A woman’s life is typically marked by several unique life stages such as, menarche, pregnancy, childbirth and menopause. These stages are exclusive to women, and as such can provide specific challenges to a woman’s quality of life. One area of the body commonly impacted by these life stages, and the changes that come with them, is the pelvic floor. A group of small, but very important muscles, found at the base of the pelvis, the pelvic floor has a huge role to play throughout a woman’s life and is often overlooked. Pelvic floor dysfunction has been found to impact at least 25% of women at some stage of their life before they turn 80, and even doubles after this.
Pelvic floor dysfunction encompasses any symptom or sign that the activity or functioning of these muscles may be less than ideal. The pelvic floor muscles form a muscular “sling” at the base of our pelvis and work to support and hold in our pelvic organs, provide bladder and bowel continence (ability to control movements), are involved in healthy sexual function and childbirth. It is easy to see how, in any disorder or disease relating to the pelvis or it’s associated organs, normal healthy functioning of the pelvic floor can be easily compromised.
Common issues that may cause someone concern about how their pelvic floor is functioning can include:
- Bladder disorders such as involuntary leakage of urine (stress or urge incontinence) and even overactive bladder syndrome (dysfunction of bladder filling and emptying)
- Bowel disorders such as involuntary leakage of faeces (poo) or flatus (wind), termed faecal incontinence, and even concerns with stool type such as, chronic constipation or diarrhoea
- Loss of support of pelvic organs (pelvic organ prolapse)
- Pelvic pain disorders and sexual dysfunction
- Pregnancy and childbirth specific issues or injuries
Issues associated with pelvic floor dysfunction can be highly sensitive, often thought of as “taboo”, and difficult for the individual experiencing them to discuss. These conditions can be complex and there is often a broad range of overlapping medical issues associated with pelvic floor dysfunction, requiring medical assessment and management with a multidisciplinary team. In all this complexity, the role of the pelvic floor muscles can be forgotten, despite the strong evidence that exists to support pelvic floor physiotherapy in the management of a lot of these conditions.
A women’s pelvic health trained physiotherapist is key in the multi-disciplinary management of someone with pelvic floor concerns. They are specially trained to help women manage pelvic floor dysfunction across the lifespan, with strong evidence supporting their involvement in management of all pelvic floor conditions. A women’s health physiotherapist will perform a highly individualised assessment and can work with you to help manage your pelvic floor concerns in a variety of ways, such as:
- Postural, ergonomic and biomechanical modifications related to symptom onset or aggravation
- Management of associated or contributing musculoskeletal conditions
- Prescription of appropriate pelvic floor exercises, stretches or even relaxation
- Help with healthy bladder and bowel habits, in order to avoid conditions such as chronic constipation which is known to aggravate pelvic floor dysfunction
- Pain management techniques and treatments for chronic pelvic pain conditions and to help support normal, healthy sexual function
- Prescription of supportive devices such as pessaries for pelvic organ prolapse (where appropriate)
- Lifestyle advice to support pelvic health such as general exercise prescription and weight management
- Pregnancy management, pain relief options and positioning for labour and childbirth, postnatal assessment and treatment and longer-term guidance for safe return to exercise
If you have any concerns regarding your pelvic floor health, or have been advised to see a physiotherapist for your symptoms, please reach out to your local clinic to see how one of our Women’s Health Physiotherapists could help you today.
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Kahyaoglu, S.H. and Balkani, K.P. (2016). Effect of pelvic floor muscle exercise on pelvic floor muscle activity during pregnancy and the postpartum period. Neurology and Urodynamics. 35 (3), 417-422.
Kenne, K.A., Wendt, L. & Brooks Jackson, J. (2022). Prevalence of pelvic floor disorders in adult women being seen in a primary care setting and associated risk factors. Scientific Reports. 12, 9878.
Sung, V. W. & Hampton, B. S. (2009). Epidemiology of pelvic floor dysfunction. Obstetrics & Gynaecology Clinics. 36 (3), 421 – 443.
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Shockwave is not a new treatment modality; it has been around since the 1980s where it was initially used to treat kidney stones. Its use in lower limb injuries, is more recent (since the 1990s) where there are several conditions where it has been used effectively and, in some instances, is a legitimate alternative to injections and even surgery.1 A shockwave is a form of an acoustic wave that carries energy and can propagate through tissues causing a biological response.
When referring to this treatment modality, shockwave is more of an abbreviation with the correct term being extracorporeal shockwave therapy. There are a few different types of shockwave therapy that can be used to treat musculoskeletal conditions. The most common for lower limb injuries is extracorporeal radial shockwave therapy; less common is extracorporeal focused shockwave therapy.
The most common musculoskeletal conditions for which shockwave therapy is used are lower limb injuries, particularly plantar fasciitis and Achilles tendinopathy. These conditions are typically treated once per week and the average treatment length is about five sessions but can vary between two and eight sessions. When performed correctly, for the right person and in conjunction with good advice and appropriate exercise or load modification, shockwave therapy has a success rate as high as 90%2 - this is without the need for injections, surgery and consequently no down time.3,4
Other conditions that may be treated with radial shockwave therapy include tendon tenosynovitis, tibialis posterior tendinopathy, muscular trigger points, patella and quadriceps tendinopathy osteoarthritis of the knee/s, gluteal medius tendinopathy or greater trochanter pain syndrome (which includes hip bursitis as part of that syndrome) and medial tibial stress syndrome (shin splints).
How shockwave works
Different mechanisms of action of radial shockwave have been proposed over the years. The production of cavitation bubbles within the tissue is one of the physical mechanisms that has been shown to occur in the tissue5 and may be in impetus to a number of biological processes in the tissue. In terms of the biological process, there have been multiple mechanisms identified including down-regulation of substance P released by C nerve fibres6 which assists with the down regulation of pain. This reduction in substance P would also reduce neurogenic inflammation7 which again will assist with pain relief. Apart from pain relief, shockwave can also induce protein biosynthesis, cell proliferation, neuro and chondroprotection, and destruction of calcium deposits in musculoskeletal structures.8 More recently, shockwave has been shown to increase lubricin expression/production.9 Increased lubricin expression may contribute to pain and symptom relief in musculoskeletal disorders by decreasing erosive wear on tendons and septa.
Muscle injuries in sports do result in player lay-off times and can have an impact on individual and team performance. Extracorporeal shockwave therapy has been used in premier league soccer for a number of years, but the data to date has not been shared outside the clubs. Morgan10 compared injury data by Ekstrand11 and showed that the use of shockwave significantly reduced the mean lay-off times in professional soccer players (reduced by 58% for type 1a injuries, 55% for 2b injuries, and by 21% for 3a injuries). The results suggest that use of shockwave therapy in acute muscular injuries has significant benefits with respect to healing times and returning back to pre-injury status.
New emerging areas in shockwave therapy
There are other emerging areas of shockwave therapy in musculoskeletal therapy. These include treatment of spasticity via induction of transient dysfunction of the nerve condition at the neuromuscular junction12 (similar action to Botox) so watch this space!
Overall, radial shockwave therapy is a proven safe technology and treatment modalities, with very little side effects and no down time (compared with surgery). Shockwave therapy has substantial scientific evidence substantiating its use with these musculoskeletal conditions. If you are unsure if shockwave therapy is right for you, please discuss this with a health professional in a clinic that specialised in the modality. They will be the most equipped to navigating you in deciding if it is the right modality for your condition.
Physiotherapist, Exercise Physiologist, Internationally accredited shockwave therapist, SCDA trainer
B.Sc(Nutrition & Food Science), Grad.Dip.Sci(Exercise Rehabilitation), B.Sc(Physiotherapy)
1 Wuerfel T, Schmitz C, Jokinen LLJ. The Effects of the Exposure of Musculoskeletal Tissue to Extracorporeal Shock Waves. Biomedicines. 2022, 10(5):1084.
2 Wang CJ, Ko JY, Chan YS, Weng LH, Hsu SL. Extracorporeal shockwave for chronic patellar tendinopathy. Am J Sports Med. 2007, 35(6):972-8.
3 Li H, Lv H, Lin T. Comparison of efficacy of eight treatments for plantar fasciitis: A network meta-analysis. J Cell Physiol. 2018, 234(1):860-870.
4 Othman AM, Ragab EM. Endoscopic plantar fasciotomy versus extracorporeal shock wave therapy for treatment of chronic plantar fasciitis. Arch Orthop Trauma Surg. 2010, 130(11):1343-7.
5 Csaszar, Nikolaus & Angstman, Nicholas & Milz, Stefan & Sprecher, Christoph & Kobel, Philippe & Farhat, Mohamed & Furia, John & Schmitz, Christoph. (2015). Radial Shock Wave Devices Generate Cavitation. PloS one. 10.
6 Andersson G, Backman LJ, Scott A, Lorentzon R, Forsgren S, Danielson P. Substance P accelerates hypercellularity and angiogenesis in tendon tissue and enhances paratendinitis in response to Achilles tendon overuse in a tendinopathy model. Br J Sports Med. 2011, 45(13):1017-22.
7 Richardson JD, Vasko MR. Cellular mechanisms of neurogenic inflammation. J Pharmacol Exp Ther. 2002, 302(3):839-45.
8 Simplicio CL, Purita J, Murrell W, Santos GS, Dos Santos RG, Lana JFSD. Extracorporeal shock wave therapy mechanisms in musculoskeletal regenerative medicine. J Clin Orthop Trauma. 2020, 11(Suppl 3):S309-S318.
9 Zhang, D., Kearney, C. J., Cheriyan, T., Schmid, T. M., & Spector, M. Extracorporeal shockwave-induced expression of lubricin in tendons and septa. Cell and Tissue Research. 2011, 346(2), 255
10 Morgan, J.P.M., Hamm, M., Schmitz, C. et al. Return to play after treating acute muscle injuries in elite football players with radial extracorporeal shock wave therapy. J Orthop Surg Res, 2021, 16, 708.
11 Ekstrand J, Hägglund M, Waldén M. Epidemiology of muscle injuries in professional football (soccer). Am J Sports Med. 2011, 39(6):1226–32.
12 Vidal X, Martí-Fàbregas J, Canet O, Roqué M, Morral A, Tur M, Schmitz C, Sitjà-Rabert M. Efficacy of radial extracorporeal shock wave therapy compared with botulinum toxin type A injection in treatment of lower extremity spasticity in subjects with cerebral palsy: A randomized, controlled, cross-over study. J Rehabil Med. 2020, 30;52(6):jrm00076.