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

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