Comedy Continence and Collaboration

This week we are delighted to publish a blog from Elaine Miller aka Gusset Grippers or should that be Gusset Grippers aka Elaine Miller? Either way please follow on Twitter here

 I’m a physiotherapist specialising in pelvic health. This means I spend most clinic days elbow deep in leaky ladies. It’s a great job, I absolutely love my work, and at the risk of sounding like a cliche, I really want to help people – and conservative measures to manage or resolve incontinence can transform
lives.

WHO DO YOU SEE?

The people in our clinic have these issues:

– chronic Pelvic Pain
– pregnancy related leaking
– pregnancy related pelvic girdle pain
– rectus diastasis
– vaginal prolapse
– male and female sexual dysfunctions
– stress incontinence
– urgency of bowel and bladder
– frequency of bowel and bladder

It takes an average of 7 years for someone who leaks urine to seek help. During that time their presentation often becomes more complex – it seems stress incontinence is a gateway disorder, it is common in younger women but older women present with mixed incontinence.

WHAT DO YOU DO?
Anything you do with a neck or a knee you can do with a pelvic floor – if the muscles are a bit weak, strengthen it, they are a bit tight, relax it, if there’s tight knots in the muscle poke them. I could dress that up in sciencey bits, but, in essence, my skills are:

– muscle strengthening
– muscle down-training
– postural correction
– breath work
– bladder retraining
– manual therapy
– electrotherapy
– return to exercise
– bladder and bowel retraining
– desensitisation
– hand holding and education

That’s what we do with the women who come to clinic.

However, we know that women don’t always recognise the problem – they think it’s normal, or not too bad. Women are used to dealing with mess and pads and can easily pick up products to manage their symptoms when they are getting bread and milk. Products which are advertised on prime time tv telling them that a pad is the answer.

Many women are also very busy – and it’s a challenge to get them into clinic and then to get them to comply with exercise regimes and lifestyle adaptations.

ARE YOU BUSY?

Yeah. There is plenty of work. About 1:3 women wet themselves, which is a shocking figure. It’s incredibly difficult to get an accurate figure from the research though.

Have a think about this…

Of the estimated 1:3 women in the world who leak an estimated 25% seek help.

So, this woman who seeks help… represents every single woman that has had treatment, is on a waiting list and who has participated in research.

But I am interested in the rest of them.

The other thing to note about the group of women who seek help, is that they are overly represented by urban, white middle class women, and as most of the research is conducted on participants recruited via clinic, the research is focused on urban, white and middle class women. They are, of course, deserving of help and treatment, but, it means that we know very little about women in geographically remote, culturally diverse and economically deprived areas. We know LOTS about these women, but, again…I’m kind of interested in the rest of them.

So, this figure of 1:3? All these pink women? I think that figure is far too low – leaking is so common that many of us think it is normal. Incontinence has not been a public health priority because it is not going to kill you. The secondary effects, however, are massive.

The most significant of these is that leaking is a barrier to exercise. 1:6 premature deaths now associated with diseases of inactivity – more than smoking. so, how much does this cost? If there are stats, I can’t find them.

There’s figures for the cost of pads, but, not the burden of disease figures. Madeleine Moon, a labour MP in Bridgend, held a debate about incontinence last September. She said:

With an ageing population, this is serious. Incontinence is under recognised, under researched, under resourced and an unknown drain on the public purse.

The Australian government commissioned their own study to look at the total costs of incontinence – including all the secondary effects – and came up with a figure of $43billion pa.

I’m no economist, but, as the two countries have similar societies and health profiles, it suggests to me that the financial burden incontinence poses to the UK is probably enormous.

So, what are we supposed to be doing with patients?

Kari Bo’s work found that about 30% of women bear down instead of pulling up when doing a pelvic floor contraction. Therefore, the recommendations state that we should do an internal examination to make sure the woman is contracting properly.

That’s fine for the one consenting woman who has come into my clinic – but there’s 10 million leaky ladies out there…

We need to find a way to educate women about what they can reasonably expect from their genitals, encourage self management and clinic if that doesn’t work.

We HAVE to be able to reach these women in the community and educate them where they are going for help – which is pilates, yoga and online forums.

This is what Pelvic Roar is for – physio lead collaboration in pelvic health campaigning.

We want to provide evidence based information for professionals, patients, industry, campaigners and charities – anywhere where women are going so they can signpost them to clinicians and raise awareness about continence in general so that people know that help is available.

These problems are very embarrassing and that prevents people from seeking help. I wondered whether humour could be a way of tackling the taboos which surround these issues – so I wrote a comedy show about pelvic floors.

Gusset Grippers is evidence based – so, it counts as CPD, which is possibly the funniest thing about it. The audience leave knowing what their pelvic floor is, what it does and how to look after theirs.

This summer at the Edinburgh Fringe is was given 5* and had a sell out run – I’d like to think that’s because I’m hilarious, but, it’s really because women are desperate for this information.

Anecdotally, it seems to work. If you make a socially cohesive group of people laugh about something then they will talk. That means they share experiences and encourage each other to seek help.

The plan this year is to take the show to the areas we are lacking data – geographically remote, culturally diverse and economically disadvantaged places – and follow up 6 months later to see if they were prompted to see their GP.

So what about practical stuff for you to teach your patients – and for you too?

The difficult thing is teaching people how to engage their pelvic floor correctly – i.e. without holding their breath and without using their glutes or quads. The one that works the best is “imagine you need to hold in a fart”. We know that you get good pelvic floor engagement if you think about your back passage.

Take a deep breath in, sigh out, and #squeezeandlift your bumhole. Keep breathing and hold it for a count of 10 seconds. Then do10 quick flicks in a row, and do both of those three times a day.

You have to do them a LOT to make the difference – three times a day for three months until patients are dry, and then once a day, every day until they die. Make a habit of doing them, have a look at the squeezy app is really good and if you’re on twitter follow me @gussiegrips “when I tweet you twitch your twinkle”

Static kegels are only a small part of what your pelvic floor should be doing, they are a good start. So, if they don’t work, or, doing them is painful (eg if there’s a hypertonic pelvic floor) then get a referral to physio. The thing we underestimate in health care is the impact that leaking has on a person’s wellbeing. There was a study done which asked terminally ill people what their “line” was i.e. at which point did they anticipate that life would not be worth living. It was a small study, only 180 patients with serious illnesses. They did structured interviews and nearly 70% of the respondents considered bowel
and bladder incontinence to be a worse prospect than any other health state. It was more awful to contemplate incontinence than being ventilated, tube fed or in pain.

There is something visceral about our need to be clean and dry. This stuff really matters and it’s easy to lose sight of mild to moderate incontinence when dealing with people with complex needs – but, the impact that fixing this can have on a person’s wellbeing is massive and is cheap to deliver.

So, go on, do your pelvic floor exercises.

Gusset Grippers web site can be found here

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