So what does a Women’s Health Physio do? This is a question asked by physio friends as well as other friends. There are probably images in people heads of lots of probing, funny instruments and a bin full of used gloves at the end of the day, but to be honest the majority of the job is just the same as any other physios, just that its based around the pelvic area (which yes, does involve the vagina…).
As a junior MSK physio, I remember asking a senior how to treat de quervains and them turning around and saying ‘its just another joint, use the same principles as you would the knee’. Whilst at the time I felt this was a bit flippant, the basic premise is the same albeit a couple of subtle differences.
There are three main groups of patients I see: patients with continence, prolapse, and varying forms of pelvic pain, whether it be in pregnancy, postnatally or otherwise. There are others, but these are the bulk of my caseload. In this article I’m going to give some insight into the key principles I consider when treating pelvic pain, specifically pregnancy related pain.
Ady (my husband) who is a musculoskeletal physio, every now and again comes home having treated a pregnant lady, and is a wee bit freaked out by what he should and shouldn’t be doing. Its funny as a lot of our personal development as physios has evolved from us chatting about what we do late into the evening, and being more honest with each other than perhaps you would be with colleagues. So although I give him advice, usually it’s just calming him down so he can think a bit more rationally. So here’s my first point: it’s just a pelvis, which just happens to be attached to a pregnant lady.
Now I am pregnant, I’m coming to understand that a pregnant woman is an incredible force. Healthcare staff seem to cower at our presence which unfortunately leaves a lot of sitting on the fence with regards to advice and decision making. The umming and ahhing is quite difficult to deal with. My preference (for treating ladies and receiving advice myself) is to get the woman engaged, and to be a part of the decision making process herself. Educate clearly, propose different scenarios and outcomes, suggest treatment ideas and then choose the most pragmatic one – together. This is different than umming and ahhing with phrases such as; ‘welllllllll, you could do this’. ‘You could do that’. ‘I suppose you should be on the safe side.’…. ‘But there’s no reason why you couldn’t.’ Its common place for me to hear ladies who’ve been seen before for pelvic girdle pain, been provided a pelvic stability belt and told there’s little that can be done until the baby is born. ‘It will resolve in the end’. Deal with it. This leaves ladies confused, lacking self-efficacy and full of hopelessness. A perfect set up for inactivity and pain.
So my ethos is to be calm, be clear, make collaborative informed decisions. This should be at the heart of all physio practice, however, with the tremble inducing pregnant lady, it is admittedly not always easy to apply. Getting a clear obstetric and gynae history is paramount, and weight should be placed on this in the decision making process with her. There is no doubt that the lady who it has taken many years to conceive with complications versus the first time healthy low risk pregnancy will require a totally different approach, but that’s for another blog post.
However, the main principles that I consider when looking at the pelvis are what are being widely banded about in musculoskeletal practice: loading, pain sciences and exercise for strength and control; and coaching.
The ‘tendinopathy crew’ have certainly provided some great narrative on the management of tendinopathy over the past few years. At the heart of this is Jill Cook and Craig Purdam, but others have seemingly joined the gang. There is a list of articles that provide this narrative at the bottom of the blog post. The key feature is about loading, and the effect of overloading and underloading primarily tendons, but the theory fits well with all soft tissues. This fits in nicely with mechanotransduction, outlined well by Khan and Scott - the identification that our tissues change with the stress that is placed/ not placed upon them.
So for me, there is an obvious change in load with pregnancy and a more subtle one. The obvious one being that the developing baby, fluid filled uterus and not to mention swollen breasts creates extra load. The more subtle one is caused by society, suggesting pregnant women need to slow down which causes overloading not by the addition of load, but by reduction of efficiency of the system that manages load i.e. they get weaker and stiffer. Add extra weight AND take away regular movement (which maintains strength and efficiency) and you’re on a rocky road. I think it also explains why some get it, and some don’t: some women stop, some slow down and others don’t.
I’ve now got a different idea on this since carrying the little lady inside me. Firstly, my weight and size varies hugely on a day to day basis. Its ridiculous. I went for a wee before swimming the other day and before going to the loo I had a massive tummy on me and on coming out it was gone. From one 24 hours to the next visible changes in size can be seen (growth spurt!). However, take another few days and little will change. If a non-pregnant patient’s weight and body shape went up and down that quickly or variably, it could be something to ponder on as the cause of a soft tissue issue.
Not least is this a biological/ metabolic issue for the tissues around my pelvis and tum, but it’s just a logistical and mechanical one for the whole region. Sometimes I can squat, with weight translating through the heels and an extended lumbar spine, but sometimes the bump is too big or she has moved around (yep little baby Sweeney is a girl) and I just can’t find a base of support for simple physics to work. If the bump is big, then I have to tilt forward at the pelvis more, which makes my gluts at non-compliant length and so to get them to work is…well…a pain in the butt! But with a little exploration, it’s possible to find a position to work in. This is something to remember in clinic – you see them on a ‘small or steady growth day’, and then they can’t do it at home three days later. Have the chat and let them know what to do. Indeed, let them know the problem isn’t their gluts are weak, more that because the load from above isn’t consistent they (the gluts) haven’t got a clue what’s going on so it may take a wee bit longer to figure out how to get them to work.
Two of my favourite papers of late is that describing isometrics for pain relief by Ebonie Rio and friends, and the the neuroplastic changes that occur with tendinopathy. Not least because of knowing that isometrics are a good platform to work from for pain relief and then strength, but more because of the respect given to the underlying mechanism of cortical inhibition on weakness and the subsequent manifestation into inefficient tissues. Precedent is placed upon unravelling inhibition, and quickly, to enable progression into strengthening – the problem isn’t all in the tissues, but also in the nervous system that controls it.
You can read more about my experience of the effect of fear and pain on movement in my last entry. Its thought provoking to consider that should I not have overcome the pathophysiological component quickly, my gluts could’ve gotten weaker, which could’ve lead to an increased amount of physiological discomfort – and the vicious cycle could’ve started.
And that’s it for part one of this two part post. Part two will outline the other core concepts of pain science, exercise and coaching within my own practice. Thanks for reading, I hope you find it useful and feel free to pass the link around to others.
Bye for now x
So I am 24 weeks pregnant today with my first baby due on the 24th May 2016 which is all very excitingly overwhelming. As promised with this blog I am going to share with you the 'inner workings' of a pregnant women's health physio, all the ups and downs of the entire process from start to finish, and beyond (other WH Physios I hear you saying 'ha! did you not learn better than to get yourself pregnant?!').
Two weeks ago was a low point, the onset of a right pain in my bum, literally. Over the course of a few days I developed left buttock and sacroiliac pain to the point that I couldn't stand up, lift my leg, get in and out of the car without wincing or feeling a click and having to do it at half speed. This was hard hitting, I have never had to slow down like that, ever! This was when the hormones started to make me freak, all rationality wanted to go out of my head, I was already imagining crutches and the consequences of putting on extra weight due to inactivity. Then, I thought no - and copped myself on. After having a word with myself I thought 'I can be my own case study' and put to the test what I preach to all the ladies I treat with Pelvic Girdle Pain.
My pain was triggered by changes in load to my pelvis, with activating my gluts it eased, even just doing a isometric bum squeeze whilst sitting caused an anaesthesia effect. A main contributing activity to the onset of the pain was walking our 6 month old pup on the lead, or should I say her taking me for a walk. When she pulled on the lead it sent spasms into my buttock, this could be translated to poor anticipatory activity and neuromuscular control of my pelvic stability muscles and their insufficiency to react to this increase in load on my pelvis and sacroiliac joints, thus causing spasm and pain.
It all made sense, so I got to work at addressing it, with well structured exercise and rest to allow recovery. The primary things I used were squats, single leg squats, stiff leg deadlifts and single leg stiff romanian/ stiff leg dead lifts. A little help also came from my women's health colleagues (shout out) who did an 'IOU' deep tissue massage which allowed a window of relief to be able to address the instability. Stretches including pretzel stretches / piriformis / obturator internus stretches also featured for a little short term relief to the spasm. Whilst these activities do give a little bit of relief, it must be highlighted the greatest gains (which i would mark as 'how long an intervention had an effect') were definately the strength exercises. A pelvic stablity belt also enabled me to keep mobile at work and continue with my daily activities. A very important but upsetting point was recognising the need to stop the aggravating activities which unfortunately meant not walking our pup which made me very sad. I had already given up running a few weeks prior and so giving up country walks just felt like I had nothing left! dramatic I know!
I am pleased to say two weeks down the line I am significantly better, I can walk the pup (off the lead), swim breaststroke, front crawl and backstroke again (yay!) and just completed two hours of leading antenatal and postnatal pilates classes to no detriment.
A big learning curve I have to say. It was very interesting to see the psychological effects this pain had on me and the way in which I subconsciously adapted my movement patterns and so only feeding in to the issue. This is the kind of stuff I tell my patients all the time and successfully work to address with them, but when it was myself it was a whole other ball game to address. There was great deal of denial of it initially, until my husband who is a clinical specialist musculoskeletal physio refused to have me deny it anymore! He put up with me for a week before releasing his bottom lip from his teeth one evening in the kitchen and had an hour off from 'caring husband Ady who'd better not be a smart alec' to become 'physio, smart alec and risks having to sleep in the spare room Ady'. And voila, as soon as I started to address the fear of moving and not adapt my movement patterns to avoid the anticipated pain a vast improvement was seen. The joint hadn't 'moved' and my strength hadn't gone - my butt had simply switched off as it thought it was the safest thing to do as it stops me doing 'perceived' dangerous things.
If I hadnt done this, I would have stopped other enjoyable things that keep me mobile, which would have only contributed to genuine weakness, stiffness and even more fear when other things start to trigger off the area. The start of a downward spiral...
The importance of seeing ladies early onset of pelvic girdle pain is therefore invaluable, pregnancy is already a nerve racking time and reassurance is needed early doors to avoid a chronic pain state.
Watch this space to see if it stays at bay from my left bum cheek!
Ive included some pictures for reference as to what these exercises are. Feel free to try them, but a little guidance may be useful/ safer- if so, why not book in for assessment to go over them and other interesting ways of managing your pain in the bum. Please note, I can treat actual bum pain, not 'smart alec husbands'...