picture a basketballer about to take a shot that will determine whether his team wins or loses a game. Now we know he has no choice but to take the shot, it’s very unlikely that he will shake his head, plant the ball on the ground and walk off the court. What does he do to give himself the best chance of success? He calms his breathing, relaxes his shoulders, softens his grip on the ball, quietens himself and blocks out the environmental noise. The same applies when moving differently for the first time in a long time.

If bending to pick up something off the floor has resulted in pain over and over again, it makes sense that in preparation for the task a person may hold their breath, tense their shoulders, over-tighten every one of their abdominal and back muscles and grit their teeth, possibly without even realising it. You could take a person with no back pain history, teach them to move this way and have a pretty good chance of making the activity hurt or at least feel dreadfully uncomfortable. This is pain science in practise. We are choosing to use intelligent internal cues that come from accurate knowledge to manipulate physical performance. You could use it for good, or to increase someone’s chances of failure. I choose for good.

Whether it’s in preparing for high stakes sporting moments or turning up for a training session or performing that movement that gives you grief, I urge you to stop, check in with your body and see if you can manufacture the state that will increase your chance of making the shot.

If you want to know more, or to follow the Tassie ride check out the website https://www.painrevolution.org/ and facebook page. A little more about me and my pain story can be found in the link to my fundraising page below. All donations are most gratefully received.

https://painrevolution2019.everydayhero.com/au/jane

Thanks Jane and I hope many of my readers will take on board your wise words about fear and pain, about the amazing ability of breathing and relaxing to change pain intensity and to develop the body’s inbuilt belief system to adapt to this new and evidence-based knowledge that your body is innately strong and robust not weak and fragile.

Jane needs to raise a certain amount of money towards pain research as part of the #painrevolutionride so if you feel inclined give a few dollars towards this worthy cause she would be very grateful. All monies raised goes to pain research. 

Great work Jane xx

LRSM: The new acronym for post-op gynaecological and colorectal repair surgery management

Blog Number 300: Well done me!

Today’s blog is Number 300. I started my blog back in 2011 inspired by my son who was in first year architecture and had to do a blog as a part of his uni course. It’s hard to believe today, that I didn’t even know what a blog was back in 2011, considering they are so much a part of our lives these days.

My blog is not only a way to catalogue pelvic floor dysfunction (PFD) resources for my patients and maybe anyone else who may wish to read it, but it has become a personal diary in lots of ways allowing me to remember memorable (overseas) holidays and get on a high horse about things that seem a little unjust or unfair.

Thank you to anyone who has taken the time (in this day of 20 second scrolling) to actually pause and read my blogs and also thanks to anyone who shares them or adds the link to their own website. I love the ability we have these days to share information and whilst the internet has some negative aspects, it is such a wonderful opportunity to talk about things like prolapse, pessaries, incontinence, pelvic pain and sexual dysfunction in a world-wide fashion. My blog is evidence-based but it is written in such a way that non-health professionals can read it and hopefully understand it.

I wanted Blog Number 300 to be significant because I think getting to my 300th blog is pretty amazing even if I do say so myself. But enough of my self-congratulations. And on with the blog……

Health care is riddled with acronyms. Basically just about every medical condition has an acronym, which makes it very hard as you get older to try to remember what they all mean. And I am sure there are some people who are making new ones up just to confuse us oldies. Some may use acronyms as a ploy to sound important to the patients. Some acronyms are scary… like Deep Infiltrating Endometriosis – yes DIE really??? and many researchers try to get clever with their trial names and they actually become memorable and easier to remember like the POPPY Trial Pelvic Organ Prolapse PhysiotherapY ( Results: One-to-one pelvic floor muscle training for prolapse by a physiotherapist is effective for improvement of prolapse symptoms)(1).

Today’s blog was inspired by two acronyms I saw in a recent post on Facebook and it took me a while to work them out – AVWP and PVWP. Anterior vaginal wall prolapse and posterior vaginal wall prolapse. Now I have read many (a million) articles on prolapse and have never come across those before and I am provocatively writing this so someone (maybe manyones) will call me out and say ‘Hey, that is now the correct new terminology Sue’! (I did google the International Continence Society Terminology page and didn’t see it). 

But today a patient returning for a 6 month post-op repair surgery check up inspired my new acronym and I think this is going to catch on <winking>.

LRSM. And what does it stand for? 

L for LISTEN

R for RESPECT

S for STOP

and M for MODIFY

My patient said a little phrase that just triggered these words. It really isn’t that catchy, but I like the sentiments and it gives me chance to integrate the words into this post-op post.

We pelvic health physios teach you to listen to the messages your body gives you and respond appropriately to those messages. So if you feel pelvic floor descent when you cough and sneeze, you need to counteract that descent by turning your pelvic floor on – I call it ‘bracing’ in my books but it is known as ‘the knack’. (2) If you get a bowel urge then don’t defer, make sure you try to find a toilet to evacuate your bowels using the correct position. If you are feeling pain (your pelvic floor muscles may be spasming and producing that pelvic pain), so remember to relax your tummy, pelvic floor muscles and inner thigh muscles and do some belly breathing.

The next word is respect!

Respect the state of your pelvic floor – Has there been trauma to the muscles meaning the strength is compromised such as with Levator Avulsion (and not because you are not doing pelvic floor exercises);

 

Respect the research statistics on risk of failure of your surgery – with gynae repair surgery in general there is up to a 30% failure rate (3,4) and if the patient has partial or complete avulsion it potentially may be as high as 80% (5);

Respect the surgery that the surgeon has done and the advice she or he has given you;

Respect the money you have spent on the operation and the cost of the time you may have had off work.

The next word is stop!!

Stop and think, assess, remember your guidelines and the advice from your surgeon, pelvic health physiotherapist and in my book Pelvic Floor Recovery: Physiotherapy for Gynaecological and Colorectal Repair Surgery;

And finally modify your behaviours. Sometimes its just small adjustments – learn to exhale on effort – don’t hold your breath; paced and graduated return to exercise; do more repetitions of a lighter weight; alter the position – adjustment of position can significantly alter pressures down the vagina; but make sure your physio has helped you understand the state of your pelvic floor strength and descent so you modify accordingly but don’t stop exercising completely.

So there you have it! LRSM! 

L for LISTEN

R for RESPECT

S for STOP

and M for MODIFY.

Remember it, implement it and pass it on.

Do you think it will take off? Or just confuse the hell out of another ageing physio or two?

And here’s hoping I (and my brain) have it in me to do another hundred blogs and get to 400.

If you want to follow my blog the word Follow should be on the screen somewhere – click on follow and enter your email address and the blog will automatically pop into your email box.

(1) Hagan S et al (2014) Individualised pelvic floor muscle trainig in women with pelvic organ prolapse (POPPY): a multicentre randomised controlled trial. The Lancet, Volume 383, Issue 9919, 796-806

(2) Miller J, Ashton-Miller J, & DeLancey J(1998). A Pelvic Muscle Precontraction Can Reduce Cough-Related Urine Loss in Selected Women with Mild SUI. Journal Of The American Geriatrics Society, 46(7), 870-874. http://dx.doi.org/10.1111/j.1532-5415.1998.tb02721.x.

(3) Brubaker, L., Maher, C., Jacquetin, B., Rajamaheswari, N., von Theobald, P., & Norton, P. (2010). Surgery for pelvic organ prolapse. Female Pelvic Medicine & Reconstructive Surgery, 16(1), 9-19. 10.1097/SPV.0b013e3181ce959c

(4) Wu, J. M., Matthews, C. A., Conover, M. M., Pate, V., & Jonsson Funk, M. (2014). Lifetime risk of stress urinary incontinence or pelvic organ prolapse surgery. Obstetrics & Gynecology, 123(6), 1201-1206. 10.1097/AOG.0000000000000286

(5) Dietz, H. P., Chantarasorn, V. and Shek, K. L. (2010), Levator avulsion is a risk factor for cystocele recurrence. Ultrasound Obstet Gynecol, 36: 76–80. doi:10.1002/uog.7678

London: The final travel blog 2018 trip

Hello Islington

We flew into London which was swathed in a greyness which I have heard has barely lifted over the past 6 weeks. We whinge a bit about our endless sunshine but I know most Londoners crave a blue sky and the need to squint their eyes when they go outside and relish any sign that it is going to be a sunny day. We trained it to Islington- Highbury and walked to our London digs. It was an AirBnb in Islington close to where our children are living. After the decadence of the aDLER Hotel in Innsbruck, our London flat was a shock to the system. It was a bit mouldy, a bit ordinary and had a saggy double bed – but it was close to family and that was all that mattered. We walked into Clerkenwell to meet the kids at a London pub and it was lovely to see them looking so well.

First London night at The Eagle, Clerkenwell 

The main reason for coming to London in the colder (wetter) months was to see the London Christmas lights and they didn’t disappoint! Down most streets and on most buildings were sparkling lights and Christmas trees – London takes Christmas very seriously.

      

London ‘does’ their Chrissy lights well…..very well!

The other significant reason for a November trip was to celebrate our 40th wedding anniversary. 40 years – it rolls off the tongue so easily and to be honest it really seems like yesterday that we were standing in the backyard of my brother’s new Ascot home ( which he and his wife had generously made available for our wedding and reception) taking our vows.

Sweet young things 40 years ago   

 40 years later

But for it to pass so quickly – it must have been a hoot and to produce three beautiful children, it must have been a blessing.

Our wonderful kids gave us a voucher for the beautiful Palomar Restaurant in Soho and also two tickets to Les Miserables on Covent Garden. This is our favourite live show and this production was very special. Thank you very much xx

Spectacular eggplant dish and yummy dessert from Palomar Restaurant

 

     

Off to Les Mis!

Over the course of our stay, we did lots of walking around London – The Regents Canal Walk, around Bath to watch Soph play netball, to Buckingham Palace for old times sake, past 10 Downing Street and then had lunch at the pub opposite (Bob got his pork pie there). We ‘did’ the Natural History Museum, went to the top of the Shard (again another great birthday present for Bob from the kids) and saw St Paul’s lit up at night.

     

Regents Canal walk

   

St Pauls at night from the Millenium Bridge and at the top of the Shard

We went to Maltby Markets and had some of the most delicious market food ever and walked down one side of the Thames across the Millenium Bridge and up the other side of the river. Every day in London was easily 25000 steps!

    

Maltby Markets – Delish!

One of the special trips we had planned to do was to make a day trip to Folkestone on the train so we could walk from Folkestone to Dover. It’s part of an architectural walk called ChalkUp 21and seriously we were so lucky to get to do it. It had rained every day in Dover since the start of our trip (I studied the weather app every day) and after 17 days on our second last day in the UK, it was predicted to be fine and gloriously sunny – which it was – but it started out at 4 degrees but warmed up slightly as the day progressed. As you can see the not only was the weather spectacular but the scenery was also.

We started the walk at the Battle of Britain Memorial at Folkestone and then walked along the ChalkUp21 path. It isn’t very clearly marked so take care (you’ll hear why in a moment).

 

The Battle of Britain Memorial, Folkestone

The problem with being the only sunny day in 3 weeks of rain is the path was very, very muddy and ever so slippery so it was a slow and slightly hazardous walk.

   

Real mud but they washed up well after the trip!

We managed to take the wrong path thinking the path went down to the ocean and we would walk along the edge of the water. But sadly the walk goes along the top of the cliffs and we had to climb right back up to the top. It was the first time that I actually wondered how I was going to do that because the climb down was so difficult. But the climb up was dead easy compared to the slipping and sliding of the descent.

The White Cliffs of Dover – If we hadn’t taken the wrong path we wouldn’t have seen this view. A bit daunting to climb back up to the top again!

Personally I think the Seven Sisters walk we did last year was much more scenic, but I felt a great sense of achievement completing this walk and making it to the Dover Train Station and sitting down for a scone and hot chocolate. But I am a little regretful now that I sent Bob to check out the start and finish line for the (offical) English Channel Swim because I didn’t think I could take another step to go and look at it. It was a very long walk that we had finished and my feet were killing me. 

The best part of the trip was knowing that Mike had secured his own accommodation in London. He arranged it on our second last night and that in itself is quite a feat as demand for accommodation is fierce. We celebrated at his local to say goodbye.

The funniest thing about this trip was by the time we had to depart London, I had grown quite attached to our little mouldy, saggy apartment and was sad to say goodbye to it, but there will be another trip – that’s what happens when your kids “Do London”!

London last night at Mike’s new local pub, de Beauvoir Arms 

That is the last of the travel blogs for the moment. I had to write it today because a patient asked me a question about the trip and I struggled to remember what we had done that was special. And while there is lots more that we did in London, these are some highlights and will give us lots of lovely memory prompts in the future. I apologise for the self-indulgence and boring you with all my personal blogs but it is my diary (sort of). At least I’ll never lose it and know exactly where to find it!

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