Antenatal and postnatal
A special time; whether planned or not. A woman’s body experiences massive changes in one year – from non-pregnant; to Frankensteining up a baby in the 1st trimester (all those hormones coursing around making a human); to a period of relative calm and quiet growth during the 2nd trimester; to the weight, load and center-of-gravity shifts of the 3rd trimester, to delivered with a baby in arms. That bundle of joy becomes priority and rehabilitation is focused on the growing demands of caring for and carrying your grub. Depending upon your birth experience, varying amounts of rehab are likely to be required to address your ‘weaknesses’ – be it retraining pelvic floor muscles and/or abdominal muscles after an assisted vaginal delivery, or two caesarian sections.
Specific problems include: pregnancy-related pelvic girdle pain (including low back pain); thoracic pain (midback pain); rib pain; incontinence (both urinary and faecal), pelvic organ prolapse and separation of the abdominal muscles (diastasis rectus abdominis).
Irrespective of your mode of delivery, your body has undergone massive changes. Both vaginal deliveries and caesarian sections can suffer from incontinence, although vaginal deliveries are more prone to pelvic organ prolapse due to stretching of connective tissue. The caesarian section ladies often complain of a lack of sensation above the scar, making it difficult to retrain abdomino-pelvic synergy, or core activation. They often complain of persistent low back pain.
Return to exercise should be graded, with shortening and tightening of all abdomino-pelvic muscles, prior to adding too much load and impact. Realtime ultrasound is an invaluable tool for visualizing the muscles and practicing correct activation. Electromyography and neuromuscular stimulation can help to increase sensory awareness and connection in patients who feel they have less sensation or motor activity post kids.
Hypo-pressive technique or low pressure fitness can be of great value in certain cases where they are struggling to control changes of intra-abdominal pressure.
In the interim, you should be re-establishing (or finding for the first time!) a good sensory (feeling) and motor (moving) relationship with your pelvic floor muscles and abdominal muscles. You should also not be straining on the toilet, as this can aggravate stretch caused during pregnancy.
Post surgical patients
A particularly vulnerable group are post operative patients.
HIP REPLACEMENT SURGERY can be particularly problematic due to restricted hip flexion. This dramatically impacts on the position required for defaecation. Use of appropriate aids (laxatives, suppositories, low volume washouts if need be) are highly encouraged.
Other vulnerable patients are those who have had abdomino-pelvic surgery, have high pain-relief requirements, low mobility and/or a pre-existing history of pelvic dysfunction.
Post-operative pelvic floor muscle exercises
Many individuals will require some extra voluntary pelvic floor muscle activity after surgery – be it to support the surgical site e.g. hysterectomy or prolapse surgery, or to increase pelvic floor muscle activity e.g. postnatally or post-prostatectomy.
Whilst the role of food (diet) and fluid (water) cannot be underestimated, defaecatory technique (or ‘how to poo’) and tricks to ‘call the poo’ can be very beneficial in getting that gut going again. Visceral manipulations can help to restore appropriate colonic activity, whilst the focus is on establishing a healthy toilet routine. The role of stress and inhibitory behaviours are discussed.
Choose your stool….
Impact and loading in females
…because of our stretchiness (for baring children) impact can be too much for our anatomical structures and we could leak or have prolapse. This is also true for heavy lifting. Beware the gymnasts, ballet dancers, runners and weightlifters.
Loading in males
…men are already tight, and the pressures through the pelvis during cycling can cause problems with circulation and muscle and/or nerve function.
- Just finished a big race and can’t feel down below very well, or have pins and needles?
- Is the erection still working 100%?
Male weightlifters may experience difficulties after pressing heavy weights with the legs from a deep squat/ hip flex position.
You’re all tight; focus is going to be on letting go and breathing….
Anxiety can cause dys-regulation in the autonomic nervous system; which induces whole body changes in response to stress or calm.
When stressed, the body is primed to act with adrenaline and blood being diverted to our limbs (so we can punch or run).
When calm, we perform automatic bodily functions; like digesting.
We need to get out of the constant ‘fight or flight’ caused by the sympathetic nervous system in response to stress (fright). We should spend more time with our parasympathetics firing – ‘pee, poo, pleasure’.
Management focuses on education regarding physical manifestations of stress and anxiety – it’s amazing where the body hides anger and fear in muscle tension and nerve-firing patterns. Referral to an appropriate psychologist is made, where relevant.
Cancer sufferers and survivors
Impacts of cancer treatments (surgery, radiotherapy and/or chemotherapy) on quality of life, especially sexual function, are profound and under recognised.
As a general rule: men have incontinence and erectile dysfunction after prostate cancer; whilst women are tight and dry after surgery, radiotherapy and especially dry after chemotherapy.
For the men
…we advise pelvic floor exercises to get in touch with their muscles (which they have never needed to be before) and a vacuum erection pump for the post surgical period (to maintain housekeeping erections).
For the women
…we advise on release and fun ways to stretch, and of course, a really good lubricant. We also discuss issues around sexual function and behaviour – it should be a journey, not a destination, with the focus on regaining a whole sexual being, rather than simply prepping the vagina for penetration.
If you are one of the lucky few to have survived peritonitis, there is likely to be extensive scarring in the abdomen resulting in pain and dysfunction that may be responsive to treatment.
A particularly challenging group.
Spinal cord injuries
Incomplete: we assess current function, and establish the levels of what you have lost where. Will the bowel still work but the bladder won’t empty properly? Once we have an idea about what might be over or under active, we can plan strategies accordingly.
Complete: we work out what you have and what you don’t neurologically, and implement whatever management is most appropriate to help you manage your bladder, bowel and sexual function.
Degenerative or progressive neurological conditions (Multiple Sclerosis and Parkinson’s)
Often accompanied by a decrease in bladder and bowel function, with milestones relating to functional mobility. Although no get-out-of-jail-free card, advice and compassionate management of current symptoms are available – we don’t take someone who is wheelchair-bound, been incontinent for 2 years and do internal electrical therapy.
Strokes and other vascular accidents
Can have varying degrees of functional control, and a session with a pelvic therapist, as an adjunct to your neuro physiotherapy can make a big difference.
A chronic cough puts a great deal of pressure on your pelvic floor muscles. It is not unusual for women who have been pregnant to leak when they are sick. This is compounded in patients who are sick all the time e.g. asthma, cystic fibrosis, bronchitis. The aim should not be to victimize the pelvic floor muscles during periods of excessive demand, but rather to find ways to better manage the chest e.g. regular active cycle of breathing technique that focus on mobilizing secretions for easy clearance, rather than hacking away for 45mins without getting anything up.
Sometimes the first person you tell is your pelvic physiotherapist. If that is the case, we will include psychotherapy as part of our management of persistent pelvic problems. We cannot ignore abuse as a variable and driver of pelvic pain and dysfunction. Abuse can be verbal, mental, physical or sexual – a child who holds on to everything in fear of an alcoholic parent, or a victim of date rape.