As a women’s health physiotherapist and a new mum myself, the words mummy tummy are no strangers to me. When pregnant myself last year, I recall my major concerns with my future postnatal body were stretch marks and the dreaded ‘tummy gap’, also known as a diastasis of the rectus abdominis muscles when I am wearing my professional hat.
Despite all my knowledge about pelvic floor dysfunctions and the havoc it can cause to us mums, mummy tummy was something I felt more out of control of being able to address myself. During pregnancy and prenatally I did my pelvic floor exercises religiously and whilst practising them I was gaining feedback all the while on how my pelvic floor was holding up by how they felt, how many I could do, how long I could hold them for. However, with a growing bump all I could see was more stretched and itchy skin and less feet! It wasn’t until having my little girl could I then assess how my tummy muscles had truly coped.
This is something I feel many ladies can relate to, not necessarily for the same reasons, but I feel that the number one bodily concern for mums to be besides the birth itself is loosing their tummy and waistline. I feel this is probably partly due to the fact we have a long way to go with education and awareness on other health and musculoskeletal issues related to childbearing such as pelvic floor muscle dysfunction, pregnancy related pelvic girdle pain, and life changing issues such as gestational diabetes.
I also relate this ‘mummy tummy’ fixation to social media today often portraying that your body should just ‘ping back’ after having your baby. What posts and Instagram pictures of famous celebs showing off their perfect wash board postnatal tummies doesn’t show is the 30 minutes it may have taken to set up the perfect light, angle and filter needed for that picture and the team of health and fitness experts providing her with advice and supervised daily exercises, and a nanny to help them whilst they are exercising! This is when social media is not always good for the body and mind and postnatal depression.
So my aim today is to provide some clarification and support on:
The 2nd part of this blog will then help you to understand;
The abdominal wall
Your abdominal wall is cleverly designed to act as a well designed corset, with horizontal, diagonal and vertical layers, which join at the front via a fibrous connective tissue strip. The muscles act together to support your abdominal organs, protect your spine and provide movement.
What is a diastasis rectus abdominis?
During pregnancy, the abdominal wall has to expand to accommodate your growing baby and all that comes with it, the Rectus Abdominis muscles commonly do this by stretching and widening the fibrous strip in the centre of your tummy causing the two abdominal walls to separate apart. This fibrous strip that connects the left and the right abdominal muscles is called the linea alba and it is not as elastic as the muscles it connects together and so it takes time for it to recoil back if at all once you have had your baby. It can thin and become weaker.
Diastasis of the rectus abdominis muscles (DRAM for short) can start around 14 weeks of pregnancy, and can continue to increase until delivery. Studies have found the average increase in the distance of the gap to be around a centimetre from the navel to the pubic bone and just under 3cm above the navel, with 1cm found in the upper abdomen. Research has also found though that in ladies who have not had babies that there is a great variation in the inter-abdominal muscle gap distance so what can be normal for one lady may not be for another. So classification of a diastasis is generally termed as having over 2 cm gap between the abdominal muscles. However....recent research by pioneering women's health physiotherapists such as Diane Lee and Julie Wiebe have highlighted it is not just the width of the gap that is relevant but the DEPTH and TENSION you can create across it.
What is the likelihood of having a diastasis of the rectus abdominis muscle?
Valid and reliable research is minimal in this field but what is available suggests that all new mums will have a degree of widening of the gap between the rectus abdominal muscles immediately after delivery and have a reduction in tension of the abdomen, 53% will have a true diastasis at this time, and 36% remain to have a diastasis at 7 weeks postnatally Boissonnault & Blaschak (1988). Coldron et all (2008) measured the inter-recti distance from day 1 to 1 year and found that the distance markedly decreased up to 8 weeks postnatally but little to no change after that when no exercises or advice was provided to the lady.
So my take on this was that it would be likely I would have one and so I started being proactive in my own pregnancy to prevent and minimise compromise to my abdominal muscles. Professionally it means that I now focus on DRA with all women in their Mummy MOT appointments as soon as possible and even make sure they feel it and know how to assess it themselves so they can be practical and hands on with improving the situation and being aware of what to do and what not to do….notice how I didn’t say how to reduce the gap….keep reading.
What does it mean to my body?
The abdominal wall and the tension it provides have important roles in posture, trunk and pelvic stability and movement, respiration, and support of the abdominal viscera.
An increase in the inter-recti distance and a reduction in tension and support across the abdomen put these functions in jeopardy. This may result in altered trunk mechanics, impaired pelvic stability and changed posture, which could leave the lumbar spine and pelvis susceptible to injury, and evidence is still questionable whether this results in increased chances of experiencing pelvic girdle pain, urinary incontinence, pelvic organ prolapse and back pain. Some research has found incidental findings of the above symptoms and DRA but if they are cause and effect is still questionable to date. More research is needed.
What is known is that the abdominal wall works in synergy with the pelvic floor, deep back stabilisers and diaphragm, otherwise known as your breathing muscle. Together all these muscles form the ‘abdominal canister’. If one of these muscles is not working up to scratch then it can affect how they all function. The following diagram from Burrell Education highlights this perfectly so knowing how to regain activation and support in your abdominal wall in conjunction with the pelvic floor and breath is so important in the postnatal period.
Research now tells us that the main issue with diastasis that can create changes to the contour of the tummy and possible links to symptoms is not necessarily how wide the gap is but the lack of tension and therefore support it creates across the abdominal wall. So therefore do not get hung up on purely how wide it is. This was a previous school of thought but not up to date with available research.
Therefore when assessing ladies I would then repeat the above test whilst getting them to activate the deep abdominals called transversus abdominis and the aim is to feel more tension across the gap. To do this I cue ladies to exhale as they lift their head meanwhile hollow their lower abdomen in towards them from their pubic bone to navel, imagining they are trying to fit into a tight pair of jeans. The exhale is very important to prevent you holding your breath and creating an increase in the intra abdominal pressure. If there is more tension across the gap this is good! However if someone still has a gap after recruiting their deep abdominal muscles this is a true diastasis. So in order to address it we start with activating all the core muscles of the abdominal canister in synergy to help give stability to the abdominal wall. Therefore working the deep abdominals, pelvic floor and diaphragm together can improve it!
That is a very quick insight into where to start when trying to address it, but more to come next time on that. For now, get practising assessing your tummy. If you haven't yet dared put your hands on your tummy, if it all feels a bit icky and jiggily reassure yourself that this is where to start to help addressing it. I remember how horrible it felt to touch my tummy for the first time after having our little girl but it helped me know the situation my abdominals were in after so many months of being unsure how they had coped, and this helped me get on the path to recovery sooner.
Any questions at all please just ask. If you want support at assessing this further then please get in touch for a Mummy MOT where we can go through this in detail with you and develop a bespoke programme for you.
For all you fitness and health professionals out there here are some references:
Today is an exciting day for The Powder Room Physio, Rowan House and the Pregnant couples and parents of Norwich and the wider area. Today is the day that Pregnancy & Parenthood is launched. P & P is a team of antenatal, postnatal & birth health & wellbeing specialists, working to promote health & wellbeing in pregnancy, positive birth experiences, & restoration of your body and core after birth.
Through working together as a network, we are able to provide a wealth of resources, knowledge and skills and seamless continuity of care for you, your partner and baby at this special time. In our team of health & fitness professionals we have:
To help us celebrate our launch please come visit us at www.pregnancyandparenthood.co.uk and like and share our Facebook page: Pregnancy & Parenthood. On Sunday the 30th April we will be attending the Norfolk Bump & Beyond show at the Show Ground where myself and Deborah Bagley from Babyfit will be providing talks on pregnancy and postnatal hot topics and the rest of the team will be there to answer any questions or take any booking enquiries for any of our courses running from Rowan House Health & Wellbeing centre and other locations around South Norfolk.
We look forward to supporting you through your pregnancy & postnatal journey.
Wishing you all a very happy Easter.
Improving your pelvic floor muscle function can greatly improve and prevent such issues because it has a direct role in both supporting and controlling the bladder and bowel.
Here are a few day to day tips to optimise your pelvic floor and bladder health:
1. Practice your pelvic floor exercises; See how many repetitions of short (1 second) and long contractions (aiming for 10 seconds) you can do. Practice this three times a day Try using different cues such as;
'draw your coccyx towards your pubic bone'
'imagine you are trying to stop passing urine'
'imagine you are trying to stop passing wind'
'try and draw a tampon up inside your vagina'
Make sure you aren't holding your breath! If you find this hard not to do then count or talk out loud or focus on exhaling as you squeeze.
2. Drink between 1500-2000 mls a day (if you are breastfeeding, completing vigorous exercise or perspiring a lot you may require more)
3. When going for a wee it should ideally be over 300 mls (get an old plastic jug and measure!)
4. You should go for a wee between 6-8 times over 24 hours. It is not normal to go every 30 minutes!
If you find you are going to the toilet frequently with small volumes you may need to get the pelvic floor stronger and practice 'deferring the urge' with bladder retraining techniques. The pelvic floor acts as an inhibitor to the bladder. Some call it the gatekeeper to the bladder! To improve your bladders capacity and ability to hold for longer, start by practising deferring urges at home (somewhere you know you can get to the toilet if you need to) by holding long gentle contractions of your pelvic floor. Also try to keep calm as anxiety can only make the urge feel stronger! Easier said than done I know, but sticking with bladder retraining techniques can work.
5. DO NOT practice stopping passing urine when you are actually going to the toilet. This can lead to bladder irritation.
6. Do you hover on public toilets? DON'T! This can inhibit your pelvic floor from completely relaxing to allow you to go for a wee and can lead to incomplete emptying meaning you might feel you need to go more frequently. Put down some tissues or carry wipes instead!
7. When going for a wee sit with your feet flat on the floor and lean forwards with your elbows on your knees, this helps to position your bladder and urethra opmtimally to empty.
8. Do you go to the toilet 'just in case'? DON'T! If you are going out the door but have only been to the toilet 30 minutes ago do not go again if you don't feel you need to! This can lead to a reduction in your bladders ability to store urine and can then lead to frequency and urgency issues.
9. What colour is your wee? Urine should be clear enough for you to read a newspaper through in the bottom of the toilet pan. If it is cloudy, yellow-dark yellow, contains blood or has a strong odour you should seek medical help. You may have a lower urinary tract infection or something else requiring assessment and treatment.
9. Do you live off that hot cuppa to get you through the day? Alcohol and caffeine can be an irritant to the bladder as well as a diuretic meaning you may need to go more urgently. Try to limit your tea, coffee, cola and alcohol intake, however if you are suffering with urgency or urge incontinence you may want to consider cutting this out. Water, herbal teas and decaff tea and coffee can be good replacements.
10. If you are suffering with any bladder urgency, frequency or incontinence symptoms make sure to visit a Women's Health Physiotherapist. They can review your pelvic floor function and assess your bladder habits and diary and make changes to minimise and manage these symptoms which can be life changing.
I hope this information helps you to be proactive in your bladder health. Some of the above are things you may not think to think about because they can be just 'your normal', and toileting habits aren't typical dinner table conversation so you may not be aware of what is 'normal' and what isn't. If you have any questions just ask or book yourself in for an appointment.
Until next time,
The Powder Room Physio
BBC News recently highlighted that nearly one in 10 British women suffer from painful sex, however little is still known about how much Women's Health Physiotherapists can help treat and relieve these symptoms.
The recent survey of nearly 7,000 sexually active women aged 16 to 74, in BJOG: An International Journal of Obstetrics and Gynaecology, suggests this medical problem - called dyspareunia - is common and affects women of all ages. The survey results highlight that many find the subject embarrassing and taboo which acts as a barrier to seeking help. Despite the recognition of the problem in the media, there is little mention of how us Women's Health or Pelvic Floor Specialist Physiotherapists can help. As a consequence the Pelvic, Obstetric and Gynaecology Physiotherapy Association (POGP) is running a 'Pucker up your Pelvic Floor' Campaign for the month of February to try and signpost women and men for sexual dysfunction this valentines day.
Painful sex is particularly reported amongst ladies in their late 50's and 60's which can be linked to menopausal changes and vaginal dryness issues. Followed by young sexually active ladies. I for one can vouch for dyspareunia issues for the first six months postnatally (for those of you that know me, sorry for the over sharing but I wouldn't be doing my job fully if I didn't acknowledge this!) After having a kiwi suction delivery requiring an episiotomy I bruised horrendously which caused me to sit down consciously and tentatively for at least 6 weeks followed by months of cautious touch and tenderness. Thankfully I can say that things have healed well and any discomfort has been relieved, but had I not 'physioed' myself and applied all the advice, exercises and treatment I would give to a client in a similar position things may be very different now.
Painful sex was seen to be strongly associated with vaginal dryness, feeling anxious about sex and lack of enjoyment of sex. Vaginal dryness is a common byproduct of the menopause but it is also apparent in the early months postnatally related to hormonal level changes and breastfeeding. There are many other emotional, psychological and physical factors contributing to painful sex which can be complex to treat.
People may associate pelvic floor exercises (kegals) with prevention of incontinence but may not know that strengthening, toning and knowing how to relax the pelvic floor muscles has an impact on sexual enjoyment and performance too. A condition called vaginismus can develop as a consequence of a vicious cycle of experiencing pain (i.e from childbirth and healing tissues), anxiety and fear, causing tension in your body including the pelvic floor muscles which causes tightening around the vagina and pain during intercourse.
Pelvic Health and Women's Health Physiotherapists specialise in completing assessments and examinations of the pelvic floor to help you understand what your pelvic floor is doing and if it is contributing to your symptoms. It is very common for you to not know what your pelvic floor muscles are doing, this is partly related to the fact that you cannot see them in action like you can with your biceps on an arm curl. Therefore, if you are in doubt, don't delay and seek a Women's Health Physiotherapists advice. You can download a free pelvic floor exercise booklet from the POGP website http://pogp.csp.org.uk/publications.
For the month of February The Powder Room Physio is offering 10% discount on purchase of a Mummy MOT postnatal assessment gift certificate. If you are suffering from pain during sex, regardless if you had your child 6 weeks ago or 6 years ago then contact The Powder for more information: firstname.lastname@example.org, 07734455184.
For more information on how you can get involved in the Pucker up campaign, visit: http://pogp.csp.org.uk/news/2017/01/31/pucker-your-pelvic-floor-pogp-campaign-february-2017
So being on the other side of birth as a Women's Health Physio...what are my thoughts; Firstly that I survived, yes! Has it changed my perspective on things? Will I Support ladies differently when treating them? Did I do my pelvic floors as I preach to others? Find out here in my reflections and thoughts on my preparation for labour and the process from start to finish ....
So our little baby girl arrived 12 days early, this took me, my husband, family and pilates class that I was due to run that day entirely by suprise! I woke that morning happy and relaxed with a lazy morning in bed, enjoying materntiy leave, I reached for my phone and sent a facebook post to my dad wishing him a happy birthday, thanking him for all his love and support and stated 'bets on to see if you have a granddaughter with the same birthday!'....now on reflection I am sure through some physiologically hormonal in tune way I knew it was going to happen....I was also due to run my final pilates class that afternoon and I had made sure to send information to my colleague who was due to cover from the following week just in case anything was to happen....Who knows, maybe it was coincidence.
So that morning I went for a sunny walk with my family and dog to the local park and made a comment that I had started to waddle in the past few days and suddenly felt a bit lethargic with wanting to do things which is not like me...I had the idea of maternity leave being a chance to do DIY and get things done, pah! I also had a little pelvic pain around my hips and lower back more so that day a little like period pains.......this turned out to be it all kicking into action! We then went for lunch at a restuarant with 7 members of my family, and I could have eaten a horse I was so hungry. I had myself a yummy spinach and ricotta cannelloni and wanted to drink loads, I made a comment to my mum that my period type aches had started to get a little wave like and stronger. Minutes later I felt this almighty swelling and pressure in my lower tummy and a sudden sensation of release and I was soaking wet! .....an immediate feeling of excitement grew within me, and I turned to my mum to say I think my waters have just broken, to which she could see immediately what I was referring to. The chair and my lap were soaked! So there I was in the middle of a restaurant with potential panic and embarassment to set in, but I truely account for the sense of calm that washed over me to the hypnobirthing course and its preparation both me and my husband had done over the previous 6 weeks.
'Own your Birth' Hypnobirthing course led by Hypnobirthing trained midwife Emma Dufficy Rope, was money well spent. We went to four evening sessions with her, along with two other couples. Emma highlighted at the beginning that having your birthing partner there was as important as you going through hypnobirthing as they are your 'toolkit' provider. Both of us invested in it whole heartedly and I would 100% like to highlight that it isn't going to work for you if you just turn up to the sessions and then go away and not talk about it or spend time practising.....come on practising relaxing is hardly the biggest chore! So we made no excuses.
The sessions consisted of learning about the physiology of labour which is truely fundamental to getting into the hypnobirthing mindset. Emma explained the physiological origin of perceived labour pains and the purpose of them. She removed the idea of pain from our vocabulary with the use of 'surges' rather than 'contractions' and 'labour', and helped us to adjust our mindset and outlook on 'surges' as a positive not a negative experience, by emphasising that they would bring us closer to meeting our little ones. She also allowed us the time to discuss and verbalise to one another what our most wanted and most dreaded labour experience would be, this helped me and Ady to communicate and be prepared for how to deal with such situations if they arose......and to be realistic that they might occur rather than wearing a pair of rose tinted glasses and deny all acceptance of complications arising. It was so important to work as a 'team' rather than having our own experiences seperately, and i owe Ady everything for really getting on board with it for me. Emma taught us many different forms of relaxation which were great, this mostly taught us the power of distraction and focus. Breath control was also a huge part of this, this formed one of my main distraction strategies in labour. All of the above strategies have the aim of tapping into our own natural analgesic, the 'love hormone' oxytocin which is produced in high levels in pregnancy but off the chart levels in labour.
With all this in our 'toolkit', it made me the calmest and most collected member of my family in that restaurant..they were all hysterical wanting to call me an ambulance! In a timely and calm way I managed to call the hospital, call Suzie who kindly covered my pilates class that day, and call my husband whilst also getting a change of clothes and organising my family and who was going to drive me home. My mum drove me home, and in all the confusion we had left my house keys with my dad.....panic neaaaaarly struck but instead, I took some deep breaths and used my surroundings as a form of focus; taking in the country air, feeling the beautiful warm sun on my back and having a walk around the garden whilst we waited for Ady and the keys so we could get the all important hospital bag and head to hospital!
Ady arrived, excited as well (whether he was secretly pooping himself we shall never know!), he did a great job of keeping me calm and happy, packing the car up. Hugging my mum and dad (who had also arrived by then) goodbye was such a ground breaking moment to know that when we saw them next we would have given them a grandchild :)
I waddled into the car with contractions that were timing pretty regular at 3-4 minutes apart for 30-45 seconds (things were appearing to progress quickly!) and set up my TENS (transcutaneous electrical nerve stimulation) machine and oh waow was it good. I turned it up as I could feel a contraction building and it really helped to dampened it down and help me focus on deep breathing with a long expiration, blowing out all the tension. Our journey went smoothly, a lovely sunny drive with no traffic thankfully. As we walked across the hospital carpark it was apparent things were progressing as I was finding it hard to walk during a contraction.
As we arrived at the hospital, we were immediately transferred to the central delivery suite rather than the midwife led birthing unit. It was explained to us that due to our little lady having a poo inside me which was obvious when my waters broke that they recommended she needed constant CTG monitoring with a strap around my tummy and ideally this needed to be done on my back....at this point Emma and her mindfulness skills came in very useful. Nearly all mums want a water birth and to hear those words that it had been denied from you could easily send you in a state of whole body mental and physical stress with a total plummet of all the oxytocin levels we had been working so hard to keep high. So i had to make a decision about how to address this. I had one of the last coherent conversations prior to her being born then with the midwife, and reasoned with her that i would really like to be able to move around if i can't be in the water, as this was one of my biggest fears that we had practised and rehearsed in the sessions. She then agreed to check her heart rate and if she didn't seem in any distress i could be up on the bed rather than lying down. This helped to give me some element of feeling of control and empowerment in the situation rather than be completely useless, and as everything was fine i managed to stay in a high kneeling position for the next 6 hours!!! In that time i had the Julie Flood hypnobirthing CD on repeat (god only knows how many times the poor midwife Anna and Ady heard that!), which kept me focused the whole while on my deep breathing and visualisation exercises. I didn't hear the CD as much as Ady or Anna as i was in a fluctuating state of consciousness and subconsciousness, it is now so hard to describe the feeling but I was 'away with the fairies', at one point I was dreaming and nearly started to talk to Ady as if my dream was real! To the point that Anna could only work out if i was having a contractiuon by the CTG machine readings....I blocked out every beep of the machine, every conversation of staff walking in and out and managed to focus and tell myself none of that mattered, I was in control.
I then got to a point of feeling the need to go for a poo (lovely I know!) and Anna said right its time to push, for an hour and a half I was then stood or leaning over the bed making good progress but due to the protocol of not pushing over a certain length of time when the baby has had a poo already the decision was jointly made that the doctor come in to assist with a kiwi delivery (suction cap to help hoover her out!). With prior knowledge about instrumental deliveries, episiotomies and tearing and all the statistics running through my head I managed to keep calm and tell myself in that moment it was in her best interest. After two attempts of suction with an episiotomy (cut) out popped our little girl. What a feeling of overwhelming happiness in that moment, having your baby who has gone everywhere with you but you have never met, to be suddenly on your chest. Waow. Undeniable devotion to her from that moment on.
After a little while we managed to latch and feed for the first time which could be such as anxiety ridden moment but all the while Ady was calmly reminding me you can do this, no need to worry and so the oxytocin remained high. In fact for the next 24 hours I was like I was on morphine, as high as a kite! This love drug stuff is great I told myself! and so I made it through with only TENS pain relief to show for it, and to this moment it astounds me just how powerful a state of mind can be. It has got me thinking of Professor Lorimer Moseleys work into the role of thr brain and pain and his stories of those with snake bites or nails in the shoe (https://www.youtube.com/watch?v=gwd-wLdIHjs), which highlights how beautifully our body and all that we feel and perceive is controlled by our brain....and a lot can influence its output; our preparation, hormones, environment, previous experiences and many others. This is another reason I have wanted to share my positive birthing story to help the next lady who is about to go through hers. As first times mums a lot of what we have to go on is what those nearest and dearest say to you, and we have a habit of retaining and remembering the bad horror stories not the good......how does this influence our oxytocin levels do you think?! Interestingly my dog has recently been spayed or the equivalant of a hysterectomy, and she has no idea it has happened and would have been running around as normal from the minute the anaesthetic wore off if she could. Our neighbours 1 year old son just had a heart valve replacement and his mum said he is as happy as can be and no different. Our culture has a quite medical and painful outlook on childbirth and it has me wondering about the powerful implications on a ladies birthing experience and how the culture could creates a vicious cycle of events...
This is just my one experience of birth mixed with a physios scientific mind, I have no idea what my next birthing experience will hold but I certainly know I will be visiting Emma again for our next course of hypnobirthing. I am 100% aware that not everyone has positive birthing stories and this blog has never been written with the aim to cause upset, it is purely to help promote the awareness of strategies to prepare for one of the most life changing experiences. Preparation is key. Visit Emma's website for more info: www.ownyourbirth.co.uk
so, I hope I can influence just one ladies delivery, or outlook on pain in general.
Well hello.....Remember me?! I hang my head in shame that it has been two months since the last blog, but I do have an excuse! There has been a slight development in our lives with the addition of our little baby girl, she decided to suprise us and arrive 12 days early. There was none of this 'first baby always are overdue', don't believe it ladies. She announced her arrival in true movie style via my waters breaking when out to dinner at a busy restaurant with my entire family (details will be in a follow up blog of my experience of labour and hypnobirthing!), and she has been keeping us very busy and wrapped around her little finger ever since.
Only one week earlier at 37 weeks pregnant I had put together a few videos for you of some of the key exercises I incorporated into my pregnancy workout, which helped me to remain active and pelvic pain free in pregnancy, and enjoy an active labour. As highlighted in previous blogs, exercise in pregnancy is encouraged in national guidelines and current research but for the ladies questioning it in early pregnancy, the information and support available to them can still be inconclusive, 'wooly' and thin on the ground. This is where your Women's Health Physio comes into play, a voila! So I have been my own guinea pig and taken one for the team in my own pregnancy, (although there is no secret I am an exercise addict) with good results and no glitches I will be pleased to add!
The videos include; exercises for key pelvic and core muscle groups that need maintaining and strengthening, including; 1) gluts, which are essential in order to cope with the centre of gravity and pelvic tilt adjustments that occur with a growing bump, and 2) the deep abdominal muscles that have to accomodate and support a growing bump, whilst they lengthen and have altered mechanical alignment with the changing contour of the abdomen. They also highlight day to day things to be aware of such as the way you stand, sit to stand and move around with a growing bump, showing you that you can be exercising your core muscles at any time not just in your gym gear.
The aim of the videos are to highlight what level of physical activity is possible to maintain if you lead a healthy and active pregnancy, with a well structured programme and good form. In them I talk about the importance of developing your own body awareness (proprioception), and that the need to understand a good technique with each exercise is paramount. This is above overloading with weight which can lead to poor form, not to mention too much strain through a core and pelvis which is already under strain and under a high intrabdominal pressure system. Your body is going through daily changes and therefore being aware of your form and posture is key in order to avoid injury. Therefore, if you are not familiar with these exercises and haven't been active or doing similar exercises, don't reach for the kettlebell and 'give it a go'. Completing a tailored and structured programme is paramount, A) to avoid injury, B) to save your energy at this time of high demand, and so make it as efficient a programme as possible to achieve the maximum gains.
As mentioned in my previous blog 'Folic Squats', there is a need to targert prenatal exercise uptake and fitness awareness, so that ladies like myself can enter pregnancy fit and able to sustain a programme such as this. This routine is not something I had picked up the week before, but a modified programme I had been doing throughout the year prior to my pregnancy, therefore my body was robust enough to tolerate and thrive.
If you would like to know more of what's possible for you in your pregnancy, I would highly recommend having a one to one with a women's health physiotherapist, or personal trainer who specialises in antenatal exercise. This is not a time to stop, it's a time to listen and become in tune with your body, and care for it. By that I mean don't expect it to have to cope with extra weight gain whilst becoming sedentary, unfit and inactive without repercussions. i.e pain, weakness, and reduced physical tolerance. Don't get me wrong, IT IS important to have those days / evenings on the sofa when you just feel drained from growing your baby and cannot face doing anything at all (I had plenty of those!), but equally keeping with a scheduled regular exercise routine will boost your energy and tolerance in pregnancy....and ultimately help you perform in the grand finally of childbirth and keep you going in those early sleepless baby days! Not to mention reducing your risk of complications in pregnancy such as gestational diabetes and heart related conditions.....a win win really!
Have a look, like and share of my youtube channel 'The Powder Room Physio' where you can view me sporting a nearly ready to pop bump whilst giving demonstrations, advice and education on my pregnancy exercise programme............enjoy! Apologies if you catch an eyeful of my bump making an escape out of my tshirt, it fitted me the week before! And apologies if the sound quality is lacking at times.
Squatting is a very natural position for us to move into, we do varying degrees of it when we sit down, get in and out of a car, on and off the toilet and reach for something on the floor. Over time, we as a race have gotten progressively worse at it as we have developed furniture to assist us with squatting for tasks such as toileting, or preparing food which we would have traditionally done in a deep squat position. It is so important for maintaining range of motion of the back, hips, knees and ankles, it is also excellent at maintaining the length and strength of the buttocks (gluts) and the pelvic floor. It is also excellent to help prepare the body for the childbirth and ensure complete and relaxed pooing!
If you are not used to squatting, it is important to be aware of the ideal posture as it could feel unnatural. The heels should remain heavy on the floor with your body weight over them. Your pelvis should be in an untucked position with the tip of your tailbone pointing up behind you, not tucked under you like a dog with its tail between your legs. Therefore the whole of your spine is extended, and your chest and eyes lifted. You can also start by sitting back on to a higher stool, then a normal height chair, then a foot stool. Good form is paramount so maybe use a mirror or partner to be able to feedback to you.
Deadlifting can be an excellent exercise for working the muscles in your posterior chain (in normal language...the muscles running down the back of you!), in particular your hamstrings (back of thighs), gluts (buttocks) and deep back stabilisers. These muscles are so important for helping you counteract your growing bump shifting your centre of gravity forward and the increasing feeling that you are going to tip over forwards!
If you have never deadlifted before, seek advice from a professional who knows how, such as a women's health physio. Key things you are looking for include;
If all else fails, you cannot go wrong with the step up. This is such a functional exercise, we step up when going up curbs, the stairs, and even in and out of the bath. Applying the principles i describe here of activating your buttocks, thighs and deep abdominals when stepping up and extending can really help to support your pelvis and growing bump.
Pelvic girdle pain can often be felt when stepping up the stairs, practising step ups in a controlled way with focus on muscle activation can help stabilise and support a weak hypermobile pelvis experiencing pelvic girdle pain. If you are suffering with PGP, as pointed out in the video, make sure to make every step count when going on the stairs or even walking along; focus on pushing down through the heel which can aid squeeze of the buttocks and give you more strength, thus reducing the feeling of your leg going to give way.
Last but not least. This is a more complex exercise challenging many body systems including your proprioception, whilst working your glut muscles intensely! It is therefore important to only do this if you are comfortable with understanding the task at hand and can be aware of good form. I would recommend seeking advice from a women's health physio or personal trainer confident in antenatal exercise prescription.
Make sure to explore my youtube channel 'The Powder Room Physio' containing other videos with advice on pregnancy posture, exercise, pilates and pelvic floor function.
Next time I will be sharing with you some of the pilates moves we focus on in the antenatal Bump to Baby and Beyond Pilates class. As mentioned in previous blogs, pilates can be an excellent form of exercise for all in pregnancy to maintain and develop an engaged and supportive core muscular system, so stayed tuned for those!
As mentioned previously, I will also be sharing my own personal experiences of labour and hypnobirthing, ekkkk!!! My role as a women's health physio can involve listening to and supporting ladies with their experiences so I feel it is only fair to share mine. Including all the undesirable bits no one talks about but everyone wants to know...
Pilates in Pregnancy is it safe & how can it help me? Will pilates help me recover after birth-when is it safe to start?
Keen to start somewhere with exercise in your pregnancy but not sure what is safe? If you have not had a chance, please look at my previous blogs....I hope that my message is getting across to all that exercise in pregnancy is safe and highly recommended. The Royal College of Obstetrics and Gynaecologists guidelines recommend all women to do the following as part of leading a health lifestyle in pregnancy;
As you may be aware I am in my first pregnancy at 34 weeks and all things going well. I have practised pilates throughout my pregnancy, both at home and whilst running weekly classes for other expectant mums and new mums. It has been a great way to keep ache free and to maintain my aerobic fitness....whilst also having the opportunity to natter to ladies in a similar stage in life about the overwhelming array of pram choices!!
After having your baby, you may be given exercises to start doing from the women's health physiotherapist or midwife who visits you on the maternity ward. These will include pelvic floor exercises and some gentle abdominal exercises. You can start these the early days after delivery. Non impact low resistance exercise such as pilates can be a great next step around 6 weeks following your delivery.
For more information about pilates visit the following websites as a reliable resource:
If you are keen to join me and exercise either in your pregnancy, or once your little one has come into the world then contact me. The next course of classes is due to take place:
Rowan House Health & Wellbeing Centre, Hethersett,
Thursday 5th May - 9th June
16.15 - 17.15
17.15 - 18.15
Hello again, just a quick one today to say The Powder Room Physio, alongside other healthcare practitioners & therapists from Rowan House Health & Wellbeing Centre are looking forward to attending the 5th Norfolk Bump Baby & Toddler show this weekend. www.norfolkbump.co.uk.
For parents or parents to be it looks a great opportunity to obtain advice and information, trial various free taster sessions, and ask lots of questions to the experts in their field. It also seems a great chance to network, grab a coffee, and if nothing else have a play on the FREE bouncy castle and soft play area. 'Spring' gymnastics are also offering FREE trial sessions which I can personally recommend as a lot of fun!
Myself and Ady (husband) attended our first NCT class at the weekend (which was fantastic and very insightful), and we are hoping to catch up with everyone on the day to become enlightened together!
Rowan House have stalls 98-100 so make sure to come along and say hello. I will be there promoting the benefits of exercise in pregnancy with advertisement of the Antenatal and Postnatal Pilates classes I run at Rowan House, in Hethersett. I will also be promoting the importance of pelvic floor awareness and health. Are you doing your pelvic floor exercises? and do you know how to do them correctly more to the point? If not, come and say hello, I can offer one to one advice and education and discuss if an appointment for a pelvic floor assessment may be of benefit to you. 1/3 ladies will suffer the effects of pelvic floor issues (including incontinence and prolapse) at some point in their lifetime.....so why wait for it to happen! come and find out more.
The Pregnancy and Parenthood practitioners of Rowan House will also be selling tickets for our newly launched 'Pregnancy Retreat' Event which is set to go ahead on the 30th April 9-12pm. The retreat is a fantastic opportunity to have a morning of much needed rest, relaxation and recouperation for mums to be (and partners!), including the chance to participate in a Pilates class with myself, Hypnobirthing with Emma Dufficy-Rope specialist Hypnobirthing midwife, and complementary therapies such as Pregnancy Massage and Craniosacral therapy. For more information follow the link to Rowan House website; http://www.rowanhousecentre.co.uk/mums-event/
I am thoroughly looking forward to sunday, to be able to share professional advice.....and gain personal education in my own pregnancy! (33 weeks, only 7 to go!)
Stay tuned for my upcoming blog on our personal journey so far with NCT classes and hypnobirthing which started this week! Lets just say we can't wait for the next sessions.....
Hello again, its been a couple of weeks since my previous blog 'The Pregnant Pelvis Part 1 & 2. I left with a promise of explaining my thoughts on 'Folic Squats' next time so here we are.
I have previously highlighted my opinions on the importance of remaining fit and active during pregnancy to optimise the pelvis' ability to cope with the biomechanical and hormonal changes placed upon it during pregnancy. There is no other time in a women's life that the body changes so dramatically over such a relatively short period of time, so why should we expect it not to complain back at us sometimes during this time? Now I want to take it a step back before pregnancy and discuss when and how exercise should be considered; so lets think a little more globally, if you are considering having a baby, what measures do we know you should take to prepare yourself for it? Thankfully messages have reached the public eye about the importance of taking folic acid supplements,stopping alcohol consumption and keeping caffeine intake to a minimum, so why not use this as a tool!
Plain and simply, what I am trying to say is when you are considering taking folic acid three months prior to trying to conceive, you should be considering making your body robust for the changes to come; when you reach for the folic acid each day, follow it up with 3 sets of 12 of your finest squats! This should take way less than 5 minutes of your time, thats it! repeat this 3 times a day and you're up to 108, and you're preparing your butt for the journey ahead.
So is this safe? 108 is a very conservative number to start with, and whilst there is no denying that there is a 'right way' to squat and a 'worse way' to squat (for those of you who know me you will have heard that phrase many a time from me!), the volume is low enough to ensure you are very unlikely to cause a problem. If you do find this hard, it may highlight you should seriously consider getting fitter before the physical journey ahead...
If we are looking at addressing mass participation and starting the thought processes in the ladies of this generation that exercise + pregnancy = a health pregnancy and healthy baby, then keeping it simple maybe key. Commencing with 'starter squats', with depth of 'sittting to standing from a chair', then progress gradually to deeper squats, and getting the numbers to 5 sets of 20. Anything above this beginning to load it- its much more time efficient and you can start to achieve some significant load volumes with just a couple of kilograms extra. Whilst things such as the squat challenge on facebook are a good start - its much better to be doing something than watching TV - the numbers and effort can seem a bit overwhelming. once you are able to do 100 in one session, you'd be better off adding weight to lower numbers, rather than hitting 150, 175, 200...
Of course, if you have gotten to 5 sets of 20 and want to learn more than this is where booking a session with myself (or any exercise professional with experience is delivering exercise to mums of expectant mums) may prove beneficial to further you're knowledge before just sticking a load of weight on your shoulders. But the basic message is simple: if you are thinking about embracing motherhood, which entails putting your body through a crazy 9 months (at least...) then why not get as prepared as possible.
And just to point out, the reason I’ve chosen squats it because of the simplicity of the movement and the fact everyone has to do a form of one during the day. There are MANY other beneficial exercises to try, this is just a gentle nudge in the right direction.
But if you are wanting to strive for the optimum during pregnancy then there is no denying that liaising with a personal trainer or women's health physiotherapist would be advisable; this could be months or even in the year before you are planning to conceive. This way you can receive an individualised tailored programme to your needs and abilities, thus making it as timely and effective as possible, so that you really can prepare your musculoskeletal frame in the best way possible for the requirements to come.
I think it'd be very useful if when reaching for the packet of folic acid or pre pregnancy supplements on the shelf in the supermarket, the reverse side had a section on 'Folic Squats'. Yes, they are just squats, but everyone likes something with a fancier name...
So, food for thought if this is on your lifetime agenda ladies, or partners - I know that without my husbands support and encouragement it would have been much harder, so exercising as a team can be key to keep you motivated and compliant! We've just come back from a pretty slow 12km bike ride which I wouldn't have done without Ady shouting words of encouragement from alongside me. I've got jelly legs, but hey - 31 weeks in, I think that's acceptable?!? And its given me an excuse to stick my feet up, open an early easter egg and get to writing this blog.
Any thoughts welcome as always; as said previously, this is my own opinion as a 31 week pregnant women's health physiotherapist, speaking from first hand and professional experience. It is only an opinion but hopefully achieves my aim of getting people talking and debating!
If there are any ladies out there wanting to know more about 'folic squats' or pre pregnancy exercise or pelvic floor health then please get in touch. Feel free to comment, email, text or call to arrange a time that is good for you for an assessment. For more information, browse the rest of my website of visit www.rowanhousecentre.co.uk.
Happy squatting this Easter!
This post is part two of a post outlining some of the key concepts I use within my practice, to answer the questions of ‘what does a women’s health physio do, and how does she think and reason her treatment for the Pregnant Pelvis?. Part one looked at loading, and the extra consideration required when dealing with pregnant ladies. Part two will finish up with pain science theory, exercise in pregnancy and education.
Pain science theory is key to contemporary physio – MSK, neuro or otherwise. But within Women’s Health there are many other things to consider. Let’s remember that hormones have a role to play. Not only the physiological effects but those on our fears and emotions to cause some irrational outbursts. Thankfully, I’ve skipped all these: Ady, my family and friends haven’t had a hard time AT ALL….(this is my official apology! Soorrrry).
But there’s also the rational, genuine fears:
‘It’s only 5 months and my back hurts, what happens if I do something and it gets worse?’
‘I’m not managing now, what’s birth going to be like?’
‘what happens if this doesn’t go away after birth, what kind of mum will I be?’
‘Am I hurting the baby by moving weirdly or exercising?’
These are genuine things that have ran through my head, and sometimes it’s hard to decide what rational and what’s irrational, but either way, it nearly stops me doing things that ultimately help me feel physically and emotionally better. Now I should know better being a physio, so just imagine the effects on the general populations approach to movement…
There are lots of decent resources online for to help us address this pathophysiological component of pain: Peter and Jack on youtube (whatever happened to Jack I wonder), pain-ed.com and in particular the video regarding myths and back pain, Lorimer Moseley’s lecture involving the snake bite on you tube and of course, Explain Pain (the book). With so much going on for ladies at this time causing both rational and irrational worries, maybe a chat and coffee is the best starting point rather than 3x12 squats.
Which leads me to exercise. Put simply, exercise works. Unfortunately there are so many sources of information for the pregnant women which suggest different things regarding exercise. Regrettably this can include old wives tales and emotional rather than scientific advice from over protective friends or family. As a result of juggling all this information, emotions and being overwhelmed, the twisted logic could lead to the assumption that doing nothing is safer, and a journey into a sedentary pregnancy state. There are some very good medical reasons for not continuing exercise during pregnancy, and there is reason to be cautious when starting new exercise during pregnancy. But if only the message was clearer that continuing aerobic and strength and conditioning exercise is an integral part not an optional part of leading a healthy lifestyle in pregnancy, then issues of gestational diabetes mellitus, obesity, shoulder dystocia, pre eclampsia, dyspnoea and not to mention pelvic pain could be significantly addressed.
And I’m not talking starting 5km runs or learning to climb. Just the basic strength and conditioning exercises that maintain strength, control and balance coupled with good aerobic conditioning. The Royal College of Obstetricians and Gynaceologists suggests that reasonable goals of aerobic conditioning in pregnancy should be to maintain a good fitness level without trying to reach peak fitness level or train for athletic competition. Key to this is that prevention being better than cure, so preparation is key. It’s my firm belief that you should make a change in your exercise lifestyle once you start taking folic acid three months prior to planning to conceive. I think a little leaflet inside pre pregnancy supplement packs would go down a treat. Or rather than the squat challenge on facebook, an encouragement to do ‘folic squats’: squatting for a healthy pregnancy.
Additionally, exercising during pregnancy helps maintain a healthy weight. Weight gain is an inevitable part of blooming, with your growing foetus and 40% increased blood volume to name just two reasons. But its commonplace to see extra maternal weight being put on. The tagline ‘you’re eating for two’ is not tremendously useful, and not true. Not only is there extra load translation requirements through a struggling to stabilise ‘softening’ pelvis, but it is also putting more strain through a fatiguing pelvic floor. Incontinence can strike, and who wants to exercise when they leak whilst doing step ups?! Another vicious cycle! But on the whole preventable or at least the risk can be reduced with good planning.
It is important to remember that there are some conditions that will outright stop the ability to exercise, and in which case maintaining a healthy weight will be very hard. The advice I give is not to make expectant mothers to feel bad but at the same time it has almost been normalised that modern mums will put on lots of weight above and beyond the weight of the baby and other products. A great way of reducing the risk of pelvic pain is to quite simply manage your weight as best you can – with professional advice, exercise or careful diet planning. Ask your midwife.
And of course a reward of a cheeky lindor/ double decker or bowl of popcorn now and again is completely acceptable…
With a ‘clicking’, ‘grinding’, or ‘giving way pelvis’ that a baby is due to come out of, encouraging pregnant women to participate in exercise is not always the easiest thing to do in clinic, because they do sound like things that are not going to respond positively to movement. So therefore it’s important that coaching and education is utilised well to engage, and this may take a bit more time. I like to highlight and not underestimate to the lady the relatively quick changes in load, body shape, biomechanical strain, and therefore form and force closure abilities of the pelvis that can all create pain at this time. I ask, ‘when else can you think of in a person’s life these changes occur so dramatically and quickly?’ This is not meant to scare, but to emphasise that this is enough to warrant the level of pain they are experiencing, to help rationalise it and develop strategies to reduce and manage it.
Coaching and educating is a skill, and one I would certainly say I’m still in the process of perfecting. Cognitive Behavioural Therapy (CBT) theories and frameworks can be very useful approaches. Mike Stewart has some great resources and information on the use of good language during sessions (if you get the chance to see Mike, do so, his delivery of information is just so good). Finally, I’d recommend checking out one of Ady’s old colleagues Bradley Scanes article which gives a nice introduction to motivational interviewing on http://www.paintoolkit.org/news/article/motivational-interviewing-a-way-of-talking.
What specific strength and conditioning exercises do I use? This varies with clinically reasoning for the individual’s situation. I wanted to run during pregnancy so I needed running economy exercises, but these wouldn’t be used for the expectant mum who want to be able to do long country walks. For specific strength and conditioning exercises to address the many onslaughts upon the pregnant pelvis, the gluteal muscles are key stabilising targets at this time. Activating these can help to reduce inefficient compensatory stabilising mechanisms such as over recruiting the adductors and the pelvic floor. Reiman (2012) did a great systematic literature review displaying the percentage of max voluntary isometric contraction of glut max and med during varying exercises, well worth a look to give guidance on varying intensity exercises dependant on the lady’s situation. It’s interesting to consider that the contemporary view of exercise through pregnancy is ‘core based’ and quite gentle, which doesn’t really target the gluts with resistance. Squats, deadlift variants, step ups, single leg control work and glut band work should all be in a well prescribed exercise set. I like the single leg work to be in standing if at all possible for the functional proprioceptive value but also for weight bearing. Weight bearing exercise is not only good functional loading practice for the pelvis but it has been shown to reduce the length of labour and decrease delivery complications.
Aerobically, most guidelines advocate the upper range of 60-70% maximal heart rate for sedentary women prior to pregnancy and 60-90% upper range for those wishing to maintain fitness during pregnancy. The Talk Test is also widely used as a ladies heart rate increases during pregnancy and so could be misleading to them. On the Borg Scale of Perceived Exertion ‘moderate exercise’ should be between 3-5; and you should be able to carry on a conversation. Not only does our heart rate increase but so too does our rate of breathing. Ladies need educating to expect this otherwise it could be a scary deterrent.
Finally, the Pelvic Obstetric and Gynaecology Physiotherapy special interest group have a great read; ‘Fit and safe exercise for the childbearing years’ which nicely categorises ladies into four types of exerciser, giving recommendations on suitable types of exercise for them. It is however advised to avoid exercise that may put the foetus at risk of trauma…so no snowboarding holiday for me this year (and so the sacrifices begin…). Some benefits to exercise in pregnancy which can be a selling point that I highlight to ladies, is that those who exercise experience less insomnia, stress, anxiety and depression.
So there you have it. These are my own views, using the research available, and of course not everything can be conveyed well in a blog, but hopefully it’s found to be useful.
If you are a pregnant lady or planning to be; in general exercise is good in pregnancy but there are some things to consider so why not book yourself in for a bespoke assessment and advice session at Rowan House with myself? Hopefully the message has gotten across that a Women’s Health Physiotherapist specialises in providing individualised advice and support to keeping you active and able in you pregnancy and beyond. Some information can be shared by email, but obviously there is a limit to not being able to see you physically.
I also run pregnancy and postnatal pilates classes, designed to address all of the above, with a small class of 6 ladies, it gives the ability to tailor exercises and education to your individual needs. For more information or to find out how to book, click on the ‘services’ tab above.
Also look out for the upcoming blog that aims to explain these ideas in a lay fashion. It’ll be entitled ‘folic squats’.
Do you have any other queries about women’s health physio, or something you’d like to see in a blog post? Why not drop me an email and I’ll try muster something up.
Bye for now x
Royal College of Obstetrics and Gynaecology – Exercise and Pregnancy -https://www.rcog.org.uk/globalassets/documents/guidelines/statements/statement-no-4.pdf
Pelvic Obstetric and Gynaecology Physiotherapy – Fit and Safe Exercise in Pregnancy Lealfet - http://pogp.csp.org.uk/publications/fit-safe-exercise-childbearing-year
‘Peter O Sullivan and Jack’ video. Accessed on 22.2.2016 on: https://www.youtube.com/watch?v=j4gmtpdwmrs
‘Back pain. Separating fact from fiction’ video. Accessed on 22.2.2016 on: http://www.pain-ed.com/blog/2015/09/22/back-pain-separating-fact-from-fiction/
‘Pain. Is it just all in your mind?’ video accessed on 22.2.2016 on https://www.youtube.com/watch?v=-3NmTE-fJSo
Baechle, T. R., Earle, R. W. and Wathen, D. (2008). ‘Resistance training’(pp381-412). In: Baechle, T., R. and Earle, R.,W. (Eds.), Essentials of strength training and conditioning. (pp. 381-412). Champaign, IL: Human kinetics.
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Butler, D. & Moseley, L (2003). Explain Pain, Adelaide, South Australlia: Noigroup publications.
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Meadows, L. & Williams, J. (2009). An Understanding of Functional Movement as a Basis for Clinical Reasoning (pp23-42). In Raine, S., Meadows, L. & Lynch_Ellerington, M. (Eds.), Bobath Concept: Therory and Clinical Practice in Neurological Rehabilitation. Chichester, UK: Blackwell Publishing Ltd.
O’ Sullivan, P (2005). Diagnosis and classification of chronic low back pain disorders: maladaptive movement and motor control impairments as underlying mechanism, Manual Therapy, 10, 242-255.
Potach, D. H. & Grindstaff, T. L. (2008). ‘Rehabilitation and Reconditioning’. (pp529-539). In: Baechle, T., R. and Earle, R.,W. (Eds.), Essentials of strength training and conditioning. (pp. 381-412). Champaign, IL: Human kinetics.
Rathleff, M.S.; Molgaard, C. M.; Fredberg, U.; Kaalund, S.; Andersen, K. B.; Jensen, T. T., Aaskov, S. & Olesen, J. L. (2014). High-load strength training improves outcome in patients with plantar fasciitis: a randomised controlled trial with 12 month follow up, Scandinavian Journal of Medicine & Science in Sport, 25:2, 1-9.
Reiman et al (2012), A literature review of studies evaluating gluteus maximus and gluteal medius activation during rehabilitation exercises, Physiotherapy Theory and Practice, 28 (4), 257-68
Rio, E., Moseley, L., Purdam, C., Samiric, T., Kidgell, D., Pearce, A. J., Jaberzadeh, S. & Cook, J. (2014). The pain of tendinopathy: physiological or pathophysiological?, Sports Medicine, ,44, 9-23.
Rio, E., Kidgell, D., Purdam, C., Gaida, J., Moseley, G. L., Pearce, A. J and Cook, J. (2015). Isometric exercise induces analglesia and reduces inhibition in patellar tendinopathy, British Journal of Sports Medicine, o, 1-8. (initially accessed by BJSM online first).
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Scanes, B (2015). Motivational interviewing: a way of talking accessed on : 22.2.2016 at http://www.paintoolkit.org/news/article/motivational-interviewing-a-way-of-talking