The Role of Physiotherapy in Endometriosis
By Alex Diggles, Physiotherapist
Physiotherapy has been suggested but I don’t know if this will help me.
It’s a day like any other and I’m preparing for my next patient. I walk out to the waiting room to see a familiar face, a woman mid-20’s who smiles but looks unsure. We sit down in our treatment space and I start with my first question; would you be happy to share your story. Often the response can be, I’m not sure why I’m here. This is true for those that have read up about pelvic pain and all its facets whether there be a background of Endometriosis, painful periods, painful intercourse or bladder or bowel issues. There can be uncertainty about how a physiotherapist has a role or how the pelvic floor muscles are involved.
Persistent pelvic pain is any discomfort between your belly button and the top of the legs. Pain is truly complex and beyond what I hope to discuss today but pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. This is the best current working definition we have but this fails to describe the complete control that pain can have on your life, social events, school, work and relationships. When you have pelvic pain we know there can be overlap, talking between all the organs and tissues within the pelvis and this can change how sensitive the nerves are, how protective the entire system can become.
As a physiotherapist my role is simply to provide a change of input to your system so that it moves, feels better and can recover. Pain is a protective response and our bodies find this information very important as it is our most common sign of danger. When we are considering the structures in the pelvis, the muscles play a huge role in controlling when we empty our bladder or bowels, being able to allow penetration and are part of the support of our trunk. If you were expecting something to hurt, for example if I said I’m about to punch you in the arm you would tense up and pre-empt this. When muscles do this for a long time and repeatedly, they can be tight, stiff and this can then affect them working properly often leading to cramp, spasm or ongoing pain. The stabbing, gripping or inability to stand upright from pain may be due to your pelvic floor cramping. Also being unable to feel comfortable during intercourse or that it is too tight can be due to muscles not relaxing effectively during desired intimacy. It can be hard for muscle to “un-learn” and this is the role of physiotherapy.
We have all been exposed to exercise and treatment whether it be ourselves or the culture we’re from. Often, there is the view that physio involves intense exercise, “no pain, no gain” and massage techniques that hurt but should help. This is not going to be helpful in a system that is like a meerkat, ready to react with any small input.
In my first assessment, I am most focused on finding out how pain interferes with your life as this will guide whatever treatment we work out together. Assessment should not be painful. In saying this, my role is to change the protective response of the muscles and slowly encourage the body to move again. So, during an assessment I aim to look at what strategies your body has to reduce its “meerkat” or over-protective response. This can include how you breathe, body relaxation and the quality of the local pelvic floor muscles.
The only reason I have the job I have is due to where the muscles are; how they work or how you can get them to change. There are many ways to assess the pelvic floor. From this point, most of you are already crossing your legs and increasing tension as a way to protect your pelvis and this is a normal response. My assessment can include gently touching your tummy wall, using ultrasound on to see your pelvic floor move (not an internal ultrasound), visual examination of the genital region or touch. Touch is the one most woman are most worried about. I think this is because that every other exam you have ever had reaffirms that this areas hurts. When we assess together it is to provide evidence to you that there is muscle factors that we can change and if we find pain or threat, we stop and see if we can change it. If there is pain our aim is always to acknowledge and change rather than push through it.
So, we’ve found the muscles are overactive; what does this mean? When you touch a muscle that is overactive it is often tender and this worsens if we contract it. Muscles that are overactive also don’t relax well (or at all) are jerky when they turn on. Think of your hand, if you went to pick up a cup but could then not put it down on conscious thought it makes your hand hard to control and would start to ache from holding that pose. The pelvic floor can be jerky, hard to control and our job together is to find how we can best cue or facilitate a muscle to relax and then turn on and off gently. A range of techniques and equipment can be used for this and it is difficult to say what would be the best for you. I often start with good education, strategies we know can help with pain (you may already have these) and some level of local awareness of what the muscles are doing. This can be thinking about what you can feel and trying to change it regularly each day to learn a new pattern, self-touch to the area to provide you with evidence that it can feel better or even starting with more general exercise to calm the whole system. Treatment will always be specific to you and your symptoms and will not push past what you feel is comfortable. It just doesn’t help to make things feel more painful!
Treatment can also vary in response time. Some women can progress really quickly and can re-learn how to get the muscles to move better and the body’s sensitivity to settle. I have seen this in as little as a few sessions or as long as 12 months.
Having to deal and find treatment for pelvic pain is complex and in my experience pelvic pain is best treated with a coordinated and multidisciplinary approach. If you feel you would benefit from the opinion and assessment by a women’s health physiotherapist, I would love to be there to help change your story.
Alex is incredibly passionate about empowering her patients to heal, improve and understand how best to optimise their own health and wellbeing. A key element in her care is ensuring a complete and holistic plan that provides up-to-date treatment options and focuses on achieving full recovery. While Alex has recently become a mum and is happily balancing a work life and two vibrant young children, she was recently awarded the title of Women’s, Men’s and Pelvic Health by the Australian Physiotherapy Association.
For more information go to https://alexandradiggles.com
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