Pelvic pain, not pelvic floor pain

Let's start off with a message of b'sha'a tova to Will & Kate (a.k.a the Duke and Duchess of Cambridge) - and all other expectant mothers out there. I'm reliably informed Kate is a regular reader of these blogs, but in case she misses this one, I have no doubt she's getting this advice from her own physiotherapist (By Royal Appointment).

I will address pelvic floor pain sometime in the near future as most of my pelvic floor blogs are more to do with incontinence. However today I am focusing on pelvic pain, the various causes and what is in the realms of normal-no-need-to-worry pain. 

Pregnancy is a very exciting time in one's life but it can also come with lots of fear and worry. The fear and worry is normal, as long as it's all about ensuring that this new life is safe and healthy and has everything it needs for the best start in there life.

As mentioned in previous blogs, two common causes of pelvic pain are relaxed joints and pressure from the weight of your growing baby. If the pain is constant or there is bleeding, unusual discharge, or strong cramping, it is time to see your doctor rather than visiting your physiotherapist.

With that in mind, it is very common to experience cramp-like pain that feels like your period is coming between weeks 8-12; this is your uterus expanding and as long as there is no bleeding this is within the normal realms of pregnancy.

Functional ovarian cysts, which form due to changes in the way your ovaries make or release eggs are also very common and and normally harmless. They can grow larger during pregnancy and the pressure that your growing uterus puts on your ovaries can cause persistent pain. If the cyst ruptures, the pain may suddenly get worse. It is therefore important to tell your doctor if you have a history of ovarian cysts so he can keep an eye on them or any potential growing ones. On very rare occasions a cyst can twist. This is called torsion, it is serious and needs immediate attention. It sometimes occurs after vigorous activity or having intercourse and is followed by very sharp pain, severe and constant and sometimes nausea, vomiting and sweating. 

As mentioned in a more recent post another common pain is round ligament pain. It is common to the second trimester and the pain is felt from your side, as the ligament that goes from the top of the uterus down to the groin stretches. It is felt more when walking or standing up from a chair. The uterus tilts and pulls on the ligament. Lying on the painful side can often help with this

Especially is the third trimester one can experience pain from the pressure on the baby in your pelvic region, often during movement when walking or in a moving car, because the baby bounces with your movements. Rest can ease this pain.

Braxton Hicks contractions is the pressure or tightening in the pelvis that comes and goes spontaneously. They are often described as practice contractions, often from week 20 onwards and triggered by dehydration (drink lots of water). If however they continue for more than 4 an hour for 2 hours and you are before week 37 it is good to check that it is not preterm labour and go and get checked out.

Relaxed pelvic joints also cause a lot of pain; this is one for the physiotherapist. Caused by the hormone relaxin which relaxes your joints a ligaments, it is common to feel pain over the pubic bone, and down your legs. There are many previous blogs on this.

Constipation is another common complaint and can cause pelvic pain; drink lots of water and eat fibre rich food. It is also important to assume a good position while on the toilet. Ensure your knees are higher than your hips and learn forward. This is the optimum position for the stool to come out with the least obstacles. 

There are many other reasons for pain, some of which are more serious than those mentioned above. For this reason, it is important to get regular check-ups throughout your pregnancy. If you experience any of the below list it is important to go to the doctor immediately

•  
• Pelvic pain that you can't walk or talk through
• Any bleeding
• Fever and/or chills
• Severe headache
• Dizziness
• Sudden swelling of the face, hands, and/or feet
• Persistent nausea and/or vomiting
• Less than 10 fetal kicks in one hour, from 28 weeks until delivery
• More than four contractions in an hour for two hours
• Watery, greenish, or bloody discharge

If you are suffering from pain during your pregnancy and would like to book an appointment, please contact me on 0544485086 or by email to tamaramay.physio@gmail.com. I can arrange to see you privately or through Leumit in Bishvilaych Women's Comprehensive Medical Centre in Givat Shaul, Jerusalem or a home visit if you live in Gush Etzion.

When Massage Could Help Relieve Your Pregnancy Pain

Pregnancy is an exciting time period in one's life. However it can also be an extremely daunting time and high stress levels don't do you any favours. With rockets flying it is good to do everything you can to keep as calm and healthy as possible.

The body undergoes some big changes during pregnancy, including postural changes, change in hormone imbalance, weight gain, enlarged breasts, increased plasma and blood volume and the shifting of some of your organs. As a result of these changes many women suffer from pregnancy aches and pains.

Now some of these pains need addressing by a doctor or physiotherapist as they are beyond the realms of normal but some are completely normal and don't need addressing by a medical professional. So what do I advise to those patients that don't fit into the category of medical help but who are uncomfortable and want to do something about it? Firstly I suggest exercise, which has many benefits; if you are unsure what is safe you can read previous blogs or get in touch with a physiotherapist.

I also suggest pregnancy massage by a qualified professional. This is a safe, drug-free relaxing way to reduce and relieve the common discomforts that one can experience. It can improve not only your own physical and mental well being but also your baby's.

Back pain and sciatica are very common in pregnancy. As the posture of one's body changes during pregnancy so so does the centre of gravity, which in turn effects the musculoskeletal system. As the muscles adapt to the new posture they can compress the sciatic nerve, which in turn causes radiating pain from the lower back down to the leg. Massage loosens those muscles and releases the pressure on the nerve. It can also help increase range of motion and elasticity in the joints and muscles.

As the muscles begin to work harder due to the increased weight gain, there is an increase in the production of toxins that literally stick the individual muscle fibres together, which then aggravates nerve endings and causes pain. Massage releases that pain by breaking down the adhesion, releasing trigger points and pushing circulation into the area to increase oxygen and to stimulate the removal of toxins.

Let's move onto leg cramps. Although the reason is not known there are theories that the extra load on the leg muscles may well be a factor. Low levels of minerals and the lack of blood flow through the muscles during prolonged siting or lying could be a cause. As well as eating bananas, massage can also help by again stimulating blood flow and stretching the muscles

Muscle balance can be caused by the quick postural changes and sudden increase in breast size and are often the main cause of sudden upper back pain. Headaches are often caused by the surge of hormones along with an increase in the blood volume circulating the body. Massage relieves the muscle tension and stretches the shortened muscles in the head, neck and shoulders.

Massage can also reduce stress levels which reduces anxiety, improves mood and can increase sleep, which is very important to do before the baby comes and keeps you up at night.

The weight gain and increase in plasma and blood volume increase pressure on the hip, knee and ankle joints. Swelling is often caused by the decreased circulation and increased pressure on blood vessels. Massage helps stimulate soft tissue to reduce the collection of fluids in swollen joints, which also improves the removal of waste products carried by the lymph system. So massage can help flow of blood to the legs to reduce the chances of swelling, varicose veins and blood clots.

With all that being said it is important to determine whether your aches and pains are within normal range and therefore a massage will help or whether to go to a physiotherapist for a more long term treatment to treat the cause of a problem (with the option of a massage on the side). It is also best to discuss the options first with your doctor and if you still not sure what is the best treatment to call a physiotherapist to determine the most appropriate cause of treatment.

If you are suffering from pain during your pregnancy and would like to book an appointment, please contact me on 0544485086 or by email to tamaramay.physio@gmail.com. I can arrange to see you privately or through Leumit in Bishvilaych Women's Comprehensive Medical Centre in Givat Shaul, Jerusalem or a home visit if you live in Gush Etzion.

Understanding Round Ligament Pain

Round ligament pain is a sharp pain or jabbing feeling often felt in the lower tummy or groin area on either or both sides. This believe it or not is one of the most common complaints during pregnancy and is most common during the 2nd trimester.

There are several thick ligaments (ligaments are what joins two bones together) that surround and support your uterus. One of these ligaments is called the round ligament. This connects the front part of the uterus to the groin (hence that is where the pain is felt).

As your baby grows and your uterus and tummy therefore also grow the round ligament is therefore forced to stretch. If it becomes too stretched it starts to strain. If this happens then sudden movements can cause the ligament to tighten quickly (a bit like an elastic band snapping quickly). This is what causes a sudden and quick jabbing feeling. Ligaments are suppose to tighten and relax slowly when bones bend and straighten.

The symptoms of round ligament pain include a sharp sudden spasm in the belly. More often affecting the right side more than the left. The pain also only lasts a few seconds. Some exercises may cause the pain as well as rapid movements such as sneezing, coughing, laughing, rolling over in bed and standing up too quickly.

How can the pain be relieved?

If you feel it is necessary then you can take over the counter painkillers like paracetamol or acamol. Make sure you are not taking Nurofen (Ibuprofen).

Specific exercise is very good for this. Some exercises are counterproductive to round ligament pain but exercises that keep your stomach and core muscles strong are good. Stretching is also helpful. Often one of the more helpful exercises is putting your hands and knees on the floor, lowering your head and pushing your backside into the air.

Try to avoid sudden movements. Change positions slowly, especially standing up.

Bend and flex your hips before you cough, sneeze or laugh to avoid pulling on the painful ligaments. Heat can also help relieve the pain, but make sure not to put the heat directly over the baby.

Round ligament pain is often quick and not long lasting but you should be aware if anything changes and when to go to the doctor immediately; for instance, severe pain, pain that lasts more than a few minutes, fever, chills and pain on urination and if you are having difficulty while walking.

Stomach pain during pregnancy could have one of many different possible causes and it is important for your doctor to rule out serious conditions such as inguinal hernia, appendicitis, and stomach, liver and kidney problems. Pre-term labour pains can sometimes also be mistaken for round ligament pain.

Physiotherapy is not your first port of call on this one. The diagnosis should be made by the doctor first so that everything else can also be checked. Upon diagnosis and only after that is physiotherapy then appropriate to advise on correct exercises.

If you are suffering from round ligament pain and would like to book an appointment, please contact me on 0544485086 or by email to tamaramay.physio@gmail.com. I can arrange to see you privately or through Leumit in Bishvilaych Women's Comprehensive Medical Centre in Givat Shaul, Jerusalem or a home visit if you live in Gush Etzion.

Taking your Pelvic Floor to the Next Level

As mentioned on previous blogs the pelvic floor muscles help support your bladder bowel and uterus, which is why they are the muscles we strengthen and exercise when having incontinence problems. The pelvic floor muscle also help to make up the core muscles of one's body. They are the foundations that help stabilise the pelvis, along with the deep muscles of the back and abdomen. This is why with prolapse one can experience back pain or abdomen pain. This is also the reason to integrate core stability exercises into your daily work out routine as well as your specific pelvic floor contraction exercises.

A good exercise to start with is lying down on your back with your knees bent in a sit up position (do not do sit- ups) and raise your bottom off the floor and hold for 2-3 seconds before lowering (not flopping) back to the ground.

When you have mastered that exercise it is time to start progressing your exercises. Only start progressing your exercises when you are ready. It is much better to do fewer exercises correctly and exercise the muscles you intend than to exercise lots and wobble all over the place because you are incorporating all other muscle groups that are not suppose to be working in order to perform the activity.

The next good exercise to do is still in the the sit up position, one leg at a time move forward 10 cm and bring back to starting position.

When you can do this easily raise one leg in the air so the hip is at 90 degrees and straighten the leg in the air and lower to the floor slowly, then switch legs and do the same.

Then move onto both hips at 90 degrees, lowering 1 leg to the floor and then switching.

The both hips at 90 degrees again and 1 at a time straightening the knee while lowering to the ground.

When you can do all these exercises without wobbling around while lying on your back still keeping both your legs straight raise and lower in a controlled manner.

If you are suffering from pelvic floor problems and would like to book an appointment, please contact me on 0544485086 or by email to tamaramay.physio@gmail.com. I can arrange to see you privately or through Leumit in Bishvilaych Women's Comprehensive Medical Centre in Givat Shaul, Jerusalem or a home visit if you live in Gush Etzion.

Pelvic floor tips

I have written many blogs about the importance of doing pelvic floor exercises but now here are some tips to help you do them every day. Pelvic floor muscles are functional, which means they need to get used with other muscles. Now it is true that often in sessions I get patients to isolate the muscles but it is important to do the exercise when lifting something heavy and incorporate the exercise in all heavy lifting activities.

Now it has to be said but breathing is very important. When holding your breathe during exertion means bearing down on your pelvic floor. So it is very important to breath through all exercise.

When exercising it is important to remember that high impact exercise can weaken the pelvic floor so if you are having problems choose a sport with little impact such as cycling and avoid things like your star jumps and wide leg stances. If the muscles are overstretched during exercise it is harder to contract properly.

Now just as important as it is to get a good strong contraction during exercise to the pelvic floor so it is it to be able to relax properly. That means in between each exercise make sure you are fully relaxed before continuing your exercise routine.  

When trying to get you pre-pregnancy body shape back the term core is often thrown around. Core exercises are really important and will help get your body back into shape. However what is often forgotten is that correct pelvic floor exercise can also strengthen core muscles too, so incorporate them into you regular exercise regime.

Often when leaking one starts to cut back on the water that they drink. Especially in this hot weather I do not advise this. Lots of water and fibre are important in maintaining a healthy pelvic floor. Straining and constipation only weakens the pelvic floor (remember the pelvic floor holds up your bowels as well as bladder and uterus). A healthy diet of lots of fresh fruit and veg with lots of water is great for the pelvic floor as well as the benefits it gives the rest of your body.

If you are suffering from pelvic floor problems and would like to book an appointment, please contact me on 0544485086 or by email to tamaramay.physio@gmail.com. I can arrange to see you privately or through Leumit in Bishvilaych Women's Comprehensive Medical Centre in Givat Shaul, Jerusalem or a home visit if you live in Gush Etzion.

When Not To Exercise

In many of my previous blogs I have written about the importance of exercise. Specific exercise can help alleviate many of the common pregnancy aches and pain. However it is also important to be aware of when exercise is not going to be helpful and in some cases detrimental.

If there is ever vaginal bleeding one must stop exercising and go straight to the doctor, do not pass go and do not collect 200 [insert preferred currency]. There could be many reasons for the bleeding, some more serious than others, but either way it always needs to be checked out.

If you have dyspnoea before exertion, dizziness, headaches, chest pain or muscle weakness these are all more reasons to go to the doctor straight away. Do not wait for your next appointment but rather go straight away.

If you have calf pain (back of the leg) or swelling then it is best to rule out thrombophlebitis. This again is something that should not wait till the next appointment.

The more familiar reasons to take your self straight off to the doctor are preterm labour, decreased fetal movements and amniotic fluid leakage.

Treatment is often much more useful when started sooner rather than later, therefore do not push off going to the doctor, even if you think it is not serious. Doctors expect patients to come in with these symptoms and it is their job so they will not look down on you for going.

Pregnant women with uncomplicated pregnancies should be highly encouraged to continue and even start (gently) with exercise. There are many benefits to exercise, but just as important as it is to exercise, so too are the signs of when not to exercise and when to take your self off to the doctor.

If you are suffering from any pain and would like to book an appointment, please contact me on 0544485086 or by email to tamaramay.physio@gmail.com. I can arrange to see you privately or through Leumit in Bishvilaych Women's Comprehensive Medical Centre in Givat Shaul, Jerusalem or a home visit if you live in Gush Etzion.

Aerobic Exercise During Preganancy

As well as exercises to strengthen specific areas of the body, raising your heartbeat and working up a sweat is also very important during pregnancy and highly recommended. It will help strengthen your heart and lungs as well as maintain muscle tone. Now most sports are suitable if you are pregnant (for those of you that were already doing a sport), but what about the couch potatoes? I do not advise couch potatoes to start training for a marathon while pregnant but on the other hand I would not advise to continue being a couch potato all through your pregnancy, as long as there are no complications and you have not been advised to be on bed rest. I am therefore going to mention each sport specifically, as to what the correct advice should be, as it is important to pick a sport that you enjoy. 

Dance routines and aerobic exercise is safe to continue as normal if you are experienced, although you may want to tone down the intensity level and make sure you do not exert yourself to the point of exhaustion, which could deprive your body of oxygen. However if you are a beginner I would advise low impact dance or aerobics, or even water aerobics. 

Swimming and exercise in water is great. In water you weigh just a tenth of what you are out of the water. It is gentle on your joints but also allows you to boost your strength and flexibility. 

Gym machines such as step, rowing and treadmills are also great to use during pregnancy, including beginners. You can adjust speed, inclines and tensions to a level of comfort for you starting slowly if you are a beginner. Make sure you stretch beforehand and take it slowly. During the 3rd trimester it is best to avoid jumping and fast running and be very careful to avoid falling over.

Jogging for the experienced runner is also fine and during pregnancy you can stick to it but you may want to consider limiting your distances and sticking to a more level terrain (or use a treadmill). If you were not a runner before pregnancy I would suggest you stick to walking for now. Bear in mind that loose ligaments and joints during pregnancy can make running harder on the knees and also make you more prone to injury, so make sure you do not over do it. 

Kick boxing during pregnancy, now it takes a great deal of grace and speed, 2 things that are reduced during pregnancy. You may find you are not able to kick as high or move as quickly but if you are still comfortable getting exercise from kickboxing and you are not a novice it is fine to continue. Be careful to avoid movements that you have difficulty in doing or that cause you to strain, and remember not to over do it. 

Outdoor sports such as cycling, skating, hiking and skiing are not to be taken up as your new sport especially as they test your balance but again if you are experienced (except skiing) in this area and are comfortable to continue it is fine. However high altitudes, slippery conditions (skiing) and rock climbing are not advisable. Be careful about safety; don't cycle in wet conditions, or windy and rocky paths and always wear a helmet. With skating as you get bigger your balance will become more challenging and then it is time to hang to your skates up for a while. Skiing is too dangerous as there is high risk of serious injuries, even if you are in the Olympics. 

Last but definitely not least I will mention walking, which is great for everyone anywhere and everywhere. Start slow and build up to a brisk walk.

With all this exercise don't forget to drink, drink and drink some more, especially in the hot weather. 

If you are suffering from any pain and would like to book an appointment, please contact me on 0544485086 or by email to tamaramay.physio@gmail.com. I can arrange to see you privately or through Leumit in Bishvilaych Women's Comprehensive Medical Centre in Givat Shaul, Jerusalem or a home visit if you live in Gush Etzion.