Q&A on women's health physiotherapy with senior physiotherapist Dr Rachel Bromley - ANSWERS BACK

[HeatherMumsnet]

Were running a Q&A on Womens Health Physiotherapy with Nuffield Health. Their senior Womens Health Physiotherapists will answer all your questions on musculoskeletal problems and issues with the bladder or pelvic floor. These might be antenatal or postnatal problems associated with pregnancy or childbirth, or gynaecological problems.

Dr Rachel Bromley is a senior physiotherapist. She qualified as a physiotherapist in 1992 and has been specialising in continence and womens health since 2005. She has recently completed a Masters Degree in Continence and Womens Health at Bradford University. Rachel is the clinical lead physiotherapist for Womens Health within Nuffield Health and as such teaches and mentors other physiotherapists within the company who have an interest in womens health and continence. Dr Bromley has had additional specialist training in the assessment and treatment of a variety of womens health conditions, including urinary stress incontinence, urgency, symptoms of prolapse, voiding dysfunction, pelvic girdle pain and other pregnancy related conditions.

Laura Haworth qualified from Cardiff University in 2004 with a BSc in Physiotherapy. She has worked in Australia and New Zealand. Back in the UK, Laura joined Pilates Art and completed her equipment and mat-based Pilates training through the APPI Institute. She worked in their Hampstead clinic for eighteen months and became part of the womens health special interest group, working towards developing a private womens health service. Laura joined Nuffield Health in 2011. Since January, she has been based at the Nuffield Health Wharf Medical Centre in Canary Wharf where she has been assisting in the development of the womens health service.

Post your questions to the experts before 18 November and well upload the answers to this thread on 27 November.

This Q&A is sponsored by Nuffield Health

[Geneticsbunny]

I have suffered badly with PGP for my last two pregnancies. Other than lots of pelvic floor exercises what else can be done to minimise problems?

Thanks

[ClearlyMoo]

I have an ongoing lower back problem and my physio have me a Serola belt for sacoriliac joint stabilisation in very early pregnancy. I do Pilates fortnightly (one on one) and have a daily physio routine. I work long hours at a desk and sit in car for 2.5-3hrs/day. Recently I've been experiencing pain in my bottom (around my coxys) when I release pressure (ie stand up). Could this be linked to my sacroiliac issue? Do I need to go back and see physio?! Would wearing my belt help? Thanks very much in advance.

[CrispyFB]

I realise this is slightly off topic and I know it is not your fault at all but..

We have private health insurance and Nuffield provides the physio part of that. How is it fair that earlier in the year you paid for me to be treated for a knee injury that was only really a problem when I was skiing, yet won't cover me for any care whatsoever when I can hardly walk and am in constant agony night and day from 16 weeks thanks to PGP/SPD?

Apparently pregnancy is a "lifestyle choice" but clearly skiing is not

Every UK private health insurer is the same. I can understand not providing antenatal care obviously, but PGP is not an inevitable consequence of pregnancy and other complications such as ERPCs and c-section delivery if medically required are covered.

Most NHS physio offerings are inadequate when it comes to PGP, and for most women the only relief they can get are through private options. I resent effectively paying three times (as a taxpayer for the NHS, for private health cover and then again to a physio) for treatment.

Okay, vent over!

--

Back on topic with a proper question! I never had PGP or stress incontinence until I was pregnant with my first child. I assumed the two were unrelated but willing to be proven wrong! But I recently purchased a Serola belt (I am 20 weeks pregnant) and I have found when I am wearing it that my often very bad stress incontinence greatly reduces. Why would this be?? Or could it just be a coincidence of timing with when I started wearing the belt during this pregnancy?

Thank you!

[Pookdids]

I have just been referred for specialist physio for rectocele/cystocele, with a view to having surgery in six months if things don't improve. I've got to wait until the beginning of January to see the physio - I go to the gym regularly (although I've had to modify what I do quite a bit and don't feel able to do anything high impact)
Do you have any advice for things I should/ shouldn't do when exercising while I wait for the initial physio? Obviously I'm keen to do all I can to avoid surgery...

[lotsofquestions000]

I am 5wks post rectocele repair and when I get the all clear really want to be able to go back to things I was doing before, gym, hill walking zumba and a bit of running?
Plus I have an allotment and do a lot of heavy gardening,
I know that I will have to be careful in the future but want to know if you can recommend appropriate PF exercises and how I can adapt gym stuff so that I can still get a good workout but not risk a relapse. Also what is the time scale for extra precautions (ie when will the healing of the surgery be at the strongest its going to be!) I have heard/read so many conflicting stories I am totally confused now!

[PinkStarStuck]

Hello...I have had x3 babies since 2007, all of them fairly sizable - 8lb - 9lb 10oz. With all 3 pregnancies my stomach muscles have separated and I've needed to do quite a lot of work with a physiotherapist to get get them to (almost) meet in the middle.

I am pregnant with my 4th...is there anything that I can do to stop the separation happening again or at least to minimise it? Is there a special belt that I can buy easily in the country that I can put on PP to help, the NHS hospitals usually give out large tubie grip which IMO doesn't work as well as a pair of spanx!

My 2 younger babies were my biggest, but oddly enough with those 2 pregnancies I put on far less weight than with my first as I was on the go rather than sitting behind a desk as I was with my first pregnancy.

Any advice greatly appreciated...(and any tips on how NOT to look 6 months pg when I am 9 months pp...).

[nevergoogle]

What a great Q&A. I'm also a physio so my question is 'can I have a job?'.

Actually no, I have proper questions.

Working with older people in the community, incontinence is often a problem which is overlooked by many health professionals particularly where clients have co-morbidities with higher impacts on the clients function.
Do you think more could be done with regards to physiotherapy treatment for continence for those unable to access hospital appointments?
Which training courses would you recommend to give a good insight into best practise for the generalist physiotherapists where specialising is not always appropriate?

[QuietNinjaTardis]

Ok this is embarrassing but I'm 37 weeks pregnant and think I'm leaking a bit after I have a wee. My bladder is crap anyway and I need to wee a lot but I've never leaked. I do my pelvic floor exercises but after I have a wee I think a bit more is coming out even though I do my best to squeeze out as much as poss. Anyway of fixing this while pregnant or will it get better after the baby's here?
Also have been seeing an osteopath for SPd/pgp which has helped a lot but have been getting horrible hip pain at night and also during the day I've been getting what feels like sciatic pain but near my groin at the top of my thigh. It happens when I'm walking about and I have to stop as its so painful. Any ideas what this is and How i can stop it?
Thank you.

[BummyMummy77]

From early on in this pregnancy I've been getting bad back pain in the middle back, just to my right side of my spine. It's always been in this one tiny spot and has gotten so bad at 41 weeks I can hardly stand.

Is there anything I can do now to relieve the pain and is there anything I can do in my next pregnancy to avoid this happening again?

[IamInvisible]

I had severe SPD in my last pregnancy 17 years ago. I was wheelchair bound by the time the baby was born. I never managed to get rid of the crutches permanently afterwards. It was so bad my pelvis remained really unstable so I had the symphysis pubis fused 8 years ago. Unfortunately that failed, so was redone by another surgeon almost 6 years ago. I have since had both my SI joints fused too. Because of the ongoing pain and the fact that the screws from the front plates could be felt through the vaginal wall(sorry tmi) the front plates were taken out 2 years ago.

I am in severe pain and am unable to walk unaided. I have regular steroid and LA injections done into the SI joints, and I also have them done into multiple areas of my pelvis, including the SP, under GA. I have discovered I have an Acetabular labral tear in my left hip from a recent MRI, too. Recently it feels like the bottom of my pelvis has started flexing again.

The problem is from using crutches all the time, my wrists, hands, elbows and shoulders are really, really painful. Is there anything I can do to alleviate this?

The other thing is my leg muscles are wasted, and my knee caps are loose because of this according to my GP. I was sent to see yet another physio with the view of hydrotherapy, but he said that anything he did would cause me too much pain. I have seen so many physio's but no one knows what to do with me to help give my muscles a bit more strength. Is there anything that could be done to help me?

(Sorry its so long)

[gussiegrips]

Another physio here:

When do you think women are most receptive to the important information about pelvic health?

I'm not sure that the "get 'em when they're pregnant" is effective - at that stage we're all only really interested in information about getting the baby out.

WWYD?

[ScienceRocks]

Why isn't more known about SPD, and what to do about it? I saw an amazing physio two years after dd2 when my spd was still troubling me, and she really helped me, but she's the exception not the norm. Why is this the case? The long term effects of SPD are awful.

[idlevice]

Did you find SPD/PGP issues during & after pregnancy were not well known about when you worked in Australia? When I had it with my second pregnancy I was told by a physio it was normal pregnancy niggles without even an examination & it is hardly mentioned on Aussie parenting forums. Luckily 2yrs of physio back here in the UK sorted it out for me but I dread to think it's perhaps not widely recognised there & many women are suffering.

[ChaffinchOfDoom]

Hi, I am 20 weeks pg with my 3rd,
I broke my coccyx in a fall while pg with no, 2 , and have occasional bad pain in lower back, not lately though
I am getting quite bad sciatic pain in my right hip/bum cheek area, and sometimes it is quite agonising meaning I limp or it hurts to sit on the loo. Also my right knee is getting sore, but I have a habit of folding my knees under me when watching TV, am trying to stop that..

as far as sciatic / pgp/ spd goes I know to be careful pushing supermarket trolleys, what else can I do to minimise pain?
I don't really want physio, there's no way I could afford private, and am worried they'd hurt my back worse. So I need day to day advice -
is it better to sit with legs straight, or to lie on settee, for example
Hip is particularly bad when I stand in kitchen to wash up, is this due to general bad posture, leaning on my right hip?

also generally are health spa masseurs trustworthy? again I feel like they could really ruin my back if I trusted them, consequently I have never tried a massage; is this needless worry or are they better avoided by someone with old back issues?

thank you

[theyoniwayisnorthwards]

I have a large separation of the rectci after two big babies two years apart. I have had hugely conflicting advice from different sources about what to do about it and I'm worried about making it worse. My GP sent me for an X-ray which confirmed the gap is huge but she doesn't seem to know what to do about it. I bought a splint from a program called the tupler technique but another fitness instructor said no splinting. Where can I go for sound advice? I am waiting for an nhs physio appointment but would pay to see someone privately for some definitive answers.

[gastrognome]

I had my two children in Belgium, where pre- and postnatal physiotherapy is routine for many (if not most) women here (including the possibility in many hospitals of your physio attending the birth to provide support). A physio may also come round the hospital as well to help women learn some basic exercises to help the pelvic floor recover.

Anyway during the postnatal physio sessions the technique used was hypopressive exercise, where you basically empty your lungs and lift the ribcage while pressing your hands against a stable surface (it's hard to explain). You can literally feel the pelvic floor rising back up inside the body when you do the exercises.

My question is: why isn't this approach (hypopressive technique) more common in the UK? It really works.

[breatheslowly]

Could you comment on the statement "it's pregnancy, not birth that damages the pelvic floor".

It seems to be bandied about, but I had a great pelvic floor throughout pregnancy. The MW who was at my delivery said that I had unusually strong PF muscles. But a crap birth seems to have ruined my PF to the point that I am likely to need surgery at some time in the future.

Is there any truth in the statement or is it a way of deflecting women from requesting CS?

[thejoysofboys]

Hi. I had moderate PGP/SPD when pregnant with my second child. There is only 18m between my children & my midwife said this contributed to my situation.

2.5yrs later and I'm still uncomfortable. I manage day to day but if I am on my get more than usual or walk too far I suffer for it afterwards. Do I just have to put up with the pain or can I do something to improve the situation?

[Lcy]

I really enjoy running but since my second child I have had to stop because after every run I would get pain in my right hip to the extent it would hurt to put my foot on the ground. I had SPD in both pregnancies, 2 C-sections, and have a tendency to carry the kids on my right hip.

I am planning to go and see a physio but was wondering if you have any suggestions? I would really like to start running again.

[SuiGeneris]

I have rectocele and cystocele following a forceps delivery 3 years ago. I also very bad spd in both pregnancies, but hip issues are ok now. I used to do Pilates but no longer have time since returning to work. Could you suggest some exercises to do at home to improve things? I am fed up of having to be careful about what I do.

Also, why do people in the UK not take spd seriously? In other countries it is an indication for a c-section, because vaginal birth can make it worse. I asked and was told it would be fine but it took 6 months of hospital physio to recover from the vaginal birth (hip-wise) while after the private c-section I had for DC2 I needed no physio and was fine in 48 hours. Why cause women so much pain?

[ILoveAFullFridge]

I have been told that women should not do full press-ups but only knee-press-ups. Why is this? I presume it appliesto your 'average' woman, rather than the likes of, say, Beth Tweddle!

I am very unfit, with many chronic joint niggles, but once upon a time (20+ years ago!) I could do full press-ups. I am trying to improve my core-stability and overall strength. If I ever get that far, would it be OK for me to attempt full press-ups again? I had SPD in pregnancy, if that is relevant.

[NeverKnowinglyUnderstood]

I have issues with my undercarriage.
my youngest child is now 7 and since he was born I have been unable to pass stools without manual excavation. My cervix sits at the opening to my vagina when I am upright but seems to slip back when I lie down, so each time I have spoken to the gp about it they have said it isn't good but nothing that needs extra help. GP said it was just one of those consequences of giving birth about having to manually excavate.
I am over weight by about 2 stones but find any level of cardio exercise uncomfortable, I walk alot but think to loose weight would need greater levels of cardio.
What am I asking??? not sure really, but I guess where do I go from here. I am nearly 40 and I can't imagine still having to do this when I am 80!

[Solo]

I will be 50 early next year and have had two vaginal deliveries, the last one at the end of 2006. I had (double) continence problems for several years after the last birth (when I needed to go, I had to go quickly), but seem to have sorted that out somehow.
My GP whenever I have to have a vaginal examination is always telling me I have weak PFM's and to work on them. I find this really difficult to do for some reason. I also have part of my posterior wall sitting visibly at the entrance which the GP never mentions, so I assume it's part of the lack of muscle tightness and tone.
Is there anything I can do to sort this out? and how can I do the exercises that I find so difficult now? they didn't used to be!
I have not had a menstrual period for about 12 months either, so I presume it's all going to go south from now on, but I really don't want to become an incontinent old lady as my GP puts it!
I'm a couple of stones overweight if that's relevant.
Thank you.

[Rooners]

Hiya,

Is there anything I can do about a small separation (diastasis) and a small hernia? Separation is only about 2-3 fingers I think and nothing sticking out except my belly button - which I want to go back in. I'm normally healthy and not overweight at all, low BMI.

Someone said they did ballet for a couple of years and theirs went back in, which made me wonder,

Is there some sort of pilates based exercise I can do at home? The thing is I have been offered surgery (though they said it can wait for several years, it's not a massive problem) but the thought of surgery scares me especially as I've got to do a lot of lifting, (including the baby!) and am worried it would all be for nothing.

So I am after a way to make the area stronger either to minimise the hernia or to make the chances of a successful procedure, when I get round to it, better. Consultant and GP have not been willing to give any advice on this side of things.

Any thoughts gratefully received as I feel a bit 'broken' and want to do something about it.

[PavlovtheCat]

I have had a microdiscectomy for an L5/S1 prolapse. I also have a slightly out of line vertebrae of the same area, probably the reason for the prolapse. I have had returning symptoms since the surgery in June of this year and have been told it may have re-prolapsed, awaiting MRI. Also told it could be nerve damage/scar tissue build up.

I saw a Nuffield Physiotherapist for three sessions while waiting forever for my NHS referral post surgery (still waiting) who have me some exercises in quite a tough regime to do to build core stability. I have worked to this, before return of leg pain. GP told me to stop. Physio had said here would be some residual pain and to work through it.

There is conflicting advice now and I don't know whether to proceed with exercise.

What is your view on continuing exercise with leg pain (sciatica) while the diagnosis is unclear (ie, it might be a re-prolapse, might be internal scarring, might be nerve damage from prior to surgery unlikely). And, can a nuffield physiotherapist give muscle massage to address back pain and muscle spasm while there is leg pain? Would this be beneficial?