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

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.

 

 

 

 

 

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“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.

On the Geneva Express to Venice

Panaroma from Chateaux de Tourbillon showing the nearby Basilique de Valere both situated at Sion, Switzerland

We departed Chamonix early in the morning to catch the Mont Blanc Express to Sion. The reason we planned to stay in Sion is because this fantastic direct train from Geneva to Venice stops in Sion for a pick up. And this little stopover turned out to be an unexpectedly fantastic 24 hours. We arrived at 10 am and Sion did look a little industrial and dour, but we dropped our bags and wandered into the ‘old’ part of town and there was a street market going on – by 11am everyone was drinking wine, there was a fabulous flamenco guitarist playing, little kids were dancing and I was won over instantly.

   

Sion Friday morning markets  A fabulous flamenco guitarist

The music must have triggered the need to have a Spritzer at 11.30am especially as everyone else seemed to deem it was ok to have a drink before lunch. There is an easy-to-follow numbered tourist walk through Sion – it has two quite impressive castles and some very, very ancient history. Sion is one of the most important pre-historic sites in Europe. The oldest trace of human settlement comes from 6200 BC during the late Mesolithic age. (1) I doubt I would say to people – Sion HAS to be on your must visit list, but if you are like us and it is a pick-up point for the direct train to Venice, then definitely do it. (Friday would be the best day – with that street market and all).

The train network is spectacular in Europe- I wish we had something similar in Australia. It’s so nice to sit back and watch the country side speed by while writing a blog. Departing at 9.15am we arrived at Venice at 3 pm. Unfortunately it was raining, but it has always been very hot, sunny and dry in Venice, so it makes for a nice change.

The Art Biennale happens every 2 years, alternating with the Architecture Biennale. As Bob is an architect, we have only ever attended the Architecture Biennale (for professional CPD reasons). What drew me to Venice this trip was the fabulous sculpture by Lorenzo Quinn called Support – his inspiration being the prediction that Venice will be lost to the Adriatic Sea in under 100 years due to rising sea levels caused by climate change. The hands symbolise the support needed to hold up the magnificent buildings that have existed for thousands of years.

      

The reason we came to Venice! Bellisimo Lorenzo

When government coffers are dwindling and budgets are tight, often the first funding that gets mooted to be slashed are those funding the arts, but when a sculpture can be so ‘visible’ and generate such conversation with just its ‘visibleness’ (I made that word up) then no amount of Senate Committee estimates and research can match that. Arts funding is essential to fight for, just as climate and environmental research is. This terrifying article shows us the future and it isn’t all rosy unless by rosy you mean the colour of our skin when we step out of the house without sunscreen to put the clothes on the line. I have a friend who is right into the science of Climate Change and I asked him to fact check the article I have linked and he has said – yes you better believe it.

Venice didn’t disappoint – we had another beautiful dinner at Vinaria – their food is so special and different to the usual enormous menus of spaghetti, pizza and seafood that Venetian restaurants often have. But at the same time as being delicious and different they are quite reasonably priced.

  

Anchovy stuffed dumplings  Pasta with Artichokes and zucchini flowers    Outside Vinaria

The next day we did a fast cruise through the Art Biennale (held between 13 May – 26 November 2017, Central International Exhibition, 57th Venice Biennale 2017, Arsenale and Central Pavilion, Giardini. Curator: Christine Macel.) It was raining quite heavily so we decided to buy a one day transport pass so we could hop on and off the vaporettos rather than walking the quite long distances to the Giardini – our first stop at the exhibition. The transport is fantastically expensive in Venice – a vaporetto is 7.5 euro each regardless if you go one stop or up the Grand Canal to all stops. You can get on and off as many times as you like within the one hour – after that it’s another 7.5 euro. So we decided 22.50 for the day pass (24 hrs) was better value because of the heavy rain and the big puddles!

                

Some pieces from the Art Biennale

The next day we headed to the train station – a short walk from our accommodation Hotel Marin– and after quite a few visits to Venice being close to the train station is a very easy location to base yourself. Dragging your luggage long distances over the cobblestones and bridges of Venice is no fun. So it was back to work for me – our train trip to Florence meant the start of the ICS (International Continence Society) Conference and signalled I had to get my brain out of holiday mode and into conference mode and I wasn’t sure it was going to be that easy…..holidays are such fun.

Hotel Marin 10 minute walk from the train station (very small rooms but reasonably priced and clean)

Farewell Venezia  and hello to Firenze.

(1) Sourced https://en.wikipedia.org/wiki/Sion,_Switzerland 13/9/17

Chamonix and World Physiotherapy Day 8th September 2017

September 8th each year is World Physiotherapy Day, so what’s the most important piece of advice I can give you on World Physiotherapy Day?

Start moving and keep moving.

After a week in Chamonix, I have seen what it takes to improve balance as we age; how to obtain the best homuncular refreshment there possibly is and how to stave off the effects of arthritis and obesity. And it all revolves around getting out in the fresh air and hiking.

  

This area is so beautiful and supercharged with visual splendour. It is so easy to want to start moving and keep moving. It is also so easy to use public transport to get around. The car certainly has a lot to answer for with turning us lazy. After scrambling over rocky paths, my ankle proprioceptors have been turned inside out and are buzzing with their new-found energy. Whilst Meg Lowry’s App ClockIt to help with balance and coordination is fabulous, I do think it could become redundant, if we went made a point of going for regular bush walks on very uneven surfaces every weekend.

We have many bushy areas in our local suburbs – even just going to Mt Cootha and clambering over some rocks, up an incline will refresh your balance every week. Taking the kids to the bush is a great way to introduce them to hiking early. Over here in Chamonix, there were many families with young kids in tow with their hiking boots on enjoying the fresh air and the mountain scenery. Of course it was pleasantly cool, and that is one thing that really makes hiking in Australia – well in Brisbane at least much harder. When it can reach 30C in winter in Brisbane, it is hard to hike in the summer months.

But enough of this World Physio Day message- back to my travel memories – because if I don’t write it down, in just a flash I may forget it.

After having spent a frenetic weekend getting the most out of our time with Jimmy and Sophie and our mountain passes, we decided to have a formal rest day on Monday, which meant a late start and a leisurely walk around town. As I said in the previous blog, the festivities of the Ultra Trail Marathon, were still apparent and the town was full of tourists (not in a Venice way) who were very happy and enjoying the fun and frivolity. One of the traditions of Chamonix must be a waiter and waitress race, where they walk briskly along a (quite a long) set course carrying a tray with 2 bottles filled with water and 2 drinks. The winner is not just the first person across the line, but the one with the least spillage. Careful measuring of the fluids left in the bottles and glasses were recorded and then the winner was decided. The crowd cheered and the music gave the town a wonderful buzz.

     

The famous waiter race of Chamonix The official starting car 

    

The houses, restaurants and streets were adorned with flowers

On Tuesday, with brilliant sunshine, we headed off with our mountain pass to the Plan Praz and the Telepherique du Brevent (2523 metres) and sat for a hot chocolate at surely one of the most scenic cafe decks ever. There was extensive glacier education there on the extent of change of the glaciers over time.

Hot chocolate at surely one of the most spectacular cafes ever

We then caught the bus to Argentiere (No2) to the peak Aguile de Grande Montets. We headed to the Telepherique to Les Grandes Montets at 3295 mtrs. The air was thinner there ,just like at Du Midi, but I took it slower and it didn’t seem to bother me as much. I thoroughly recommend this lookout as it is much less busy than Du Midi and again in the extreme category for spectacular beauty. We had a picnic lunch and watched some mountaineering training on the mountain slopes.

The training school for mountaineering

We then caught the bus back to town to a station called Le Praz and caught the Telepherique De La Flegere to Stage one and then further to the top in an open chair lift <insert horror emoji here> to Col L’Index (abbreviated to Index). I sat frozen (with fear not the cold) as we travelled up an enormous distance over a very rocky mountain and I did not move a muscle which made it difficult to get off the moving chairlift. All my family will tell you I am not great with heights and to have achieved this was a milestone. Unfortunately, we were too late this day to finish the walk to the intended destination (Lac Blanc) but instead just walked down from the top back to the Telepherique. We then caught the Number 1 bus (or 2 as well will take you to Chamonix) back to town.

The walk down from the top to the Telepherique

Wednesday was a late start as I was feeling stiff from all the downhill walking from the day before. We bought another 2 day pass and caught the  Telepherique at Du Midi to the mid-station called Plan de L’Aiguille and with the intention of walking to Montenvers and seeing the Ice Cave which was shrouded in cloud on our first day. The cloud cover when we set off was very thick and unfortunately we headed up, instead of down and spent an hour walking and arrived back at the beginning again. But in the process we saw this very pretty small lake.

Detour to Lac Bleu actually went up instead of down as there was a really heavy fog.

This was quite a difficult walk, with narrow paths and lots of rocky ridges. I did manage to put one of my hiking sticks on the edge of a path and into thin air and toppled over the edge, ageing Bob by a decade at the same time. Fortunately there were lots of bushes to cling onto, but I did concentrate even harder after that little slip.

We saw quite a few Marmots on this trip.

    

And there were many cairns – stacked stones along all the trails

We eventually made it to Montenvers- Mer de Glace – the beautiful glacier and mountain area where the Ice Cave is located and which was in total white-out the other day. The misty cloud had cleared by the time we reached it today and it was truly spectacular. I have also made a mental note to add a stay at the Grand Hotel du Montenvers, which has just been recently renovated, to my bucket list. Yes I will be returning to Chamonix!

    

 

 The Montenvers Glacier

Today, Thursday, was the last day of hiking before we head off to Italy. Sadly the day was very, very misty with no view of anything much. We caught Telepherique De La Flegere again and for a second time got on the open ski lift L’Index. I was this time more frozen with cold than fear. We walked for 2 hours to get to Lac Blanc – what was described as a stroll in the park was quite a difficult walk, but I imagine it was truly worth it in full sunshine. We waited and waited hoping the mist would lift, in the process warming up with a delicious hot vegetable soup on a terrace watching a mist float over the lake.

  

Lac Blanc very misty sadly 

There was some wispy gaps in the cloud which allowed some special photos to remember this very beautiful lake. The walk down to the Telepherique was spectacular and interesting, until right at the end where it took a nasty uphill turn. I have worked out I am excellent on the flat and downhill but less so on the ‘ups’ but the thought of missing the last gondola down and having to walk it down got me through to the finish.

Chamonix is one of my favourite places and I am quite sure we will have another visit one year. I thoroughly recommend it to you as a place to hike in summer and I am sure if you are a skier, it would be special for winter pursuits.

To all my Physiotherapy Colleagues – Happy World Physio Day

(And to all my family, patients, staff and friends my foot has been magnificent – allowing me to hike between 15000 -20000 steps each day!)

Networking with Elaine Miller and Mont Blanc #mustdo #bucketlist

Elaine Miller (otherwise known as Gusset Grippers) is a Women’s Health Physio and wonderful comedienne from Edinburgh. She has just completed a sold out stint at the Edinburgh Fringe doing an evidenced-based show on the pelvic floor! You have read about her many times on my blog. I met Elaine years ago on Facebook and we have become firm virtual friends. We met IRL (in real life) a couple of years ago at The Women’s Health Summit and as I was coming to London on my way to Florence for ICS 2017, we arranged to meet in York as it is approximately half way between London and Edinburgh.

We had a delicious spread at Mannions in York – worth the trip alone for the morning tea. 

It was so good to be able to brainstorm some ideas with Elaine and chat about her future gigs – many of which are in Australia later this year. Using comedy to bring continence and sexual dysfunction out of the cupboard is such a brilliant idea and Elaine does it with such aplomb! Saying pish in Scottish is far less awkward too. York is a gorgeous city – very historic and lots of fabulous pubs and cafes to eat at.

   

Friday saw an early start and an Uber to Heathrow to fly onward to Europe. We flew into Geneva and hired a car driving to Annecy in a very quick time. Annecy is a beautiful French town with a definite old and new section. We stayed in the old section and it was easy to wander around for hours, stopping occasionally for a pizza and Aperol spritzer.

      

The next day we headed with great excitement to Chamonix and Mont Blanc. This has been something I have wanted to do since our wonderful walks around the Swiss and Italian Alps in previous trips and some very good friends had stumbled across Chamonix accidentally and reported its beauty to us.

The first day was rainy and chilly as we headed up to Montenvers and the Mer De Glace – via a little red train to 1913 metres to see this famous glacier.

    

The panoramic view of the mountains was obscured unfortunately by cloud and rain, but we were able to still descend to the Ice Cave and witness for ourselves, as we climbed down the 448 steps, the terrible effect of global warming on the depth of the glacier. It’s quite staggering how much it has receded, particularly in the last 2 years, between 2015 and 2017.

     

448 steps down and up to the Ice Cave

     

At the entrance to the Ice cave and Bob and Jimmy at ‘The Bar’ inside the Ice Cave

 

This dog accompanies one of the workers and spends the day at the glacier every day

The most frequently visited app on my phone around holiday time is the weather app and the completely clear yellow sun with no clouds showing on the app for Chamonix was the best news there could be. It was to be Sophie and Jimmy’s last day in Chamonix and to see the tip of Aguille Du Midi revealing itself above the mountain in front of our hotel was very exciting. I’ll let the photos do the talking, but this should be a must on any bucket list you create.

     

I would recommend staying a week in Chamonix. The town is exciting and very pretty and just sitting in any cafe and looking in any direction and there’s a stunning view to behold. There are so many walks to do – I would definitely recommend getting at least a 3 day pass to get onto all the gondolas to the different areas – this includes the Du Midi but you’ll pay an extra 29 euro to take the Panoramic Mont Blanc Gondola to Helbronner which travels across to Italy. It takes 30 minutes each way and allow time to spend there checking out the different view to the Italian Alps.

    

To get the most out of the day we grabbed some quick lunch and then headed off to the Mont Blanc Tramway – it was the final day this was open so we were very lucky with the timing (we had no idea this would close for the season so early). It was very crowded and as time was short (and I was suffering with a touch of altitude something) we decided to jump back in the return trip and then set off hiking from the train station at the top of the mountain down to Les Houches. It was such a beautiful walk and a great way to finish Sophie and Jimmy’s stay with us.

 

  

The busy Mont Blanc Tramway and the mountainside wildflowers and panoramic vistas on our hike

We were a trifle worried when we chose these dates for Mont Blanc because the famous Ultra Trail Marathon is on at this time. But if anything I think it makes it more exciting to be here with the UTMB on (but accommodation is difficult to get at the last minute).

Time for bed but there is more to come with the beautiful Chamonix…..

The Seven Sisters #alert #thisisatravelblog #formymemory

 

The Seven Sisters a highlight of our Brighton excursion

We’ve had a hectic couple of days- testing out my foot well and truly. I do look a little ‘lame’ by the end of each day but the pain is forgotten as the Spritzer kicks in.

Bob:Upper photo Circa 1976 & lower photo 2017  

Yesterday we ventured back in time to visit the iconic Sutherland Ave- we replicated the photo Bob took 41 yrs ago and then moved onto his old stamping ground The Warrington. It is a very nice, typical English pub and you couldn’t wipe the smile off Bob’s face, especially as he downed his warm bitters, bangers and mash and the Scotch egg that completed the trip down memory lane.

The Warrington

 

We then moved onto Abbey Road- dicing with death to reproduce the Beatles walk across the zebra crossing. It must be very amusing (or quite annoying) for the residents watching the parade of tourists every day.

  

The iconic Abbey Road crossing        

     

 We didn’t really research the photo before         

Up to Little Venice and then to Hyde Park where they were in full throttle at Speakers Corner. I did ponder grabbing a low ladder and sprouting on about the virtues of pelvic floor exercises and the value of using the correct defaecation dynamics.  All the speakers were very intense and looked a little fanatical – mostly in the name of their favoured religion, but it made for interesting theatre.

It was a glorious day for Hyde Park- if not a little hot – but the temperature allowed for an ice-cream to be consumed, so we sat on the grass and watched the passing boats on The Serpentine (the large lake in the middle of Hyde Park). We then walked a short distance to Knightsbridge and the iconic Harrods. There must be an invisible vapour that is pumped across the doorstep of Harrods that entices you to go mad with purchases. I went to Harrods back in 1984 and swore I would never go again – and I never did use the special hair rollers (?!?!) that I purchased there 33 years ago. But as I said, you get in there and say “What the hell let’s buy some mementos of our visit here for presents back home”.

   

Harrods -it is a truly spectacular building                      

Lorenzo Quinn collection at Harrods

We are especially going to Venice to see Lorenzo Quinn’s sculpture depicting global warming so it was a lovely surprise to see this showing of his sculptures at Harrods.

 

The weather was a full page 3 spread

The next day we ventured south on the train (on the hottest Bank holiday London has seen) to check out Brighton…..with a couple of million others. (I will be writing a separate blog on the toilets in England. I will be writing to the Director General of British Rail in fact, but I will keep this a positive travel log of the last few days of London, rather than taking you through the highs and lows of my train trip to Brighton). It was hot, the beach is very pebbly and it was very choked with people, so we made a quick decision to catch the bus on to find The Seven Sisters. I can thoroughly recommend this trip. If you want to do this, catch the 13X bus from Brighton and get off at Seaford and find the start of the walk to the Seven Sisters. If you do it this way, when you get to the top of the hill, you will walk towards the Seven Sisters facing a most glorious view. It’s a lovely grassy walk, quite a lot of it next to a golf course. Take a picnic lunch and sit up on the cliff facing the Seven Sisters and just soak up the panorama.

 

Then once you reach the Seven Sisters Tourist Office you can catch the bus back to Seaford and pick up the train to Brighton, or alternatively, get off the train at Lewes and change to a London train that takes you to Victoria Station. I have certainly found the transport system here fantastic. As I said previously, get your Oyster card (and keep it topped up), download City Mapper London onto your smart phone and it’s so easy. You really can’t have a car in London and why would you when the trains, tube and double-decker buses are so good.

The 29th August dawned another brilliant day – some food shopping happened to get ready to throw a surprise birthday dinner for Soph – the surprise was well and truly a surprise and it was so nice to meet some of Sophie and Jimmy’s friends. Mothers need to visualise where kids are living, who is who and what they do when living thousands of miles away- and meeting their friends has been very nice. Living in London and walking the streets and using the tube has been good too- it makes it appear less scary when you see it in action.

Today I got punished for complaining about the hot weather – just like that, it dropped from 29C, sunny and muggy to 14C cold and wet. But it didn’t really matter as we had planned some birthday festivities for Soph’s 29th birthday. We headed to a beautiful restaurant, The Duck and Waffle, up the top of the Heron Building (110 Bishopsgate, London EC2N 4AY) for lunch. You are zipped up to the 40th floor in a glass lift and the view is truly spectacular. Their signature dish is obviously the duck and waffle with mustard maple syrup, but we had quite a few tasting plates which were very different and delicious.We then headed off to see The Lion King at the Lyceum Theatre in 21 Wellington Street
London WC2E 7RQ. It was a magnificent production and the hundreds of kids that were there were so well-behaved and thoroughly enjoyed the show. A delightful show for the kids when they’re a bit older.

As Jimmy would say ‘A sneaky chocolate fondant to finish at the Duck and Waffle

Tomorrow is a networking day with one of my Women’s Health colleagues from Edinburgh, Elaine Miller. We are meeting in York and will be talking up a storm about continence promotion and I look forward to our collaboration and exchange of ideas.

Until next time.

 

 

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