CONCEPTS IN WOMEN’S HEALTH ONLINE SEMINAR – via zoom meeting; Live stream

with Corina Avni

Live stream time; mod 1; 9am – 12noon; SA time; mod 2; 1-4pm SA time; Mod 3; 1-4pm SA time; Mod 4; 9-12pm SA time; Mod 5; 1-4pm SA time; Mod 6; 9.30-12.30pm SA time; Mod 7; 1-4pm SA time; mod 8; 9-12pm SA time; mod 9; 1-4pm SA time – please check your own local time.

Past Pax Feedback;

I thoroughly enjoyed this course! It’s a great starting point for anyone wanting to start working in women’s health. Corina is an animated, enthusiastic and knowledgeable presenter. Her deep understanding and passion for women’s health is obvious. She has a knack for making complicated concepts understandable. Thanks to her and Club Physio for keeping us learning during lockdown! I’m excited to learn more and am looking forward to doing some face to face women’s health courses post-covid19 – Claire

The Club-Physio Course by Corina Avni on Concepts in Pelvic Function and Women’s Health was absolutely incredible. Corina has such a beautiful way of simplifying and explaining concepts ensuring you will never forget what you have learnt. The course covered many various aspects of pelvic function and really broadened my knowledge. Thank you for producing such an amazing course and presenting it with such passion – Kara

It was great to have the opportunity to meet Corina in this online women’s health course. With a lot of irreverence she’s able to simplify and transmit her excellent knowledge in this field of physio, making you more and more interested in the topic! – Priscilla

To be honest this was my first online course . I am looking forward to taking more online women’s health courses. The experience of this class has been nothing but positive 😊 The course was everything you said it would be Corina – it was really fortunate for me to meet you through this course. Thanks Club physio. Shagufta

Thursday, 16 April 2020: Module 1; Anatomy including ‘build a pelvis’ practical

Saturday, 18 April 2020: Module 2: Physiology of pelvic function / Neurophysiology of pelvic function

Sunday, 19 April 2020: Module 3: Pathology of pelvic disorders

Thursday, 23 April 2020: Module 4: Medical testing in the pelvis / Clinical reasoning in the pelvis

Sunday, 26 April 2020: Module 5: Assessment history taking / Assessment motivation and Ethics

Thursday, 30 April 2020: Module 6: Management planning / Up-training vs. down-regulation / Practicals

Sunday, 03 May 2020: Module 7: Management in the pelvis

Thursday, 07 May 2020: Module 8: Electrotherapy in the pelvis / Medication and surgery in the pelvis / Practicals

Sunday, 10 May 2020: Module 9: Practicals

9am to 12noon each day. SA time

Concepts in Pelvic Function and Women’s Health

This modular course covers basic concepts in pelvic function and women’s health. It does not include an internal vaginal examination, and as such you are not fully equipped to do a comprehensive assessment of pelvic function – you will not come away as a pelvic or women’s health physiotherapist. It will be a first step into the pelvis – to understand the complex relationships between bladder, bowel and sexual function. Comprehensive questioning combined with clinical reasoning will allow you to provide simple treatment strategies of education and advice for (pelvic) women’s health related issues.

Module 1: Anatomy including ‘build a pelvis’ practical

3 hours; 75 slides

Outline – We cover anatomy of bony pelvis, sexual dimorphism, ligaments and associated structures, muscles, fascia, neurovascular components, viscera, the interstitium and the autonomic nervous system.

Objectives

• to understand the implications of bony pelvic structure for movement
• to explore the role of ligaments in contributing to pelvic structure
• to create a 3D model including the pelvic floor muscles
• to consider the relevance of neurovascular compromise in the pelvis
• to visualize the associations and relationships of the viscera

Take home messages:

1. Function dictates form and vice versa
2. Movement is an essential aspect of biomechanical pelvic health
3. Everything fits together
4. Dysfunction in a system that supplies the whole pelvis impacts the whole pelvis
5. When you delve into the pelvis, you have to consider the autonomic nervous system

Module 2: Physiology of pelvic function / Neurophysiology of pelvic function

2a. Physiology of pelvic function

1 hour 30mins; 32 slides

Outline – We cover simple biomechanical function of the pelvis, before exploring the pelvic floor muscles; bladder, bowel and sexual function; and continence and defaecatory mechanisms.

Objectives

• to understand the biomechanical function of the pelvis and its dynamic role during gait
• to explore the various functions of the pelvic floor muscles
• to consider the various stages of visceral function
• to connect the role of continence mechanisms with anatomical structures
• to visualize the associations between and relationships of the viscera

Take home messages:

1. Movement within the pelvis is normal and essential
2. The pelvic floor muscles have a range of functions; hence dysfunction in and of the pelvic floor muscles can impact on other functions e.g. bladder, bowel and sexual function
3. Both bladder and bowel need to fill and empty
4. A change in anatomy can impact on continence mechanisms
5. Dysfunction in one area can impact on other aspects of pelvic function – co-morbidity

2b. Neurophysiology of pelvic function

1 hour 30mins; 38 slides

Outline – We cover neural control (both central and peripheral), receptors, innervations. We learn how bladder filling and emptying is governed by 9 micturition reflexes, and delve into bowel function including bowel and defaecation reflexes.

Objectives

• To understand central and peripheral control of bladder and bowel function
• To differentiate between sensory and motor dysfunction
• To list storage and voiding micturition reflexes
• To describe the cascade of bowel reflexes
• To engage in discussion on case studies of simple pelvic dysfunction caused by disordered reflexes

Take home messages

1. Disruption in neurological control can be assessed through pelvic dysfunction
2. Sensory and motor dysfunctions present differently
3. Celebrate bladder emptying as well as storage
4. Utilize simple bowel reflex enhancing techniques to encourage normal bowel function

Each patient is unique – the success of your intervention will rely on a comprehensive assessment

Module 3: Pathology of pelvic disorders

3 hours; 76 slides

Outline – We cover pelvic floor muscle dysfunction, including pelvic organ prolapse, urinary incontinence and retention, and faecal incontinence and constipation.

Objectives

• To conceptualize the range of pelvic dysfunctions
• To list different types of pelvic organ prolapse and describe POPQ
• To differentiate between 9 different types of urinary incontinence, and the impact of urinary retention on pelvic symptoms
• To differentiate between 4 types of ano-rectal incontinence
• To identify the difference between constipation, slow colonic transit and obstructed defaecation

Take home messages

1. There are many things happening in a small space, all impacting on one another
2. Prolapse is normal, but not desirable – keep your insides on the inside
3. Urinary incontinence is common and preventable with correct management, for which you need correct diagnosis
4. Bowel problems are also common and preventable with correct management, for which you need correct diagnosis
5. Treat the system, not the symptom

Module 4: Medical testing in the pelvis / Clinical reasoning in the pelvis

4a. Medical testing in the pelvis

1 hour 30mins; 36 slides

Outline – We cover urinalysis, urodynamic studies, X-Ray, ultrasound (pelvic and abdominal), cystoscopy, colonoscopy, anal manometry, defaecating procotogram, CT scan and MRI

Objectives

• To appreciate the range of support in testing for differential diagnoses
• To be able to select the appropriate medical test to exclude further pathology (infective, anatomical or sinister)
• To discuss patient presentation based on urodynamic studies report
• To identify which ultrasound approach would add most value to your assessment
• To adapt your intervention based on findings from a defaecating proctogram

Take home messages

1. There is a range of support in the form of testing
2. All presentations non responsive to therapy should be investigated further (**internal examination)
3. Whilst invasive, urodynamic studies help identify drivers of dysfunction
4. Ultrasound is your friend, allowing you to visualize that which used to be unseen
5. Sometimes you can’t treat anatomical derangement and may need to rely on behaviour modification or, in extreme, cases surgery

4b. Clinical reasoning in the pelvis

1 hour 30mins; 27 slides

Outline – we reiterate the value of a sound assessment in forming a clinical hypothesis; focused questions can often provide significant insight into pelvic dysfunction. We differentiate between hands-on treatment vs. hands-off rehabilitation and management. Education as a cornerstone of pelvic health is highlighted.

Objectives

• To appreciate the multiple steps involved in the process of clinical reasoning
• To learn that the hypothesis is a gateway to management
• To accept that pelvic patients are best managed in the context of a multi disciplinary team (MDT)
• To acknowledge the range and scope of what you can do, even without an internal; knowing when to refer on
• To discuss the impact of education of anatomy and function on understanding and awareness

Take home messages

1. Multiple steps are involved in the process of clinical reasoning
2. A clinically sound working hypothesis is a gateway to management (have second and third hypotheses in mind…)
3. Multi disciplinary teams (MDTs) differ, based on many factors (need, geography, resources etc); find good clinicians to support you in the management of your pelvic patients
4. You can do so much, even without an internal; know when to refer on

Discuss the impact of the education of anatomy and function you to received to date on your understanding and awareness

Module 5: Assessment history taking / Assessment motivation and Ethics

5a. Assessment history taking

1 hour 30mins; 39 slides

Outline – We cover how to take a history, commencing with presenting complaint, all the way through past medical history including obstetric and gynae history. Subjective assessment is broken down into sections for prolapse, bladder, bowel and sexual function, and pelvic pain.

Objectives

• To establish a process for subjective assessment or history taking
• To learn to differentiate potential pelvic disorders based on clinical presentation
• To differentiate between symptoms and systems
• To ask leading questions around identified symptoms and explore the extent of pelvic dysfunction
• To practice asking someone 5 difficult questions

Take home messages

1. History taking is like creating a story of the patient
2. Different pelvic disorders, with different drivers, present differently
3. Identify and treat the system, not the symptom
4. Ask leading questions, then ask more questions
5. Go and ask someone 5 difficult questions

5b. Assessment motivation and Ethics

1 hour 30mins; 21 slides

Outline – We cover benefits of an internal assessment, discuss goals and expectations of the patient, and consider ethical issues including consent and confidentiality. Infection control and hygiene offer an opportunity for debate, given the various states of lockdown and social distancing.

Objectives

• To understand the limitations in scope of practice due to not being able to assess the pelvic floor muscles via digital palpation
• To assess patient’s goals and expectations
• To establish the various drivers, or causes, of patient presentation
• To understand the importance of consent and confidentiality (POPI)
• To appreciate the sensitive nature and special precautions necessary with patients who have pelvic complaints

Take home messages

1. You are not a pelvic or women’s health physiotherapist, but you can add value
2. Educate, normalise experience, advise on simple lifestyle modifications, refer on if no response
3. You can’t exclude the pelvic floor muscles until you have examined them – either digitally or via ultrasound
4. Protection of patient information

Be mindful of how difficult the experience of sharing may be for the patient

Module 6: Management planning / Up-training vs. down-regulation / Practicals

6a. Management planning

1 hour 15mins; 35 slides

Outline – we cover thinking about findings of subjective history taking, we consider all we know about anatomy, neurology, function and pathology and we select appropriate management strategies for 5 case studies

Objectives

• To think about what your subjective history taking has indicated which systems are contributing to which symptoms, and then to think some more
• To consider the full scope of the case – off-setting health needs with resources
• To select management strategies based on sound assessment

Take home messages

1. Think about what your patient has told you; think about your anatomy and physiology (and neurophysiology and pathology….)
2. Consider what you have to work with / at your disposal
3. Select management strategies based on sound assessment principles

6b. Up-training vs. down-regulation

1 hour; 23 slides

Outline – we discuss the difference between increasing and decreasing inputs (and outputs) for various hypotonic and hypertonic patient populations, and review the relevance of selective attention and mindful awareness.

Objectives

• To differentiate between the need for up-training (switching on) vs. down-regulating (switching off)
• To review patterns of hypotonic vs. hypertonic pelvic disorders
• To explore the role of selective attention in clinical presentation
• To consider the role of mindful awareness in clinical presentation and management
• To review the impact of changes in autonomic nervous system activity

Take home messages

1. Some patients need up-training (switching on), some need down-regulating (switching off), and some need a combination of both
2. Hypotonic and hypertonic pelvic disorders present differently; they may have the same symptoms but have different causes – treat the system, not the symptoms
3. Selective attention to visceral function is an issue (too little vs. too much)
4. Mindful awareness will improve clinical outcomes
5. Autonomic nervous system activity dictates your background state of being

6c. Practicals

45mins

• Breathing
• Active cycle of breathing technique

Relaxation

Module 7: Management in the pelvis

3 hours; 73 slides

Outline – we cover PFM rehabilitation for different types of urinary incontinence and pelvic organ prolapse. We then look at management for stress urinary incontinence, over active bladder, post void residuals and recurrent urinary tract infections. Different management options for bowel dysfunction are also presented. Management of sexual dysfunction and chronic pelvic pain is only outlined, due to insufficient assessment (no internal vaginal examination) to provide full pelvic physiotherapy treatments.

Objectives

• To understand how education and change behaviour and hence function
• To become aware of one’s own bodily functions and responses
• To have strategies for PFM rehabilitation for its own sake, and for incontinence and POP
• To consider the challenges in POP management
• To learn strategies for managing bladder and bowel dysfunction (disclaimer: sex and pelvic pain not covered)

Take home messages

1. Education changes behaviour and hence function
2. Be aware of your own responses to bladder and bowel signals
3. The PFMs can impact on so many symptoms, you might as well have a good relationship with them!
4. POP management is frustrating and requires patient compliance and buy-in

You have multiple strategies for managing bladder and bowel dysfunction (disclaimer: sex and pelvic pain not covered)

Module 8: Electrotherapy in the pelvis / Medication and surgery in the pelvis / Practicals

8a. Electrotherapy in the pelvis

1 hour; 28 slides

Outline – we cover biofeedback, including pressure, ultrasound and electromyography (EMG); and we explore the rationale behind neuromuscular stimulation.

Objectives

• To select appropriate electrotherapy based on patient presentation, need and resources
• To appreciate the range of biofeedback and imaging techniques available
• To understand the role of neuromuscular stimulation in managing pelvic disorders, and when it is not appropriate

Take home messages

1. Electrotherapy is nice-to-have but by no means essential
2. There are a range of biofeedback and imaging techniques available
3. Neuromuscular stimulation, whilst useful for some hypotonic pelvic disorders, is not indicated for all (many) pelvic patients

8b. Medication and surgery in the pelvis

1 hour 15mins; 36 slides

Outline – we cover common medications used in the management of pelvic disorders, and review some of the surgical options available.

Objectives

• To review neurophysiology, using mediation in the pelvis as a revision tool
• To review anatomy and physiology, using surgery in the pelvis as a revision tool

Take home messages

1. Medication acts via neural pathways – it doesn’t cure the pelvic disorder per se, but may ‘mask’ the symptom
2. Surgery in the pelvis is used to ‘correct’ anatomy

8c. Practicals

45mins

• Pelvic floor muscle contract and relax
• Abdominopelvic synergy

Weighting for PFM activity

Module 9: Practicals

2-3 hours, depending

• Bladder training
• Post micturition dribble (PMD)
• Post void residuals (PVRs)
• Recurrent urinary tract infections (UTIs)
• Defaecatory technique
  • how to poo
• Defaecatory technique
  • how to improve colonic motility
• Constipation massage
• Fluid and fiber intake

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Live stream time; mod 1; 9am – 12noon; SA time; mod 2; 1-4pm SA time; Mod 3; 1-4pm SA time; Mod 4; 9-12pm SA time; Mod 5; 1-4pm SA time; Mod 6; 9.30-12.30pm SA time; Mod 7; 1-4pm SA time; mod 8; 9-12pm SA time; mod 9; 1-4pm SA time – please check your own local times