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Incontinence and Bowel Management for Women, Men and Children.
Women’s Health Physiotherapist Brisbane, Australia.
Pelvic Floor Dysfunction Treatment.

Happy New Year- Welcome 2018

I think it’s always a good idea to have a Plan B- because life being life, there’s always going to be a spanner in the works of Plan A. I know this pussy cat’s dilemma all too well. I have a wardrobe ranging from a size 12 to size 16 and I refuse to ever throw out the size 12’s because you never never know……

There is lots of disagreement on social media about the value of New Years Resolutions but we have been doing them for a long time now (how long Vonny?) – same wonderful friends, every New Years Eve so there’s a bit of a tradition that must go on. We write things down in a designated book and after dinner each year on New Years Eve we dig out the book and see who has achieved their goals for the year. It’s a bit of fun and the boys take it quite seriously with some healthy competition adding up how many they have achieved and each claiming they have won the count.

So again this New Years Eve I will be contemplating my goals for the year and attempting to knock a few of them over. You can see from the cat meme there will be the perennial one about my weight. It’s very difficult as we race past menopause and into older age. The weight is difficult to shift and yet the evidence is strong that keeping a healthy weight range helps with urinary incontinence;(1) and being overweight or obese is associated with progression of prolapse (POP= Pelvic Organ Prolapse). Interestingly, weight loss does not appear to be significantly associated with regression of POP, suggesting that damage to the pelvic floor related to weight gain might be irreversible. (2); it’s helpful for ageing joints meaning less pain and more ability to keep exercising; it’s helpful for plantar fasciitis; it’s helpful for a healthy heart and good blood pressure and so it goes on. So yes, I will write the usual resolution regarding my weight.

And after the most blissful 2.5 weeks at the beach this year, there will definitely be more beach sojourns (both short and another longer one at Christmas time). They are just so relaxing and refreshing and pleasant. Even though I have still been ‘working’ with writing and keeping an eye on things at work, the sound of the waves and the view from the veranda hardly makes it feel like work. This year I am booking them before I get home, because once I get home there is always too much to do and we don’t make it away. But if its booked then its more likely to happen.

There will also definitely be some travel plans. When you can still walk and are relatively healthy, I think it’s imperative to exhaust all your travel desires. Travel widens our horizons but reminds us every day how gorgeous our beaches are and how relaxed we are as a nation. (It also reminds us that our nation is big and probably has some room to share.)

But also this year I am including some of the things I encourage many of my patients to consider introducing into their lives – some may think they are ‘airy fairy’ but they are important to manage the stresses of life and to help us function at a high level when we are dealing with stressors. This year, one of my patients got very organised and when she got home from her consultation wrote down all the stressors that we had nutted out and then written down the suggested strategies and ended up with a very busy piece of paper with her programme of how to tackle her pain issue. She sort of did her own infographic of what we had talked about- but just hand written and on a scrap of paper. She had all the headings we had discussed and suddenly it looked like the framework of a pretty cool programme.

You see she just ‘got it’.

She suddenly understood why her pain flared at times and why it diminished at others. She realised that core elements such as sleep and healthy eating had taken a dive and communication within the family had gone off the rails because everyone was so busy working and just trying to keep their heads above water. She realised her muscle tension was increased by clenching when she was in a high state of anxiety but with some easy strategies (letting go with her belly and inner thighs and doing regular belly breathing through the day) she had made good gains in quite a short time.

So I have created my own infographic for my major ‘airy fairy’ 2018 goals, because like everyone, I have some life stresses and stressors and I’ve turned it into a pretty picture that I can keep reminding myself about what I must do through the year.

Happy New Year to all and if you’d like to use my infographic feel free

References:

(1) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2877497/

(2) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684063/

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Merry Christmas – Did I ever mention I love Sunshine?

Whilst I do love sunshine – the Vitamin D one- I really am talking about Sunshine Beach. You saw from the last blog that we have been coming to Sunshine for quite a while- it turns out when we really thought about it – it has been 41 years that we have been coming. Whilst Noosa – or Ole Noose as we like to call it- has been a favourite, we first started our love affair with Sunshine back when we were first going out. We stayed at a place called Heatherlea in Arakoon Street and it was quite ‘out there’. It was architecturally designed with a loft for a bedroom and a giant painting of a naked lady that went from one level to the next in a giant void and had a really deep, giant spa bath inside the house- fully tiled.

We felt very avante garde and trendy even renting this house for a weeks holiday. It had a view to the Sunshine Beach headland and even back then we realised Sunshine was very special. As I said in the previous blog we have created many beautiful memories there with the kids and ourselves – one of the more tragic ones is one of an opportunity lost at Sunshine. It goes like this…..

I once had a notebook where I wrote down every feed, when I first brought my first baby Katie home from hospital, because apparently I couldn’t remember which breast should be the one I started with the next feed. This notebook then accompanied us to the beach for a holiday where we ventured with a newish baby (when she was way too young- I remember the horror of trying to shield her from a raging Sunshine Beach wind). When I found the book 20 or so years later, there was the opportunity lost written down in black and white. Because next to that other beautiful house we loved so much – Sails– was a block of land which suddenly came on to the market.

In this book I wrote down some figures- the land (overlooking the Pacific Ocean, high up with elevated uninterrupted views of that Pacific Ocean and the headland!) was on the market for $50,000 (this was 1985). Now Bob being an architect, who better to design and supervise the building of a special beach house then he! In between writing down left breast, right breast, I budgeted $50000 to build the architectural masterpiece and I wrote down that if my mother and father, my brother, my sister and us – all contributed $25,000 each we could do it.

But did we do it? No of course not. We had just brought home a new baby and it was just a pipe dream. The mere fact that the beach house on that block of land would now be worth about $3 million is something I also sadly remember every time we come to Sunshine.

Alexandra Bay is just 30 minutes walk from Sunshine Beach

So the moral of this story? Sometimes you have to take a risk and go for something if you have a belief it may be the right thing to do.

I did that two and a half years ago when I decided at 59 to expand and employ some physios to help me and bought our current premises. And I have been blessed with working with some fabulous physios who are just as passionate about helping their patients as I have always been. I am also very lucky to have gorgeous secretaries who are excellent at their job and enthusiastic and caring with our patients also. We have said goodbye to Amanda in October this year as she headed off for some exciting travels and then back to Melbourne to work. And now we are saying goodbye in January to Celine, who has been with me for over 3 years as she travels to Spain to work and live. Thank you Celine for all you have done and we all wish you well in your world exploits. We will miss your efficiency and I doubt the drawers will ever be the same without you.

Maddy, Sue, Amanda and Celine

But the main purpose of this blog is to wish you all – my patients, my pelvic health colleagues, my friends and family and anyone else who trips over my blog and decides to read it – a very Merry Christmas. I hope your day with family is special; I hope if some special family are away overseas that they have fun and enjoy the opportunity eating their hot roast veggies and pud and custard on a cold Christmas Day instead of sweltering in Brissie (34 degrees tomorrow Soph- love ya lots and Jimmy too- we should be all in our Budgie Smugglers here); and for those who won’t be sharing the Christmas fare any longer, we never forget you and think of you many times.

Jimmy in his Budgies- anytime, any place

Merry Christmas xx

 

Memories

Sue fishing Sunshine Beach 2017

I’m back at the beach refreshing after a giant year and one of my favourite pursuits is having a fish. It’s so relaxing and simple – go to the shoreline, do the twist and feel the pippies with your feet, get out the knife and voila the bait is ready and out goes the line. The waves are rhythmical, relentless and there’s plenty of time to think. I have wonderful memories of fishing. My father Neil started me fishing when I was a young girl. So I always think of Dad when I fish.

Every year we’d head to Burleigh or Miami and every afternoon we’d head down to the water and stand side by side and throw out a line. He taught me the difference between the bite of a whiting, a dart and a flathead- the elusive flathead. I remember a day when we both caught a big flathead each – he was pretty excited. Today I did a wonky cast and had a chuckle about a day Dad and I went at 5pm and there was a roaring onshore, easterly wind blowing. It was pretty unpleasant, but Dad was determined he would still have his fish. It was too strong for me, so I sat on the beach and next thing he did a wonky cast and back came the hook, line and sinker straight back up the beach. We called it quits after that. Every year I come to the beach and fish, I think of Dad – which is nice. It’s a nice memory.

I also have wonderful memories of some fabulous holidays with the kids when they were little. We would come to a house called Sails every year. When they were little we could come at any time of the year and so it didn’t break the bank to have beach side house. It was always very windy on that gorgeous veranda overlooking the Pacific Ocean at Sails at Sunshine, but we’d always try and sit out there and eat our meals – a baby, a toddler and a Grade Oner. One year there was a spectacular phenomenon at night. We were eating our meal and suddenly when we looked out to the waves – efflorescent algae lit up the waves as they broke. We couldn’t believe it. Sadly no iPhones in those days so no photos to prove it. We’ve never seen it again but secretly every year I hope we’ll look out and see that amazing sight again.

Halley’s Comet

Another Sails holiday was spent searching the night sky for Halley’s Comet. Halley’s Comet only makes an appearance every 75 years so it was 1986 and we were on the verandah of Sails – so exciting because we were away from the city lights. The build up was more exciting than the event though. We looked and looked and didn’t see anything. But the process was fun. 2061 is the next visitation so it will be my kids and grandkids who will have to try and see it. They must remember to book at Sunshine to do so!

Another year the water at Sunshine was like a millpond. Now if you have been lucky enough to visit the Sunshine Coast and Noosa, you know ‘millpond ‘ is the classic Noosa water status and Sunshine is typically a bit wild and woolly. So this particular day we couldn’t believe it – the surf at Sunshine was missing and there was a giant, still lagoon where we did some bobbing and lolling about.

All these memories popped into my head today while I was at the beach. All delightful, warm and fuzzy memories from many years ago. Memories of my childhood. Memories of my kids’ childhood. Memories are lovely things, but sometimes memories can be awful.

Yesterday I was shocked and appalled when I heard some of the statistics from the Royal Commission into Institutional Reponses to Child  Sexual Abuse. After 5 gruelling years, the Commission has released a report with 186 recommendations designed to protect children from bad adults – which is what they are.

Very. Bad. Adults.

It got me thinking about the memories these kids have. We know that adverse childhood events play a significant role in what shapes us as people. I hear many of these awful adverse childhood events from my patients, who are suffering now as adults with chronic pain.

I don’t think these kids are remembering the night that Halley’s Comet came through. Or their fishing exploits with their Dad. No they are trying to forget the horrors that these people, who were supposed to be the most trusted people in their community – their priest, or their scoutmaster or their teacher – inflicted on them. And then they’re wondering why these Very. Bad. Adults. were protected by the police or their Archbishop or their Principal and allowed to keep being around children, even when so many kids had told of their abuses.

What prompted this blog being urgently written tonight is I saw a report on the news that the Catholic Church were not going to accept the recommendations of the Royal Commission. Now the Catholic Church were implicated in 64% of all the child abuse cases – 64%!

Why are they not weeping on TV apologising for ruining so many kids lives? Ruining their childhood memories. Ruining their happiness.

Why are they not on TV showering buckets of the Vatican wealth into the Redress Fund – saying we committed 64% of these violations we will pay 64% of the money needed for the Redress Scheme. Honestly I do despair at times at the unfairness of our world.

I do commend the work of the Royal Commission. What they heard must have kept them awake at night. I also commend Julia Gillard for setting up the Royal Commission which has challenged some serious established Australian institutions.

And I hope you create wonderful childhood memories for your children and grand children and save them from Very. Bad. Adults.

 

Ageing: It’s inevitable but frailty doesn’t have to be a part of it

FFS!

Before you panic and think I’ve lost the plot and started swearing in my blog – FFS doesn’t stand for anything bad. (Even though with our politicians behaving badly you may well have been throwing the odd one of these around- Really? You’re shutting down parliament for a week?? Is that even allowed?)

No FFS stands for Falls & Frailty Suck. And they truly do. The last thing you want as you enter the age groups where they start classifying you as elderly, is to be also told you are frail. Because with frailty, comes other risk factors such as increased risk of falls and increased risk of urinary incontinence.

At our recent CFA conference in Sydney- I became aware that the word frailty kept cropping up. It was in quite a few lectures and I have to say I haven’t really been so aware of its use before.

Frailty is defined as the condition of being weak and delicate‘the increasing frailty of old age’– if you look for synonyms- infirmity, weakness, weakliness (who knew that was a word?) feebleness, debility, enfeeblement, incapacity, impairment, indisposition. 

Now they are all yukky words and ones I do not want to be remembered for as I age. ‘Oh you remember Sue Croft? She was that pelvic floor physio who demonstrated weakliness and enfeeblement in her 90’s’. Whilst I may have spent most of my life dreaming of being a size 8, like a model on a catwalk, but in fact struggled with weight issues constantly – what I know is, being underweight when you are in the elderly category is not good. If you have a fall, you are more likely to break something if you don’t have much fat covering things. And we do store some oestrogen in our fat which helps with our bone density.

No I want to be strong, robust, powerful, healthy with synonyms being vigoroussturdytough, powerfully built, solidly built, as strong as a horse/ox, muscularsinewyruggedhardystrappingbrawnyburlyhusky. 

‘You remember Sue – she was that strapping, rugged, sinewy retired (it must happen one day) pelvic floor physio’. 

Sadly frailty happens – especially if as you get older you are afflicted with ailments of back/hip/knee pain which then affects your mobility and this causes you to respond by sitting more and more and ultimately stopping exercising altogether. And as I mentioned earlier, frailty sadly also contributes to your risk of falls and many other conditions including osteoporosis.

We had a great lecture at the 26th CFA Conference in Sydney from Dr Adrian Wagg (Capital Health Endowed Professor of Healthy Ageing and Division Directore for Geriatric Medicine at the University of Alberta in Edmonton, Canada) on Incontinence in the frail elderly: report from the 6th International Consultation on Incontinence.

He defined frailty from the medical perspective.

Phenotypic model

  • Involuntary weight loss (>10%)
  • Weakness (grip strength <20th centile)
  • Slowness (<1.0 m/s)
  • exhaustion
  • Decreased physical activity

Accumulated deficits model

The more things wrong with you, the worse you do….it’s called the Frailty Index. It’s independent of the exact number or nature of deficits. It’s a continuous measure derived from a Comprehensive Geriatric Assessment.

Urinary incontinence when affecting the elderly has multiple risk factors across multiple organ systems and domains.

  • Co-morbidities (other disease processes going on)
  • Medications (multi-pharmacology)
  • Physical function impairment
  • Cognitive function impairment

There are many changes that occur with the Lower Urinary Tract (LUT) physiology with age:

Decreasing: Bladder capacity, sensation of filling, speed of contraction of the detrusor, contractile function, pelvic floor muscle bulk and tone, sphincteric resistance, urinary flow rate.

Increasing: Urinary frequency, prevalence of post-void residual volumes, outflow obstruction.

Adrian spoke about the link between periventricular white matter hyperintensities (in the brain).Studies in community-dwelling elderly link these structural white matter changes with: Mobility impairment, cognitive impairment, urinary urgency, urinary incontinence and increased prevalence of detrusor overactivity on urodynamic studies.

As you age there is a dramatic increase in multi-morbidity (defined as greater than 2 diseases) but elderly OAB (overactive bladder) patients have more co-morbidities than those without OAB.

Some examples of associated conditions and urinary incontinence:

Peripheral vascular disease, diabetes mellitus, congestive heart failure, venous insufficiency, chronic lung disease, falls and contractures, sleep disordered breathing, stroke, dementia, diffuse Lewy Body disease, Parkinson’s disease, normal pressure hydrocephalus, recurrent infection, constipation, obesity.

So what are the strategies to manage this?

Recognise the conditions which might be impairing ability to toilet successfully and think wider than simply LUTS and toileting. But there is no reason why the normal strategies that we would employ for a younger cohort cannot be employed to treat the frail elderly.

Individualised and influenced by: Goals of care, treatment preferences, estimated remaining life expectancy. Sometimes the only possible outcome may be containment (especially with decreased mobility and dementia).

Recommendations for practice:Active screening for incontinence in all older frail persons as they don’t spontaneously report their symptoms; clinicians need to assess and manage co-existing co-morbidities (which may impact on continence status or the ability to toilet); environmental cues such as toilet visibility, signage, colour differentiation in frail older patients with cognitive impairment.

He talked about the 4 M’s

Mentation, mobility, motivation and manual dexterity.

There should be a comprehensive continence assessment before any recommendation for containment pads; interventions for incontinence should be multi-component, interdisciplinary and person centred; support for caregivers.

Treatment: 

Fluid management; caffeine restriction; alcohol restriction. Dehydration may actually increase the risk of UI in frail elders because of its significant association with constipation and delirium.

Prompted voiding except when people need the assistance of more than one person to transfer- these elders should be managed with ‘check and change‘ (of pads). Functional training in combination with PFMT (pelvic floor muscle training) reduces urinary incontinence and improves walking time in frail older women (Level 2 evidence) (Wagg A Incontinence in frail older persons” ICI 2017)

Impaired mobility:

Many studies have shown an association between stress and urge incontinence and a reduced level of physical activity or physical impairment: Poor mobility 4.7 times the risk of UI; difficulty walking increased the odds of UI by 23-81%; physical impairment measured by SF-36 associated with any and severe UI; ADL disability increased risk of UI by 175%,; increased prevalence of UI associated with physical impairment.

Pharmacological interventions:

  • Short term treatment with oxybutynin-IR has small to moderate efficacy in reducing urinary frequency and urgency UI when added to behavioural therapy in long term care residents. (level 2 evidence)
  • Low dose oxybutynin ER does not cause delirium in cognitively impaired nursing home residents. (Level 1)
  • Oxybutynin IR has been associated with cognitive adverse effects in persons with dementia and or Parkinsons disease (Level3).
  • Fesoterodine is effective in ameliorating the symptoms of OAB in robust community dwelling and medically complex older people (Level 1) – this drug is not currently available in Australia.
  • There is insufficient to determine the efficacy, tolerability and safety of the following agents in the elderly (Level 4): intravesical Oxybutynin, transdermal Oxybutynin, Tropsium, Tolerodine, Darifenacin, Solifenacin, Mirabegron, Duloxetine, oral and topical oestrogen.
  • Excessive anticholinergic load is associated with cognitive impairment in frail older adults (Level 3)
  • Anticholinergic agents should be prescribed with due regard to underlying anticholiergic load in older persons. (level 3)
  • The effect of cholinergic load on persons with mild demetia is uncertain (Level3).

(Wagg A Incontinence in frail older persons” ICI 2017)

An algorithm from the 2017 ICI Report on Incontinence in the frail elderly

The most important messages I would like you to take from this:

  • Start moving, keep moving, stay moving.
  • Work on having a healthy bladder and bowel in your earlier years and throughout your life, so your later years are less bothersome
  • If you are a patient reading this – take care when putting any medication in your mouth
  • If you are a health care professional – then treat your elderly patients as you would your younger patients- they are never to old to be properly assessed and given an evidence-based treatment plan
  • Keep your bones as strong as you can – healthy diet, lots of exercise, good variety of exercise, lots of extension exercises, Vitamin D levels adequate.

And below is a little bit of light-hearted fun from my Mum’s mate, Peg. (They are both around 92 with marvelous intact brains.)

Nine Important Facts to Remember as We Grow Older

#9 Death is the number 1 killer in the world.

#8 Life is sexually transmitted.

#7 Good health is merely the slowest possible rate at which one can die

#6 Men have 2 motivations: hunger and hanky panky, and they can’t tell them apart. If you see a gleam in his eyes, make him a sandwich.

#5 Give a person a fish and you feed them for a day. Teach a person to use the Internet and they won’t bother you for weeks, months, maybe years.

#4 Health nuts are going to feel stupid someday, lying in the hospital, dying of nothing.

#3 All of us could take a lesson from the weather. It pays no attention to criticism.

#2 In the 60’s, people took LSD to make the world weird. Now the world is weird, and people take Prozac to make it normal.

#1 Life is like a jar of jalapeno peppers. What you do today may be a burning issue tomorrow.

Thanks to Dr Adrian Wagg for many wonderful lectures at the conference.

Day One of the 2017 National CFA Conference: Workshop snippets

The next few blogs are going to be in note form – snippets, pearls of wisdom, new research etc. These blogs are for me just as much for you- and I am going to put everything in – and it may not even make sense, but later I will be able to follow up at a later date, so I apologise if it’s a disjointed read.

Modern physiotherapy management of the post prostatectomy patient (transperineal ultrasound workshop)

Stuart Baptist, (e.stuartbaptist@ssop.com.au) a Men’s Health physio in Sydney, conducted this workshop and I think he did a great job. He made the content practical and no-nonsense and I will be implementing some of this in a practical sense in our treatment of our male patients – mainly with respect to our handout- I will be making it better directed at the different male approach to health management and also with the exercise prescription.

We had the opportunity to see a former patient of Stuarts have a transperineal scan- he had a prostatectomy last year and he is now dry and being very active. His candour was appreciated by the group and we are grateful to him for his wonderful cooperation. Having followed Ryan Stafford’s work and use of perineal RTUS already, it was great to have Stuart live scanning and see the difference in the contraction with different cueing. He closely explained the optimal direction of the pull of the muscles in the front compartment mid urethra (P4) (gaining a better mid-urethral posterior displacement) as opposed to a cuing as though you are holding wind (a more anal squeeze giving more posterior lift). Remember that Ryan’s work has shown that best choice of words for best cueing for optimal contraction is ‘shorten the penis’ – with good explanation I’m sure men get the concept, but if they don’t like that thought then Stuart gave other examples- pull in the turtle’s head; reverse the train back into the station and Jo Milios likes ‘nuts to guts‘.

Stuart also reiterated the different mindset of the male brain and approach to health issues and highlighted the importance of the way physios give information to the man who is quite often in shock from his diagnosis.

He spoke of the Emotional intelligence of the Physio

Pull back when giving too much information – the patient is male, frustrated, frightened, stressed, having received multiple messages and sometimes conflicting ideas; he recommended choosing words wisely-words are very powerful. Educate gently and with compassion; men need to understand why things happen, to develop compliance. Male functional view of life- if its not broken don’t fix it.Men need to know what you have right now and what needs to be done to get you back to normal. Men can’t ‘see’ the PF muscles, therefore it’s hard for them to connect easily with them.

3 sphincters

  • Internal (prostate/bladder neck) Autonomic in nature- often damaged during TURP- often affected by surgery (stops retrograde ejaculation); External sphincter(autonomic) used during filling phase, Moderate distension of bladder inhibits parasympathetic activity When full increases parasympathetic tone (bladder); External (voluntary) aka rhabdosphincter. Striated used to voluntarily stop urine.

Surgical trauma to

  • muscular structure
  • nerve- from a recoverable neurapraxia to a complete surgical resection

Recovery of:

  • continence (can be weeks to months)
  • erectile function (months to year)
  • no guarantee of outcomes
  • many variables- such as obesity

Autonomic training:

  • Very important
  • Fluid type (what you drink, how much)
  • Bladder training strategies, urge control more urine storing more training for autonomic sphincter has to work- bladder used to holding more. Demand more of the system during the day

URILOG Chris Robinson-App for logging fluid/urine

Activity modification– if doing too much too soon immediately post-op- encourage to slow down in early bit- use pads -tells how much failing in the system; PACE AND GRADE return to work/ exercise

VOLUNTARY PFM TRAINING

Was originally developed from Kegals; Recent RCTs questioned the effectiveness of PFMT- Glazener 2011- anal probe so not effective way to train muscles. Ryan Stafford UQ pioneering work from 2012-2017 – target more effective PFMT gaining better urethral compression.Transperineal US is reliable and valid- Judith Thompson

Sean Mungovan, Westmead we can identify at risk patients and selectively target for greater effectiveness. Mungovan SF, Sandhu JS, Akin O, Smart NA, Graham PL, Patel MI. Preoperative Membranous Urethral Length Measurement and Continence Recovery Following Radical Prostatectomy: A Systematic Review and Meta-analysis. Eur Urol. 2017 Mar;71(3):368-378. doi: 10.1016/j.eururo.2016.06.023. Review.  Open Access Link: http://www.sciencedirect.com/science/article/pii/S0302283816303414

Stafford 2017– looking at continent men and incontinent men http://onlinelibrary.wiley.com/doi/10.1002/nau.23371/abstract

  • Incontinent men strained and got worse- PFMT necessary; Striated urethral sphincter should be the principle action, that’s where Transperineal US helps  

Principles of Motor leaning

  • Identify the sensation
  • Repeat it
  • Give feedback
  • Repeat it
  • Give realistic expectations to patients

PF Hypertonicity

  • Chronic frequency
  • SIJ
  • Korisani 2012, Transab US scan CPP reduction in bladder base motion
  • Davis 2011 statistically valid inc in anorectal angle in men with CPP; Draw a line tracking the anorectal angle

Preop training

  • Down training first
  • Breathing
  • PF muscular release
  • Global muscle flexibility
  • SIJ/LBP (guarding
  • CBT
  • Then commence gentle motor training

Preop and early postop motor training protocol

  • Looking to reinforce the difference between sensations
  • Vary the challenge
  • Anal/ testicular/Penile
  • Testicular and penile (NO ANAL)
  • Each effort is a lift/sustain (3 small breaths- no diaphragm)

Reps and sets

  • Motor learning principles during skill acquisition
  • Mental engagement and focus(environment) in car when arrived home
  • 5 circuits (20 contractions)
  • 4x?day
  • @20% effort(max)
  • If bulbocavernosis motion poor but urethral sphincter good don’t worry
  • After th posterior motion/displacement

POST OP PERIOD

Catheter period

  • No PF exs during this period- maybe visualisation exercises without actually doing
  • Do down training if needed
  • Rest
  • Exs for respiratory circulation bowel’

Early catheter removal

  • relative rest
  • modify all activities
  • resume light motor control ex
  • ICIQ-SF
  • 24 hr pad weight checking
  • Optimal daily URILOG; Busy quiet day= average weekly scores

ICIQ-SF: Light <20g/24hrs ICIQ<6; Moderate >20-<200 ICQ-SF;Heavy >200 ICI-Q

Targeted Rehab Strategy

Heavy leaker

  • Wet overnight
  • Disruption to autonomic sphincter
  • Rest and bladder retraining+++
  • Light motor control exercises develop
  • Penile clamp- only as firm as need (trial and error)-Max 3 hrs at one time, Periods of higher activity more than rest periods, Phasing out approach over 6 weeks 3hrs 3 times a day, down to
  • Monitor pad weigh and record weights of pad
  • Consistent fluid intake.
  • Copies the empty storage empty phase of the normal bladder.
  • Stimulate the autonomic phase of the bladder- awaking the system againDiscuss with urologist if not getting improvement- ?more rabdosphincter damage.

Moderate leaker

  • Spurty leakage, not dripping all the time
  • Dry overnight
  • Get pad free as soon as possible onight
  • Dry physical activity- progress to HIIT- stairs, hill climbing 45 secs recovery level- more bladder volume- 3 units of rest
  • 1 unit of work 95% of capacity
  • Highest intensity of exercise they can be dry
  • Stair climbing
  • 2 mths out exercise bike
  • Light motor control ex develop into increasing intensity (without loss of accuracy/anterior bias)
  • Rapid reaction time training
  • Record PB for x20 contractions (how fast can you do reps and maintain form)
  • Off to on off to on
  • Progress to functional training

Light Leakers

  • End of day
  • No pad o’night
  • What is the PFs function thru the day
  • Interaction of PF and diaphragm(Smith 2014)

Treatment

  • Postural control and pad phasing-get them away from pads
  • Pilates /Global postural rehabilitation (Fozatti2010) Megan? Men’s class?
  • Get fitness up a bit

Video of diaphragm and PF work FRENCH

Urgency/OAB leaker

  • Pattern of leaking is not related to physical activity but more due to caffeine/ETOH/poor bladder habits
  • Often poor sleeping due to nocturia
  • Rx Bladder training
  • Deferral strategies
  • Neuromodulation PTNS
  • Medications

PF downtraining

  • Evaluate SIJ/LS
  • Functional Specific training Stafford 2017

If valsalvering and leaking under load- breathing out as they start to move and move smoothly

Examples of higher end functional challenges

  • Strength training 75-80% of max contraction
  • Need to add resistance  as doing PFMT- resistance training
  • Sit to stand stand to sit NOT SQUAT
  • Pick up and put down NOT A DEADLIFT
  • Twist and reach – timing of PF intensity
  • Golf swing- back swing and follow thru
  • Step up
  • Bent over row
  • Turkish get up

PROGRESSIVE DEMAND

Resistance

  • Specific to body part- heavier for legs theyre lifting 5kg in training but leak when lift the 20kg of mulch. Match the challenge to what theyre lifting

Depth of Motion

  • Deeper is harder vary the height of the chair

Speed of motion

  • Faster is harder Theraband Golf swing

Bladder volume -Backpressure causing increasing Intrabdominal back pressure

VOLUNTARY TO AUTOMATIC SHIFT

Do you practise driving a car? It is practising your skills. Humans very plastic. Takes 10000 hrs to get expert/high performance- P Plate driver concept- check the rear vision get a honk every so often. Skill consolidation means ongoing training/compliance is essential; Continence muscles and the aging process affects recovery.; 2 weeks post op; Record pad weight scores.

Penile clamps

  • Dribble stop
  • Weissner clamp

ERECTILE DYSFUNCTION

  • Penile rehabilitation
  • What you always wanted to ask
  • 3rd part of the trifector
  • Veil of afrodite not just the main NV bundle laterally
  • Erections=blood flow night time erections 6-8 times a night- housekeeping- maintains health doesnt have to be penetrative sex- maintain length of penile tissue. Normal nocturnal penile tumescence
  • Penile fibrosis, shortening and peyronnes- difficult for penetrative sex further down the track

When should rehab start

  • Urologist led- get good relationshop with the urologist
  • Liase with sexual health dr and counsellor/sex therapists if needed- teaching about intimacy with partner doesn’t have to be penetrative sex- find a good one for the men
  • There is natural recovery
  • Manaual massage/stimulation- try and get an erection- get partner to do it- intimacy together (shower if urinary leakage)
  • Pills– Viagra Cialis Levitra- daily dose (endothelial dose) empty stomach first ting in the morning; Booster dose- 45-60 mins prior to sexual activity Viagra 25 mg daily booster up to 100mg; Cialis can be as low as 2.5mg Up to 20mg- longer half-life in the body. Start straight away after prostate surgery. Stay on until get natural recovery. Some research start before the surgery SSRIs for 9 months- better long term outcome
  • Pumps not dependent on stage of neural recovery- get an erection passively- even if no stimulation or romance – cost $10 in a sex shop to $2000- huge variability- patient confusion- poorly taught and poorly understood when used well can develop an erection sufficient for penetration – may need a penis ring to maintain. Stuart sells $100. What makes a good pump- one  power pump (insert photo) has a good seal; How to use- trim/shave- (hairs get trapped in seal clear hair around base of pump); Lubricant (water based) for seal; Pressure gauge- LOW PRESSURE GENERATION- 3 pumps and then look at it- watch blood move in- penis starts moving into the tube- then give it another pump- give it time (up to 30 mins if needed); include bulb filling time (5 mins) one pump every minute use the right penis ring (avoid metal ones- get rubber one)- tell patient to buy a couple (we need to order into the clinic size #3-remind patient there will be a dry orgasm-seminal vesicles and prostate tissue been removed. (Tantric sex- yogis-pump half an hour, ring for 15mins)
  • Pricks (injections) aka Intracavanosal injection- erection in 30sec. Surgeons routinely give an injection; Cavajet-simple to usedial a dose; between 10-2 oclock; side effect can be pain; TriMix-Dr led/Self draw; more modifiable

Doctor guidance very important

Programme

  • Every morning in shower penile massage
  • 3 times a week pump
  • Once a week injection
  • Which should I recommend? Patient specific

 CONCLUSION/SUMMARY

  • EMOTIONAL INTELLIGENCE USE IT
  • EDUCATE WITH COMPASSION
  • EARLY MOTOR CONTROL EFFECTIVELY RTUS
  • BE AWARE OF HYPERTONICITY
  • MANAGE AUTONOMIC AND VOLUNTARY REHAB
  • CLASSIFY TYPE OF INCONTINENCE AND TREAT SPECIFICALLY
  • INTEGRATE PFM TRAINING INTO FUNCTIONAL SPECIFIC TRAINING
  • FEEL COMFORTABLE TALKING ABOUT SEX
  • AFTER 2 YEARS OF NO ERECTILE FUNCTION- HARD TO ACHIEVE RESULT
  • PENILE PROSTHESIS- BRILLIANT
  • INECTIONS

To the physios who may read this -I would recommend this workshop to you if you get the opportunity.

 

 

 

 

 

“Sit like a man?”

 (1)

Sam Heughan plays Jamie Fraser in Outlander (SBS)

Am I just shamelessly cashing in on the pulling power of Jamie Fraser or do I really have a relevant message here for all you ladies (and sometimes men)? I promise you this is an important message and I know no one better qualified than Jamie (who cares what his real name is?) to teach us about the importance of letting your abdominals and pelvic floor muscles relax during the day….. many, many times through the day.

Now Jamie has some serious abs (see explanatory photo below) and lets face it, it may be the dream of a few women and probs plenty of men to have a six pack like he has.

 (2)

Jamie Fraser from Outlander (SBS)

Can there seriously be a drawback to having a rock hard belly? Can there seriously be a problem to having incredibly strong pelvic floor muscles? Surely that’s a win – win situation? Society has indoctrinated women to always sit with their legs crossed (so no one can look inappropriately up their dresses). This goes back centuries and is still the norm for women to sit tall and cross their legs sometimes wrapping them tightly around their calf.

 (3)  (4)

Society (particularly women’s magazines) also always promotes women to strongly pull in their tummy – having a ‘flat tummy’ is the essential look – well if you peruse the Myer swimsuit catalogue or check out the female body builders at a competition at least.

 (5)

Francine Abbott at her first body building competition

But if you do this all day and all night when you are out in a slinky little short dress, then for sure you will rarely be relaxing your abs or pelvic floor and this can lead to pelvic pain and sometimes an overactive pelvic floor for some women and men. This can result in dyspareunia (painful intercourse), incomplete urinary voiding, defaecation difficulties (incomplete evacuation, pelvic floor dyssynergia) and for men sometimes penile and testicular pain and erectile dysfunction. Sometimes it is wrongly diagnosed as prostatitis.  This chronic tension in these muscles not only causes pain but can cause the muscles to fatigue and not be as effective when you actually may need them, such as recruiting them to lift a heavy box or prior to a cough or sneeze to prevent leakage of urine, gas or faeces.

So when looking for the ideal picture to demonstrate this posture that I encourage patients to adopt: “Sit like a man” who should I find but Jamie (well a photo of him ‘in real life’ Sam Heughan) sitting perfectly – legs apart therefore inner thighs relaxed, belly relaxed and I’m assuming pelvic floor relaxed. Thank you Jamie xx

So my message to everyone is:

Balance all engagement of the tummy and pelvic floor with plenty of relaxation

If you actually do have pelvic pain, or a feeling of incomplete emptying of the bladder or bowel or painful intercourse or if you are a guy – a diagnosis of prostatitis from your GP, or erectile dysfunction or penile or testicular pain – try this exercise of just letting go with your abs and pelvic floor regularly; sit slumped rather than bolt upright (which ‘engages your core’); sit with your legs apart and adductors (inner thighs) relaxed; do some tummy breathing (as you breathe in your tummy rises up under your hand and as you breathe out it drops away, keep the breathing gentle and slow) and see the difference this makes.

 (6)

And you girls out there who love Outlander can thank me for your early Christmas present!

(1) https://www.pinterest.com.au/pin/553028029228315238/

(2) https://www.google.com.au/search?q=jamie+fraser&rlz=1C1CHBF_en-GBAU702AU702&source=lnms&tbm=isch&sa=X&ved=0ahUKEwj8ruPo2bfXAhXEJJQKHQldD5gQ_AUICigB&biw=1637&bih=698&dpr=1.13#imgrc=D_ISLk3Mm5PKgM:

(3) https://www.pinterest.com.au/pin/214835844696149908/?lp=true

(4) http://mobile.wnd.com/2017/05/stop-this-madness-women-of-fox-news-suddenly-hiding-their-legs/

(5) http://thenewdaily.com.au/news/people/2017/09/23/frances-abbott-bikini-competition/

Lymphoedema treatment now offered at Sue Croft Physiotherapy

As you are aware there have been some new staff members at Sue croft Physiotherapy and one of the girls, Alex, is trained in lymphoedema management. I asked her to write me a blog to let you know what lymphoedema is and how to manage it.

Lympha-what?
Lymphoedema is the swelling that occurs when excessive amounts of lymph fluid accumulate in the tissue. This is caused by a compromised lymphatic system, which normally returns the lymphatic fluid back into the bloodstream. It mostly affects the limbs although it can also involve the trunk, breast, neck, head and genital area. 

The lymphatic system is a network of lymphatic vessels and lymph nodes throughout the body. The vessels start like tiny fingers in the tissue and are getting larger on their way to the heart. The lymph system is no closed circulation, it is more like a half circuit. Our blood circulation system processes around 20 litres of blood every day through the capillary filtration in our skin, muscles and organs of which only 17 litres returns directly back into the blood vessels. The 3 litres left in the tissue is the interstitial fluid or lymphatic fluid that has to be picked up by the lymphatic vessels.

The lymph (from Latin, lympha: water) is a clear, protein-rich fluid that also carries any waste products from the tissue and bacteria. To help the lymph moving towards the heart the larger lymph vessels have muscles in their walls that help them to slowly pulsate and valves that only allow the fluid to go one way. On the way to the heart the vessels pass through many lymph nodes which act like filters. These ovoid shaped lymph nodes are present throughout the body but more concentrated around the trunk, neck, armpits and groins. They are important for a properly functioning immune system as they are major sites for B and T lymphocytes as well as other white blood cells.

The primary function is the filtering of the lymph fluid to identify and fight infection. That is when they become enlarged such as during tonsillitis. Lymphoedema may arises because the lymphatic vessels or nodes have not been formed correctly or due to damage. 

Primary lymphoedema is the result of a congenital condition that affects how the lymph vessels were formed. It might be a result of a reduced number of vessels, vessels with an enlarged diameter and even the absence of vessels in some parts. Primary lymphoedema is present at birth or becomes apparent during puberty (sometimes it does also develop later in life). About one person in every 6000 will develop primary lymphoedema and females are more affected than males.

Secondary lymphoedema often occurs as a result of cancer treatment including the removal of lymph nodes and radiotherapy to groups of lymph nodes. About 20% of breast, genitourinary-gynaecological cancer and melanoma survivors develop lymphoedema. But it can also arise for other reasons for example following trauma, venous disease, infections or obesity. Secondary lymphoedema is the most common type.

 1.

Lymphoedema is a chronic condition, but there is treatment available. The most important things to keep in mind when lymph nodes have been removed is to take precautions in order to prevent lymphoedema.

Precautions for people at risk of developing or living with lymphoedema: 

  • Avoid limb constriction, for example jewellery, tight clothes and even measuring blood pressure on an affected arm.
  • Avoid injuries to your skin including injections (or any needle for that matter).
  • If you get bitten by mosquitos or sustain cuts ensure to keep the area clean and apply antiseptic cream if needed in order to avoid infections.
  • Avoid extremes of temperature and sunburns.
  • Watch for early signs of infections such as increased warmth, redness, tenderness and swelling.

 2.

As lymphoedema is progressive, early interventions are recommended. People at risk of developing lymphoedema should always be mindful of early warning signs and seek professional help as soon as possible. Early signs might be transient swelling, heaviness, stiffness, aching, tightness or temperature changes. Shoes or jewellery might feel tighter. Lymphoedema has a gradual onset and if swelling appears suddenly deep venous thrombosis (DVT) and infection has to be excluded.

The aim of lymphoedema treatment is to reduce the oedema and maintain the improvement.

  • It is important to understand how the lymphatic system works and what factors might compromise it further.
  • Skin care to optimise the condition of the skin and ensure prompt treatment of infections
  • Exercise to improve the lymphatic and venous flow.
  • Manual lymphatic drainage to reduce swelling and stimulate the lymph flow. Self massage is usually taught for self-management.
  • Compression therapy to preserve the reduction of the swelling. Depending on the degree of the lymphoedema it might be initially compression bandaging followed by prescribed compression garment.
  • Awareness of healthy diet, fitness and weight management are important factors too.

 3.

The treatment has to be individualised depending on the degree. With mild lymphoedema – education, skincare and exercises might be enough. There are other treatment options available for lymphoedema such as laser therapy, taping, hyperbaric oxygen and medications but there is need for more research to evaluate the benefits.

Thanks Alex for this overview. Alex is available for appointments on Monday, Tuesday and Wednesday (ph: 38489601) if you have problems following cancer treatment or you have questions about treatment for primary lymphoedema. Alex also conducts classes on a Tuesday at my exercise studio, Studio194 and does one-on-ones on a Monday morning and Tuesday at 12.15pm.

References:

Australasian Lymphology Association: http://www.lymphoedema.org.au/;

Human Physiology: From cells to systems, Chapter 10 and 12

Stuiver MM, ten Tusscher MR, Agasi-Idenburg CS, Lucas C, Aaronson NK, Bossuyt PMM. Conservative interventions for preventing clinically detectable upper-limb lymphoedema in patients who are at risk of developing lymphoedema after breast cancer therapy. Cochrane Database of Systematic Reviews 2015, Issue 2. Art. No.: CD009765. DOI: 10.1002/14651858.CD009765.pub2.

Images

1.http://biology-igcse.weebly.com/functions-of-lymphatic-system.html

2.http://www.bridgetohealth.com.au/lymphoedema.html

3.http://www.opchealth.com.au/jobst-measuring-board

 

Family Feud: Physiotherapy Wars

There’s a bit of disquiet in our physiotherapy profession. I’ve been a Physio for 40 years and I’ve never seen anything like it. But I suppose if there had been anything like it years ago, we wouldn’t have necessarily known about it – but thanks to social media, the family tiff is there for all to see. All the dirty laundry is being chucked in the street, there’s cursing and swearing and it’s starting to get ugly. I thought I’d write about it in case anyone out there who’d like to get some treatment for their ailments is worried that as a profession we are spending much of our time navel-gazing and not paying attention to our patients.

Mind you lots of the angst revolves around a pretty good principle – that what we do in our clinical practice should be evidence-based. And the carry-on has been from those who believe some physios……maybe many physios, are not responding to the evidence in the literature and abandoning the old comfy go-to treatments that actually have no evidence that they do anything or if patients do respond to techniques such as manual therapy, it might be for a different reason to the ones we were taught 40 years ago.

The bone of contention is that the evidence is weak or non-existent in some aspects of traditional musculo-skeletal physiotherapy treatments such as:

  • manual physiotherapy treatments (mobilising and manipulating joints)
  • strict posture alignment philosophies
  • using machines such as therapeutic ultrasound (not real-time ultrasound which is use to view muscle contractions or like we use to check bladder emptying) and a few other types of machines
  • dry needling treatments
  • and courses promoting very complicated techniques with fancy names.

There has been a kind of revolution in the pain science area – and it only took about 50 years to build momentum. The philosophy when following Pain Science research is that once all red flags have been looked for and eliminated as a cause for the pain:

  • that more hands-off strategies have better value for solving a patient’s pain
  • that promoting self-efficacy in our patients has better long-term outcomes
  • promoting confidence of the patients in their bodies, (not fear that something might fall apart without using certain postures, alignments, belts or 5 Step Programme with a fancy-pants name) has better efficacy
  • empowering patients with knowledge about chronic pain to deal with potentially inevitable flares and recurrences in the future
  • that if some hands-on is required that it may work on a different principle to what we were taught many years ago.

The argument is that whilst physiotherapy as a conservative strategy causes no harm, it can be costly for a patient if they are encouraged to come twice weekly for a treatment to keep the ailment ‘under control’. Or it makes the patient feel broken when fear-mongering language is used to describe their condition. Or that the explanation for the pain/condition sounds so complex that the patient can’t self-manage it – it requires ongoing long-term assistance from the physio.

We are very lucky in continence and women’s health because it is one of the well researched areas in physiotherapy with good evidence about pelvic floor muscles training and other conservative life-style strategies improving the outcomes for incontinence and prolapse management. And to be honest I haven’t a lot of experience with this mentality of over-servicing and using machines (called bells and whistles) because certainly in the area of women’s health and continence promotion, this is mostly based on a longer initial appointment which has time for an assessment, comprehensive education of the bladder, bowel, pelvic floor muscles, teaching strategies for self-management of their bladder and bowel condition, pain management as necessary, an extensive home programme; with review once at a month post the first appointment and then often a follow-up at three months and that’s it.

Of course with persistent pain problems it may be necessary to see patients more often than a 3 month appointment. Once I started employing more physios to help with the workload and they had musculo-skeletal experience and we started seeing musculo-skeletal patients, the philosophy of Explain Pain is one I have encouraged at our practice and the girls are very good at helping patients with treatment that embraces education, some hands-on, a programme of exercise and ongoing self-management.

 

Books from NOI Group for understanding pain.Explain Pain and The Protectometer

I know I have had patients over the years who have been seeing a chiropractor and paid in advance for 2 treatments a week for three to six months (???) and I have been shocked at that concept and wondered about the ethics of it – what if the patient gets better after the second visit? But I suppose because of the ruckus in social media there must be some physios who are using treatment techniques that are not evidence-based; who are putting people on machines – maybe to satisfy the patients’ view that they have always had ultrasound/ short wave diathermy or whatever and they need it today; and who are using overly-complex posture/alignment theories to make the patient fearful about how to sit and move.

The problem as I see it is that social media has provided a platform for physios who have lost patience with the slow uptake of the newer approach on managing pain by many musculo-skeletal physios and they are now using shock tactics to blast the profession out of the dark ages and into reading the evidence, acting on the evidence and changing their beliefs and practises. There has been some fruity language and disparaging comments about these practises (not the noun practices) and for many physios this is offensive – and can be seen as running down our profession. But I can see their point of view  and let’s face it – it can only be good for the longevity of our profession to be seen to be completely evidence-based and not just sticking with old-age practises because they’ve always just done it that way.

Being around for 40 years as a physio I have seen a lot change from what I was taught when I was in my black and white checked gingham mini (very mini) massage/prac outfit. (Unfortunately in my day at Uni we didn’t take photos of every moment in our lives and so despite searching and searching, there is NO photo of this little number we all dressed up in to do our pracs! If anyone from my vintage has said photo I would really love to see one.) I have been very determined over the years of working that I remain relevant and up-to-date and have attended the majority of conferences and workshops that have been available in Continence and Women’s Health and pain management over the years. This has meant that I have attended 3 Explain Pain courses over the years and every time there is more evidence and explanations that really kibosh many of the techniques and treatments I was taught 40 years ago.

However the biggest revolution in my continuing education has been thanks to social media, which I embraced back in 2011. My daughter who is in Public Relations taught me about Twitter and Facebook from a professional point of view (not from a Kardashian point of view) and it has completely revolutionised the amount of reading I do (evidence-based articles, patient case studies, other professions view on things – the Urologists are very active on Twitter). The beauty of Facebook and Twitter is they provide an opportunity to experience and participate in a kind of debating without hearing the eloquent voices and the torrid debating skills. Sometimes the debates deteriorate into a schemozzle and hate-fest, but the debates are mostly informative and do change your thinking.

I admit to regularly changing my narrative and handouts in clinic after a good stoush on Facebook – I go back and forensically change any words that may strike the fear of God into a patient’s mind – and I am reviewing my books to do the same things. This keeps me feeling comfortable working still at 61 – I don’t want to just go into work to go through the motions and top up the super for a comfortable retirement. I want to be offering our patients the best treatment there is based on the evidence and the best treatment there is to make them feel like they are in control and have strategies to continue for the rest of their lives. Yes they may pop in for a review yearly for a top-up of more confidence-building information or to trouble-shoot a snag they have hit. But as physios we should make them feel like they can do this and they don’t need twice weekly hands on/machines on from us.

What is useful to do on a regular basis is exercise!

   

My main goal in providing a place that provides opportunities for exercise – dance, pilates, yoga, barre and our new combination class (aerobics plus pilates)- is to progress patients onto exercise and movement for pleasure, for dementia prevention, for strength training and for pain management. Getting patients to love exercise – to see exercise and movement as a life-long strategy for good health and a happy life and keep them away from the physio is actually my goal.

      

But like most families, I am sure we will resolve this little hiccup. We shouldn’t be afraid to embrace Change because change keeps us on our toes and keeps us alive and vibrant – not stuck in the mud and reminiscing about the good old days back in the fifties. Change makes us relevant and not redundant. It makes us feel easier when we sleep at night knowing we are telling the patients the correct science and not winging it; it makes us make the patients feel empowered and independent, but with the knowledge they can call on us at any time for a review and we’re not going to use it as an opportunity to string it out for weeks / months.

Postscript:

As I had hoped the first photo has emerged of PART of our prac outfit (Thanks to Anne who sent it to me). Yes it’s the black and white check bikini top on the hanger – the bottom part has vanished. It’s even more skimpy than I remember! I would be so excited (as would others in our cohort) if someone had a photo of one of us modelling it. Please send to sue@suecroftphysiotherapist.com.au

October 11: International Day of the Girl

October 11 2017 is International Day of the Girl. This is a United Nations initiative with the theme being: ‘EmPOWER Girls: Before, during and after crises’. Throughout 2017 there has been growing conflict, instability and inequality, with 128.6 million people this year expected to need humanitarian assistance due to security threats, climate change and poverty. More than three-quarters of those who have become refugees or who are displaced from their homes, are women and children [1]. Among these, women and girls are among the most vulnerable in times of crisis. Displaced and vulnerable women and girls face higher risks of sexual and gender-based violence, as well as damage to their livelihoods [2]; girls are 2.5 times more likely than boys to miss school during disasters [3]; and displaced girls are often married off as children in an effort to ensure their security. (4)

Some of you may be reading this and feel disconnected from this situation because you can’t contemplate something like that happening in Australia. Sadly many girls live in situations here where they are exposed to domestic violence, sexual assault and because of this, their education is disrupted; they suffer with anxiety and depression and they are repressed. How can that be in the 21st century in a wealthy country like Australia? What can we do at the grass-roots level to address that? Encouraging women to be visible in positions of power to act as role models for girls; teaching boys to respect girls and women; not tolerating misogyny; educating girls about sexual health, understanding their bodies and their anatomy; valuing girls and women.

And how can we as a country not shudder with horror at the thought of young girls – millions of them around the world – being displaced and suffering just because of where they are born?  The idea of such a day is to expose the situation and encourage us all to contemplate the facts. The United Nations plea on the International Day of the Girl Child, is to encourage us to commit to investing in skills-training and education for girls and livelihood activities for young women around the world who are facing crises. Far from being passive recipients of assistance, these girls are leaders who will use the skills that they develop today to rebuild their communities, and create a better future.

Now there’s a thought!

(4) http://www.unwomen.org/en/news/stories/2017/10/statement-un-women-day-of-the-girl-child

Final days in London #moreselfindulgentholidayblogging

The end of the ICS Florence conference signalled the end of the holiday was close. Still we tried to cram as much as we could into those last couple of days. Sadly on the morning of our departure from Florence there was a devastating attack on the London Underground at the morning rush hour with a crude homemade bomb – only partially detonating – but still severely injuring quite a few commuters. This news of course crushed the previous confidence I had been feeling with London, but the Londoners themselves just keep on keeping on which I suppose is born of necessity (they have to work, eat and drink at pubs) but also from a history of years and years of attacks and battles. I admire their strength in adversity.

We cabbed it from The City Airport, which is out near Greenwich and had a great chat with a cabbie all the way to Soph’s place. He filled us in on his twice yearly holiday to Turkey and apparently men love their pampering as well as girls, because when he goes to Turkey he always has an hour and a half session at an old fashioned barber which involves a shave with a straight blade (his head also), massage, hot towels etc.

Looks a trifle scary to me

We have caught a mixture of cabs and Ubers on this trip and the Ubers are definitely cheaper – but news after we returned to Australia was that  Uber are not able to continue operating in London after September 30th – apparently they are not necessarily good employers and have to make some serious changes to their company conditions.

Friday night was a return to The Warrington for a pub meal and then a visit for Bob to the townhouse, Soph’s friend, Laura is now living in- that used to be The Vienna Hotel 41  years ago. He was wandering around, visualising where he and Mark, his travelling buddy for 6 months used to bunk down. It must have been surreal for him – I know I still have to pinch myself that this coincidence has happened.

Bob concentrating on taking the selfie at The Warrington

Before we headed back home we decided to catch the tube to Piccadilly Circus and walked up to Oxford Circus along Regent Street with all its lights and grandeur. It was about 11.50pm and the streets were hustling and bustling – it seems London never sleeps.

The next day we went to Regents Park to watch Soph play AFL against the English team – yes you heard it right. Soph whose sport is netball – came to London and got herself in an AFL team (Go the Mighty Demons) because one day she was watching Jimmy train and she got asked if she’d like to trial – she got in and her all girl’s team ended up winning the Grand Final. As they were the winning team for the comp they got to play against the English AFL team (which sounds incongruous) to give them some practise. It was amazing watching the game in real life as opposed to the ‘streamed’ game at 1am like we had to when the Grand Final was on.

.  

The game in action   A nice scone with jam and cream and muffin may have been consumed in this cute cafe

On the way to the game we passed some magnificent architecture (read very posh homes) and then as we entered Regents Park saw many lovely sculptures – scattered through the gorgeous parkland. I love art out in the real world as opposed to locked up in galleries – such a nice thing for kids to see and play around and on.

 

 

Regents Park London

After the game we walked and walked to locate an English pub that had pork pies on the menu and unfortunately that was harder than we thought it would be. We ended up with another sort of pie at a pub and then dropped into Sainsbury’s on the way home and bought some mini pork pies to have as a snack with a gin and tonic – thanks to Elaine for my pressie of some gin and flash tonic.

  

Elaine’s Gin and Peach Tonic and the mini pork pies

Topped up with those deliciousness we then headed for another local tradition in Soph and Jimmy’s stamping ground – we lined up at 6.30pm outside the Camden Head Pub to get an entrance to the Angel Comedy Club – its free but there is an expectation that if you laughed hard you will make a donation.

    

We laughed hard and we gave our donation. There were 6 acts and a fabulous host – all very funny and the atmosphere was so happy. I’d definitely recommend this to you if you staying in London, just catch the tube to Angel. Then when it’s over do what we did- go to Franco Manca’s for the best (and cheapest) sourdough pizza I’ve ever had.

After a sleep-in on Sunday, we decided to earn our breakky by walking along the canals near Islington to a gorgeous restaurant, The Towpath Cafe, (36 De Beauvoir Crescent, London N1) set in two storage units  facing the canal.

 

The food was delicious and so different to the normal take on breakfast. We then headed off to the Columbia Road Flower markets – it was very very busy, vibrant and colourful – and the flowers were very cheap.

  

The long walk continued then to a craft beer festival at Clissold Park and Jimmy was underwhelmed with the craft beers (and he is a bit of an expert) but the grounds were magnificent and we did get to sit for a bit.

 

The next stop on this great big walk around London was back to Islington and the Myddelton Arms for a famous Sunday Roast. These are legendary and our roast lived up to the stories – it was simply enormous. We met one of Katie’s friends from Australia, Steph, for a drink and a meal and we were all suitably filled to the brim after it was over.

    

Settling in for the Sunday Roast at the Myddleton Arms

This was to be our last hurrah in London. The next stop was Heathrow and the plane home. It was an amazing holiday and wonderful stay both times in London and Soph and Jimmy did a great job of showing us London. We have lots of lovely memories, but writing these blogs with the photos does help us both remember them even better so thank you for humouring me while I write them.

I know that more important than my travel blogging is the information gleaned form the conference in Florence. I will be writing it up as I kept lots of notes but it may take a few more weeks. The conference was a great success, with lots of inspiration and new ideas to try. One of these included a new class that we will be running when Amanda leaves (which is all too soon), to replace one of her 6.30am Pilates classes. It’s being taken by Jane Cannan, one of our physios and is called Physiofitness. It involves lots of exercises in standing, lying and sitting set to music and with an emphasis on the pelvic floor.

Hopefully the next blog will be lots of conference titbits.

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