Year: 2020

What should I look out for when choosing a Pelvic Floor Physiotherapist?

I have had a few emails and messages recently from women who don’t live in the area (I’m based in Cheshire) and want to find a Women’s Health Physiotherapist close to them.

I thought it would be useful to write my thoughts in a blog for anyone who might need it.

There are a few things to consider:

• This might sound obvious, but make sure the physiotherapist that you chose has skills in internal examination and treatment. There are physios out there claiming to treat pelvic floor conditions without doing internal assessment. Internal assessment is really important if you have pelvic floor problems – how else do you know what’s happening down there if it’s not assessed?

• Experience – it is usually best to choose someone who has been working in the specialism for a long time. Experience brings knowledge, and knowledge brings better care and treatment. I have been working in the specialism for over 10 years and have assessed and treated hundreds of women, but I’m still learning every day. It’s a complex area and you need to be sure your physiotherapist is highly skilled to allow you to have the best assessment and treatment.

• What is your end goal? How important is this goal? Think about this and talk to your physiotherapist about it at your first session. For example, if you want to be able to run a marathon without bladder leakage you need to discuss this at the first session! Will the physio work with you to help to try and reach this goal?

• You need to be sure you are comfortable with your physio. So often, the women that attend my clinic talk about the importance of ‘clicking with their physio’. If you are having issues with your pelvic floor, you will be discussing some really intimate things and you will be likely to have an internal examination. It’s always a good idea to check the physio out before hand – look at their website, check their social media page (if they have one), talk to others who might have been to see the physio. Call the physio if you want to have a chat with them before considering booking in. Get a feel for them because it needs to ‘feel right’! (In my experience, most pelvic floor physiotherapists are lovely though!)

• Virtual appointments – appointments over video have become common practice with the recent COVID-19 pandemic. You may now find that a lot of pelvic floor physiotherapists are offering these as well as face-to-face sessions. Yes, a pelvic floor examination cannot be done over video (and yes an examination is really important as I have already said!), but there are quite a few things that can be achieved over video. So perhaps think about a virtual appointment if you really want to have a session with a particular physio. That way you could literally see any physio in the world!

The magic that occurs 6 weeks after having your baby… or does it?!

“I’ve had my 6 week check… I’m good to go”

Many women are eager to exercise after having a baby. Is your driver the headspace that exercise gives you? Perhaps you are an athlete and you normally pursue exercise at a high level? Is it to help shift baby weight? Perhaps you have been comparing yourself to other mums? Scrolling through Instagram and seeing yummy mummies with amazing bodies doesn’t help with this…

Whatever your motivation to get back to exercise, more and more women are wanting to exercise soon as they can after childbirth. And do you know what, I completely get it. I have been there 3 times myself after each of my boys were born. For me, the major drivers were getting ‘me time’ back and getting that endorphin release.

Just last year, guidelines were published offering guidance on returning to running after having a baby. The guidelines were welcomed by a lot of people – me, other Women’s Health Physiotherapists, fitness professionals as well as mums themselves! I use these guidelines as a framework which very much underpins my practice.

One thing I can say is that it is impossible to give a timeframe for return to exercise that suits ALL women – we are all different, we have all been on a different journey, we all have different bodies, and we will all have different exercise goals. As a Specialist Women’s Health Physiotherapist, I have been assessing, treating and advising postnatal women for many years. I get asked these questions time and time again:

“When can I exercise again?”

“How should I build up my exercise up?”

“What exercises or movement should I avoid, if any?”

“Can I now do sit ups?”

“Am I allowed to do impact exercise?

“Can I do weight-lifting?”

If a post-natal mum asks me a question like this, I cannot answer it accurately unless I fully assess her. Without an assessment, it is impossible to give clear individualised advice. One size DOES NOT fit all!

Physiotherapy Assessment

So, if a woman wanting to return to exercise comes to clinic, what happens in order for me to give her the individualised advice that she needs? I carry out a ‘subjective assessment’ where I ask a series of questions:

• What kind of exercise do you want to do?
• Have you previously exercised?
• What level do you want to get to with your exercise?
• What was the mode of delivery – vaginal delivery / caesarean section?
• Give me your birth story…
• Were there any complications? If so, what were these?
• Are you breastfeeding?
• How are you feeling since having the baby? Are you having any problems?
• Are you having any urgency or leaking from your bladder or bowel? Do you have any heaviness down below?
• Do you have any other health problems / concerns?

These are just some of the questions I will ask. I use her answers to build a clear picture of the person sat in front of me.

Clearly all women will have a different story and will have different answers. Following on, I would carry out a thorough physical examination (‘objective assessment’). This would include assessing:

• Posture and action of the diaphragm
• Relevant functional movements and sport specific tasks for that woman
• Strength and flexibility in the muscles around the hip, back and pelvis
• Function of the abdominal muscles, including diastases recti
• Pelvic floor muscles – including contraction, relaxation, co-ordination, endurance AND strength
• For possible pelvic organ prolapse
• The attachments of the pelvic floor (during some vaginal deliveries the pelvic floor muscles can lose some of their attachment to the bones of the pelvis)
• The size of the opening in the pelvic floor (the medical term for this is gh+pb)

It takes around 90 minutes to complete an initial assessment. Most women then require treatment and rehabilitation over several appointments to ensure a safe return to post-natal exercise.

The risks of an early return to exercise…

So, what are the risks of a return to exercise too early? Pelvic organ prolapse, bladder problems, bowel problems, pain, worsening diastasis recti – just to name a few…

The ‘6 Week Rule’

Most women follow the standard ‘6 week rule’ and resume after their post-natal GP check. Sadly, few women actually receive a thorough assessment of their body at their GP check and are often just told that they can resume exercise.

I believe the ‘6 week rule’ can be harmful. It puts all women into the same bracket. It assumes that your body has healed, that you know how to build up / adapt / change / return to your exercise of choice. It also assumes that that all deliveries and recoveries are the same, that all women’s bodies the same and that all women are returning to the same activities.

Let’s think about a runner who has broken her ankle. Typically, her leg will have been placed in a cast, she will have been told to use crutches and will have probably been told not to weight bear on it for 6 weeks. She sees her doctor at 6 weeks and the cast is removed because her bone has heeled back together. Does she at that point start running right away? Of course not! She will follow a progressive rehabilitation programme to get back to running. This is often under the guidance of a physiotherapist. The physiotherapist will treat, guide and direct the athlete working on flexibility, strength and function. After a period of time (typically 3-6 months after the initial injury), she will be able to safely get back to running knowing that she has the strength and flexibility to do it.

So why is pregnancy and childbirth any different? No matter how ‘simple’ the birth is; there is major trauma to the pelvis, pelvic floor and abdominal muscles. Why are women not given the same attention and rehabilitation as an athlete with an ankle injury. This completely baffles me!

Finally…

In summary, there is no magic that happens at 6 weeks. Each and every post-natal woman (especially one wanting to resume exercise!) needs to have a thorough individualised assessment with a Specialist Women’s Health Physiotherapist. This assessment needs to take account of her exercise goals, her body and her birth journey in order to guide her back to exercise safely.