The Importance of Physiotherapy for Pelvic Health

Pelvic floor weakness is experienced by the majority of women at some point in their lives, often after childbirth when it is estimated that 80% of women sustain damage to their pelvic floor, and during Menopause when the reduction in oestrogen causes thinning and weakening of muscles, although symptoms can occur at any time. Regardless of when this happens, a pelvic floor dysfunction can manifest in temporary and sometimes long-term urinary or faecal incontinence, pelvic organ prolapse or sexual dysfunction (pain, leakage, reduced awareness). Despite how common these symptoms are, with 1 in 3 women experiencing incontinence in adult life, it takes on average women 7 years to mention symptoms to her doctor and only 25% will seek professional help. These symptoms are inconvenient at best and debilitating at worst and conditions for which physiotherapy can help. While NICE guidance recommends referral for supervised pelvic floor muscle rehabilitation and bladder retraining as the first line of treatment for women experiencing urinary incontinence, it is not taken up by many who are often unaware that effective conservative treatment exists, or even worse, assume the condition is normal.

The pelvic floor muscles run from the pubic bone to the tailbone, supporting pelvic organs, such as the uterus, bowel and bladder. The muscles are shaped like a sling and relax when the bladder contracts, allowing urine to escape.

Pelvic floor muscle training is proven to be effective in restoring the pelvic floor, according to Clare Pacey, Pelvic Health Specialist Physiotherapist at Kings College Hospital and Nuada Medical. It appears, however, that many women are never made aware that Women’s Health Physiotherapy even exists. We commissioned a survey last month revealing that a referral to this type of specialist support was only made in just over a quarter (28%) of cases.

The effects of incontinence are vast, with some sufferers reporting a psychological morbidity, such as depression, and nearly a quarter taking time off work due to their condition. Furthermore, over a third of women report that urinary incontinence has significantly affected their relationship. Clare Pacey feels strongly about this:

“It is shocking that women are suffering in silence, particularly when NICE guidelines so clearly state a defined treatment pathway. There is no need for women to continue to endure the physiological and psychosocial effects of urinary incontinence, when it has been demonstrated that three months of supervised pelvic floor muscle training with a Women’s Health Physiotherapist is often all that is needed to improve or resolve symptoms. Furthermore, the guidelines state that internal examinations should always be completed to ascertain whether pelvic floor exercises are being carried out correctly. Research shows that up to 44% of women do exercises incorrectly, with verbal instruction only.”

The importance of a healthy pelvic floor holds great value in other European countries, such as France, where Women’s Health Physiotherapy is commonly prescribed. Clare, who has extensive experience treating a variety of patients with pelvic floor weakness and dysfunction, continence problems, pelvic pain and sexual dysfunction, continues:

“In France, all new mothers are offered up to ten sessions with a Women’s Health Physiotherapist as part of standard postnatal care. Through this, it has been ascertained that a quarter of women have a problem, whether urinary or faecal incontinence, issues with abdominal muscle separation, pelvic organ prolapse or sexual dysfunction. Rehabilitation is offered routinely. This begs the question – why is this not the same in the UK? We could help so many more women and prevent future issues by offering the support as par for the course.”

Beyond The Bump — The Importance of Post Natal Assessment with a Specialist Women's Health Physiotherapist

CARRYING AND DELIVERING A BABY IS NO MEAN FEAT AND HAS A SIGNIFICANT IMPACT ON A MOTHER’S BODY. IT IS ALSO NOT UNCOMMON FOR NEW MOTHERS TO FEEL REALLY ANXIOUS ABOUT WHAT HAS HAPPENED TO THEIR BODY AS A CONSEQUENCE OF PREGNANCY AND CHILDBIRTH.

Understanding exactly how your body is healing and recovering is critical for Women’s Health Physiotherapists from a clinical perspective but is also so beneficial from an emotional perspective for you as a new mother. Less time worrying about whether you are or will be ‘normal’ again and more time focusing on how far you have come with realistic expectations for getting back to you!

In France the Government provides all women with la rééducation périnéale – up to 10 sessions of therapy to restore the postnatal pelvic floor and retrain the abdominal muscles following the birth of a child. A rhyme to the reason why they all have such enviable figures and flawless composure right?! Cue the UK where despite the prevalence of pelvic floor related issues, post-natal care with a specialist Women’s Health Physiotherapist has an extremely low profile and is not available routinely under the NHS. Here, a woman attends her six-week postpartum check-up with her GP and, if nothing is seriously wrong, is reminded to do her Kegel exercises, cleared to have sex again and sent on her way.

JUST BECAUSE MINIMAL CARE AND CONSIDERATION FOR WOMEN’S HEALTH ISSUES IS THE NORM HERE IN THE UNITED KINGDOM, IT DOES NOT MAKE IT RIGHT!

Your body undergoes many changes during pregnancy and continues to change postnatally. It is important to address any issues that occur at this time so as to prevent problems later in life. Childbirth can lead to pelvic floor trauma, perineal tears and pudendal nerve injury (the nerve which supplies your bladder and pelvic floor). Consequently the pelvic floor can become dysfunctional and you may experience urinary or bowel urgency and/or incontinence, urinary frequency, incomplete emptying, pain on urination/defecation and pain or discomfort with sexual intercourse. In fact one third of women experience post-natal urinary incontinence1 and 83% of women at 3 months and 64% at 6 months experience sexual problems2 such as pain on penetration, during intercourse or with orgasm, vaginal dryness, vaginal tightness, vaginal looseness or loss of sexual desire.

A POSTNATAL ASSESSMENT WITH A SPECIALIST WOMEN’S HEALTH PHYSIOTHERAPIST IS CRITICAL TO ESTABLISH THE CAUSE OF THESE SYMPTOMS AND TO CORRECT AND REBALANCE – SO THESE SYMPTOMS DO NOT REMAIN, OR WORSEN.

Because of the level of knowledge and investigation carried out by a Women’s Health Physiotherapist these specialists are also the best placed health practitioner to confirm the status of healing of the separated abdominal muscles (Diastasis Recti) and the appropriate type of exercise or exercises to begin your “comeback” with. Commencing the wrong type of exercise too early or the right type too late can be inefficient or more seriously, can have a long term consequences for your health and happiness.

Diastasis Recti is the separation of the left and right sides of your rectus abdominis. This occurs due to the growth of the baby in the uterus pushing against the abdominal wall and pregnancy hormones that soften connective tissue. Separation often occurs in the third trimester of pregnancy when the abdominals are at their greatest stretch. Most pregnant woman will have a small separation (i.e. one to two fingers’ width) after pregnancy and this is not usually a problem and should resolve naturally on it’s own within 6 weeks. However, if the gap at your midline is more than two fingers’ width and has a visible bulge, you may have a diastasis of your rectus abdominis and need to see a Physiotherapist. Diastasis recti can be problematic after pregnancy when the abdominal wall is weak and it may make it harder for you to regain your tummy tone and return to your normal exercise routine.

It is important to have an assessment to determine which exercises are suitable for you. Many women remain abnormally widened at 8 weeks postpartum and this distance remains unchanged at 1 year without treatment3. If your abdominal muscles remain weak, you are more likely to suffer from back pain and have an increased risk of a hernia. 60% of women will have ongoing abdominal separation at 6 weeks post childbirth4 and 66% of women with a diastasis rectus abdominis have a pelvic floor support dysfunction5. Returning to exercise too soon or completing exercises incorrectly can sometimes cause more harm than good. If you have abdominal separation and are unable to create tension within the linea alba (the connective tissue that attaches the right and left sides of the rectus abdominis) then the pressure within the abdomen when exercising incorrectly could cause your tummy to bulge – worsening the issue. If you have a pelvic floor weakness or dysfunction and are unable to coordinate the pelvic floor muscles with movement and your breathing, then the pressure created may go downward potentially causing or worsening an organ prolapse.

BEYOND THE BUMPTM IS BEYOND HEALTH’S POST-NATAL SPECIALIST ASSESSMENT THAT WE BELIEVE EVERY WOMAN SHOULD HAVE FOLLOWING CHILDBIRTH. THE CONSULTATION WITH CLARE PACEY, BEYOND HEALTH’S SPECIALIST WOMEN’S HEALTH PHYSIOTHERAPIST INVOLVES;

Review of your prior medical history and personal goals which could range from confidence in your pelvic floor, returning safely back to exercise, getting your pre-baby tummy back, returning to sex, running a marathon or getting ready for another baby!
The use of vaginal examination and/or real-time ultrasound and functional tests to investigate in detail the impact of pregnancy and labour on your abdominals, pelvic floor and pelvic stability muscles.
Depending on your results and goals:
Advice will be given as to whether any specific treatment is required (this could include manual therapy techniques, internal release to scar tissue or tight/ overactive pelvic floor, acupuncture, relaxation and breathing techniques, advise on toileting and positional modifications, specific exercises, provision of muscle stimulators to improve activation or vaginal dilators to assist in release and relaxation, Pilates and onward consultant referral).
Formulation of a restoration programme to relieve symptoms and improve overall strength, stability, function, performance and confidence.
Following the assessment the Physiotherapist will provide you with a report of the findings of the day.

At Beyond Health we are determined to raise the profile of Women’s Health and in turn see that women are not limited by any symptoms associated with pelvic floor dysfunction or diastasis recti. We want new mothers to return to doing the things they love as quickly and safely as possible following childbirth and keep doing these things for all the years to follow! We want them to understand that with specialist guidance and care they can look and feel just as they did prior to pregnancy or, better than ever!

To book in for a Beyond The BumpTM assessment or to have a confidential discussion with Clare Pacey please contact Beyond Health at 020 7610 7070 or email us at be@beyond-health.co.uk.

1 Mørkved, K. Bø, 1999

2 Barrett et al 2000

3 Coldron et al 2008, Liaw et al 2011

4 Bakken Sperstad et al, 2016

5 Spitznagle et al 2007

Diastasis Rectus Abdominis

DRA is a thinning of the linea alba that allows a mother’s abdomen to stretch; it is a natural part of the baby making process. In fact, 36% of women remain abnormally wide at 5-7 weeks postpartum.

Conservative diastasis resolution is possible at any time with good education and training. Improvement has to do with the bodies’ capacity for fascia recovery and the willingness to change how you are using your body. I regularly help women who are years beyond their last delivery – here are the top tips I share with my clients.

GET ALIGNED
The number one piece of advice I can offer any woman is to know what good alignment is and to maintain it as best they can throughout pregnancy and beyond. This is a vital part of correcting a diastasis. Many women lean back as their tummy grows during pregnancy and often this continues postpartum, too.

Is your rib cage too far back, are you breathing with your upper chest, is your pelvis tucked under?

If so I want you to untuck your bottom (you need glutes!) – shift the ribcage over the top of the pelvis. This is the optimum position for the pelvic floor and gluteal muscles to activate.

Remember to be conscious of your alignment when exercising too. Exercising in correct alignment will promote a better result from your fitness program.

BREATHE
I encourage my clients to exhale prior to movements, such as lifting their baby. This activates the inner core. Continuing this exhale throughout the exertion will help protect and maintain diastasis closure throughout the activity. It also prevents breath holding which causes increases in abdominal pressure.

EXERCISE
Unfortunately, dealing with diastasis recti isn’t simple and straightforward and there is no set protocol for all women. Generally it requires individual assessment of the deep central stability system (diaphragm, transversus abdominis, pelvic floor) that creates tension over the fascia and regulates abdominal pressure and a personalised progressive exercise programme to rebuild the abdominal wall and restore optimal function. In some cases this may include bracing or taping when appropriate, but that’s not in everyone!

No abdominal exercises are forbidden – your ability to perform an activity needs to be assessed. Exercise that makes the abdomen bulge or causes you to fix your abdominals is best avoided.

Exercising the abdominal muscles correctly during pregnancy decreases the presence of diastasis rectus abdominis post natally by 35%.

During pregnancy I would recommend avoiding any activities that cause the abdomen to bulge, to stop sit ups once the uterus comes above the pelvis brim (12-14 weeks), to minimise twisting activities and maintain good alignment.

SURGERY
For some women physiotherapy is not enough and a surgical abdominoplasty is necessary. A woman would be appropriate for this if she has completed her family and is one year postpartum, has trialled and failed a multi tiered rehabilitation pro-gramme and is unable to generate sufficient tension through the abdominal wall for resolution of function. Surgery should always be combined with a rehabilitation programme as an abdominoplasty will restore anatomical structure but not the abdominal muscle function.