Endometriosis...and how physio helps

March is Endometriosis awareness month.

Of all the conditions that I treat in the clinic, this would be the most common one. Many women will be in for other issues such as leaking, back/pelvic girdle pain, painful sex and when I ask about their periods…endo is often mentioned or suspected. 

According to no endo.org.nz, around 1 in 10 women in New Zealand have endometriosis. That’s a lot of women! My patients experience:

•  Painful, like excruciating pain from the moment they had their first periods

• Heavy bleeding

• Fertility issues

And unfortunately, their journey to diagnosis is not easy. It takes roughly 7 years from onset of symptoms to diagnosis - 7 years of PAIN EVERY MONTH before finally a health professional can help them. Sometimes its health providers that do not know enough about endo, and unfortunately other times its women's symptoms getting dismissed …”it’s not that bad, just take some ibuprofen, all women get period pain”.

This is not ok. If this is your experience, I am sorry. If this is your experience, know my door is always open and I will listen and help you as much as I can.

If you are reading this blog, I’ve no doubt you know the symptoms. You have been on this journey for a long time. You will know we actually know very little about this condition but we think there is a big link to oestrogen. During the month when oestrogen is highest, ovulation (around day 14) and a few days before your period - this is often when pain and symptoms are at their worst. Which is often why the pill is suggested as this suppresses your body’s natural oestrogen. 

So I’ll skip the signs and symptoms and get straight to some extra info that I have learnt/come across and some things you might not know how physio can help.

The amount of endometriosis lesions or adhesions in the pelvic cavity is not a direct correlation to how much pain you will experience - some women have a few adhesions and experience severe pain, and other women have heaps of lesions, no pain and only find out they have endo due to infertility issues. Remember, pain is a very complicated thing - check out these videos I made about pain to help explain just a small component of it. Our experiences of pain are different - comparing pain between 2 women with endo is impossible. 

Simply removing the adhesions will not make the pain go away. During surgery, the specialist will cut away the adhesions, and inside the abdomen will be full of little cuts. These hurt! It might have been keyhole surgery with a little scar on the outside, but on the inside there is still a decent amount of trauma post surgery. What happens when you have pain in the body? Inflammation, muscle spasm and the body protects the bits it thinks need protecting. So post surgery pain can be from this inflammation and muscle spasm…including the pelvic floor

If the pelvic floor spasms, sex will become painful, peeing and pooping can also become painful as the pelvic floor can’t relax enough to let things in and out. Women with endo also report experiencing overactive bladder/urinary urgency, IBS, painful sex - and are these 3 separate conditions or are they related to the endo…more often they are related to endo.

If there is no cure can physio really help? Yup it sure can.

When I assess a patient with endo for the first time, I take an extensive history. This is key to figuring out the best place to start treatment. I’ve got a heap of tools in my treatment tool box to help with pain, the first being education. If you don't understand why you are experiencing pain, nothing will help it. So really knowing why you are experiencing pain the way you do is crucial - and it's often different for everyone. Physio can also:

• Teach you how to breathe and relax the pelvic floor if it's too switched on

• Show you how to massage the pelvic floor to help with relaxation

• Give you exercises and stretches to help relax and stretch the pelvic floor, plus all the other muscles around the pelvis - hello pelvic floor yoga!

• Figure out if the pelvic floor is tight or super switched on…or both

• Help you deal with your bowels - whether it's runny poos, painful poops or constipation or a mix of them all.

• Help decrease pain with sex

• Help get you back to doing what you love to do, with a bit less pain.

No matter where you are in New Zealand, or the world, if you have found this blog and endo is a part of your life (or you think it might be) please get in touch, get in and see me in person or online. There is more you can do than you might think!

Keep fighting the fight Endo Warriors. 

New to yoga? Start here with a 60 minute class!

This is a blog I wrote for my studio website, inverted Fitness and I wanted to share it here too. I hope you enjoy it and let me know how you go with the 65 minute class!

Welcome welcome welcome and thank you so much for wanting to know a bit more about yoga with us at Inverted Fitness! Lesley is our resident teacher having completed her 300 Hour Power Yoga Training and now onto another 200 hour training because…why not!

Yoga at this wee studio is fun and fabulous. As soon as you walk in the door you can feel the welcoming and warm vibe…something I’m very proud off! Students love the relaxed and chilled out vibe; we talk, we laugh and sometimes even cry during class (not because anyone is mean, but because its been a hard day!), you can truly be yourself here. Whether you follow along with every move, or take heaps of breaks to just breathe, showing up and getting on your mat is what’s important.

I’ve been a Physiotherapist for 13 years and now work predominately in Pelvic Health. Breathing is a huge part of my treatment plan for many different conditions, and this is what has blossomed my love of yoga. Honestly, teaching women to breathe to help with their pain, their anxiety, their pelvic floor dysfunction and seeing the results is incredible.

I’ve put together a collection of videos below to help explain some basic aspects of yoga:

1. Welcome video explaining about why breathing is so beneficial during yoga

2. Diaphragmatic breathing

3. Ujjayi breathing

After you have finished watching the videos there is a 60 minute Intro to Yoga Video…yip a full 60 min video for you to have a look at, follow along with. It’s a very basic intro, only a few poses explained with well to let you get a feel of what class is like. Remember we do move quicker and do not hold poses for as long as I do in the video but you will get a feel for it.

Return to Running After Baby...part 2

What happens during a Return to Running screen?

To do a full assessment, pelvic floor examination is strongly recommended. I complete a full assessment including bladder and bowel function, sexual dysfunction, previous injuries, pregnancy and birth history followed by a pelvic floor examination (if consent is given) to check for signs of dysfunction, weak/over active muscles, tummy muscle separation and teach you all about your core and pelvic floor. If there are any issues, we will make a plan to tackle those first and get them under control. This does not mean you have to stop exercising – we might have to just modify what you are doing/how you are doing it.

If there are no issues, we can then progress to the strength and impact screen. The body has to be strong enough to cope with impact so checking muscle strength is the next step. If there are any weaknesses this will be your homework for a few weeks to build strength.

Next step is the impact screen. This is designed to check how your body and especially pelvic floor will respond to an increase in load and pressure going down through it. It will highlight if there are any loading issues for example pain, leaking, pressure/heaviness – do you need to relax the pelvic floor more? Change your landing technique? Strengthen your pelvic floor more? If there are any issues then we work on these too.

Emily (from EmPowerMe Fitness) and I are working on a 6-8 week Return to running course….stay tuned for more info!!

Once you are symptom free, strong enough and your body has shown you are ready for impact….lets go! You can gradually ease back into whatever you would like to train for. For example:

• Running – perhaps start a couch to 5km 8 week plan

• Netball – preseason like drills to ease back into impact

• Cross fit – low reps of jumping and landing (body weight only) and increase reps, speed, height, distance as you are able

Often return to impact will show up problems that women didn’t realise they had. I will often see them after 6-12 months when they have tried running but have developed issues. If this happens don’t panic – we just need to figure out what is going on and get a plan in place.

 If you are ready to get back into running and impact exercise…you know who to call!

Risk factors for potential issues returning to running

• Less than 3 months post natal

• Pre-existing hypermobility conditions

• Breastfeeding

• Pre-existing pelvic floor dysfunction or lumbopelvic dysfunction

• Psychological issues which may predispose a post-natal mother to inappropriate intensity and/or duration of running as a coping strategy

• Obesity

• Caesarian section or perineal scarring

• RED-S (Relative Energy Deficiency in Sport)

Signs and symptoms of pelvic floor and/or abdominal wall dysfunction

• Urinary and/or faecal incontinence

• Urinary and/or faecal urgency that is difficult to defer

• Heaviness/pressure/bulge/dragging in the pelvic area

• Pain with intercourse

• Obstructive defecation (e.g. constipation, staining to empty bowels)

• Pendular abdomen, separated abdominal muscles and/or decreased abdominal strength and function

• Lumbar/pelvic pain

Reference: Returning to running postnatal – guidelines for medical, health and fitness professionals managing this population. Tom Goom, Gráinne Donnelly and Emma Brockwell Published – March 2019

Return to Running After Baby...part 1

It’s been 6 weeks since bubs arrived, and I’m ready for running and impact exercise right?

Em No.

When the clock strikes midnight on Week 6 post natal, the body tissues do not magically heal to allow you to go straight back to pre-pregnancy exercise (sigh…if only it were true though!!)

De Mattos Lorenco et al. 2018 completed a systematic review to look at all the research on urinary incontinence in female athletes. They concluded “High-impact activities showed a 1.9-fold prevalence over medium-impact activities and 4.59-fold prevalence over impact activities”

Running can create ground reaction forces between 1.6 and 2.5 times bodyweight and will increase intra-abdominal pressure, but just how much of this is absorbed by the legs and the pelvic floor? Have a look back at these blogs to understand about the core and pressure system .

The pelvic floor muscles therefore need to be strong enough to support this pressure, but also be able to adapt and move with the changes in pressure to stabilise the pressure in the abdomen.

Pregnancy puts a significant amount of pressure onto the pelvic floor. The pelvic floor has a “U” shaped space (see blue line on the picture to the left) for the urethral and vaginal openings.

The U shaped space actually widens during pregnancy and even more so during a vaginal delivery. After a C-section the space will decrease but it can take up 12 months for this space to return to a similar size after a vaginal delivery. But it will never return to prenatal size. Why is this important? Look from the side

You can see the vagina is in the middle of the pelvic organs and canals. If there is injury or laxity in the tissues that support the organs, the tissues becomes over stretched and the organs will descend into the vagina causing a pelvic organ prolapse. The vagina sits above the levator gap, therefore an increase in this width means less support for the organs.

After a caesarian section, the uterine scar will still be thickened and healing at 6 weeks post natal (which is one reason C-section recover takes longer) . But studies have also shown that abdominal fascial has only 51-59 % of its original strength at 6 weeks, and 73-93% of its original strength at 6-7 months ( Ceydeli et al. 2005, taken from Return to Running Guidelines see reference below)

Looking at the anatomy and statistics above, you can see why these guidelines were needed.

The guidelines state:

“a low impact exercise timeline is followed within the first 3 months of the postnatal period, followed by a return to running between 3-6 months post-natal at the earliest. In addition to this every post natal mother, regardless of delivery mode, should be offered the opportunity o receive a pelvic health assessment (from 6-weeks postnatal) with a specialist physiotherapist to comprehensively assess the abdominal wall and pelvic floor including vaginal exam as indicated”

We also know that:

“The evidence supporting individualised pelvic floor rehabilitation for the management of urinary incontinence (Bo, 2003; Dumoulin et al.2018; Price et al. 2010), POP (Hagen et al. 2013), sexual dysfunction (Braekken et al. 2015) and the prevention of POP (Hagen et al. 2013) is well established. (RTR gudelines).

Although the guidelines recommend 3- 6months, again this does not mean at bang on 3 months you are ready for a 5 km run. If you have any signs and symptoms of abdominal wall or pelvic floor dysfunction, or risk factors then allowing the body as much time to heal AND be symptom free AND reduce your risk factors will give you the safest return to running/impact experience. A pelvic floor assessment is strongly recommended too, there could be a prolapse that is not giving you any symptoms, or you may have risk factors for developing pelvic floor dysfunction later on in life. Simply not having symptoms of dysfunction is not a good enough reason to commence running.

Reference: Reference: Returning to running postnatal – guidelines for medical, health and fitness professionals managing this population. Tom Goom, Gráinne Donnelly and Emma Brockwell Published – March 2019

The Liver is connected to...the shoulder???

Let me start with an amazing experience I had during the Visceral Manipulation course. I had some work done on the on the connective tissue of the small intestine.  After baby number 2 I had a two and a half centimeter separation of my abdominals with a lot of sinking and sponginess around my belly button. It has stopped me from getting back on my pole and progressing with my yoga. BUT after this treatment the tissue along my tummy felt a lot firmer, its now easier to connect to my middle fibres of transverse abdominis AND the gap is now down to a centimeter and a half. Mind BLOWN!!

But now to the liver. This is just one example of how complex and intricate the body is.

The liver lives here…

Can you see it moving up and down with the breath on this MRI?

http://yogaphysicaltherapy.com/wp-content/uploads/2016/01/breathing_mri.gif

You can see it sits on right side of the body at around the level of the 7th to 10th ribs. The main artery entering the liver is the hepatic artery and the portal vein takes the blood away. It has a few different nerves that help it function including the vagus nerve and the phrenic nerve. When the liver is stuck or restricted within it’s fascia (the tissue that surrounds the liver) it can cause restrictions in places you would never think. These include:

• Neck pain at levels of C4/5

• Right shoulder blade

• Right shoulder joint

  • How you ask? Well the phrenic nerve that goes to the liver comes from the neck and has some nerve branches that got to the shoulder and the shoulder blade. When nerves enter the spinal cord, they all go into the same part so when you affect one nerve lower down, it affects the nerve higher up! (It’s a lot more complex than this…but hopefully you get it!)

• 7th -10th thoracic vertebrae (mid back) and ribs

  • The liver sits behind/in front of these structures and is attached to them with some connective tissue

 The liver is also associated with the following emotional/psychological responses

• The core of your personality

• Intense anguish

• Rage

• Strong fears

• Unbearable difficulties

• Depression

• Decrease in creativity.

I know this seems a bit airy fairy…Liver problems = anger? But remember the brain is a complex complex organ and the neural connections within the body that produce emotion are closely liked to connections that control muscles and sensations.

So maybe that longstanding pain in your shoulder neck or bad could be some referred pain or restriction coming from your liver!

What is Visceral Manipulation?

If you have read any of my other blogs, you will have realised by now:

1. I am addicted to learning EVERYTHING I can to help my patients

2. I keep finding new explanations and reasons as to why things happen in the body – and how all the systems are connected.

I reckon Visceral Manipulation is bridging the gap between the musculoskeletal system, the connective tissue, the nervous system and the organs. Are you seriously telling me the liver can cause headaches? Yes I am!

Let me start with the background of whom developed visceral manipulation.  A chap named Jean-Pierre Barral was born in France in the mid forties. He started his career as a physiotherapist and went on to study Osteopathy.  When he was working in a Lung Disease Hospital in his hometown, he had the opportunity to perform cadaver dissections (you know…looking inside bodies). He notice around the viscera (internal organs) was some extensive tissue thickenings and he realised these thickenings were altering the mechanical tensions on the surrounding tissues. This led Jean-Pierre into the theoretical and practical development of the visceral manipulation techniques that are taught in these courses.

The viscera are the internal organs of the body typically in the chest, thorax and abdomen.  The quote below is taken directly from my study guide and it states that

“Visceral manipulation is a manual therapy consisting of gentle specifically placed manual forces that encourage normal mobility tone and inherent tissue motion of the viscera there connective tissue and other areas of the body were physiologic motion has been impaired.”

Our bodies need movement to be healthy (motion is lotion!) so for an organ to be healthy and functional optimally it has to be able to move with the structures and tissues surrounding it. If the tissues lose the normal motion, they do their job inefficiently and may become stuck.  In a nutshell, Visceral Manipulation is assessing and treating the motion of an organ.

Musculoskeletal physiotherapists bread and butter has always been the muscular skeletal system including the skeleton, muscles, ligaments and tendons to name a few.  As time has gone on we have discovered that the body is more interconnected than what we first thought. There is connective tissue that runs through the entire body, through the different layers of tissue and surrounds every organ.  If you take away the skin, the muscles and the vascular system but left the connective tissue in place you would have the perfect outline of a human being.  Connective tissue must be able to move between the layers of tissue within the body. When there are restrictions present it can cause restrictions in other places of the body.

So why on earth would I want to be concerned with the organs you ask?  Well let me tell you.  Through his extensive research and clinical practice Jean-Pierre has discovered organs are connected to other structures and even emotional response is due to the extensive neural (nerve) network throughout the body. In the next blog, I will use the liver as an example of an organ can connect to the rest of the body.

This was a fantastic course. My class mates above were a cracker bunch of humans. I learnt so much from them as well as the course itself. I don’t say it often but I was blessed and privileged to meet them all. If you are a manual therapist, massage therapist, physio, osteopath – you need to get on one of these courses. It will change how you practice!

If you want to learn more about this amazing therapy, please check out https://www.barral.co.nz/ or send me an email and I will gladly share my experience.

My first experience with Visceral Manipulation

Last week, I was on a course all about Visceral Manipulation. When I first signed up for it, I was a bit nervous and to be honest a bit skeptical about what I was going to be learning about especially as I knew it had something to do with the organs.

An incredible and very brilliant physiotherapist that I used to work for Krissy Gunn (who owns Contact Physiotherapy in Methven) introduced me Visceral Manipulation several years ago. I saw Krissy back in October 2020 to learn a bit more about it and she took me through a session. I could not believe what was happening.  Krissy knows I have two kids, but I had never told her that I'd had two cesarean sections or had any issues with my bladder. Through what is called the “General Listening” she was able to pick up that there was something going on in my pelvis and started to do some work releasing around my bladder.  I had been to the toilet for a pee just before my appointment with Krissy so my bladder was pretty empty. After about 15 minutes of treatment I could feel my bladder fill suddenly and rushed to the toilet to pee (a lot!) again. I explained to Krissy after my first cesarean section I’d had a lot of scar tissue that stuck my bladder to my abdominal wall and this was only discovered when I had my second Cesarean section with my daughter. During pregnancy I didn't really need to pee any more than usual, which is odd considering during my first pregnancy I did have to go way more than usual.  During my second cesarean, the obstetrician spent an extra 30 minutes taking the scar tissue away from my bladder and I had a catheter in for an extra  day post-op to try and stop the scarred tissue from reforming.  For 6 months after the second surgery I didn’t have great sensation and after some visceral manipulation my sensation and urge to go is completely fine.

Then Krissy brought out the big guns (no pun intended haha). She done some treatment to the base of my neck using Craniosacral Therapy. I was still breastfeeding and my daughter always preferred one breast more than the other.  Her neck range of movement seemed fine but Krissy had me place my fingertips ever so gently on base of my daughter’s neck similar to where Krissy had her hands on my neck. When she started treatment, my neck and head would release and follow the same movement of my daughters head and after a few minutes it was all done It felt AMAZING, I was instantly tired and slept peacefully for the first time in months. My daughter breastfeed perfectly on both sides. Th biggest improvement for me was that my anxiety was a hell of a lot better for honestly the first time in years. So naturally I went  home, looked up all about this Visceral Manipulation and booked into my first course.

Krissy has done all of these courses several times to really hone and perfect her skills. She was an incredible and experienced physiotherapist anyway and adding these skills on top of her physiotherapy  expertise means she has ever more techniques for approaching dysfunction in the body.  I'm going to write a separate blog on what Visceral Manipulation is and all about my course, but below are some case studies from Krissy’s practice show you how awesome visceral manipulation is. 

Please please check out Krissy’s Website and Facebook Page to learn more about her and the amazing services she offers.

Case Studies from Krissy’s patients

• A 52 year old man had a ten year history of tension and discomfort in his stomach and such severe acid reflux he had taken up to three ant-acids a day without relief. He had sought treatment from various GP’s and practitioners over the years with no benefit. After working his sphincters he felt immediate relief and a further two sessions on his stomach and duodenum resolved them completely. He is looking forward to regaining the five kg he had lost as he couldn’t eat!

• It was a similar story with a 46 year old farmer who was struggling to do sit ups due to acid reflux. A two year problem which was steadily getting worse and was only temporarily relieved by medication. Stress and anxiety increased the symptoms. Treatment resolved the physical symptoms and correspondingly reduced the anxiety but I would expect that high stress situations will necessitate further sessions as the increased input from the neural system kicks off the cycle again. He will incorporate relaxation exercises- if he gets time!

• A 50 year old mother of three had ongoing pelvic pain following a hysterectomy and follow up surgeries for pelvic floor repair and release of adhesions. We don’t work directly over surgical sites however connective tissue runs all through the body so working other organs helped considerably with her pain, bladder control and ability to exercise.

•  A 16 year old student had been unable to participate in athletics and cross country due to shoulder pain while he was running. It was severe and disabling however his shoulder examination was unremarkable. The diaphragm shares neural connections with the neck and shoulder and working in this area and providing strengthening exercises resolved his problem. Now he is regretting it with no excuse to avoid training on those cold foggy mornings!

How often do you need to exercise the pelvic floor?

Honestly….It Depends!

Are you strengthening the pelvic floor? Or does your pelvic floor work too hard and you need to practice relaxing? Are you wanting to get back to walking the dog? Running? Yoga? Picking up the washing basket?

Your individual goals will change what you exercise plan is.

Check out my video below to help you get a better idea of what I mean.

How to contract your Pelvic Floor & Core

The number one question I get asked from patients in the clinic/email/message is:

“Can you just teach me how to do pelvic floor exercises?”

Of course I can…but just learning how to do a pelvic floor contraction is not going to fix your problems. But it is the starting point. Relaxing is just as important and contracting these muscles.

I teach core and pelvic floor in lying - but from the video you will see this isn’t a function position. It is for training purposes only

 Remember: an individual assessment is a must to get the best cue for you, and also to check you are doing it right!

The images are used with kind permission from myPFM.com