JEMS is being used by rehabilitation practitioners in a vast array of different fields, and in this first guest blog, I have invited Womens’ Health Specialist Physiotherapist and JEMS Certified Clinical Rehabilitation Practitioner Kim Van Deventer to collaborate on this piece to share some of her thoughts and insights. Kim hopes to break down some of the perceived barriers between the specialty of Women’s Health and the work of musculoskeletal practitioners by highlighting some of the possibilities, and encourages them to engage with this area, because, as she says, if you are treating women, especially those presenting with low back or pelvic pain, then you have a potential Women’s Health patient on your hands.
Shifting Boundaries, Discovering Links and Starting Conversations: Integrating Women’s Health into Musculoskeletal Rehabilitation May Be Easier Than You Think.
As an MSK Physiotherapist or rehabilitation professional what do you think of when you hear ‘women’s health’? If you are anything like I was a few years ago, then your first instinct is probably to mentally run in the opposite direction when you hear anything that sounds like ‘women’s health’, ‘incontinence’ and ‘prolapse’.
I felt that I had no business advising or treating women with women’s health issues since it was such a specialist field and there were other people who were better equipped to help these clients.
However, after seeing one too many postnatal clients with recurring issues, and being a new mum myself, I realised that I was missing a vital component in my clients’ treatment programmes.
Time to evolve
I dived into education in the Womens’ Health field in order to fill in the gaps in my own knowledge, and immersed myself in a field that I found increasingly compelling.
One thing that stood out from the very beginning was how preventable many of the issues are, but how little information is available to people when they need it most. If you are treating women, then you have a potential women’s health client on your hands. One in three women experience stress urinary incontinence (SUI) and 1 in 5 pregnant or postnatal women experience pelvic girdle pain (PGP). You may be the only link between your patient and the invaluable information that could alter or affect her life in the long term, if you can just have the confidence to ask the questions.
I am not implying that you do not need any extra training or skills to assess and treat women’s health clients effectively. However, MSK professionals can be confident that they do have skills and knowledge that can make a difference to their existing patient base.
Common but not normal
The two most common conditions which you may come across in your clinics are pelvic girdle pain (PGP) and stress urinary incontinence (SUI).
PGP is something women are not afraid to tell you about or seek help for, in fact it may be their presenting complaint. Prolonged standing, getting into and out of a car, moving around in bed and climbing stairs are amongst the common aggravating factors for the pain that these patients experience in the area of the symphysis pubis and/or sacroiliac joints. Add a lack of sleep, extra children, long walks for school runs and house cleaning into the mix and you have a recipe for an almost complete shutdown. This is usually followed by hospital admission, and it is a terrible situation for a family to be in.
You have the ability to prevent this from happening!
Help for PGP
Many women become dependent on manual therapy ‘fixes’, and they simply do not believe that exercise, or changing how they perform their daily tasks, can help them.
I have found it works best to not talk too much, but to validate their pain and then get them to feel the ‘decompression’ with better self-carriage. I teach them this in different functional positions but I begin with their meaningful tasks.
Once I’ve ‘won’ them over it is about simple, practical exercises that they can do ‘on the go’ if possible.
Simple things can make big differences
The biggest challenge for many women is letting go of their coping mechanisms enough to allow the ‘system’ to begin correcting itself. Breathing works beautifully here because it gives a woman a quiet sense of the power that she has to consciously change the levels of tension in her own body.
Breathing exercises help to increase awareness, and regulate intra-abdominal pressure, which in turn helps to reduce the risk of developing other conditions which are often associated with PGP such as pelvic organ prolapse and stress incontinence. These are pressure problems, and regulating relative pressure between the abdominal and thoracic cavities is fundamental in relieving that pressure.
JEMS has several big contributions to make for these patients. During pregnancy, women often lose the sense of themselves in their bodies, and helping them to reconnect and reboot their awareness is a fundamentally important aspect in retraining their movement choices. Our JEMS teaching methodology is ideal to foster this process.
Mechanically, I have found that JEMS principles and techniques work brilliantly with these ladies, offloading joints with better force management, normalising muscle tone with easy auto activation tasks, and improving quality of movement.
The exercises I find most helpful (to begin with) for antenatal clients are balloon walking (actually balloon everything!), foot listening, vertical hip releases and seated ball bounces. I progress them as I would any other patient, taking into account their limitations (ie.bellies) of course!
Postnatal rehab is never complete without multiple variations of greyhound. Facilitating relaxed natural activation of deep abdominal muscles and working on developing that CLA is top priority for them in the early stages. If there is evide
nce of diastis recti (abdominal muscle separation) then this is particularly important.
String of pearls bridge, hip pops, hips swivels, ski jumper and over the top work well with postnatal ladies, improving dissociation and mobility of hips, pelvis and lumbar spines with positive muscle activation.
Superman, step ups, balance exercises, space invaders, tail ups, wall squats, thigh slides and knee creepers work really well for both groups.
Progressions are aimed at encouraging mobility and support from the feet right up to the shoulder girdle. I continuously remind them to search for that sense of effortlessness and to relax their breath wherever they are and during whatever they are doing.
How about SUI?
This is worth asking about directly in an assessment, because women do not always disclose information about it spontaneously. It can be embarrassing, or perceived simply as a normal by product of the child-bearing process, but although SUI is common, it doesn’t have to be.
Traditionally the focus has been on the hypotonic pelvic floor, but it is important to know that a hypertonic pelvic floor is an increasingly common dysfunction, and is also responsible for causing SUI. A muscle which is already shortened has limited capacity to contract even more, and a sneeze or landing from a jump can easily create more force than it can
Do be aware that although pelvic floor issues are commonly related to pregnancy or childbirth, it is becoming more common amongst fit and active nulliparous women too, so don’t be shy to ask your athletes, gymnasts or dancers about it. I have also found Bootcamp, Crossfit and military-type fitness groups are almost like breeding grounds for SUI!
The point is that we need to start talking about this with all women and we need to take the ‘correctness’ out of our conversations with clients and colleagues. Avoiding questions and discussions about urinary leakage, pelvic pain or sexual dysfunction is not helping us to be better clinicians.
Where do we start?
Women commonly need help and support to enable them to stop mentally separating the pelvic floor from the rest of their bodies.
In an MSK setting, breathing is once again an excellent way to bring their awareness to their pelvic floor. I do
’t focus on repetitions here. It is more about mindfulness and getting their ‘brains into their pelvis’ than getting the right number of sets and reps done.
As you breathe, your diaphragm descends and presses the abdominal and pelvic organs downwards. This places a slight pressure on the pelvic floor and, if it is relaxed, it responds with a little reciprocal contraction. The abdominal wall, diaphragm and pelvic floor dance together to balance the abdominal pressures. Women often believe that they should be holding their pelvic floors in a state of constant contraction, however it is helpful for them to understand the dynamic nature of their pelvic floor
An important thing to remember is that the pelvic floor muscles, like the transversus abdominus, are also feed forward muscles. They activate in preparation for movement so you cannot only work on training them in isolation or at rest. The good news is that simple every day movements performed in a good alignment, together with a relaxed breath, will automatically activate the pelvic floor muscles.
Of course for some women, primary strength of the pelvic floor muscles is a key issue. Current research suggests that 10 x 10 second holds (4 second rest in between) followed by 10 fast contractions (1-2 sec rest in between) 3-6 times per day is best for strengthening the pelvic floor. I find that this is not very practical and it is also difficult so patients need to w
ork up to this number, and NOT start there!
I have found that asking patients to do the exercises little and often throughout the day during different activities of daily living (ADL’s), together with breathing exercises show better results, and begin to integrate pelvic function more normally. It is much more practical for them and, in my experience, it improves compliance.
When it comes to breathing during movement the focus is not on breathing in or out with movement or rest. All they need to do is make sure that their breath is relaxed and that they are not holding it when they move. Keeping things simple is vital.
Integrating functional activities
I have learned that if you want a busy and sleep deprived mum to stick to your programme or follow your advice then you have to get creative, keep it interesting and make sure she feels it works EVERY time.
I always add lower limb exercises such as JEMS-based variations of squats, lunges, step ups, and single leg balance drills which they can add to their ADL’s as far as possible.
I teach them the basics of each movement, how to keep it ‘healthy’ and how it is meant to feel when they are performing the movement. Effortless and light is the aim.
I ask them to find and explore movements that are similar to these exercises in their daily lives. Whether they are playing with their children, walking to the bus stop, putting washing in the machine or picking up toys, every movement they do can be a nourishing movement for their bodies.
Their movement can either be good for them or limiting: they can decide. That is their power and their
Does incorporating the pelvic floor into rehab really matter?
A healthy and responsive pelvic floor is crucial in maintaining balance and support in the pelvis for effective force management throughout the body.
If your aim is to adequately restore and maintain efficient global movement then it is imperative to consider the pelvic floor when planning your rehabilitation programmes.
So, how has JEMS helped me?
As you can see, I use JEMS all the time. When I first started seeing women’s health clients I realised that I had more confidence and mental clarity to carry out assessments without being distracted and overwhelmed by the symptoms. JEMS is like a secret language and it makes things seem so much simpler, no matter who is in front of you.
I now find that I am not labelling. I am listening. It has made the move into a specialist field a little bit less daunting.
Providing more options for your patients
If you are willing to learn, and you are not afraid to have an open mind when it comes to common women’s health conditions, then you may just be as pleasantly surprised as I was at what you are capable of helping with. Remember that we are all in the business of promoting wellness and preventing injury, the cornerstones of which are early intervention, education and self-empowerment.
With JEMS we learn to encourage, facilitate and to use our words to empower people to take control of their own bodies. The techniques are about setting a woman up to succeed by promoting automatic responses, and preparing her for the rigors of very different physical loading through effective movement strategies.
If you can combine these aspects with a fundamental understanding of normal pelvic floor behaviour, then you are quite capable of helping most women who attend your clinic.
If my clients with chronic debilitating conditions had a choice between having no help or receiving a little bit of practical, useful information and guidance when their problems first started, I know that they would have chosen the latter. Even if the only thing that you have to offer your clients is the opportunity to talk about their issues and let them see the bigger picture, this can still be incredibly helpful. So put your women’s health hat on and be brave!
Break through those barriers, build that bridge and start the conversation. You never know how many more lives you may change for the better.
Kim Van Deventer’s innovative online Women’s Health physiotherapy service can be found on www.mastermumphysio.com