Physiotherapy Trauma Talks
In Physiotherapy Trauma Talks we discuss the key roles that physiotherapists and other healthcare practitioners play in the management and rehabilitation of patients with traumatic injury. Experts in trauma care offer their insights about in-hospital patient care and post-discharge follow up service delivery. New research in the field of trauma care and rehabilitation is shared to provide answers to your questions.
Physiotherapy Trauma Talks
Pelvic Health After Trauma: A Physiotherapist's Guide with Professor Corlia Brandt
The journey to recovery after pelvic trauma doesn't end when the bones heal. For many patients, the invisible consequences of their injuries—urinary incontinence, bowel dysfunction, and sexual problems—can persist for months or even years, dramatically affecting their quality of life and ability to reintegrate into society. For physiotherapists wanting to expand their knowledge in this specialized field, Corlia Brandt recommends several resources, including her own project, PelvicInc.com, which aims to provide reliable information for both patients and clinicians. Podcast website: https://physiotherapytraumatalks.buzzsprout.com/2431934/episodes
Book: Cardiopulmonary Physiotherapy in Trauma: An Evidence-based Approach’ published by World Scientific: https://doi.org/10.1142/13509
Hi there, fellow physiotherapists. I am Helene van Asvegen, your host for Physiotherapy Trauma Talks, where we discuss everything related to trauma care. So if you are passionate to learn more about physiotherapy in the field of trauma, to ensure that you provide the best possible care for your patients, then this is the right podcast series for you. In our previous episode, we discussed the physiotherapy management of patients with pelvic and or acetabular injuries in the acute care setting. In that discussion, natasha and Jikiswa shared their experiences of managing these types of patients, from the time of their admission into ICU through their management on the trauma ward and how they prepare their patients for discharge.
Speaker 1:In today's episode, I want us to take a closer look at the long-term recovery of these patients and the role that physiotherapists can play in helping them with their recovery and improving their quality of life. Joining me for this discussion is Corlia Brandt, an Associate Professor in Physiotherapy at the University of the Witwatersrand in Johannesburg. Cordelia, welcome to the discussion. Thank you very much, eliane. So, cordelia, would you mind telling our listeners what inspired you to work and do research in the field of pelvic health, which is a field of physiotherapy that not many physios work?
Speaker 2:in? Yes, indeed. Well, it was actually by accident, to tell you the truth. I trained more in neuromusculoskeletal physiotherapy postgraduate. But then I helped someone out who was in private practice at that stage doing locum work, and she was actually treating patients with power claw dysfunction. So I thought in my head, okay, I must just, you know, kind of prepare and at least look like I know what I'm doing. So I started reading up a bit on it and I realized the more I read and with my background in endomusculoskeletal physiotherapy, that there were some things that did not make sense to me and that's where it actually triggered my interest. From there on, I became involved then with the Department of Obstetrics and Gynecology the University of the Free State and started attending the clinics and learned some new skills on assessment and management of patients. Yeah, and that led to eventually a PhD in it. Wonderful.
Speaker 1:So you are definitely an expert in the field and a very good person to have this conversation with. I hope so, cordelia. If we think about adults who were involved in high injury that caused pelvic trauma and in your experience up to now, what type of symptoms or complaints do these patients typically have months down the line as they continue to recover from the injuries?
Speaker 2:Yeah, well, unfortunately to say, is they kind of suffer from every type of pelvic floor dysfunction that you get, specifically urinary incontinence, problems with bowel dysfunction, as well as sexual dysfunction. We did a study with one of my master's students a while ago where we actually looked at patients three months and six weeks I think three months post acute pelvic fracture and we found that actually the sexual dysfunction domain and the bowel dysfunction domain were mostly affected and the scores on I think we used the Australian pelvic floor questionnaire actually worsened as the time went by. Sure, yeah.
Speaker 1:So it is quite serious how these injuries can impact on patients' quality of life and, I suppose, the social integration back into society as well, because if you struggle with urinary incontinence or bowel incontinence it must make you feel quite isolated and not really willing to return to interactions with others. Can you maybe talk a little bit about the underlying pathology or mechanisms associated with these symptoms? What would be the cause of the urinary incontinence, bowel incontinence and sexual dysfunction?
Speaker 2:Yeah, well, I think.
Speaker 2:If you think about the anatomy of the pelvic floor muscles, so the pelvic floor muscles is basically a group of muscles and they're attached to the pelvic ring.
Speaker 2:So, needless to say, if there is a fracture, it is going to disrupt the pelvic floor muscles as well, the fascia and also the ligaments going together with that, and usually it's one of two things that happens.
Speaker 2:So either it can cause weakness because of the pain, inhibition and the failure of the muscles due to the trauma, maybe as well, or it could cause an increased tone of the muscles due to pain, most likely, or because it is also triggered by inflammatory responses and that increase in tone lead to a decreased blood supply, and that, for example, is why it also affects sexual dysfunction other than only the pain that patients might have. In many instances, the incontinence is usually due to weakness of the muscles and failure of the muscles and the ligamentary systems as well, but not only the muscles, also the ligaments that support, for example, the pelvic viscera, because if you think of the anatomy, the fascia is a continuous system and if you follow the fascia from the muscles to the viscera, it's actually continuous. So wherever you get a disruption, it's going to affect the other component as well.
Speaker 1:And just maybe explain how it will affect the fascia.
Speaker 2:Well, first of all, the fascia around the muscles is continuous with the ligaments. So if there is a disruption of the ligaments, it is going to affect the fascia of the muscles, which again can lead to one of two things to affect the fascia of the muscles, which again can lead to one of two things either a failure of it, meaning there will be weakness, or it won't be able to contract properly and support the organs, leading to pelvic organ prolapse, or it also works, obviously, on the sphincters of the urethra as well as the external anal sphincter. So if there is a disruption or weakness, those sphincters will not work or function normally. And then also, you know, it could also go the other way, because patients have fractures and injuries, the connective tissue that forms due to that can also cause problems and actually stiffness on the other hand as well.
Speaker 1:Okay, yeah, now, thank you very much for that nice explanation. So, as a physiotherapist, when you have a patient like this coming to your rooms, what would be important to assess? To determine what is causing the patient's problems and what the specific issue is?
Speaker 2:Yeah. So that's actually quite an extensive assessment as well, because you need to look further than, obviously, only the pelvic area. The pelvic floor muscles work together with the other muscles, such as the diaphragm, you know, during breathing, which is also affected, especially if patients have been hospitalized for a while, maybe in ICU and ventilated. So that can also lead to incoordination of the muscles not working properly and not controlling the function of the bladder. So we will look basically at the whole, you know the thorax. We will look at the functioning of the abdominal muscles and the back muscles as well, working together and even other symptoms patients might have, such as hip functioning, the SIJ, the lower back can all contribute to problems. And then, if indicated, we will do an internal assessment as well. And I think many times patients are not prepared for that or they don't know about it. But I always tell patients, you know if, if you compare it, for example, to a gynecological investigate or assessment, it is definitely not as bad. But that's unfortunately the only way we can assess the pelvic floor muscles. You can't really do it from externally, but we have some tools that help us assess it, for example EMG, emg, electromyography especially if you suspect maybe nerve injury or something like that, because you want to know is the innervation normal or is it just a weakness that the patient has?
Speaker 2:And then we also do palpation of the muscles to see if there's any connective tissue or scar tissue maybe.
Speaker 2:And then what is also very useful is to do a perineal ultrasound, because it's not very invasive, you do it superficially but it shows you very nicely. You know all the organs. You can see the bladder, you can see the uterus, for example, you can see the rectum at the back and as the patients contract, you can also see the movement of the muscle and see what's actually happening there on the inside. So I think that's why it is sometimes a bit more difficult to assist these patients, because it's not like when you contract the biceps muscle. You can see it contract, you can see the muscle bulk. You have to kind of palpate and try to see on the inside, if I can put it that way. Yeah, so it is quite a comprehensive assessment and you want to rule out any other factors that can contribute it, including sometimes we forget medication that patients are using can also really have quite a big effect on the bladder functioning either retention or leading to incontinence, depending on the type of medication.
Speaker 1:Okay, that's very interesting because I don't think we would often think about that.
Speaker 2:Yes, no, definitely. So usually one of the first questions you know we ask is on what medication are you on? Yes, because you don't always think about it. In that sense you know if you take medication you don't. Well, I think most people don't go to the leaflet first of all and see what is the contraindications or the consequences of using the medication. But it is an important question to ask.
Speaker 1:Okay. So after patient assessment, if you've identified that you think this particular patient suffers more from urinary incontinence, what type of intervention strategies would there be for physios to consider in managing that particular problem?
Speaker 2:Okay. So if we look at urinary incontinence, most of the times it is due to weakness of the pelvic floor muscles, or you know times it is due to weakness of the pelvic floor muscles or you know any reason leading to weakness of the pelvic floor muscles. So first of all, we must look at what is the cause of it and try to treat that. But for weakness, specifically, you will look at pelvic floor muscle training. So, as well as functional integration when you are strengthening the muscles, that's very important. What does that mean?
Speaker 2:Okay, so, for example, you know your treatment of a patient.
Speaker 2:I can almost say maybe you know a sedentary type of patient sitting there all day, maybe not very active, will differ from, for example, if you are treating a long-distance athlete because they need more than the normal strength for them. And also important then is to, when you assess, to differentiate which component of muscle strength is affected Is it strength or is it more endurance, for example and that you determine while you are assessing the patient. So the type of exercises you prescribe for these patients might be slightly different. So, for example, if it's a patient with stress-reducing incontinence, where the problem is the increase in intra-abdominal pressure is too much and then they can't contract strong enough to prevent leaking. You will focus quite a lot on strong, fast contractions, whereas if the problem is more related to, for example, pelvic organ prolapse, that's, a descent of the pelvic organs, or, you know, for example, in an endurance athlete where you saw the endurance might actually be the problem, then you will focus more on low load contractions, long contractions, but not necessarily maximum effort from the patient.
Speaker 1:Okay, and you mentioned earlier in our discussion that it's not just muscle weakness that can cause problems with urinary function and bowel function, but also increase in muscle tone.
Speaker 2:So what do we as physiotherapists do about that? Yeah, so maybe before I go into the increased tone. So I think the important thing is also to understand that if a patient has increased tone of the pelvic floor muscles, it does not necessarily mean that they have strong pelvic floor muscles. Increased tone means there's too much activity in the muscles, and that's what we see with the electromyography. So electromyography just gives an indication of activity but not of the strength of the muscle as such. So you can have a muscle with increased tone but still have weak muscles, and that's also sometimes what makes it a bit more complicated to assess and treat in the end. But if you have a patient with, for example, pelvic pain, which many times also goes together with sexual dysfunction, or, for example, patients that complain of constipation, that's many times an indication of the pelvic floor muscles with increased tone. So they will want to focus more to relax the muscles and bring the activity of the muscle down.
Speaker 2:Okay, and there's different strategies to do that. You can use exercises. However, the aim would be on the principle of contract and relaxation and not to strengthen. So if you do too many contractions or too much emphasis on contracting, you will actually increase the tone, but that must then be incorporated or, you know, given together with other strategies to, for example, for the patient to relax.
Speaker 2:Breathing exercises is a basic example of something that you can do. Also, check that all the other muscles the abdominal muscles, for example, or the multifidus muscle in the back and the diaphragm if the coordination between the muscles is correct and there might be some weakness there which sometimes lead to overcompensation by the pelvic floor muscles. So any relaxation technique, including, for example, mindfulness, can also help to bring the system down, and the vagal nerve stimulation, for example, is also something that we focus on a lot there. So your approaches are completely different approaches and unfortunately, sometimes, I think, when patients look for information on the internet or wherever they just see pelvic kegel exercises usually what they see, but there's obviously a lot more to that and the problem is, if they do, then Kegel exercises, it might actually increase the problem that they have instead of helping. So that's why it's so important, first of all, to get a correct assessment and to base your management on what you found.
Speaker 1:Yeah, so we spoke a lot about patients needing to understand how they perform the exercises, when they contract, when they relax. Is there a way that we can show them what they are managing to achieve through exercise therapy that will prompt them and help them to do the exercises more effectively?
Speaker 2:Yes, that's a very important point that you have there. First of all, it does not help that you treat a patient and give them exercise to do and they go home and they do it incorrectly because again it might just increase the problem that they are having. So what we do is we usually use biofeedback. There's different ways that you can do that. The easiest usually is manual palpation and to kind of, you know, try to explain to them what the correct contraction is. For example, you know, don't squeeze your legs or your buttocks.
Speaker 2:That's very important because many patients, you know, think of a squeeze action, which is actually not true. When the pelvic floor muscles contract, they move upwards and it's almost kind of a suctioning effect. So in that process, you know the sphincter is closed, but if you tell someone to squeeze, you know they understand it wrong and they squeeze the buttocks and the legs. We also use the EMG, which is a very nice tool to use because you get a little graph when you are testing the patient and you can see when they contract, you see the readings goes up and when they relax it goes down and you can actually set a certain value on the EMG. So when the patient reach that value of contraction, there's actually a little alarm that goes off, so they know exactly when they are doing the right thing or the wrong thing, and it also helps for them to look at the graph and see the activity go up and down when they do something.
Speaker 2:Yeah, so they're getting the visual input, but also the sound input, Absolutely yeah, so they actually start enjoying that, because it's kind of a challenge sometimes, especially if someone has been doing the wrong thing for a very long time.
Speaker 2:It sometimes takes a bit of time to get them out of that habit because you know you need to influence again or create some new neural pathways and then maybe a method that we use that's not that common and it's also maybe not that important, or, you know, because the equipment that you need for it is quite expensive but is a perineal ultrasound where you can physically see the muscle moving.
Speaker 2:So maybe just an interesting example that I can give you here is we once assessed a patient and we asked the patient to contract the pelvic floor muscles In her mind. She was contracting it, but what was happening is what we saw the muscle actually literally moved in the opposite direction of the contraction and that's what we call a paradoxical pelvic floor muscle contraction. But it is very difficult to get a patient out of that habit and you can think there's a lot of proprioceptive issues there to address to get them out of those habits, and that's why it is so important, you know, when you teach someone pelvic floor muscle contractions to do it, to make sure that they do it correctly.
Speaker 1:Yeah, you've touched now on a point that I wanted us to talk about, and that is our role as educators and how we need to ensure that we communicate effectively with the patient and they understand exactly what is required from them as they go home and do the exercises on their own, and I suppose part of being that educator is, next time you see them, to review the exercises that they've done at home and to see if they've done it correctly or not, and then correct whatever they do wrong.
Speaker 2:Yes, no, absolutely. You know, I always kind of tongue in the cheek. I always ask the patient to show me what they have done. You know, and whatever you see in front of you is usually a very clear indication they have exercised or they haven't done the exercises. So it is important to follow up. So if you are treating patients, I know some people have classes where they put the patients in that they can come and exercise in an exercise class and there's definitely a place for that. But you can't just put a patient in a class doing exercise unless you know they are doing it correctly.
Speaker 1:Yes, no. I think that's very important and I think the group exercise is good for the emotional well-being and forms like a support structure for them. But it's important to also have that individual reassessment and see if they do the exercises correctly.
Speaker 2:Yeah, no, absolutely. And also, you know, to do a frequent reassessment to see how they are doing. You know, reassess your muscle string, reassess the MG, the tone. There's some, you know, there's a lot of assessments that we can do to try and see if the patient is improving. But yeah, definitely the exercise classes is an important component because I think it kind of leads to another important aspect that we also want and that's to get patients to talk about these problems. You know, I always say it's not something like a headache that you will sit around a tea table and talk to your friends with. It's a bit more sensitive and patients are usually very shy to talk about it, even with their medical, you know, even with their GPs, unless they ask them specifically about it. So to get the word out there and to break the stigma is quite an important component as well.
Speaker 1:Yeah, Then I wanted to ask what do you think are important elements for physiotherapists to think about when they provide counseling or education to these patients about pelvic or sexual health? Yeah, so that's a tricky question, I think.
Speaker 2:I think first of all, they must first of all assess their own ability to give the proper advice. If they do not feel equipped enough, I think they should refer the patient to someone who might give them the proper advice or, you know, ask for some assistance maybe. So you know, there are basic things, like I said in the beginning as well, because the pelvic floor muscles do not function in isolation.
Speaker 2:You can do something, anybody can do something for pelvic floor muscles, muscle functioning, even if they haven't had training, by just assessing, do a proper neuromusculoskeletal assessment of the back and the SIJ and the pelvic area, the things that we usually do, sij in the pelvic area. You know the things that we usually do. But when it comes to specific issues of the pelvic floor muscles, then you do need some extra training in it to know what you are doing and to pick it up. So I don't want to discourage anybody, you know, not to say no, we're not going to assess or treat the patient because we don't have training. But I do think that you can assess the patient and if you can pick something up that something is not right, refer the patient appropriately to a friend or a colleague who can assist or can give you advice on where the patient should be going.
Speaker 1:Yeah, and I think at this point it's appropriate to point out that there is a Women's Health Special Interest group as part of the South African Physiotherapy Society. For our listeners, Corlea, are there any other sources or societies that they can access on the internet to get some more information about this topic, to just improve their own learning and empowerment in dealing with these patients?
Speaker 2:Yeah, so definitely there is. So maybe also again just to link with the previous point where we talked about referral. So don't think, if you can't find a physiotherapist in the area, that you're kind of stuck, because we work very closely together with the urologist and the urogynecologist as well. And I'm just saying that because some of the sites that I'm going to mention now is specific. For example, the Urogynecology Association site, and they have a very nice patient platform where they have patient leaflets which explains you most of these conditions in lay terms, with some illustrations, and also give you advice. Or there's also places where you can contact someone. Just to note, this is an international organization, so you might get to someone not in South Africa, but luckily we have a solution for that as well. So, as you said, the South African Society of Physiotherapy also has a public and women's health group which can give you the advice that you need or refer you to someone in your area if you need some treatment or to refer to a colleague.
Speaker 2:And then I've also, with a project that I started in 2022, I think I've developed a site. The aim of the site is basically to give resources that is reliable to patients and clinicians, and the site is called pelvicinccom. The reason for that is as we said earlier on. Patients unfortunately go onto the internet. Look at a lot of advice that comes up, but unfortunately a lot of that advice is not really reliable and we don't know where it's coming from and they give the incorrect advice sometimes and we don't want that. So I wanted to kind of create a one-stop shop where you can go to get some resources. Whether it's a webinar you want to attend or a conference or article you want to read or a video you want to watch, I try to put it on there as well to make it easier to find reliable information.
Speaker 1:That's fantastic, and we'll put the links to these various sites on our podcast website, cordelia. Thank you so much for this very interesting discussion. I've learned a lot from you this afternoon, and I'm sure our listeners have as well, so thank you so much for your time and your contribution. Thanks, eliane.
Speaker 2:I'm always eager to talk about women's health.
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