Journal of The ACP in Womens Health

Journal of the Association of Chartered Physiotherapists in Womens Health
Editor: Ros Thomas (ros.thomas@virgin.net) Production editor: Andrew J. Wilson (ajwpublishing@gmail.com) News editor: Helen Forth (helsandjohn@theforths.net) Websites editor: Jenny Kinahan (Jkin64@aol.com) Papers in other journals editor: Becky Aston (becks@wjsa.freeserve.co.uk) Committee member: Gill Brook (gill.brook@lineone.net) Committee member: Kathleen Vits (kmppvits@aol.com)
Contents
Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Postnatal maternal mental health: an update on depression and post-traumatic stress disorder following birth by D. Bick & C. Rowan 4 Motivational interviewing and health behaviour change: an overview and their relevance to womens health by C. A. Lane . . . 14 Quote me happy: can acupuncture make those hormones happy? by J. Longbottom . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 The perils of the perimenopause: contraceptive and hormonal needs in the perimenopause by A. E. Evans . . . . . . . . . . . . . . . . . 27 Multi-convergent therapy in the treatment of medically unexplained symptoms: a brief journey in time by M. Sadlier . . . . . . . . 33 Bladders behaving badly: a randomized controlled trial of group versus individual interventions in the management of female urinary incontinence by L. A. Hill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Mammographic breast screening (Dr Kate Gower Thomas) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Presentation reections: Margie Polden Memorial Lecture: A midwifes perspective (Rachel Kerr) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 GUM clinic: what to look for (Gill Brook) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Hormonal treatment of severe premenstrual syndrome (Clair Jones) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Management of inherited bleeding disorders in pregnancy (Peter Collins) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Assessing outcomes of urinary incontinence treatment using the International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form by C. Jouanny . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Executive committee response to Conference discussion groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Conference and course reports: Research Ocers Study Day (Yvonne Coldron) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 The WellBeing of Women (WoW) Show The Womens Health Show Thats Serious Fun (Paula Igualada-Martinez) . . . . . . 53 Pushy Mothers (Helen Forth) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Cognitive Behavioural Therapy in the Physical Health Setting (Geraldine Buckley) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 ACPWH Conference (Carole Broad, Michelle Gormley & Hannah Gray) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Master Class in Advanced Urogynaecology (Riette Vosloo) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 An Introduction to Pilates in Womens Health Physiotherapy (Ann Dennis) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 The Unique Role of the Womens Health Physiotherapist in Antenatal Classes (Jane S. Brazendale) . . . . . . . . . . . . . . . . . . . 61 A Functional Approach to Assessment and Treatment of the Pelvic Girdle in Pregnancy and Postpartum (Paula Riseborough) . 62 Physiotherapy for Pregnancy Related Pelvic Girdle Pain (Alison Crocker) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 From your executive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Round the regions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Area representatives 20062007 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 PhD thesis reports: Multiple sclerosis and lower urinary tract dysfunction (Doreen McLurg) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Characteristics of abdominal and paraspinal muscles in postpartum women (Yvonne Coldron) . . . . . . . . . . . . . . . . . . . . . . . . 78 Visit to the UK (Elisabeth Pulker) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Book and DVD reviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Website watch (Jenny Kinahan) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Notes and news . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Letter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Papers in other journals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Reading list . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Writing for ACPWH Journal: guidelines for authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Price list of publications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . back cover The opinions expressed in these papers are those of the authors and not necessarily those of the editors and publishers.
2007 Association of Chartered Physiotherapists in Womens Health
Journal of the Association of Chartered Physiotherapists in Womens Health, Spring 2007, 100, 23
Editorial
Welcome to the hundredth edition of our journal! I wish to thank Gill Brook, my predecessor, for the fantastic job she has done over the past 3 years in developing our Journal into the very professional and expansive tome that it has become. She has, of course, been well supported by the expert advice and experience of Andrew Wilson, our production editor, and the Journal subcommittee. I wish her every success in her retirement, but Im delighted that shes not disappearing completely and remaining on the Journal subcommittee to help me into my new role. Im very grateful for this because Im negotiating a very steep learning curve, but I hope I can rise to the challenges that are bound to confront me. The rst one was thrust upon me immediately since this is our hundredth edition. The Journal subcommittee decided to mark the anniversary by reproducing some of the earliest newsletters. Both Andrew Wilson and I had fun looking at the early newsletters now stored for us in Edinburgh by Fitwise Management Ltd. Sadly, reproduction was not possible, so I have instead extracted some very early references to the birth of the idea of an Association newsletter from the minutes taken from executive committee meetings from 1949 onwards. These form our cover montage.
To further commemorate the hundredth edition, we present a list (Table 1) of all past editors of the Journal of the Association of Chartered Physiotherapists in Womens Helath (formerly the Newsletter of the Obstetric Association of Chartered Physiotherapists and then the Association of Chartered Physiotherapists in Obstetrics and Gynaecology, and the Journal of the Association of Chartered Physiotherapists in Obstetrics and Gynaecology). When sitting down to write this, my rst editorial since taking over in October, I decided to look back to Gills rst editorial (Spring 2004), only to nd that she had asked Jill Mantle to contribute instead. Jill used the opportunity as a timely reminder to us of the importance of research in womens health, and of our important and continuing role in obstetrics points that are just as relevant today. The main reason that Jill Mantle was asked to contribute was that Gill had just retried as chairman, and therefore, considered that the issue already featured her quite heavily. I seem to be following in Gills footsteps, but I didnt have the foresight to ask someone else to contribute, so Im afraid you will have to put up with me both in the editorial and in some of the inside pages as well but at least I shall have the authority in future to monitor which photographs are used and which are not!
Table 1. Former Journal editors Editor Anonymous* Mrs Margaret Williams Miss J. Common Mrs D. Mandelstam Mrs P. Boughton Mrs Margaret Williams Mrs J. W. Cox Mrs Anne Bird Mrs Ruth Davidge Mrs Christine Campbell & Anne Kite Mrs Christine Campbell & Mrs Georgina Evans Georgina Evans & Deborah Fry Deborah Fry Pauline Walsh Daphne Sidney Mary Bray Gill Brook *Probably a team eort. Numbers 17 814 1519 2026 2728 2939 4048 4959 6061 6267 6869 7074 7578 7985 8687 8893 9499 Dates 19481958 March 1958January 1962 January 1962December 1964 December 1964March 1969 March 1969October 1970 October 1970July 1976 July 1976Winter 1981 Winter 1981July 1986 July 1986July 1987 July 1987Summer 1990 Summer 1990Summer 1991 Summer 1991February 1994 February 1994February 1996 February 1996February 2000 February 2000Spring 2001 Spring 2001Autumn 2003 Autumn 2003Autumn 2006
Editorial
At Conference in Cardi, which was the last opportunity for me to wear the chains of oce before handing them over, Jill told me she never had a photo of herself wearing them when she was chairman, so one of my rst actions as Journal editor is to rectify that (see p. 58). The Journal subcommittee met at the end of November 2006. The more observant amongst you will notice a number of minor changes in the Journal, some of them reecting the increasing involvement which Fitwise Management Ltd has with ACPWH. Our new chairman, Pauline Walsh, will be bringing you up to date more fully in the Autumn 2007 issue, when the handover to Fitwise is complete. In the meantime, I would lke to draw your attention to the contact details (see the inside front and back covers) for the team in the key areas of nance (expenses and subscriptions), the membership database, and the distribution of small quantities of the books and leaets.
One of the next challenges facing us will be producing a commemorative edition for the sixtieth anniversay of our Association in Autumn 2008. We already have a number of interesting ideas. In the meantime, Im planning two new, regular pages in the Journal dedicated to Education and research, and an Honours section highlighting members achievements such as fellowships, distinguished sevice awards and recipients of the Anne Bird Prize. Gill never missed an opportunity to ask you to consider writing for the Journal, or to encourage someone you know or work with to stop hiding their light under a bushel and share their hard work with us all, so neither should I. Or you can just tell me about a course, write me a letter or contribute in any other suitable way Please e-mail me with any comments on the current edition or ideas for the future. Ros Thomas
Cover photograph: Montage of very early references to the idea of an Association newsletter from the minutes taken from executive committee meetings from 1949 onwards.
Copy deadline
Copy (including disks) for the Autumn issue of the Journal (no. 101) must be submitted to the editor by 12 April 2007. Please note that academic and clinical articles must be received well before the deadline since time must be allowed so that they can be informally reviewed. Manuscripts should be printed on one side of A4 paper, double-spaced with a wide margin, and adhere to the authors guidelines found on p. 105. Articles for consideration should be sent to Mrs Ros Thomas, Byway, Chapel Lane, Box, Corsham, Wiltshire SN13 8NU.
ACPWH CONFERENCE 2006
Postnatal maternal mental health: an update on depression and post-traumatic stress disorder following birth
D. Bick & C. Rowan
Centre for Research in Midwifery and Childbirth, Faculty of Health and Human Sciences, Thames Valley University, London, UK
Abstract Maternal morbidity after birth can be widespread and persistent. A number of physical and mental health problems may be experienced, including backache, stress urinary and faecal incontinence, perineal pain, and depression. Up to half of all women who have given birth will experience the postnatal blues, the symptoms of which should be self-limited and transitory. A more severe health problem, depression, is experienced by around 13% of women, and 12% may experience a traumatic response to their birth. There are concerns that the current organization and content of postnatal care fails to identify much of this morbidity. Service evaluations and womens views of care suggest that mental health services for postnatal women are fragmented and uncoordinated, particularly across the care sectors. Current evidence does not support the implementation of a national screening programme for depression or the use of single-session debrieng interventions to prevent psychological trauma. To enhance the care of women with mental health needs, relevant healthcare professionals should be aware of the signs and symptoms of problems after birth, and all women should be oered a chance to talk about their birth and to ask questions about their delivery. Management should be planned and tailored to individual need.
Keywords: debrieng, depression, maternal health, postnatal care, post-traumatic stress disorder.
Introduction Recent research has shown widespread and persistent maternal physical and psychological morbidity after childbirth (Brown & Lumley 2000; MacArthur et al. 2002). In addition to a number of chronic physical health problems, such as backache or perineal pain, postnatal women are also more vulnerable to mental health problems. A variety of physical, psychological and psychiatric problems may be experienced, ranging in severity from transient psychological symptoms (more often termed the postnatal blues) to depression, anxiety, psychosis and post-traumatic stress disorder (PTSD).
Correspondence: Professor Debra Bick, Centre for Research in Midwifery and Childbirth, Faculty of Health and Human Sciences, Thames Valley University, 3238 Uxbridge Road, Ealing, London W5 2BS, UK (e-mail: debra.bick@ tvu.ac.uk).
Although giving birth is viewed as a positive, life-changing event for a woman, for those who experience mental illness after birth, it is an event that can trigger a period of isolation and despair that may impact negatively on their infants emotional and cognitive development, and their relationships with their partner and family (Lovestone & Kumar 1993; Murray & Cooper 1997; Boath et al. 1998). Maternal mental health has been described as a public health priority (Bick 2003), with suicide now accounting for the highest number of maternal deaths in the rst year after birth (Lewis & CEMACH 2004). The present paper describes current research in relation to postnatal mental health illness, with a particular emphasis on depression and PTSD, issues in relation to the prevention of mental health illness after birth and the need to consider revision of maternity service provision.
Postnatal maternal mental health
Health after birth It was previously assumed that most women fully recovered from giving birth within the 68-week postnatal period (Bick & MacArthur 1995). Evidence from large observational studies undertaken in a number of countries has found that this is not the case (MacArthur et al. 1991; Brown & Lumley 1998; Saurel-Cubizolles et al. 2000). For some women, health problems can be severe, persisting for months or even years after they have given birth (MacArthur et al. 1991; Glazener et al. 1995). Commonly experienced physical symptoms include backache, faecal and urinary incontinence, perineal pain, sexual health problems, and fatigue (MacArthur et al. 1991; Glazener et al. 1995). Symptoms may be associated with interventions or events during labour and birth, such as the use of forceps or emergency Caesarean section (Glazener et al. 1995), or personal factors, such as the level of postnatal social support available to a woman (MacArthur et al. 1991). What is clear from the research to date is that few women voluntarily report problems to their healthcare provider, but will give information on their health if they are asked (Bick & MacArthur 1995; Brown & Lumley 1998). However, many will have unmet health needs because the current provision of care focuses on routine observations and examinations, and increasingly early discharge from postnatal services does not allow sucient time to identify and appropriately manage maternal health problems (Bick et al. 2002).
(Chaudron & Pies 2003). Post-traumatic stress disorder is an acute anxiety symptom associated with exposure to an extreme event, such as being involved in combat, a major disaster or road trac accident. Prior to the inclusion of childbirth as a possible stressor in the fourth edition of the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; APA 1994), PTSD was considered to be a reaction to an event outside the range of normal experience (Slade 2006). Depression Depression is one of the few postnatal maternal health problems to have been extensively studied (Gaynes et al. 2005). The wide prevalence of depression referred to above (SIGN 2002) is a result of the range of inclusion criteria used to describe the study population, the timing of assessments in relation to the birth, the length of follow-up and the diagnostic criteria used. Some studies have reported point prevalence, while others have described period prevalence. OHara & Swain (1996) conducted a meta-analysis that showed an average prevalence of depression after birth of 13%, based on data on over 12 000 women from 59 studies, mostly undertaken in developed countries. There has been some debate as to whether depression is more likely to occur following birth, or whether rates are similar to those found in the general population. Depression is reported twice as frequently in women as in men (Ebmeier et al. 2006), although this gender dierence may not persist in later life (NCCMH 2004). A study by Cox et al. (1993) found that the odds of depression in the rst 5 weeks after the birth were three times that of a comparison group of women who had not recently given birth. Gaynes et al. (2005) reported that symptoms of depression after the birth appear to be greatest at 3 months postpartum, although the data included in this Agency for Healthcare Research and Quality review had wide condence intervals and did not allow conclusions to be reached as to whether depression was higher in any month following the birth, or indeed, during any trimester of pregnancy. Women may experience a spectrum of symptoms, and timely referral and appropriate diagnosis are essential to ensure that they receive eective management tailored to their individual needs. Two classication systems to guide the diagnosis of mental health problems are available to clinicians and academics working within 5
Postnatal mental health Women may encounter a number of psychological and mental health problems following childbirth. The symptoms may be experienced for the rst time after giving birth, or represent a recurrence of a previous mental health problem or an ongoing disorder. Observational studies have reported that around half of all women who have undergone childbirth will experience the postnatal blues, symptoms of which should be transitory and self-limiting (Kendall et al. 1981; Stein et al. 1991). Maternal depression, which is a more severe illness, has a reported prevalence of between 4.5% and 28% (SIGN 2002). At the most severe end of the range of mental health problems is psychosis, which aects one or two women in every thousand (SIGN 2002), and may be triggered by the recurrence of previous mental health disorders such as bipolar disorder or schizophrenia
D. Bick & C. Rowan
the eld of perinatal mental health: the DSM-IV (APA 1994) and the tenth edition of the World Health Organization International Classication of Diseases (ICD-10; WHO 1992). The DSM-IV criteria for major depression are that the individual will have experienced one or more episodes of depression lasting for at least 2 weeks, and will report four or more of the following symptoms (APA 1994): too much or too little sleep; appetite or weight disturbance; psychomotor agitation or retardation; loss of energy; feelings of worthlessness or excessive guilt; problems with concentration or indecisiveness; + loss of interest in sex; and + recurrent suicidal thoughts. + + + + + + Minor depression includes one or more episodes of depression lasting for at least 2 weeks with fewer than four of the above symptoms. The ICD-10 (WHO 1992) distinguishes between none, minor, moderate and severe depression, and whilst there is some overlap between the symptoms included within the criteria, there is a lack of consensus as to which is the most appropriate diagnostic criteria to use. Many studies have used DSM-IV criteria, but anecdotal evidence from the UK suggests that clinicians are more likely to use the ICD-10 in practice. The recently published guideline on the management of anxiety from the National Institute for Health and Clinical Excellence (NICE) used the ICD-10 classication (NICE 2004), while the NICE guideline on the management of depression used DSM-IV criteria (NCCMH 2004). The SIGN guideline on depression and puerperal psychosis (SIGN 2002) did not refer to either classication in a section on diagnosis. Around two women in every thousand will be admitted to hospital with a diagnosis of a non-psychotic condition, usually very severe postnatal depression (Oates 2003). Healthcare professionals should also be aware of the fact that a woman may also experience depression in pregnancy (Evans et al. 2001). The systematic review of studies by Gaynes et al. (2005) found that approximately 14% of pregnant women will have a new episode of major or minor depression during pregnancy, a statistic identied using a variety of screening instruments. Considering only major depression, 7.5% of women have a new episode during pregnancy (Gaynes et al. 2005). These estimates are not signicantly 6
dierent from the prevalence of depression reported among women of a similar age in the general population (Cooper et al. 1988; OHara & Swain 1996). Risk factors for the development of depression after birth have been examined in a large number of studies that have investigated potential associations with maternal, obstetric and sociodemographic characteristics, obstetric interventions, parity, marital status, hormonal disorders, previous psychiatric history, and personal relationships (Bick et al. 2002). Because of the range of outcome measures assessed, the timings of the investigations and the instruments used to assess the outcomes, these ndings are not conclusive. Nevertheless, some potential risk factors have been commonly identied. It is apparent that some social factors increase a womans risk of becoming depressed. These include life stresses such as bereavement, unemployment, illness, migration and lack of social support networks (OHara & Swain 1996; Austin & Lumley 2003). Women who have a history of abuse, and those with drug and alcohol problems also have higher rates of mental health problems after giving birth (Brockington 1996; Buist 1996; OHara & Swain 1996). Between 20% and 40% of women with a previous history of postnatal depression are likely to suer a relapse after a subsequent birth (Cooper & Murray 1995). Post-traumatic stress disorder Research on postnatal psychological and psychiatric morbidity has mainly focused on the eects of depression, but there has been increasing recognition that, for a small proportion of women, symptoms of trauma may present after giving birth. Post-traumatic stress disorder is estimated to occur in 16% of women (Creedy et al. 2000; Czarnocka & Slade 2000; Soet et al. 2003; Ayers 2004; White et al. 2006). Traumatic birth is more often associated with specic physical intervention, such as sustaining an episiotomy or severe perineal tear related to an instrumental vaginal delivery, but childbirth can be psychologically traumatic for some women. Beck (2004) described a traumatic event in relation to birth as one that occurred during the labour or birth in which there was actual or threatened serious injury or death to the mother or her infant, or in which the woman giving birth experienced intense fear, helplessness, loss of control and horror. It is important to note that, whilst women may report psychological trauma
or have symptoms of a stress response after birth, not all will go on to experience symptoms that meet the DSM-IV criteria for acute PTSD. According to the DSM-IV, PTSD is classied as an anxiety disorder that encompasses three clusters of symptoms: reliving the event (e.g. suering ashbacks), persistent avoidance of reminders and hyperarousal. Several characteristics have been considered as predictors of PTSD. Robust studies have consistently demonstrated that a high level of obstetric intervention during labour and delivery is associated with a risk of developing psychological trauma symptoms in the postnatal period, particularly if an intervention (administered either routinely or under emergency situations) happens in the context of intense pain (Ryding et al. 1998; Creedy et al. 2000; Soet et al. 2003). Women who have an emergency Caesarean section or instrumental vaginal delivery are more likely to report symptoms of PTSD than those who have a planned Caesarean section or a normal vaginal delivery (Ryding et al. 1998). However, since an apparently normal birth could be traumatic for some women, it is dicult to dene what constitutes traumatic birth based on mode of delivery or the extent of obstetric intervention to which a woman is exposed. Some women may be more vulnerable because of previous trauma or personality factors, and there may be mitigating factors such as lack of social support. Can mental health problems after birth be prevented? Screening There is limited research evidence that primary prevention of symptoms is clinically or cost eective. Based on the ndings of the studies reported above, it is increasingly important that women and healthcare professionals are aware of the signs and symptoms of mental health problems after birth, which may be amenable to treatment (Dennis 2005). One of the most commonly used tools to identify women at risk of depression is the Edinburgh Postnatal Depression Scale (EPDS; Cox et al. 1987), a 10-item self-report scale on which women who have recently given birth are asked to rate how they have felt in the previous 7 days. It has been used internationally as an outcome measure in research studies as well as an intervention in routine clinical practice. A number of translated versions are available that have been tested for validity and reliability (Aonso et al. 2000). A
maximum score of 30 can be achieved, with a score of 1213 considered to identify those women more likely to have depression (Cox et al. 1987). Using this cut-o, the EPDS has been found to have a sensitivity of 6895% and a specicity ranging from 78% to 96% at 6 weeks postpartum when compared to a diagnosis of major depression following a psychiatric interview (Cox et al. 1987; Murray & Carothers 1990). The EPDS has usually been oered to women by their health visitors to complete at approximately 68 weeks after the birth. There are concerns that a single administration of the EPDS after birth will not accurately identify those who are depressed to the extent of requiring treatment (Oates 2003). Guidance on optimal number of times that the scale should be administered is not available. Qualitative data suggests that women who complete the scale on more than one occasion learn how to respond accordingly (Shakespeare et al. 2003; Thurtle 2003), although this was not found to be the case in a large randomized controlled trial (RCT) of a new model of midwifery-led postnatal care (MacArthur et al. 2003). In addition, other factors that may aect the screening outcome should also be considered, including the relationship between the woman and the healthcare professional, the environment in which the woman was asked to complete the tool, and the way in which the healthcare professional administers the tool (Raynor et al. 2003; Shakespeare et al. 2003). Cultural dierences may make it inappropriate for use with women from ethnic minority groups, since depression may be construed as a Western concept of illness (SIGN 2002), and there is a dearth of evidence as to its acceptability amongst dierent ethnic groups. Concern has also been expressed that the scale may actually be measuring two separate entities, i.e. depressive feelings and anxiety (Brouwers et al. 2001), and it has recently been suggested that a revised, eight-item version of the EPDS would provide a more psychometrically robust scale (Pallant et al. 2006). The NICE postnatal care guideline (NICE 2006) has adopted the National Screening Committee (NSC) recommendation, based on a review by Shakespeare (2001), that suggested that the EPDS should not be used as a routine screening tool, but it may serve as a checklist for postnatal mothers when used alongside professional judgment and clinical interview. 7
D. Bick & C. Rowan
Antenatal and postnatal interventions A number of antenatal or postnatal interventions for women deemed to be at risk of depression have been evaluated. In paper based on a full Cochrane Library systematic review, Dennis (2005) assessed the eects of psychosocial and psychological interventions compared with usual antepartum and postpartum care on a womans risk of developing postnatal depression. Fifteen studies were included in the review, providing data on 7967 women. The outcome of the review was that diverse psychosocial or psychological interventions did not signicantly reduce the risk of postnatal depression. The one intervention that did show promise was the new model of midwifery-led extended postnatal care (referred to above), which focused on the identication and management of postnatal physical and psychological health problems. This was associated with a reduction in depression at 4 and 12 months (MacArthur et al. 2003); however, further evaluation of this intervention as part of routine National Health Service (NHS) care is required. A Cochrane Library systematic review was unable to draw clear conclusions about the eectiveness of antidepressants given prophylactically to prevent postnatal depression in those with a previous history of depression or postnatal depression (Howard et al. 2005). Debrieng A number of studies have evaluated the eectiveness of debrieng to prevent mental health problems after birth, including depression and PTSD. The term debrieng describes a structured process that is intended for the primary prevention of acute psychological morbidity as a result of experiencing a traumatic event (Dyregov 1989). Psychological debrieng evolved in the late 1980s as a way of assisting the rst responders to traumatic incidents, notably remen, to talk in a structured way about what had happened. It was proposed that a one-o session of debrieng would help to reduce psychological trauma and prevent PTSD (Mitchell 1983). In the 1990s, debrieng, also known as critical incident stress debrieng, was adopted as a therapeutic response for people who experienced a wide variety of traumatic events. Despite the upsurge of interest in implementing debrieng after trauma, a Cochrane Library systematic review (Rose et al. 2002) found no evidence of the eectiveness of singlesession debrieng for the prevention of PTSD in the general population and some potential for 8
harm. Recent recommendations for the management of PTSD in primary and secondary care are that watchful waiting should be instigated after traumatic events, since most people will recover from trauma experiences with good social support (NCCMH 2005). To date, eight RCTs have compared postnatal psychological outcomes following debrieng or counselling interventions after birth. Two trials found a positive association: in one, a midwifeled counselling intervention was compared with current care (Gamble et al. 2005), while the other described a midwife-led debrieng intervention (Lavender & Walkinshaw 1998). A third RCT reported evidence that the intervention (midwifeled debrieng on the postnatal ward following operative birth) resulted in harm in the shorter term (Small et al. 2000), with no long-term dierences at 46-year follow-up (Small et al. 2006). In the other ve RCTs (Priest et al. 2003; Tam et al. 2003; Ryding et al. 2004; Kershaw et al. 2005; Selkirk et al. 2006), there were no dierences in outcomes. Methodological issues, in addition to the timing of the intervention assessed and study inclusion criteria, may have accounted for dierences in the eectiveness of the outcomes. In UK maternity services, the term postnatal debrieng has been used to describe a variety of post-birth discussions, which are mainly oered by midwives with the intention of providing women with an opportunity to talk about their birth experiences. This sometimes less structured approach to debrieng in the childbirth arena has led to some confusion about the purpose and the eectiveness of such interventions (Alexander 1998). A number of evaluations have been published of this service provision that do show that women who use the service value the opportunity to talk about their birth and the events surrounding to it (Charles & Curtis 1994; Baxter et al. 2003; Dennett 2003). However, none of the studies published to date has included data on clinical outcomes, and further work is required on the training needs of midwives to enable them to deliver these interventions, the timing of oering an intervention, the aims of this service provision and whether it meets the needs of women from a range of ethnic backgrounds.
Maternity service care for women who have mental health needs There is clearly a need to ensure that the identication of mental health needs becomes part of
the routine provision of postnatal care oered to all women, which includes appropriate referral and management for women with mental health needs, including signs and symptoms of trauma and depression. A recently published survey by MIND (2006) found that most of the 148 women questioned attributed the problems that they experienced to a lack of understanding by health professionals, and inadequate advice and information. Women also felt that more support should be oered to womens partners and their families. Two-thirds of the women surveyed had to wait over a month or more for treatment, with one in 10 having to wait over a year. Over two-thirds of women were admitted to a general psychiatric ward rather than a specialized mother and baby unit, and most of these women were admitted without their babies. Women also reported a lack of communication and coordination between services, an issue highlighted in the most recent Condential Enquiry into Maternal and Child Health (CEMACH) report (Lewis & CEMACH 2004). If healthcare professionals are to address womens mental health needs, they will require guidance and support, since a number of issues would have to be addressed. These include being able to discuss mental health symptoms with women, increasing awareness of the signs and symptoms of mental health problems, and provision of eective care, including timely referral to the most appropriate healthcare professionals. There is a dearth of evidence about the extent to which guidance is in use in current practice. Tully et al. (2002) undertook a survey to identify the use of policies and guidelines in relation to the identication and management of antenatal and postnatal depression; 182 units, 86% of the then total units in England and Wales, provided information. Over one-third of units had policies or guidelines on maternal mental health needs, although only one-fth indicated that these covered postnatal depression and psychosis. Although most respondents indicated that women were routinely asked about their mental health history during their booking visit, few units had audited the services oered to women with mental health problems. A survey of 78 mental health trusts in England (Oluwato & Friedman 2005) found that, although protocols on mental health needs were available in 58% of the trusts, 16 (48%) considered these to be outdated or inadequate. A suite of guidelines intended to inform the management of mental health needs within the
NHS in England and Wales have been published or are in development (www.nice.org.uk). There is also a NICE guideline programme for the maternity services, which include recommendations for the care of pregnant and postnatal women with mental health needs. The NICE guideline on antenatal care (NCCWCH 2003) recommends that women are asked early in pregnancy if they have had any previous psychiatric illnesses, and that women who have a history of psychiatric disorder should be referred for a psychiatric assessment. Guidelines for postnatal care (NICE 2006) recommend that all women should have an opportunity to discuss and ask questions about the birth, and in line with the Cochrane Library review by Rose et al. (2002), single-session debrieng should not be oered. A guideline on antenatal and postnatal depression is scheduled for publication in 2007 (www.nice.org.uk). The impact of these guideline programmes, which aim to reduce variation in practice and ensure that the most clinically and cost eective care is provided, is as yet unclear, with local services expected to audit the outcome of service provision.
Discussion Women can experience a range of psychological and psychiatric health problems after giving birth that may have a long-term impact on their health and well-being, as well as implications for the health of their infants and families. For some, these will be experienced in addition to physical morbidity after birth. The present paper has described some of the mental health symptoms which may be experienced, focusing on depression and psychological trauma, as well as issues surrounding prevention and the need to address the content and delivery of maternity services. Because much maternal physical, psychological and psychiatric morbidity remains unidentied by healthcare professionals and unreported by women, it is important to increase awareness of the signs and symptoms of mental health problems after birth, including depression and PTSD. This should be targeted at users and providers of the maternity services, given the concerns raised by the women in the survey conducted by MIND (2006), i.e. that healthcare professionals did not appear to understand mental health needs, and as a consequence, were unable to oer adequate advice and support. Since there is evidence to support the contention 9
D. Bick & C. Rowan
that a personal or family history of depression or postnatal depression increases the risk of these mental health problems (re)occurring after giving birth, it is imperative that a womans mental health history is documented in order that appropriate postnatal care can be instigated. All women should now be asked about their personal and family mental health history at their antenatal booking visit (NCCWCH 2003), and any current symptoms should be explored, although there is little information about the extent to which this takes place, or if it is making a dierence to womens experiences of mental health problems. The evidence to date indicates that, although women with mental health problems may be identied during pregnancy, appropriate management plans may not have been put in place (Lewis & CEMACH 2004) and communication between the members of the multidisciplinary team may not have been optimum. Therefore, referral pathways need to be clear. Universal screening of women who may be at risk of depression using a tool such as the EPDS is not currently recommended by the NSC, although it is still commonly used in postnatal care. Some of the issues in relation to the shortcomings of the EPDS have been described, including the environment in which it is administered, but much of the data to date has come from research studies rather than outcomes of routine clinical practice. From the qualitative data that are available, women may not nd completing the EPDS acceptable (Shakespeare et al. 2003), suggesting that time to talk about feelings and emotional well-being may be a preferred alternative. If this is to be an option, then there are clearly training needs to be addressed, including communications skills, for all relevant healthcare professionals (Shakespeare et al. 2003). The evidence to date does not support the use of interventions during or after birth to prevent mental health problems, with the exception that planned and tailored midwifery-led care may reduce the risk of depression (MacArthur et al. 2002, 2003; Dennis 2005). Formal debrieng should not be instigated, and clarity relating to the content and benet of debrieng interventions currently oered by the maternity services is required so as to ensure that outcomes are benecial and services directed at the women most in need of their support. Healthcare professionals may continue to focus on physical symptoms rather than addressing any mental 10
health needs a woman may be exhibiting, although there is clearly a complex relationship between physical and psychological symptoms (Brown & Lumley 2000), and women have reported a lack of focus on their emotional needs after birth (Singh & Newburn 2002). The evidence does suggest that women value the opportunity to talk about their birth, which should now be oered as part of routine care within England and Wales (NICE 2006). There is general agreement that the postnatal services, particularly those provided by midwives, need to be revised to enable women to receive tailored, individual care based on their needs (MacArthur et al. 2002). There are concerns that, because of limited resource capacity, postnatal services in the community are being cut back, with the potential that health needs will remain unmet. Clearly, not all women will require intensive postnatal visiting, and it is an important requirement that those who do require care are identied and supported eectively. Managers, policy-makers and healthcare professionals should ensure that postnatal services receive equal priority with antenatal and intrapartum care. Concerns about the care of women in the UK have come to the fore following the report of the 2004 CEMACH, where suicide was identied as the leading direct cause of maternal death. This is a devastating outcome for all concerned, and is an extreme consequence of an illness that aects thousands of women each year. The needs of women with mental health problems are not consistently identied or addressed, and much further work is required to ensure that comprehensive service provision is implemented, given its potential to aect the longer-term health of the woman, her infant and her family. References
Aonso D. D., De A. K., Horowitz J. A. & Mayberry L. L. (2000) An international study exploring levels of postpartum depressive symptomatology. Journal of Psychosomatic Research 49 (3), 207216. Alexander J. (1998) Confusing debrieng and defusing postnatally: the need for clarity of terms, purpose and value. Midwifery 14, 122124. American Psychiatric Association (APA) (1994) Diagnostic and Statistical Manual of Mental Health Disorders, 4th edn. American Psychiatric Association, Washington, DC. Austin M. & Lumley J. (2003) Antenatal screening for postnatal depression: a systematic review. Acta Psychiatrica Scandinavica 107, 1017.

Ayers S. (2004) Delivery as a traumatic event: prevalence, risk factors and treatment for postnatal posttraumatic stress disorder. Clinical Obstetrics and Gynaecology 74 (3), 552567. Baxter J., McCrae A. & Dorey-Irani A. (2003) Talking with women after birth. British Journal of Midwifery 11 (5), 304309. Beck C. T. (2004) Post-traumatic stress disorder due to childbirth: the aftermath. Nursing Research 53 (4), 216224. Bick D. (2003) Strategies to reduce postnatal psychological morbidity. Disease Management and Health Outcomes 11 (1), 1120. Bick D. & MacArthur C. (1995) The extent, severity and eect of health problems after childbirth. British Journal of Midwifery 3 (1), 2731. Bick D., MacArthur C., Knowles H. & Winter H. (2002) Postnatal Care: Evidence and Guidelines for Management. Churchill Livingstone, Edinburgh. Boath E. H., Pryce A. J. & Cox J. L. (1998) Postnatal depression: the impact on the family. Journal of Reproductive and Infant Psychology 16 (23), 199203. Brockington I. (1996) Motherhood and Mental Health. Oxford University Press, Oxford. Brouwers E. P., van Baar A. L. & Pop V. J. (2001) Does the Edinburgh Postnatal Depression Scale measure anxiety? Journal of Psychosomatic Research 51 (5), 659663. Brown S. & Lumley J. (1998) Maternal health after childbirth: results of an Australian population based survey. British Journal of Obstetrics and Gynaecology 105, 156161. Brown S. & Lumley J. (2000) Physical health problems after childbirth and maternal depression at six to seven months postpartum. British Journal of Obstetrics and Gynaecology 107, 11941201. Buist A. E. (1996) Psychiatric Disorders Associated with Childbirth. McGraw-Hill, New York, NY. Charles J. & Curtis L. (1994) Birth afterthoughts: a listening and information service. British Journal of Midwifery 2 (7), 331334. Chaudron L. H. & Pies R. W. (2003) The relationship between psychosis and bipolar disorder: a review. Journal of Clinical Psychology 64 (11), 2841292. Cooper P. J. & Murray L. (1995) Course and recurrence of post natal depression: evidence for the specicity of the diagnostic concept. British Journal of Psychiatry 166, 191195. Cooper P. J., Campbell E. A., Day A., et al. (1988) Non-psychotic psychiatric disorder after childbirth: a prospective study of prevalence, incidence, course and nature. British Journal of Psychiatry 152, 799806. Cox J. L., Holden J. M. & Sagovsky R. (1987) Detection of postnatal depression: development of the 10item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry 150, 782786. Cox J. L., Murray D. & Chapman G. (1993) A controlled study of the onset, duration and prevalence of postnatal depression. British Journal of Psychiatry 163, 2731. Creedy D., Shochet I. & Horsefall J. (2000) Childbirth and the development of acute trauma symptoms: incidence and contributory factors. Birth 27 (2), 104111. Czarnocka J. & Slade P. (2000) Prevalence and predictors of womens experiences of psychological trauma during childbirth. British Journal of Psychology 39 (1), 3551.
Dennett S. (2003) Talking about the birth with a midwife. British Journal of Midwifery 11 (1), 2427. Dennis C. L. (2005) Psychosocial and psychological interventions for prevention of postnatal depression: systematic review. British Medical Journal 331 (7507), 56. Dyregov A. (1989) Caring for helpers in disaster situations: psychological debrieng. Disaster Management 2, 2534. Ebmeier K. P., Donaghey C. & Douglas Steele J. (2006) Recent developments and current controversies in depression. Lancet 367, 153167. Evans J., Heron J., Francomb H., et al. (2001) Cohort study of depressed mood during pregnancy and after childbirth. British Medical Journal 3 (23), 257260. Gamble J., Creedy D., Moyle W., et al. (2005) Eectiveness of a counseling intervention after a traumatic childbirth: a randomised controlled trial. Birth 32 (1), 1119. Gaynes B. N., Gavin N., Meltzer-Brody S., et al. (2005) Perinatal Depression: Prevalence, Screening Accuracy, and Screening Outcomes. Evidence Report/Technology Assessment No. 119. (Prepared by the RTI-University of North Carolina Evidence-based Practice Center, under Contract No. 290020016.) AHRQ Publication No. 05-E006-2. Agency for Healthcare Research and Quality, Rockville, MD. Glazener C., Abdalla M., Stroud P., Templeton A. & Russell I. (1995) Postnatal maternal morbidity: extent, causes, prevention and treatment. British Journal of Obstetrics and Gynaecology 102, 282287. Howard L. M., Hofbrand S., Henshaw C., Boath L. & Bradley E. (2005) Antenatal prevention of postnatal depression (Cochrane Review). In: The Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD004363.pub2. DOI: 10.1002/14651858.CD004363/ pub2. Kendall R. E., McGuire R. J., Connor Y., et al. (1981) Mood changes in the rst three weeks after childbirth. Journal Aective Disorders 3, 317326. Kershaw K., Jolly J., Bhabra K. & Ford J. (2005) Randomised controlled trial of community debrieng following operative delivery. British Journal of Obstetrics and Gynaecology 112 (11), 15041509. Lavender T. & Walkinshaw S. (1998) Can midwives reduce postpartum psychological morbidity? A randomized trial. Birth 25 (4), 215219. Lewis G. (ed.) & Condential Enquiry into Maternal and Child Health (CEMACH) (2004) Why Mothers Die 20002002: The Sixth Report of Condential Enquiries into Maternal Deaths in the United Kingdom. RCOG Press, London. Lovestone S. & Kumar R (1993) Postnatal psychiatric illness: the impact on partners. British Journal of Psychiatry 163, 210216. MacArthur C., Lewis M. & Knox E. G. (1991) Health After Birth. HMSO, London. MacArthur C., Winter H. R., Bick D. E., et al. (2002) Eects of redesigned community postnatal care on womens health four months after birth: a cluster randomised controlled trial. Lancet 359, 378385. MacArthur C., Winter H. R., Bick D. E., et al. (2003) Redesigning postnatal care: a randomised controlled trial of protocol-based, midwifery-led care focused on individual womens physical and psychological health needs. Health Technology Assessment 7 (37), 98.
11
D. Bick & C. Rowan

MIND (2006) Out of the Blue? Motherhood and Depression. MIND, London. Mitchell J. (1983) When disaster strikes . . . the critical incident stress debrieng procedure. Journal of Emergency Medical Services 8 (1), 3639. Murray L. & Carothers A. (1990) The validation of the Edinburgh Postnatal Depression Scale on a community sample. British Journal of Psychiatry 157, 288290. Murray L. & Cooper P. J. (1997) Postpartum depression and child development. [Editorial.] Psychological Medicine 27 (2), 253260. National Collaborating Centre for Mental Health (NCCMH) (2004) Depression: Management of Depression in Primary and Secondary Care. NICE Clinical Guideline 23. National Institute for Health and Clinical Excellence, London. National Collaborating Centre for Mental Health (NCCMH) (2005) Post-traumatic Stress Disorder: The Management of PTSD in Adults and Children in Primary and Secondary Care. NICE Clinical Guideline 26. Royal College of Psychiatrists (Gaskell) and British Psychological Society, London. National Collaborating Centre for Womens and Childrens Health (NCCWCH) (2003) Antenatal Care: Routine Care for the Healthy Pregnant Woman. NICE Clinical Guideline 6. RCOG Press, London. National Institute for Health and Clinical Excellence (NICE) (2004) Anxiety: Management of Anxiety (Panic Disorder, with or without Agoraphobia, and Generalized Anxiety Disorder) in Adults in Primary, Secondary and Community Care. NICE Clinical Guideline 22. National Institute for Health and Clinical Excellence, London. National Institute for Health and Clinical Excellence (NICE) (2006) Routine Postnatal Care of Women and Their Babies. NICE Clinical Guideline 37. National Institute for Health and Clinical Excellence, London. Oates M. (2003) Postnatal depression and screening: too broad a sweep? [Editorial.] British Journal of General Practice 53 (493), 596597. OHara M. & Swain A. (1996) Rates and risk of post partum depression a meta-analysis. International Review of Psychiatry 8, 3754. Oluwato O. & Friedman T. (2005) A survey of specialist perinatal mental health services in England. Psychiatric Bulletin 29, 177179. Pallant J. F., Miller R. L. & Tennant A. (2006) Evaluation of the Edinburgh Postnatal Depression Scale using Rasch analysis. BMC Psychiatry 6, 28. Priest S., Henderson J., Evans S. & Hagan R. (2003) Stress debrieng after childbirth: a randomised controlled trial. Medical Journal of Australia 178, 542544. Raynor M., Sullivan A. & Oates M. (2003) Why mothers die: a public health concern. British Journal of Midwifery 11 (6), 393395. Rose S., Bisson J., Churchill R. & Wessely S. (2002) Psychological debrieng for preventing post traumatic stress disorder (PTSD) (Cochrane Review). In: The Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD000560. DOI: 10.1002/14651858.CD000560. Ryding E., Wijma K. & Wijma B. (1998) Postpartum counseling after an emergency cesarean. Clinical Psychology and Psychotherapy 5, 231237. Ryding E., Wiran E., Johansson G., Cedaer B. & Dahlstrom A. (2004) Group counselling for mothers after emergency cesarean section: a randomised controlled trial of intervention. Birth 31 (4), 247253. Saurel-Cubizolles M.-J., Romito P., Lelong N. & Ancel P.-V. (2000) Womens health after childbirth: a longitudinal study in France and Italy. British Journal of Obstetrics and Gynaecology 107, 12021209. Scottish Intercollegiate Guideline Network (SIGN) (2002) Postnatal Depression and Puerperal Psychosis. Guideline No. 60. Scottish Intercollegiate Guideline Network, Edinburgh. Selkirk R., McLaren S., Ollerenshaw A., McLachlan A. & Moten J. (2006) The longitudinal eects of midwife-led debrieng on the psychological health of mothers. Journal of Reproductive and Infant Psychology 24 (2), 133147. Shakespeare J. (2001) Evaluation of screening for postnatal depression against the NSC handbook criteria. [WWW document.] URL http://www.nelh.nhs.uk/screening/View Resource.aspx?resid=60978&tabid=288 Shakespeare J., Blake F. & Garcia J. (2003) A qualitative study of the acceptability of routine screening of postnatal women using the Edinburgh Postnatal Depression Scale. British Journal of General Practice 53 (493), 614619. Singh D. & Newburn M. (2001) Postnatal care in the month after birth. Practising Midwife 4 (5), 2225. Slade P. (2006) Towards a conceptual framework for understanding post-traumatic stress symptoms following childbirth and implications for further research. Journal of Psychosomatic Obstetrics and Gynaecology 27 (2), 99105. Small R., Kumley J., Donohue L., Potter A. & Waldenstrom U. (2000) Randomised controlled trial of midwife led debrieng to reduce maternal depression after operative childbirth. British Medical Journal 321 (7268), 10431047. Small R., Lumley J. & Toomey L. (2006) Midwife led debrieng after operative birth: four to six year follow up of a randomised trial. BioMed Central 4 (3), 19. Soet J. E., Brack G. A. & DiIorio C. (2003) Prevalence and predictors of womens experiences of psychological trauma during childbirth. Birth 30 (1), 3646. Stein G., Marsh A. & Morton J. (1981) Mental symptoms, weight change and electrolyte excretion during the rst postpartum week. Journal of Psychosomatic Research 25, 395408. Tam W., Lee D., Chiu H. K., et al. (2003) A randomised controlled trial of educational counselling on the management of women who have suered suboptimal outcomes in pregnancy. British Journal of Obstetrics and Gynaecology 10, 853859. Thurtle V. (2003) First time mothers perceptions of motherhood and PND. Community Practitioner 76, 261265. Tully L., Garcia J., Davidson L. & Marchant S. (2002) Role of midwives in depression screening. British Journal of Midwifery 10 (6), 374378. White T., Matthey S., Boyd K. & Barnett B. (2006) Postnatal depression and post traumatic stress after childbirth: prevalence, course and co-occurrence. Journal of Reproductive and Infant Psychology 24 (2), 107120. World Health Organization (WHO) (1992) The ICD-10 Classication of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. World Health Organization, Geneva.
12
Debra Bick BA(Hons) MMedSci PhD RM is a professor of Midwifery and Womens Health at the Centre for Research in Midwifery and Childbirth, Faculty of Health and Human Sciences, Thames Valley University, London, UK. She has worked on a number of large studies examining the impact of interventions during and after birth on womens physical and mental health. Debra was the clinical advisor to the recently published NICE guideline on postnatal care for healthy women and babies, and has written extensively on
issues relating to the organization and content of services for women after birth. She is the editorin-chief of Midwifery: An International Journal. Her current projects include a national clinical quality improvement programme to enhance the assessment and management of perineal care, revising the content and planning of postnatal care in hospital and on transfer home, and identifying training needs in order to improve care for women with mental health needs.
13
Motivational interviewing and health behaviour change: an overview and their relevance to womens health
C. A. Lane
School of Nursing and Midwifery Studies, Cardi University, Cardi, UK
Abstract Encouraging patients to make changes to their health behaviour is challenging for practitioners in most clinical disciplines. In relation to womens health issues, the challenges facing physiotherapists include encouraging women to adopt treatment/exercise regimes to improve recovery and well-being, as well as maintaining these practices over time. One method that has shown promise in facilitating health behaviour change in a number of clinical settings is motivational interviewing, a directive, client-centred counselling style for eliciting behaviour change by helping clients to explore and resolve ambivalence. This paper aims to provide an overview of the method, to present the evidence to date for its ecacy and to discuss its relevance to womens health.
Keywords: debrieng, depression, maternal health, postnatal care, post-traumatic stress disorder.
Introduction Bizarrely, after a couch potato lifestyle, I have discovered exercise with a vengeance . . . but while the spirit is willing, the body isnt always and the old muscles down below arent what they were. If I sneeze unexpectedly, laugh or try a particularly energetic move whilst playing tennis, then Im likely to suer a stress incontinence moment. Not great. Do I do the exercises regularly? Do I heck! Ive made a good recovery following my ankle surgery, but keeping up with the balancing exercises is hard. Theres always something more pressing to do be that writing papers, preparing for conferences, or simply trying to keep my home (that my husband continually messes up) tidy. I know how important it is to do my ankle exercises after all I waited 5 years for the surgery to put it right but building them into my everyday life is hard. Ironically, its even harder now that I am feeling a lot better.
Correspondence: Dr Claire Lane, Nursing, Health and Social Care Research Centre, School of Nursing and Midwifery Studies, Cardi University, Fourth Floor, EastGate House, 3543 Newport Road, Cardi CF24 0AB, UK (e-mail: LaneCA1@cf.ac.uk).
As I rumble towards my menopause, Im having to be much more careful about my weight and its a huge eort because I really like my food! My knees arent as good as they were and Im waiting for an operation to scrape out the torn cartilage. Ive had to have physio and I cant aord to gain extra weight. If I want to be in good nick, Ive got to look after myself. Hmm, easier said than done. Do these stories ring a bell with you? No doubt you can think of times when you have told a patient what they need to do, yet when the follow-up comes around, they do not seem to have taken your advice. How many times has a women complained that she could not do her exercises because her husband was not supportive/the kids needed her/there was so much to do at home/she had people to stay/her job was so demanding/she was so tired with everything else that she had to do over the past fortnight? In her training sessions, the present author sometimes asks health professionals, How would you feel if you had to see three patients like this in a row? Responses tend to range from exhausted and frustrated through to demoralized and disillusioned. It is perfectly normal to feel this way. After all, the reason you and your colleagues give advice like this is
14
Motivational interviewing and health behaviour change
because you care, and you want the patient to make as good a recovery as possible. On the other hand, the patient is probably feeling as frustrated with herself as you are. She may feel as though she has failed because she has not managed to do something that should be so easy, and she may also be worried that she is doing herself some damage because she has not done what she was meant to do. The present author should know she is the author of the second quotation. Health behaviour change is a challenging area for both the patient and the practitioner. The way in which this is addressed by a health professional can make all the dierence, and therefore, it is important to take a exible approach to communication. All patients are dierent, and some women will already be motivated to make the changes or adhere to the treatment plans that have been suggested for them. Other patients may be a little more dicult, and there are times when simple instruction and advice does not do the trick. So, what can you do instead? Whats your style? There are a number of dierent styles that we use when communicating with others in our daily lives. This was something the present author and a colleague discussed in some detail with a group of health visitors whom they trained in 2003 (Rollnick et al. 2004). For example, on a daily basis, it might be appropriate at dierent points to either direct, guide or follow (S. Rollnick, personal communication). Directing involves the provision of information or advice. Guiding usually involves building on somebodys strengths to help them get better at something they already know a little about. Following involves listening to and understanding somebody. Imagine the following scenarios that could occur in everyday family life, and think about what style would be appropriate in each situation: + A child runs out into a busy road. (Direct) + A child is learning to read. (Guide) + A child is crying and you do not know why. (Follow) It seems obvious where directing, guiding and following seem most appropriate. Now imagine restricting yourself to using just one style of communication for every scenario, or using the wrong style in the wrong situation imagine the consequences of directing the child who is crying/learning to read, or guiding/following the
child who has run into the road. The same principle applies when dealing with patients in clinical practice. When it comes to behaviourchange issues, some patients may require direction others may have more pressing issues and need to be followed. However, many will be most receptive to a guiding style (Rollnick et al. 2005). Looking at the psychological processes behind behaviour change can help us to understand why this may be the case.
The psychology of behaviour change There are many factors that may aect how and why patients make changes. Patients often need to feel a degree of personal choice with regard to changing their behaviour. Brehm (1966) suggested that, if a person perceives that their individual freedom is being taken away, this may, in turn, motivate them to actually perform the behaviour they are being told not to do (or of course, fail to perform the behaviour they are being told to do!). Put simply, this describes the patient who reacts to information/advice by thinking, No one tells me what to do. Many patients expect to be persuaded to make lifestyle changes, which can, in turn, result in resistance to making changes. Using empathy listening carefully and demonstrating to patient that they have been understood can help to lower resistance. For example, Carl Rogers (1959) developed the client-centred counselling framework, which draws closely on the use of empathy, because he found that his psychotherapy clients often had improved results if he listened more and allowed them to determine the rate of treatment. This led him to believe that a exible attitude to treatment was important, since encouraging the client to be self-aware and to make independent choices appeared to help them to understand the problem at hand. Self-perception can also have an eect on a patients motivation to change (Bem 1972). If patients see themselves as smokers, for example, they think they like it and want to continue doing it. If they hear themselves saying that they do not want to be smokers and they are going to quit, they may, in some cases, believe it and stop smoking. Similarly, Festinger (1957) discussed cognitive dissonance people generally feel uncomfortable when they hold two conicting beliefs for example, I want to be healthy, but I eat a lot of fatty food, which is bad for me. This, 15
C. A. Lane
in turn, may create an urge to resolve the conict which could potentially mean that the patient in the example decides to gradually reduce the amount of saturated fat in their diet. However, if patients do not believe that they can reduce the amount of fat in their diets very easily, it may be easier to despise what they feel they cannot achieve: Who wants to look like a fake supermodel anyway? Lets forget that idea. Another factor that may aect patient motivation to change is their readiness to make changes. One model commonly used to try to understand readiness is the transtheoretical (or stages of change) model (Prochaska & DiClemente 1983), which describes ve possible stages that individuals may be at in terms of making a change: + the precontemplation stage the person has not even considered that she or he might need to make changes at this point; + the contemplation stage the person has considered that there is something that she or he probably needs to change; + the preparation stage the person makes plans as to how she or he might change; + the action stage the person is actively undertaking behavioural changes; and + the maintenance stage the person maintains the changes she or he made in the action stage over a period of time. The stages are not linear an individual can relapse and fall back into former stages at any point in time. For example, perhaps the changes made in the action stage were dicult to implement, causing a patient to fall back into the contemplation or preparation stage, or a stressful life event such as a relationship breakup forced the patient back into the precontemplation stage. Two factors that can inuence patients readiness to make changes are the degree of importance that they attach to making the behaviour change, and their condence in their ability to achieve it (Keller & White 1997; Rollnick et al. 1997). In general, if importance and condence are both high, patients are more likely to feel ready to make changes. If importance and condence are both low, patients are not likely to feel at all ready to make changes. If importance and condence are somewhere in the middle of the range, or either importance or condence is high, but the other is low, patients are likely to be ambivalent about making changes. Having the condence to achieve change is recognized as a 16
great factor in making lifestyle changes. If individuals believe that they can change, this is often half the battle. If they do not believe they can change, they may not even try (Bandura 1995). To summarize the information above, it is clear that behaviour change is a phenomenon that is personal and individual to the patient. Motivation to change can be inuenced by how much freedom of choice patients feel they have, how they view themselves in relation to how they would like to be, how ready they feel they are to change, how important they think it is to change, and how condent they feel about their ability to achieve it. The fact is that we cannot make patients change or adhere to treatment regimes. That decision is, and always will be, theirs to make. However, what we can do is have constructive discussions with patients about making changes, help them to explore how they think and feel about change, and guide them in thinking about how and why they might change. One method that can help with this is motivational interviewing (MI; Miller & Rollnick 2002). The following explanation of MI is based closely on a previous description of the method (Lane 2006). Motivational interviewing Motivational interviewing originated in the addictions/psychotherapy eld, and has evolved from the work by Rogers (1959) on the clientcentred counselling framework mentioned above. The technique is similar to the clientcentred counselling framework, in that: [It] does not focus on teaching new coping skills, reshaping cognitions or excavating the past. It is quite focussed on the persons present interests and concerns. Whatever discrepancies are explored and developed have to do with incongruities among aspects of the persons own experiences and values. (Miller & Rollnick 2002) Motivation for change is drawn from the client, rather than imposed. However, MI diers from the client-centred counselling framework in that it is purposely directive: Motivational interviewing involves selective responding to speech in a way that resolves ambivalence and moves the person toward change. (Miller & Rollnick 2002) One misconception about MI is that it is often viewed as a set of techniques that can be inicted on a patient without genuine empathy and understanding. Motivational interviewing is a
clinical skill, rather than a tool. To further dene the nature of MI, Miller & Rollnick (2002) described the spirit of MI (or a way of being with a patient), and presented four principles (or conventions guiding practice) behind the method. The spirit of MI is divided into three components: collaboration, evocation and autonomy: + Collaboration refers to the patient and practitioner working together in partnership, not against each other (e.g. with the practitioner advocating change and the patient arguing why change is not a good idea). + Evocation describes the process of the practitioner eliciting the patients goals, thoughts and feelings about behaviour change, rather than providing information as to how and what they should feel about change. + Autonomy signies practitioner respect for the patients rights as an individual. Patients know their own mind, and should be allowed to choose what to do about their behaviour there is recognition that any changes that patients do decide to make are entirely their choice, and that the practitioner is not there to force them to do anything. Should patients decide that they do not want to make any changes to their behaviour, the practitioner, in turn, has to respect this decision. The four principles to be followed while conducting MI are to express empathy, develop discrepancy, roll with resistance and support self-ecacy (Miller & Rollnick 2002): + Expressing empathy describes how the practitioner should demonstrate an understanding of the patients perspective. This is mainly achieved through the use of active, reective listening techniques, which demonstrate that the practitioner understands what the patient has told them. + Rolling with resistance is the approach taken to avoid confrontation with a patient. It could be described as going along with what the patient says for a bit while demonstrating understanding for resistance as a means of reducing it. + As well as eliciting the patients motivation to change, the practitioner should support the patients self-ecacy (a persons belief that they have the ability to do something) and build on the patients condence in achieving change without telling her or him what to do. + Developing discrepancy is the most complex of the principles underlying motivational
interviewing. It involves the practitioner listening carefully to what the patient says about her or his personal values, and illustrating how this is at odds with the patients current behaviour. This is often achieved by highlighting how the behaviour in question does not t in with the patients perception of how she or he would like to be. With the spirit and guiding principles of the method in mind, the practitioner uses a number of skills to encourage the production of patient change talk (patient talk about how and why they might change their behaviour). This is accomplished through a variety of means, such as asking permission to talk about the behaviour in question, encouraging the patient to set the agenda for the consultation, assessing a patients readiness to change, asking open-ended questions, making summaries, and the skilful use of reective listening to both express empathy and to direct the patient in producing change talk. Following its success in the psychotherapy eld, MI has generated much interest within healthcare settings where behaviour change is often an issue. For this reason, the method has been adapted for use in these contexts (Rollnick et al. 1999), adhering to the spirit and principles outlined above. There are a number of strategies that clinicians can use to help implement MI into their practice with patients. Although a comprehensive guide to doing MI is not possible within the scope of a conference paper, four strategies (i.e. agenda-setting, exploring the pros and cons of change, exploring readiness to change, and exchanging information) will be outlined below to give readers an idea of how MI works in clinical practice. Agenda-setting In MI, the patient is encouraged to set the agenda for talking about behaviour change. This is particularly important if there are a number of dierent lifestyle issues to be addressed. For example, a female cardiac rehabilitation patient may have been identied as having a number of risk factors that may have contributed to her heart attack. She may need to make changes to her diet, increase the amount of physical activity that she does and cut down the amount of alcohol she consumes. It is often easier to make changes by trying to do a bit at a time, rather than trying to make a number of substantial changes all in one go. We are all at dierent stages of readiness to change over dierent 17
C. A. Lane
issues and may even be at dierent stages of readiness to change dierent aspects of one health behaviour (Rollnick et al. 1999). Illustrating the point with the example above, this cardiac rehabilitation patient may be ready to start going for a half-hour walk a couple of times a week, but may not feel ready to start going swimming too. Achieving small changes can increase self-ecacy (Bandura 1995), making a patient feel more able to make other small changes. Therefore, it is important to start where the patient feels most comfortable, and encourage her or him to suggest what area she would like to talk about, rather than selecting what the healthcare practitioner feels is the most important issue to talk about rst. It is also important to ask permission to talk about lifestyle changes, so that the patient feels that she has a choice in the matter. Encouraging the patient to set the agenda can be initiated through the use of open questions, such as, There are a number of dierent things we can talk about today. Im just wondering what aspect of your lifestyle you would like to talk about? One tool that can help with this task is an agenda-setting chart (a copy of which, along with instructions for its use in clinical practice, can be found in Rollnick et al. 1999), which contains a number of circles containing picture representations of various dierent lifestyle factors, and some blank circles for other factors to be inserted by the patient. Be prepared for the patient to raise issues that you might not have anticipated drawing again on our cardiac rehabilitation patient, worries about looking after her family may be more pressing at that particular point.
thinks would help her to move up the scale in terms of importance and/or condence. This strategy can help the practitioner to understand the patients barriers to change, and therefore, can start the process of helping the patient to overcome them. Exploring pros and cons Closely related to the importance/condence strategy, exploring the pros and cons of the current behaviour and changing behaviour can help the practitioner to understand the patients barriers to change. This strategy simply involves asking the patient what she likes/doesnt like about her current behaviour, and what she feels she would gain/lose from making changes. Exchanging information Within healthcare consultations, there often comes a point when we need to stop listening to patients and give them information. Perhaps the patient needs to know something for her safety/ well-being, she has asked you for information about what she should do, or she has misunderstood something with regard to her care or recovery. Information-giving within healthcare is usually a process in which the patient is a passive recipient. A typical example might be: You are eating too much of X. This means that you are at a much higher risk of developing Y. What I suggest you do is Z. This has the advantage of being short, sweet and to the point. However, it has the disadvantage of possibly telling the patient something she knows already, or that she may misunderstand in terms of its relevance for her. It also makes the assumption that the patient will just take the advice and do as she is told (if only it was that easy!). Within MI, information is exchanged with patients, rather than given. This involves the use of the elicitprovideelicit method, or rst nding out what the patient knows already, providing information (after asking if the patient is happy for you to do this), and then nding out what the patient has made of that information. This means that information is given in a neutral manner, building on what the patient already knows, and the interpretation of the facts is left to the patient. Exchanging information in this way can encourage the patient to actively think of how the information given applies to her as an individual, and can even save the practitioner time,
Exploring importance and condence Given the role that readiness plays in motivation to change behaviour, it can be useful to gain an understanding of this. One way this can be achieved within clinical practice is by exploring how important the patient feels it is to change her behaviour, and how condent she feels about achieving it. Many practitioners nd it useful to ask patients to rate, on a scale of 010, How important is it for you, right now, to change X? and then ask them to rate, on the same scale, How condent do you feel of success in changing X? Following on from this, there is the opportunity to ask a patient why she has given herself this score and not a higher or lower number, or indeed what she 18
since it prevents the provision of redundant information, or telling the patient what she knows already.
Evidence for the effectiveness of motivational interviewing A number of recent systematic reviews have presented growing evidence for the eectiveness of MI as an intervention. The strongest evidence is in the treatment of drug and alcohol misuse (Dunn et al. 2001; Burke et al. 2002, 2003; Hettema et al. 2005). Because MI is still a relatively new method, and it entered the general healthcare arena much later than the addictions eld, the evidence for the eectiveness of MI within healthcare settings is still somewhat limited, although it has shown much promise. Rubak et al. (2005) conducted a systematic review of 72 randomized controlled trials in healthcare settings, and found that MI interventions had a signicant eect on reducing Body Mass Index, cholesterol, systolic blood pressure, blood alcohol content and standard ethanol content, although not on the number of cigarettes per day in smokers or glycosylated haemoglobin (HbA1c) in people with diabetes. Vasliaki et al. (2006) systematically reviewed studies that used brief alcohol interventions based on MI, and concluded that the technique was eective in reducing alcohol consumption in the short term with mainly risky (rather than alcoholdependent) drinkers. A recent systematic review by Knight et al. (2006) into the eects of MI interventions on physical activity concluded that these interventions do appear to increase exercise uptake among patients, although the poor quality of the trials made this hard to determine, with just eight studies being included in the review as a result, mirroring the ndings of previous reviews that have attempted to look at MI in relation to specic health behaviours (Dunn et al. 2001; Burke et al. 2002, 2003; Hettema et al. 2005). To enhance the quality of such trials of MI, more attention is being focused on the quality of the intervention actually delivered by practitioners in a number of dierent contexts, resulting in the development of instruments to measure practitioner skill in delivering MI (Lane et al. 2005; Moyers et al. 2005; Lane 2006). One of the advantages of MI is that it appears to be benecial in helping people of both sexes to change behaviours that they are ambivalent about changing. However, a number of studies have taken an MI approach specically with
women in various contexts such as pregnant drinkers (Handmaker et al. 1999), pregnant smokers (Stotts et al. 2004), female sex workers (Yahne et al. 2002) and women experiencing marital dissatisfaction (Kelly et al. 2000; Cordova et al. 2001) and have found it to be helpful in facilitating behaviour change among these women. A fellow MI trainer has commented on how using the technique in her clinical practice with women has been useful: I work on a research study in which I run weight-loss groups for women who are overweight and have urinary incontinence, and they are very receptive to the lessons on exploring values . . . and making themselves a priority. It is quite gratifying to see the transformation among these women, who begin to carve out time to take better care of themselves and lose weight. (J. Hecht, personal communication) Conclusion Motivational interviewing is a method for which there is growing evidence that it may be an eective way to facilitate behaviour change in patients who are ambivalent about change, or who are nding it dicult to put changes into practice. No method of consulting can oer a one size ts all approach, but given the importance of being exible, and trying to use the best style of communication for each individual patient, MI is one skill that practitioners may nd useful to include in their toolbox of existing skills when employing a guiding style with their patients. Want to nd out more about motivational interviewing? More information about MI can be found on the World Wide Web at <www.motivationalinterview.org>. Health Behaviour Change: A Guide for Practitioners by Rollnick et al. (1999) and Motivational Interviewing: Preparing People for Change by Miller & Rollnick (2002) are recommended further reading. Acknowledgements Many thanks to the Motivational Interviewing Network of Trainers (MINT) and their colleagues for their ideas and support, especially: Majella Greene, Bob Mash, Marlyn Allicock, Marci Campbell, Grant Corbett, Viv Mumby, Donna Spruijtz-Metz, Cheryl Martin, Jacki Hecht, Gary Latchford, Dee-Dee Stout and Ineke Buskens. 19
C. A. Lane
References
Bandura A. E. (1995) Self-Ecacy in Changing Societies. Cambridge University Press, Cambridge. Bem D. J. (1972) Self-perception theory. In: Advances in Experimental Social Psychology, Vol. 6 (ed. L. Berkowitz), pp. 162. Academic Press, New York, NY. Brehm J. W. (1966) A Theory of Psychological Reactance. Academic Press, New York, NY. Burke B., Arkowitz H. & Dunn C. (2002) The ecacy of motivational interviewing and its adaptations: what we know so far. In: Motivational Interviewing: Preparing People for Change, 2nd edn (eds W. R. Miller & S. Rollnick), pp. 217250. Guilford Press, New York, NY. Burke B., Arkowitz H. & Menchola M. (2003) The ecacy of motivational interviewing: a meta-analysis of controlled clinical trials. Journal of Consulting and Clinical Psychology 71, 843861. Cordova J. V., Warren L. Z. & Gee C. B. (2001) Motivational interviewing as an intervention for at-risk couples. Journal of Marital and Family Therapy 27, 315326. Dunn C., Deroo L. & Rivara F. (2001) The use of brief interventions adapted from motivational interviewing across behavioral domains: a systematic review. Addiction 96, 17251742. Festinger L. (1957) A Theory of Cognitive Dissonance. Stanford University Press, Stanford, CA. Handmaker N. S., Miller W. R. & Manicke M. (1999) Findings of a pilot study of motivational interviewing with pregnant drinkers. Journal of Studies on Alcohol 60, 285287. Hettema J., Steele J. & Miller W. R. (2005) Motivational interviewing. Annual Review of Clinical Psychology 1, 91111. Keller V. & White M. (1997) Choices and changes: a new model for inuencing patient health behavior. Journal of Clinical Outcomes Management 4, 3336. Kelly A. B., Halford W. K. & Young R. M. (2000) Maritally distressed women with alcohol problems: the impact of a short-term alcohol-focused intervention on drinking behaviour and marital satisfaction. Addiction 95, 15371549. Knight K., McGowan L., Dickens C. & Bundy C. (2006) A systematic review of motivational interviewing in physical health care settings. British Journal of Health Psychology 11, 319332. Lane C., Huws-Thomas M., Hood K., et al. (2005) Measuring adaptations of motivational interviewing: the development and validation of the Behavior Change Counseling Index. Patient Education and Counselling 56, 166173. Lane C. A. (2006) The Measurement and Acquisition of Skills in Behaviour Change Counselling. Cardi University, Cardi. Miller W. R. & Rollnick S. (eds) (2002) Motivational Interviewing: Preparing People for Change. Guilford Press, New York, NY. Moyers T., Martin T., Manuel J., Hendrikson S. & Miller W. (2005) Assessing competence in the use of motivational interviewing. Journal of Substance Abuse Treatment 28, 1926. Prochaska J. O. & DiClemente C. C. (1983) Stages and processes of self-change of smoking: toward an integrative model of change. Journal of Consulting and Clinical Psychology 51, 390395.
Rogers C. R. (1959) A theory of therapy, personality and interpersonal relationships as developed in the clientcentered framework. In: Psychology: A Study of a Science, Vol. 3 (ed. S .Koch), pp. 184256. McGraw-Hill, New York, NY. Rollnick S., Butler C. C., McCambridge J., et al. (2005) Consultations about changing behaviour. British Medical Journal 331, 961963. Rollnick S., Butler C. C. & Stott N. (1997) Helping smokers make decisions: the enhancement of brief intervention for general medical practice. Patient Education and Counseling 31, 191203. Rollnick S., Mason P. & Butler C. (1999) Health Behaviour Change: A Guide for Practitioners. Churchill Livingstone, Edinburgh. Rose G. S., Rollnick S. & Lane C. (2004) Whats your style? A model for helping practitioners to learn about communication and motivational interviewing. Motivational Interviewing Newsletter: Updates, Education and Training 11, 35. Rubak S., Sandboek A., Lauritzen T. & Christensen B. (2005) Motivational interviewing: a systematic review and meta-analysis. British Journal of General Practice 55, 305312. Stotts A. L., Delaune K. A. & Schmitz J. M. (2004) Impact of a motivational intervention on mechanisms of change in low-income pregnant smokers. Addictive Behaviors 29, 16491657. Vasilaki E., Hosier S. & Cox W. (2006) The ecacy of motivational interviewing as a brief intervention for excessive drinking: a meta-analytic review. Alcohol and Alcoholism 41 (3), 328335. Yahne C. E., Miller W. R., Irvin-Vitela L. & Tonigan S. (2002) Magdalena Pilot Project: motivational outreach to substance abusing women street sex workers. Journal of Substance Abuse Treatment 23, 4953.
Claire Lane is a research fellow at the Nursing, Health and Social Care Research Centre, Cardi University. Originally from a linguistics background, she undertook her PhD in healthcare communication at the Department of General Practice, Cardi University. Claires academic work to date has focused on health behaviour change, and more specically, motivational interviewing. To this end, her doctoral studies examined the eects of training on practitioner skill in motivational interviewing, and involved the development of an instrument to measure this, the Behaviour Change Counselling Index (BECCI). Claire is currently working on the Transition from Children to Adolescent Diabetic Services (TCADS) project, which aims to investigate what methods of progression seem to work well for particular groups of teenagers. She is a member of the trial management group on the Pre-Empt Study at the Department of General Practice, Cardi University.
20
Quote me happy: can acupuncture make those hormones happy?

J. Longbottom
Private Practice, St Neots, Cambridgeshire, UK
Abstract The present paper outlines the neurophysiological and neurohumeral eects of acupuncture with reference to pain modication, and systemic enhancement of mood, well-being, sleep and quality of life in the specic area of womens health. The author seeks to integrate Western evidence-based acupuncture research with the richness of the underlying philosophy of traditional Chinese medicine in order to enhance patient care and clinical management of the more complicated case presentations within physiotherapy. The paper attempts to reinforce suggested protocols, both within myofascial pain management and systemic dysfunction, with appropriate research, in order to support clinical reasoning and best practice encompassing a variety of conditions ranging from the more peripheral, supercial gynaecological infections to systemic dysfunction, whilst retaining the scope of physiotherapeutic practice. The paper encompasses musculoskeletal dysfunction, menopausal symptoms, infertility and mild depression as a means of enhancing the physiotherapists clinical toolbox and oering a greater choice of patient care to the acupuncture practitioner.
Keywords: acupuncture, hormones, pain, sleep, well-being.
Introduction The word hormone is derived from the Greek hormon, meaning to excite or to arouse. The present paper seeks to excite and arouse further interest in acupuncture, within the scope of physiotherapy practice, in order to go beyond (but not ignore) analgesic evidence for acupuncture eectiveness. The paper emphasizes the integration of acupuncture, within an evidence-based paradigm, with the philosophy of traditional Chinese medicine (TCM), while oering an explanation of neurophysiological and neurohumeral eects that may facilitate systemic and emotional improvement. The eect of acupuncture, from periphery to brain, is presented; we take a journey to outline some conditions encountered, some protocols suggested and the supporting evidence to enhance clinical reasoning.
Correspondence: Jennie Longbottom, 13 Park Avenue, Little Paxton, St Neots PE19 6PB, UK (e-mail: jennie.longbo@ ntlworld.com).
Rehabilitation Acupuncture is increasingly nding a place in rehabilitation, and although the evidence base is growing quickly, prejudice still surrounds its use within conventional Western medical systems. This resistance stems in part from acupunctures roots in TCM, dating from 200 BC. The prevailing belief at that time was of a system of organs and channels (meridians) through which vital energy, qi, ows. Qi is inuenced by needling specic locations on the body (acupuncture points) in order to enhance or reduce qi ow, achieve balance, restore homeostasis, and promote health and healing. These early attempts at understanding disease and disharmony persisted until fairly recently. There is some stigma that still attaches itself to acupuncture, with detractors claiming that it has a placebo eect at best, and is shamanism at worst. This prejudice, coupled with initially unpromising reports (Mendelson et al. 1983), hindered acupunctures wider acceptance as an eective treatment for pain, although recent studies (Carlsson & Sjolund 2001) have been more encouraging. 21
J. Longbottom
At the periphery Acupuncture for pain control is more widely accepted. Needling is a stimulus that releases histamine and calcitonin-gene related peptide (CGRP), and causes a local inammatory reaction (Sandberg et al. 2003). The resulting therapeutic eect of acupuncture is enhanced blood ow (Cao 2002), increased phagocytic response and enhanced inammatory response to trauma with consequent tissue healing (Hsieh 1998). Interpreting the chemical responses at the periphery into clinical practice leads to acupuncture evidence in the eld of treatment of interstitial cystitis (Tucker 2004), leucorrhoea and vaginitis (Flaws 1986), and Candida albicans (Erconlani 1997). Illiev et al. (1990) found signicant changes in immunoglobulin and lymphocyte proliferation following electro-acupuncture (EA) at large intestine (LI) 4 and stomach (ST) 36. Rosted (1994) recommended a standard protocol for skin diseases, demonstrating signicant eects using lung and large intestine points. In short, there are optimistic studies for the use of acupuncture in a variety of supercial skin conditions, providing evidence of a strong phagocytic reaction and antihistaminic eect in healthy volunteers, but there is much room for further well-controlled studies in this area.
At the spinal cord Small aerent A -bres are stimulated by the acupuncture needle, causing the release of -endorphin and leu-enkephalin in the dorsal horn of the aected spinal cord segment (Han 2004). These substances block the transmission of small C-bre-mediated nociceptive input to the ascending sensory columns through the mechanism of pain gating (Han & Terenius 1982), thus reducing the experience of pain. Segmental mechanisms of pain control are most likely to act locally, and are probably responsible for the analgesic eects of needling close to the site of pain. Clinical research suggests that pain modulation for musculoskeletal management is enhanced by the use of acupuncture and manual therapy, compared with manual therapy alone (Furlan et al. 2001), for lumbar pain and pelvic pain as an adjunct to stabilization exercises (Cummings 2003), and for sacroiliac dysfunction (Betts 2005). 22
Myofascial pain Recent evidence from the USA on endometriosis pain and dysfunction (Lyttleton 1998; Whyte Ferguson & Gerwin 2005) has suggested that there is an 80% correlation in pain patterns between active abdominal muscle trigger points and the diagnosis of endometriosis. This further supports previous work by Simons et al. (1999), who suggested that the external abdominal oblique muscle may cause abdominal pain and reux; the lateral abdominal muscles causing pain and diarrhoea, and pyramidalis, mirroring endometrial pain. These active trigger points are capable of reproducing strong somatovisceral and viscerosomatic interactions, suggesting that the trigger points are activated by the visceral component, but persist after this component has resolved (Simons et al. 1999). This may result in misleading diagnoses and treatment regimes. Simons et al. (1999) proposed the energy crisis hypothesis, according to which the crisis energy leads to increased production of acetylcholine at a dysfunctional motor end plate, which increases actin and myosin lament contraction, resulting in tight bands within the muscle bre. The consequence of this is increased pressure on surrounding blood vessels, with resulting ischaemic symptoms of pain and paraesthesia, which are made worse by muscle loading and enhanced sympathetic responses, such as anxiety or stress. Research has demonstrated that symptoms such as projectile vomiting, anorexia, intestinal colic, diarrhoea, bladder and bowel sphincter dysfunction, and dysmenorrhoea (Simons et al. 1999) can result from active abdominal trigger points. Assessment and palpation of all abdominal muscles should be a mandatory component of physiotherapy management when treating patients who demonstrate these symptoms. Appropriate trigger-point needling (Whyte Ferguson & Gerwin 2005) should be undertaken, followed by myofascial release techniques (Chaitow 2001) and accompanying muscle imbalance re-education (Wedenberg et al. 2000).
Brain and limbic system The action of de qi, and the classic description of a heavy, numb or sore sensation mediated by the activation of the small C-bres are essential components of acupuncture eectiveness (Abad-Alegria & Giaz 2004). It is essential for producing analgesia (Lundeberg 1995) via the
Acupuncture and hormones
endogenous opiate system. Ascending C-bre mediates nociceptive input and stimulates the periaquaductal grey, hypothalamus and pituitary (Wang et al. 1990), which in turn stimulate the release of serotonin, norepinephrine, histamine, bradykinin, endorphin, dopamine and adrenocorticotrophic hormone (ACTH) (Chen & Han 1992). These chemicals modulate pain by both pre- and post-synaptic inhibition. Endorphin-like substances also appear in the cerebrospinal uid after needling (Shen 2001); ACTH passes to the kidneys and stimulates the release of cortisol (Han et al. 1992), a powerful systemic anti-inammatory. At the hypothalamuspituitary axis, we see enhanced levels of oxytocin release following acupuncture, leading to improved mood state, relaxation and general quality of life, whilst reducing anxiety and sympathetic hyperalgesia (Alison et al. 2003). The stimulation of -endorphin is known to deactivate norepinephrine, which is known to be responsible for increased climacteric responses in menopausal ashes, improving stamina and personal drive (Sandberg 2002; Cohen 2003). This is well presented in TCM gynaecology texts, where calming of liver and heart qi and enhancement of spleen and kidney qi (Maciocia 1998) are suggested protocols for the treatment of menopausal syndrome (Jang et al. 2003).
Beyond pain The practitioner should look beyond pain in order to encompass the TCM philosophy of homeostasis and balance, especially in the area of hormonal response. Acupuncture does not stop at the hypothalamus. The hippocampus, which is thought to be involved in memory, cognitive problem-solving skills, and the storing and processing of physical and spatial information, is believed to become highly susceptible to uctuations in oestrogen and progesterone levels. This is often reported by patients during periods of uctuation, such as the menopause, and the premenstrual and postnatal periods. In a study by Dong et al. (2001), acupuncture signicantly improved vasomotor symptoms at the end of treatment (P=0.0001) and at 3-month follow-up (P=0.003). It did not change psychosocial or sexual symptoms. Sandberg et al. (2002) found signicant changes in mood scale in the EA group over supercial acupuncture needling. Quah-Smith et al. (2005) conducted a study of mild to moderate depres 2007 Association of Chartered Physiotherapists in Womens Health
sion in postnatal patients in a primary care setting. A low-level laser was used and patients were randomized to active or inactive laser acupuncture. Beck Depression Inventory (BDI) scores revealed signicant falls (P=0.007) 12 weeks after treatment, although this study involved a small sample size and a short posttrial follow-up period. The improvement in BDI scores was not signicant at 4 weeks, but became so at 12 weeks, which may be a result of natural resolution of the disorder. Betts (2005) suggested that acupuncture may be valuable as an emotional support for postnatal patients experiencing depression that persists for more than 2 weeks. Postnatal depression is often accompanied by poor appetite, insomnia, and feelings of hopelessness and violence. Deciencies of qi, blood and yin, accompanied by stasis of blood, are important concepts in TCM diagnosis. Acupuncture is aimed at lifting qi, resolving stasis, and aiding recovery and return to homeostasis, thereby enabling the patient to manage this interim period. Flaws (2006) indicated its use in mild to moderate premenstrual tension (PMT) as a means of restoring homeostasis and preventing large doses of antidepressant therapy. Bosco Guerreiro da Silva et al. (2005) compared the eects of acupuncture on a group of pregnant women with those undergoing conventional treatment for insomnia. Statistical dierence was demonstrated in the acupuncture group (P=0.0028), with a 50% decrease in insomnia scores for the acupuncture group in comparison to the controls. Increased levels of the serum concentration of melatonin in the blood were demonstrated after acupuncture, levels that are often lowered in pregnant women. Blitzer et al. (2004) looked at the eects of acupuncture on treatment of major depressive disorder using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders criteria, as well as the BDI I and II, and Reynolds Depression Survey Inventory (RDSI), which indicated signicant improvements following acupuncture treatment (BDI, P=0.01; RDSI, P=0.03). More signicantly, none of the participants in the group treated with acupuncture met the criteria for a major depressive disorder at the conclusion of the study. Magnetic resonance imaging evidence suggests enhanced activity in the hippocampus following acupuncture (Wu et al. 1999), while acupuncture appears to modulate the limbic system (Hui et al. 23
J. Longbottom
2002). The latter study by Hui et al. (2002) reinforces the need to attain de qi stimulation in order to moderate activity in the limbic system, with particular attention needing to be paid to the area of the anterior cingulate nucleus, which is thought to be responsible for expectations and attention (Abad-Algeria & Pomaron 2004). Does this mean that acupuncture may just help us nd those things we keep losing, especially during the premenstrual and menopausal periods . . . or even at normal times of the day? Reproduction In terms of fertility and the development of a healthy foetus, it is known that healthy levels of progesterone are required for maintenance of pregnancy and stimulation of leutinizing hormone (LH) for the continued development of the corpora lutea. Recent research using acupuncture before embryo transplant and after in vitro fertilization (Paulus 2002; Lyttleton 2004; Stener-Victorin 2004) has demonstrated improved clinical pregnancy rates (42.5% in the acupuncture group compared with 26.3% in the controls; P=0.03). The use of acupuncture in the treatment of blood ow impedance in uterine arteries resulting in infertility (Stener-Victorin et al. 2003) has always been referred to as a cold uterus in TCM (Betts 2005). In a group of infertile women diagnosed with polycystic ovary syndrome, acupuncture resulted in the induction of normal ovulatory cycles in one-third of the group receiving acupuncture, compared with no ovulation in the group with hormonal implants. We must not forget the males . . . In a group of healthy, non-fertile men, acupuncture was seen to increase the viability of live sperm after acupuncture (P=0.05), as well as increasing the percentage of live, viable sperm (P=0.5) (Siterman et al. 1997). And so to sleep . . . Stimulation of melatonin from the pineal gland (Sok et al. 2003) following acupuncture enhances rapid eye movement during deep sleep while stimulating normal circadian rhythms, releasing increased levels of growth hormone and stimulation of follicle stimulating hormone (FSH). This is thought to induce deeper, dream sleep, which enhances cartilage growth via chondro24
cytes, osteoclasts for bone repair and myoblasts for muscle repair. It is thought to have a modifying eect on joint and muscle pain associated with sleep deprivation in patients with bromyalgia and chronic fatigue (Bosco Guerreiro da Silva et al. 2005). Urinary dysfunction Acupuncture has been used extensively in the treatment of incontinence and pelvic oor rehabilitation, increasing levels of arginine vasopressin as a means of controlling urine volume in order to facilitate the rehabilitation and retraining of urinary urge incontinence (Liu et al. 2002). Vasopressin causes the kidneys to conserve water and concentrates urine, reducing the urine volume (Yang et al. 2003; Kelleher et al. 1994). Kelleher et al. (1994) suggested a given protocol to lift kidney and bladder qi, in an attempt to hold uid within the bladder and help in pelvic oor retraining. And nally, the menopause . . . This is a subject that is currently very dear to the heart of the present author, and one that often causes angst and embarrassment for patients. According to TCM (Maciocia 1998), the menopause is a time when blood and qi, which have been previously required within the pelvic basin for reproduction, are taken away from the uterus and converge on the brain. Menstruation ceases and subsequent body changes take place. In TCM philosophy, wisdom and insight come with this change, and the wise woman of the village emerges. Within a Western paradigm, this is not an easy concept to embrace, but we do see vast changes in body mass index, shape, hair and skin. We also see huge uctuations in emotional responses, raging from a state of euphoria to depression, memory loss and anxiety. The menopause oers a period of mourning for some women, with children leaving home, loss of attractiveness and emotional lability. For others, it may oer a period of enhanced liberation . . . The essential problem encountered at this time is the onset of climacteric symptoms (hot ushes) owing to a fall in oestradiol, progesterone, FSH and LH, combined with an increase in prolactin (Dong et al. 2001). In the study by Dong et al. (2001), climacteric conditions were eased by 50% (P=0.00001) and physical discomfort by 50% (P=0.014), which was maintained for up to 3 months following the trial. There was no improvement in psychosexual symptoms or
Acupuncture and hormones
measured reproductive hormones. Again, in TCM philosophy, the aim is to boost kidney and spleen qi as a means of relieving exhaustion, calming liver and heart re so as to relieve heightened sympathetic hyperaemia and hot ushes. Conclusion The present paper seeks to oer the practitioner a variety of clinical tools that go beyond pain, but that may contribute to improved quality of life and well-being in some patients. It is by no means a denitive model, and there are many areas that have not been covered. The author hopes that it has oered the reader a greater insight into this powerful modality, which we as physiotherapists are privileged to have within our clinical toolbox. In the UK, physiotherapists are able to use this skill to enhance their practice, while in various other countries, acupuncture it is not available to these clinicians, remaining in the domain of physicians and consultants. Acupuncture is a powerful modality when used with knowledge, clinical reasoning skills, and against a background of evidence to support the choice of points and treatment diagnosis. Its power should not be abused and should never be used as a mere adjunct when other modalities fail to produce results. It is hoped that the present paper may change practice, and stimulate a desire to know more and seek further training in acupuncture in the exciting challenge of womens health. References
Abad-Alegria F. & Giaz C. P. (2004) About the neurobiological foundations of the De-Qi-stimulus-response relation. American Journal of Chinese Medicine 32 (5), 807814. Alison J., Douglas P., Brunton J., et al. (2003) Neuroendocrine responses to stress in mice: hyporesponsiveness in pregnancy and parturition. Endocrinology 144 (12), 52685276. Betts D. (2005) The Essential Guide to Acupuncture and Childbirth. Journal of Chinese Medicine, Kingham, Oxfordshire. Blitzer L., Atchinson-Nevel D. & Kenny M. (2004) Using acupuncture to treat major depressive disorder: a pilot investigation. Clinical Acupuncture and Oriental Medicine 4, 144147. Bosco Guerreiro da Silva J., Uchiyama Nakamura M., Cordeiro J. A. & Kulay L. (2005) Acupuncture for low back pain in pregnancy a prospective, quasirandomised, controlled study. Acupuncture in Medicine 22 (2), 6067.
Cao X. (2002) Scientic basis of acupuncture analgesia. Acupuncture in Electro-Therapeutics Research International Journal 27, 114. Carlsson C. P. & Sjolund B. H. (2001) Acupuncture and subtypes of chronic pain: assessment of long-term results. Clinical Journal of Pain 10, 290295. Chaitow L. (2001) Muscle Energy Techniques, 2nd edn. Churchill Livingstone, Edinburgh. Chen G. (2001) Understanding the increase in therapeutic eect in auricular therapy. International Journal of Clinical Acupuncture 12 (1), 5155. Chen X. H. & Han J. S. (1992) All three types of opioid receptors in the spinal cord are important for 2/15 Hz electroacupuncture analgesia. European Journal of Pharmacology 211 (2), 203210. Cohen S. M. (2003) Can acupuncture ease the symptoms of menopause? Holistic Nursing Practice 10, 161169. Cummings M. (2003) Acupuncture for low back pain in pregnancy. Acupuncture in Medicine 21 (12), 4246. Dong H. G., Ludicke F., Comte I., et al. (2001) An exploratory pilot study of acupuncture on the quality of life and reproductive hormone secretion in menopausal women. Journal of Alternative and Complementary Medicine 7 (6), 651658. Ercolani M., Bertoli F., Caramalli C., et al. (1997) Modication of psycho-immune-endocrine parameters in patients suering from Candida albicans hypersensitivity using acupuncture. Giornale Italiano di Riessoterapia ed Agopuntura 9 (1), 1120. Flaws B. (1986) Leucorrhoea and vaginitis: their dierential diagnosis and treatment. American Journal of Acupuncture 14 (4), 305315. Furlan A., Clarke J. & Esmail R. (2001) A critical review on the treatment of chronic low back pain. Spine 26 (7), 155162. Han J. S. & Terenius L. (1982) The neurochemical basis of acupuncture analgesia. Annual Review of Pharmacology and Toxicology 22, 91104. Han J. S. (2004) Acupuncture and endorphins. Neuroscience Letters 361, 258261. Han J. S., Chen X. H., Sun S. L., et al. (1991) Eect of lowand high-frequency TENS on Met-enkephalin-Arg-Phe and dynorphin A immunoreactivity in human lumbar CSF. Pain 47, 295298. Hsieh C. L. (1998) Modulation of cerebral cortex in acupuncture stimulation: a study using sympathetic skin response and somatosensory evoked potentials. American Journal of Chinese Medicine 26 (1), 111. Hui K. K., Zylowska L., Hui E. K., Yu J. L. & Li J. J. (2002) Introducing integrative EastWest medicine to medical students and residents. Journal of Alternative and Complementary Medicine 8 (4), 507515. Illiev E., Popov J. & Niclov K. (1990) The eects of psychological factors and the inuence of electroacupuncture on immunological parameters in patients. Acupuncture in Medicine 8 (2), 5658. Jang I., Cho K., Moon S., et al. (2003) A study on the central neural pathway of the heart, Nei-Kuan (EH6) and Shenmen (He 7) with neural tracer in rats. American Journal of Chinese Medicine 31 (4), 591609. Kelleher C. J., Filshie J., Burton G., Khullar V. & Cardozo L. D. (1994) Acupuncture and the treatment of irritative bladder symptoms. Acupuncture in Medicine 12 (1), 912.
25
J. Longbottom
Liu Z., Liu B., Yang T., et al. (2002) Clinical study of electroacupuncture: treatment of senile urge urinary incontinence. International Journal of Clinical Acupuncture 13 (4), 255262. Lundeberg T. (1995) Pain physiology and principles of treatment. Scandinavian Journal of Rehabilitation Medicine 32 (Suppl.), 1342. Lyttleton J. (1998) Endometriosis. Journal of Chinese Medicine 26 (January), 18. Lyttleton J. (2004) Treatment of Infertility with Chinese Medicine. Churchill Livingstone, Edinburgh. Maciocia G. (1998) Obstetrics and Gynaecology in Chinese Medicine. Churchill Livingstone, Edinburgh. Mendelson G., Selwood T. S., Kranz H., et al. (1983) Acupuncture treatment of chronic low back pain: a double-blind, placebo-controlled trail. American Journal of Medicine 74 (1), 4955. Paulus W. E., Zhang M., Strehler E., El-Danasouri I. & Sterzik K. (2002) Inuence of acupuncture on the pregnancy rate in patients who undergo assisted reproduction therapy. Fertility and Sterility 77 (4), 721724. Quah-Smith J. I., Tang W. M. & Russell J. (2005) Laser acupuncture for mild to moderate depression in a primary care setting a randomised controlled trial. Acupuncture in Medicine 23 (3), 103111. Rosted P. (1994) Survey of recent clinical studies on the treatment of skin diseases with acupuncture. American Journal of Acupuncture 22 (4), 357361. Sandberg M., Lundeberg T., Lars-Goran L. & Gerdle B. (2003) Eects of acupuncture on skin and muscle blood ow in healthy subjects. European Journal of Applied Physiology 90, 114119. Sandberg M., Wijma K., Wyton Y., Nedstrand E. & Hammar M. (2002) Eects of electro-acupuncture on psychological distress in postmenopausal women. Complementary Therapies in Medicine 10, 161169. Shen J. (2001) Research on the neurophysiological mechanisms of acupuncture: review of selected studies and methodological issues. Journal of Alternative and Complementary Medicine 7 (Suppl. 1), S121S127. Simons D. G., Travell J. G. & Simons L. S. (eds) (1999) Travell & Simons Myofascial Pain and Dysfunction: The Trigger Point Manual, Vol. 1: The Upper Half of the Body, 2nd edn. Williams and Wilkins, Baltimore, MD. Siterman S., Eltes F., Wolfson V., Zabludovsky N. & Bartoov B. (1997) Eects of acupuncture on sperm parameters of males suering from subfertility related to low sperm quality. Archives of Andrology 39 (2), 155161. Sok S. R., Erlen J. A. & Kim K. B. (2003) Eects of acupuncture therapy on insomnia. Journal of Advanced Nursing 44 (4), 375384. Stener-Victorin E., Waldenstrom U., Wikland M., et al. (2003) Electro-acupuncture as a preoperative analgesic method and its eects on implantation rate and neuropeptide Y concentrations in follicular uid. Human Reproduction 18 (7), 14541460. Stener-Victorin E., Lundeberg T., Cajander L. A., et al. (2004) Steroid-induced polycystic ovaries in rats: eect of electro-acupuncture on concentrations of endothelin-1 and nerve growth factor (NGF), and expression of NGF mRNA in the ovaries, the adrenal glands, and the central nervous system. Reproductive Biology and Endocrinology 1 (33), 133. Tucker T. (2004) The treatment of interstitial cystitis by acupuncture. Journal of Chinese Medicine 75, 3844. Wang Q., Li-Min M. & Ji-Sheng H. (1990) The role of periaquaductal gray in mediation of analgesia produced by dierent frequencies electro-acupuncture stimulation in rats. International Journal of Neuroscience 53, 176172. Wedenberg K., Moen B. & Norling A. (2000) A prospective randomized study comparing acupuncture and physiotherapy for low back pain and pelvic pain. Acta Obstetricia et Gynecologica Scandinavica 79, 331335. Whyte Ferguson L. & Gerwin R. (2005) Clinical Mastery in the Treatment of Myofascial Pain. Culinary and Hospitality Industry Publications Services, Weimar, TX. Wu M.-T., Hsieh J.-C., Xiong J., et al. (1999) Central nervous pathway for acupuncture stimulation: localization of processing with functional magnetic imaging of the brain preliminary experience. Neuroradiology 212, 133419. Yang Y., Liu Z. & Liu Y. (2003) Electroacupuncture at Ciliao and Huiyang for treating neuropathic incontinence of 30 cases. Journal of Chinese Medicine 23 (1), 5354.
Jennie Longbottom is chair of the Acupuncture Association of Chartered Physiotherapists (AACP), a member of the British Acupuncture Council and runs a private practice. She lectures at undergraduate, postgraduate and MSc level. Her special interest is chronic pain, with a particular focus on chronic pelvic pain and complex pain syndromes.
26
The perils of the perimenopause: contraceptive and hormonal needs in the perimenopause
A. E. Evans
Bristol Royal Inrmary and Bristol Nueld Hospital, Bristol, UK
Abstract The perimenopause is poorly understood by women and healthcare professionals alike. It is a time of hormonal instability, resulting in altered menstrual patterns, worsening premenstrual syndrome, and for many women, multiple symptomatology, which is often misdiagnosed and treated as depression. The contraceptive needs of older women have never been more important than they are today in our changing society, nor have their choices ever been so great. Sadly, many women over 35 years of age are not having these needs met, and unplanned pregnancy and termination rates are rising. Many women in their late thirties, and even more in their mid-forties, are experiencing the eects of their uctuating hormonal environment. Many of the hormonal contraceptive options available would help to stabilize this and ameliorate early symptoms. For those not seeking or needing contraception, there are various techniques for stabilizing a womans underlying hormonal environment: principally, transdermal or percutaneous luteal phase oestradiol, and intrauterine levonorgestrel. These techniques are little-used, and merit further exploration and validation. The present paper seeks to address some of the problems of the perimenopause and their possible solutions.
Keywords: hormonal instability, levonorgestrel intrauterine system, non-contraceptive benets, percutaneous oestradiol, perimenopause.
Introduction The contraceptive needs of older women have never been more important than they are today in our changing society, nor have their choices ever been so great. Sadly, many women over 35 years of age are not having these needs met, and unplanned pregnancy and termination rates are rising (ONS 2002). Many women in their late thirties, and even more in their mid-forties, are experiencing the eects of their uctuating hormonal environment. Many of the available hormonal contraceptive options would help to stabilize this and ameliorate early symptoms. However, most women and their general practitioners are unaware of this, or indeed, believe that they are too old to use hormones or that it would be risky in some way. For a few, there might be
Correspondence: Dr Annie Evans, Senior Clinical Medical Ocer in Sexual Health, Womens Health Specialist, Bristol Royal Inrmary and Bristol Nueld Hospital, 3 Clifton Hill, Bristol BS8 1BP, UK (e-mail: annie.dr@virgin.net).
genuine medical risk, but most could benet substantially from ecient contraception and hormonal stabilization. It should be the role of the doctor or practice nurse to proactively initiate discussion at various stages in a womans life after childbirth, and during her late thirties and forties when many women or couples may be considering sterilization. Changes in society With divorce rates in the UK running at around 41% of all marriages (ONS 2002), many women in their middle youth nd themselves back out in the sexual market-place. Not only must they cope with the demands of their growing children, they often form new relationships, and therefore, must start dealing once more with the issues of contraception and sexual health. If, as so often is the case, their ex-husband has had a vasectomy, they have not had to face these considerations for many years, and are often unaware of modern choices. 27
A. E. Evans
Box 1. Challenges in the perimenopause
+ + + + + + + + + +
Box 2. Symptoms of the perimenopause

+ + + + + + + + + + +
Y [ Y Y Y Y Y [ Y Y
Fertility Hormonal instability Termination of pregnancy rate Miscarriage rate Risk of foetal abnormality Maternal morbidity Perinatal mortality Sexual frequency Delaying rst pregnancy Women with new partners
Heavier menstrual loss Reduced cycle length Increased premenstrual syndrome, irritation, paranoia, panic Premenstrual and menstrual migraine Insomnia, tiredness Joint aches, u-like symptoms Breast tenderness Poor concentration, verbal memory Loss of libido, loss of drive Inability to multitask Inability to cope!
The perimenopause It is becoming increasingly apparent that the transition into the menopause, specically the perimenopausal period, is a gradual process that happens over many years. The age of onset and the duration of this perimenopausal phase can vary greatly (Li et al. 1996). Most women do not move from regular menstruation to sudden amenorrhoea, but rather, experience a time of menstrual irregularity, often with shortened or irregular cycles. Many women report increased premenstrual symptomatology, including headaches and migraine (MacGregor 1997), increased menstrual ow, and more painful periods. This is a time of huge hormonal variability, with hormone levels uctuating more intensely than at any other stage of a womans life. For some, this leads to a variety of problems, including insomnia, emotional lability, forgetfulness, poor concentration, joint aches and tiredness. This is a time, above all others, when a woman may turn for advice to the medical profession. To the unwary, this constellation of symptoms could be misinterpreted as depression and it is certain that signicant numbers of women are inappropriately labelled in this way. Many will be oered antidepressant medication unnecessarily. Unfortunately, at the present time, clinical trial data are insucient to establish evidence-based treatment standards and clinicians may need to rely on experience when considering management options (Rebar et al. 2000). The need to include the woman herself in the decision-making process is self-evident. The problem is to balance her need for contraception with that for hormonal support and to allow her to make an informed choice. The perimenopause as an entity has only been recognized recently and little reference is made to it in standard gynaecological texts, making its management challenging (see Boxes 1 & 2). 28
Table 1. Fertility rate (i.e. pregnancies per 100 womenyears) by age (adapted from Evans 2000) Age (years) Variable Fertility rate (%) <25 85 40 45 45 15
Decreasing fertility rates Many women assume that it is impossible to conceive in their mid-forties, and although fertility declines with age, risks of unplanned conception are much greater than expected. Reliable methods of contraception are still needed to avoid unintended pregnancy. Half of all women are still fertile at 40 years of age (see Table 1). Termination of pregnancy Women aged over 40 years in the UK have the highest termination of pregnancy rate per number of conceptions (40%) of any age group of women, including teenagers (ONS 2002). This is an indication that most pregnancies in this group are unplanned and unwanted. It would be innitely preferable to avoid this situation by allowing women sucient knowledge of available contraceptive options. What methods do older women use? There is a steady transition in the UK away from hormonal methods and towards sterilization with advancing age (see Fig. 1). By the age of 35 years, only about one in three women use hormonal methods. At least 40% of couples over the age of 40 years rely on female or male sterilization, but there are now increasing numbers of highly eective, reversible methods available. The Royal College of Obstetricians and Gynaecologists sterilization guidelines (RCOG 1999) recommended that all couples
Contraceptive and hormonal needs in the perimenopause

Box 3. Risk factors for arterial disease contraindicating combined oral contraceptive use in women over 35 years of age: (BMI) Body Mass Index
+ + + + + +
Cigarette smoking Family history of cardiovascular disease in a parent or sibling <45 years of age Diabetes mellitus Hypertension >140/90 Obesity (BMI>35) Migraine (including without aura in this age group)
Box 4. Risk factors for venous thromboembolism (VTE). N.B. Smoking <10 cigarettes per day is not a risk factor for VTE: (BMI) Body Mass Index
Figure 1. Patterns of UK contraceptive use by age and method in 2002 (information on le at Schering Health Care Ltd, Burgess Hill, UK): (IUD) intrauterine device.
+ + + + +
Previous deep vein thrombosis/pulmonary embolism Family history of unprovoked VTE in a rst-degree relative <45 years of age Obesity (BMI>39) Immobility Extensive varicose veins
should be fully counselled about all such alternatives, before proceeding to sterilisation. More than just contraception: positive health benets Many women would more than welcome the chance to eliminate some of their perimenopausal symptoms, and these possibilities should be discussed with them. The ability to stabilize a womans hormonal environment, perhaps by use of the combined Pill, in a non-smoker with no other risk factors, may well enhance the quality of her life. Combined oral contraceptive use in the perimenopause Many women who stop the combined Pill to be sterilized experience unwelcome hormonal and menstrual changes, and conversely, those who do continue the combined oral contraceptive (COC) into their forties report that they continue to feel well. There are many fears and misconceptions about using the Pill, and the duration of its use in this older age group, that need to be addressed. Modern, 20- g COCs oer rst-rate contraception, along with the benets of regular, predictable light withdrawal bleeds and masking of early menopausal symptoms. This can be of particular advantage to those women developing menorrhagia and dysmenorrhoea at this stage in their lives, where previously hysterectomy might have been considered the best option. It can also help to control worsening perimenopausal presmenstrual syndrome (PMS) and mood change, and give back a sense of control to many women
whose lives are being made more dicult by the unpredictability of these perimenopausal years. Our job is to ensure that COCs are not given to risky women. So long as a woman is a healthy, migraine-free, a non-smoker and has no other risk factors for arterial disease, the term contraceptive gap no longer applies, and at her request, the COC may legitimately be taken through to the menopause. Age alone is no longer considered a contraindication (see Box 3). The consensus of opinion is that lower oestrogen doses should probably be used be used over the age of 40 years if the COC is to be continued (Poulter et al. 1999). It would appear that the modern progestogens (usually to be found in 20- g preparations) are indeed less likely to cause cerebrothrombotic events than those found in older-generation Pills (Lidegaard & Kreiner 2002). Thus, risky women in this age group would also include those with risk factors for venous thromboembolism (see Box 4). Although a recent study by Marchbanks et al. (2002) found no increased risk of breast cancer among women who were current users of lowdose COCs in the 4554-year-old age group, the above authors concluded that their ndings may not be conclusive, and further investigation of this question is merited. It is no longer disputed that the COC provides protection from cancer of the ovary and endometrium, whose incidence rises particularly above the age 40 years. Overall, the balance would appear to be in favour of COC use in risk-free older women being benecial. It provides reliable contraception, along with the add-on benets of 29
A. E. Evans
cycle-control, symptom relief and protection from osteoporosis. The combined oral contraceptive/hormone replacement therapy overlap After the menopause (or leading up to it, if contraception is not an issue), natural oestrogen (17 -oestradiol) is sucient for symptom relief; however, it is not contraceptive. If women stay on the COC until the menopause, how can this event be diagnosed and infertility be assured? One method is to try measuring the follicle stimulating hormone (FSH) at the end of the Pill-free week in a woman of 50 years of age. If it is still normal, she cannot be advised to stop using contraception, but nor would it seem wise to continue the COC indenitely, and therefore, a switch to an oestrogen-free method might be advisable. If the FSH is at menopausal levels on two to three occasions, she might be advised to switch, if she chooses, straight to hormone replacement therapy (HRT). Hormonal stabilization without use of combined oral contraceptive The most eective method of ameliorating the premenstrual symptoms encountered in the perimenopause (whether these are predominantly physical, such as migraine, or mood-related) is to attempt to stabilize the hormonal milieu in the luteal phase. In a woman whose menstrual pattern is still regular, this is achieved by delivering a stable dose of oestradiol via a transdermal patch or percutaneous gel for the second half of each cycle. Oral dosage of oestrogen produces uctuating levels and may exacerbate the symptoms. This treatment has been shown to be eective in preventing both premenstrual/ menstrual migraine (MacGregor et al. 2003) and perimenopause-related depression (Schmidt et al. 2000). However, a prediction of the timing of the luteal phase cannot be made in women with irregular cycles, and oestrogen must be delivered continuously. This necessitates opposition with progestogen, since there may be a risk of endometrial thickening otherwise. Adding a cyclical progesterone, as in conventional HRT, may reproduce many of the premenstrual symptoms already exacerbated by the perimenopause itself. The better option is to use a locally delivered progestogen to protect the endometrium, using a progestogen-loaded intrauterine system (IUS). 30
Contraceptive choices with add-on benets in older women The levonorgestrel IUS (LNG-IUS) has been hailed as one of the major advances in the eld of contraception since the introduction of the Pill. It is not only a highly eective and reversible method, but it also has other noncontraceptive benets. Local release of LNG produces an inactive and atrophic endometrium, and therefore, normal menstrual ow is reduced. In turn, this leads to less endometrial prostaglandin production, and therefore, less dysmenorrhoea. Studies have shown an objective reduction in menstrual loss (86% and 97% after 3 and 12 months, respectively; Andersson & Rybo 1990). Seventeen per cent of users are amenorrhoeic after one year of use (Ronnerdag & Odlind 1999), 27% by the end of the rst 5 years and up to 60% after another 5 years. The number of bleeding days per cycle also gradually diminishes. Within 30 days of removal, the endometrium has returned to normal and menstruation occurs (Silverberg et al. 1986). Thus, the LNG-IUS is easily and completely reversible. Lack of systemic side-effects with intrauterine system use The systemic absorption of LNG is extremely low (two progestogen-only Pills per week; Guillebaud 1997), thus minimizing side-eects such as breast tenderness, greasy skin and hair, headaches, and abdominal bloating. The plasma oestradiol of users remains within the normal range (Luukkainen et al. 1990), which is important for perimenopausal women. Other benets of intrauterine system use The ectopic pregnancy rate in users is exceptionally low, being ten times less than the ectopic rate for Nova-T users (0.02 versus 0.25 per 100 women-years; Andersson et al. 1994). The incidence of pelvic inammatory disease is also much lower than for copper intrauterine devices, because of a combination of factors including thickening of the cervical mucus, endometrial suppression and reduced bleeding (Toivonen et al. 1991). Efficient reversible contraception The pregnancy rate in LNG-IUS users has been shown to be exceptionally low (Pearl index=0.16). The gross cumulative pregnancy
Contraceptive and hormonal needs in the perimenopause
rate at 3 years is 0.3 per 100 users. Given that the real use failure rate of many contraceptive methods reliant on committed use and user memory are considerably higher than their quoted method failure rates (or even the rates achieved in trial circumstances), it is important to recognize that real use and method failure rates are almost equivalent in the case of the IUS (Trussell 1998). User acceptability The extremely low side-eect prole, combined with the obvious benets of reduced or absent menstrual ow, less dysmenorrhoea and an improvement in PMS, are all reected in extremely high continuation rates, with one study showing 81% at 3 years and 65% at 5 years (Backman et al. 2000). Long-term use of the intrauterine system An important study of long-term IUS use was reported by Ronnerdag & Odlind (1999). The above authors followed 82 women in Uppsala, Sweden, who were oered a second IUS after prolonged, 7-year use of a rst device. The women were seen annually over the subsequent 5 years. There were no reported pregnancies and 77% of these women reported no health problems at all during the study period. At the start of the study, 26% of women had no bleeding, 70% had regular, scanty bleeds, and 4% had irregular, scanty bleeds. At the end of the second, 5-year period, 60% reported amenorrhoea, 28% regular, scanty bleeds, and 12% irregular, scanty bleeds. Overall, haemoglobin levels rose. Mean body weight rose by 0.5 kg per year (which is equal to non-hormonal users). Seven women became postmenopausal during the follow-up period, but there was no change in bleeding pattern following the introduction of HRT. Long-term benets of the intrauterine system in the perimenopause The LNG-IUS also provides an eective method of delivering progestogenic opposition to oestrogen in hormone replacement therapy (Wolter-Svensson et al. 1997), especially in the perimenopausal age group, in whom the incidence of dysfunctional uterine bleeding is high and there is still a need for contraception (Suvanto-Luukkonen et al. 1997).
Conclusion Our aim as health professionals should be to guide each woman towards informed choices, while dispelling myths along the way. We should not miss this golden opportunity to control the hormonal milieu and help improve quality of life in the perimenopause.
References
Andersson K. & Rybo G. (1990) Levonorgestrel-releasing intrauterine device in the treatment of menorrhagia. British Journal of Obstetrics and Gynaecology 97, 690 694. Andersson K., Odlind V. & Rybo G. (1994) Levonorgestrel-releasing and copper-releasing (Nova T) IUDs during 5 years of use: a randomised comparative trial. Contraception 49, 5672. Backman T., Huhtala S., Tuominen J., et al. (2000) Length of use and symptoms associated with premature removal of levonorgestrel-releasing intrauterine system: a nationwide study of 17,360 users. British Journal of Obstetrics and Gynaecology 107, 335339. Evans A. (2000) The contraceptive needs of women over 30. Trends in Urology, Gynaecology and Sexual Health 5 (Suppl.), 26. Guillebaud J. (1997) The Pill, 5th edn. Oxford University Press, Oxford. Li S., Lanuza D., Gulanick M., et al. (1996) Perimenopause: the transition into menopause. Health Care for Women International 17, 293306. Lidegaard O. & Kreiner S. (2002) Oral contraceptives and cerebral thrombosis: a ve-year national case-control study. Contraception 65, 197205. Luukkainen T., Lahteenmaki P. & Toivonen J. (1990) Levonorgestrel-releasing intrauterine system. Annals of Medicine 22, 8590. MacGregor E. A. (1997) Menstruation, sex hormones and migraine. Headache 15, 125141. MacGregor E. A., Frith A., Ellis J. & Aspinall L. (2003) Estrogen withdrawal: a trigger for migraine? A doubleblind placebo-controlled study of estrogen supplements in the late luteal phase in women with menstruallyrelated migraine. Cephalgia 23, 684. Marchbanks P., McDonald J. A., Wilson H. G., et al. (2002) Oral contraceptives and the risk of breast cancer. New England Journal of Medicine 346, 20252032. Oce for National Statistics (ONS) (2002) Social Trends Document, No. 32. The Stationery Oce, London. Poulter N., Chang C. L., Farley T. M. M., et al. (1999) Eect on stroke of dierent progestogens in low-dose oestrogen oral contraceptives. Lancet 354, 301302. Rebar R. W., Natchigall L. E., Avis N. E., et al. (2000) Clinical challenges in the perimenopause: consensus opinion of the North American Menopause Society. Menopause 7, 513. Ronnerdag M. & Odlind V. (1999) Health eects of longterm use of intrauterine levonorgestrel releasing system. Acta Obstetricia et Gynecologica Scandinavica 78, 716 721. Royal College of Obstetricians and Gynaecologists (RGOG) (1999) Evidence-Based Guidelines, No. 4: Male
31
A. E. Evans
and Female Sterilisation. Royal College of Obstetricians and Gynaecologists, London. Schmidt P. J., Lynette N., Danaceau M. A., et al. (2000) Estrogen replacement in perimenopause-related depression: a preliminary report. American Journal of Obstetrics and Gynecology 183, 414420. Silverberg S. G., Haukkkamaa M., Arko H., Nilsson C. G. & Luukkainen T. (1986) Endometrial morphology during long-term use of levonorgestrel-releasing devices. International Journal of Gynecological Pathology 5 (3), 235241. Suvanto-Luukkonen E., Sundstrom H., Penittinen J., et al. (1997) Percutaneous estradiol gel with an intrauterine levonorgestrel releasing device or natural progesterone in hormone replacement therapy. Maturitas 26, 211217. Toivonen J., Luukkainen T. & Allonen H. (1991) Protective eect of intrauterine release of levonorgestrel on pelvic infection: three years comparative experience of levonorgestrel- and copper-releasing devices. Obstetrics and Gynecology 77, 261264. Trussell J. (1998) Contraceptive ecacy. In: Contraceptive Technology, 17th edn (eds R. A. Hatcher, J. Trussell, R. Stewart, et al.), pp. 800801. Ardent Media, New York, NY. Wolter-Svensson L., Stadberg E., Andersson K., et al. (1997) Intrauterine administration of levonorgestrel in perimenopausal hormone replacement therapy. Acta Obstetricia et Gynecologica Scandinavica 76, 449454.
Dr Annie Evans is a womens health specialist at the Bristol Royal Inrmary and Bristol Nueld Hospital. This article is based on lectures given nationally and internationally, some of which have been supported by educational grants by Schering, Organon and Janssen Cilag.
32
Multi-convergent therapy in the treatment of medically unexplained symptoms: a brief journey in time
M. Sadlier
Department of Physiotherapy, University Hospital of Wales, Cardi, UK
Abstract Medically unexplained symptoms (MUS), which mostly occur in women, are generally chronic and disabling conditions that present with extensive subjective symptoms, although objective ndings or causal explanations are lacking. Not only are MUS very disabling, but these incur a high cost to both patients and health providers. Multi-convergent therapy (MCT), which blends aspects of cognitive behavioural and physical therapy in a seamless way, is one approach to dealing with conditions that defy certainty. Its emphasis is on how our perceptions, behaviours and life inuences shape or evolve us into who and what we are by way of neuroplastic adaptation. Multi-convergent therapy can not only be adapted to dierent conditions, but is also adaptable between patients within the same group. It seeks initially, from the onset of an intense therapeutic relationship, to coach and facilitate patients towards a stronger internal locus of control. Clinical decision-making becomes a shared process, with the patient involved in the development of the strategy from the beginning. Flexibility of repertoire and the dynamic of the interpersonal relationship rather than the application of a given procedure or technique is probably more predictive of positive outcome and is the hallmark of MCT. Triangulated evaluation has shown this approach to be acceptable and cost-eective.
Keywords: gender dierences, medically unexplained symptoms, multi-convergent therapy.
Introduction Patients with medically unexplained symptoms (MUS) tend to be characterized more by symptoms, disability and handicap than by any consistently demonstrable tissue abnormality (Table 1). They are often refractory to reassurance, explanation or conventional medical treatment (Barsky & Borus 1999). The same patients are frequent attendees at general practitioner surgeries (Hamilton et al. 2001) and outpatient clinics, and are responsible for a high proportion of healthcare costs (Zook & Moore 1980; Garnkel et al. 1988). Patients with MUS make up 1530% of all consultations at the primary care level (Kirmayer et al. 2004). These conditions are noted for their overlap, often sharing demographic, clinical and psychosocial features.
Correspondence: Michael Sadlier, Department of Physiotherapy, University Hospital of Wales, Heath Park, Cardi CF14 4XW, UK (e-mail: mike.sadlier@cardiandvale.wales. nhs.uk).
Indeed, it has been said that, given the overlap between these disorders, the label that is assigned is more to do with the chief complaint and clinical speciality than with the actual illness settings (Buchwald & Garrity 1994; Wessely et al. 1999; Aaron & Buchwald 2001). Comparative
Table 1. Functional somatic syndromes by speciality Specialty Gastroenterology Gynaecology Functional somatic syndrome
Irritable bowel syndrome Premenstrual syndrome, chronic pelvic pain Rheumatology Fibromyalgia Cardiology Atypical or non-cardiac chest pain Respiratory medicine Hyperventilation syndrome Infectious diseases (Chronic postviral) fatigue syndrome Neurology Tension headache Dentistry Temporomandibular joint dysfunction, atypical facial pain Ear, nose and throat Globus syndrome Allergy Multiple chemical sensitivity
33
M. Sadlier
investigations in populations from referral clinics have reported that 70% of patients with bromyalgia (FM) meet the case denition for chronic fatigue syndrome (CFS), as do 18% of those with temporomandibular disorders. Furthermore, 80% of patients with FM, 92% of those with CFS and 64% of patients with temporomandibular disorders meet the criteria for irritable bowel syndrome (IBS) (Aaron & Buchwald 2001). Aronowitz (2001) and Sharpe & Carson (2001) have argued that a price has been paid for this emphasis on measurable, objective pathology, to the detriment of a sizeable minority.
recognize that the peaks of depression occur at times of hormonal uctuation in the premenstrual, postpartum and perimenopausal phases. For example, a woman in the perimenopausal phase who has depression but is still having her periods, albeit with fairly low oestrogen levels, may end up been treated with antidepressants rather than oestrogens (Studd & Panay 2004). The predominance of female-to-male ratios is also inuenced by genetic dierences, vulnerability to psychosocial factors related to the stress response, gender roles, and the experience of physical, mental and sexual abuse (Payne 2004). Paradigm shift The deductive approach to patient presentation has made great strides in the eld of medicine, while bringing great benet to patient suering. However, it runs into diculties when the problem presentation is not so clear or when the objective ndings do not match the symptom presentation. This is the realm of MUS or disorders of function. These sizable minorities of presentations involve complex brainbody interfaces. It crosses over the traditional divide between medicine and psychology into the area of neuropsychology, where a network of interacting systems demonstrates bi-directional communication with the central nervous system, which mediates the eects of psychosocial factors, perceptions and behaviours on the production of physical symptoms (Weiner 1992). These processes are all the more important when it comes to understanding symptom presentation and narrative in women, given the greater depth of the limbic system (which inuences the formation of memory by integrating emotional states with stored memories of physical sensations), the high integration with the left and right sides of brain, the profound inuences of the oestrogen cycle, and the more sensitive hypothalamic pituitary adrenal axis. Therapy for women has to acknowledge these dierences, exploring the predisposing, precipitating and perpetuating variables to case presentation. The setting on which this exploration takes place is fundamental to outcome. Therapeutic alliance Communication is essential to maintain trust and credibility. However, the window of opportunity within therapy is limited, especially for patients who are already distressed. Such is its importance that patients can be lost or gained
Gender The rates for MUS are much higher in women than in men. With a prevalence rate of between 10% and 15%, IBS is four times more common in women, with a threefold increase in cholecystectomy, and a twofold increase in appendectomy and hysterectomy. Chronic fatigue syndrome is twice as common in women and headaches are three times more frequent. Chronic pelvic pain aects 1225% of women at any given time. Approximately one-third of women with chronic pelvic pain have IBS (Williams et al. 2005). Women with MUS form a substantial part of the workload of gynaecologists, gastroenterologists and surgeons. Each specialist investigates with their own diagnostic bias, but the source of dysfunction or pain often remains obscure, with a lack of abnormal ndings or failure of symptom resolution despite treatment of the identied pathology. The patients physical and social disability may become compounded by diagnostic confusion, and by prolonged and ineective treatments, including surgery. The end result is often a sense of helplessness in both the patient and the physician. Adding to the complexity is the presence of depression. As a co-morbid presentation, depression may worsen the prognosis of other medical illnesses, including heart disease (Frasure-Smith et al. 1993). The prevalence of major depression is double the rate in women in comparison to men. This can have a dramatic long-term eect in that women who develop major depression in the postpartum period are more likely to have recurrent episodes over the following 5 years and beyond, and their babies are more likely to develop cognitive, social and mood problems (McKinlay et al. 1987). This situation is made all the worse for women by the failure at times to 34
Multi-convergent therapy in the treatment of medically unexplained symptoms
within the rst meeting. The establishment of an equal partnership with the patient on a brief journey together facilitates this trust and credibility, which lies at the heart of the therapeutic relationship. Therefore, the therapeutic alliance is the setting in which an exploration of problems, beliefs, fears and emotions, and the facilitation of positive change, can take place between the therapist and the patient. Its prerequisites are empathic understanding, trust in the therapist and the therapeutic process, freedom of expression, and a multiplicity of perspective empirically supported treatments, such as cognitive, behavioural and cognitive behaviour therapy. It is of note that dierent forms of psychotherapy have been shown to provide eective relief for similar conditions, despite the fact that these therapies are treatment-specic (Chambless & Ollendick 2001). There is nothing new in all of this. In the mid-eighteenth century, Dr Samuel Tissot highlighted the importance of the therapeutic relationship. Paul Mobius proposed that the therapists personality was an essential tool to eect a change in the patient in 1888, while in 1891, P. Dubois pinpointed the importance of patient and therapist as partners. More recently, Horvath & Symonds (1991) stated that a solid therapeutic alliance was more predictive of outcome than either the type or length of therapy. This is consolidated by Luborsky et al. (2002) and Wampold (2001) in their empirical study of 225 depressed patients. The above authors found that the therapeutic bond formed between therapist and patient was a leading inuence on a patients recovery, regardless of the type of treatment modality used.
Table 2. Ordinary versus extraordinary management Ordinary management Clear stages Producer-pushed Authority drives interactions Outcomes by prior intention Joint action emerges from policy and strategy Extraordinary management Reection in action Consumer-led Therapeutic alliance drives interactions Outcomes emerge in time and are articulated later Policy and strategy emerge from joint action
Therapy actively interacts with the patient, changing course whenever the need arises. Flexibility of repertoire and the dynamic of the interpersonal relationship rather than the application of a given procedure or technique are probably more predictive of positive outcome (Krupnick et al. 1996), and are the hallmark of MCT. The heterogeneous nature of patient presentation, as seen in disorders such as CFS/ myalgic encephalomyelitis, FM, IBS and noninammatory pelvic pain, necessitates that the therapist has the exibility of repertoire to suit each individual patient on their journey, a journey interspersed with many crossroads and alternative pathways. It is for this reason that MCT embraces the underlying tenets of such evidence-based practice as cognitive behaviour therapy, mindfulness meditation and graded exercise therapy, adopting a synthesized generic approach that is disease-specic. Triangulated evaluation over 18 years, including randomized controlled trials has shown this approach to be cost-eective and acceptable to all the major stakeholders (Shaw et al. 1991; Sadlier & Stephens 1995; Sadlier et al. 2000; Thomas et al. 2006). Conclusion Multi-convergent therapy can be seen as a mind body approach in which the physical and psychological aspects are seamless. Its inherent exibility in dealing with the physical and psychosocial aspects of female presentation is its unique selling point. There is nothing new about the dierent aspects of MCT. What is dierent is how it is used and integrated by the individual therapist. References
Aaron L. & Buchwald D. (2001) A review of the evidence for overlap among unexplained clinical conditions. Annals of Internal Medicine 134 (9), 868879.
Multi-convergent therapy Multi-convergent therapy (MCT), which incorporates cognitive behaviour therapy, graded exercise, mindfulness meditation, hypnotherapy, connective tissue massage and appropriate advice on antidepressants, is a biopsychosocial approach that is intended to reduce uncertainty in areas of MUS, thereby facilitating success. Deale et al. (1997) echoed this philosophy of approach with their comment that, given the heterogeneous nature of some of these syndromes, what is called for is a pragmatic and exible use of a range of behavioural and cognitive techniques, closely tailored to the individual patient, rather than adherence to a rigid protocol (Deale et al. 1997) (Table 2).
35
M. Sadlier
Aronowitz R. A. (2001) When do symptoms become a disease? Annals of Internal Medicine 134, 803808. Barsky J. & Borus F. (1999) Functional somatic syndrome. Annals of Internal Medicine 130 (11), 910921. Buchwald D. & Garrity D.(1994) Comparison of patients with chronic fatigue syndrome, bromyalgia and multiple chemical sensitivities. Archives of Internal Medicine 154 (18), 20492053. Chambless D. & Ollendick T. (2001) Empirically supported psychological interventions: controversies and evidence. Annual Review of Psychology 52, 85716. Deale A., Chalder T. & Wessely S. (1997) Cognitive behavioural therapy for chronic fatigue syndrome: a randomised controlled trial. American Journal of Psychiatry 154 (3), 408414. Frasure-Smith N., Lesperance F. & Talajic M. (1993) Depression following myocardial infarction. Impact on 6-month survival. Journal of the American Medical Association 270, 18191825. [Erratum published in Journal of the American Medical Association 271, 1082.] Garnkel S., Riley G. & Iannacchinoe V. (1988) High-cost users of medical care. Health Care Financing Review 9, 4152. Hamilton W. T., Hall G. H. & Round A. P. (2001) Frequency of attendance in general practice and symptoms before development of chronic fatigue syndrome: a case-control study. British Journal of General Practice 51, 553558. Horvath A. & Symonds B. (1991) Relation between working alliance and outcome in psychotherapy: a metaanalysis. Journal of Counseling Psychology 38, 139149. Kirmayer L., Groleau D., Looper K. & Dao M. (2004) Explaining medically unexplained symptoms. Canadian Journal of Psychiatry 49, 663672. Krupnick J., Sotsky S., Simmens S. & Moyer J. (1996) The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: ndings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of Consulting and Clinical Psychology 64 (3), 532539. Luborsky L., Rosenthal R., Diguer L., et al. (2002) The dodo bird verdict is alive and well mostly. Clinical Psychology 9, 212. McKinlay J., McKinlay S. & Brambilla D. (1987) The relative contributions of endocrine changes and social circumstances to depression in mid-aged women. Journal of Health and Social Behavior 28, 345363. Payne S. (2004) Sex, gender, and irritable bowel syndrome: making the connections. Gender Medicine 1 (1), 1828. Sadlier M. (1997) Triangulated Evaluation of the MCT Clinic. M.Ba. thesis, Cardi University, Cardi. Sadlier M., Evans R., Phillips C. & Broad A. (2000) A preliminary study into the eectiveness of MultiConvergent Therapy in the treatment of heterogeneous patients with chronic fatigue syndrome. Journal of Chronic Fatigue Syndrome 7 (1), 93101. Sharpe M. & Carson A. (2001) Unexplained somatic symptoms, functional syndromes, and somatization: do we need a paradigm shift? Annals of Internal Medicine 134, 926930. Shaw G., Srivastava E. D., Sadlier M., et al. (1991) Stress management for irritable bowel syndrome: a controlled trial. Digestion 50 (1), 3642. Studd J. & Panay N. (2004) Hormones and depression in women. Climacteric 7 (4), 338346. Thomas M., Sadlier M. & Smith A. (2006) The eect of Multi Convergent Therapy on the psychopathology, mood and performance of Chronic Fatigue Syndrome patients: a preliminary study. Counselling and Psychotherapy Research 6 (2), 9199. Wampold B. (2001) The Great Psychotherapy Debate: Models, Methods, and Findings. Lawrence Erlbaum Associates, Hillsdale, NJ. Weiner H. (1992) Perturbing the Organism: The Biology of Stressful Experience. University of Chicago Press, Chicago, IL. Wessely S., Nimnuan C. & Sharpe M. (1999) Functional somatic syndromes: one or many? Lancet 354, 936939. Williams R., Hartmann K., Sandler R., et al. (2005) Recognition and treatment of irritable bowel syndrome among women with chronic pelvic pain. American Journal of Obstetrics and Gynecology 192, 761767. Zook C. J. & Moore F. (1980) High-cost users of medical care. New England Journal of Medicine 302, 9961002.
Michael Sadlier works as a physiotherapist at the University Hospital of Wales, Cardi, and is the director of the multi-convergent therapy clinic. His primary research interests are in chronic fatigue syndrome, irritable bowel syndrome and tinnitus. He works clinically in both the National Health Service and the private sector. His main focus is on medically unexplained symptoms, particularly among women.
36
Bladders behaving badly: a randomized controlled trial of group versus individual interventions in the management of female urinary incontinence
L. A. Hill
George Eliot Hospital NHS Trust, Nuneaton, UK
Abstract Incontinence is a sensitive healthcare issue. Its prevalence is estimated to be 8.5% and 57% of women aged between 15 and 64, and 45 and 65 years, respectively, and it is one of the most common chronic diseases. A multi-centre randomized controlled trial of group versus individual management of urinary incontinence in 180 women was undertaken over a 2-year period. The views of women with female urinary incontinence (FUI) were sought on the acceptability and ecacy of physiotherapy as a treatment method for FUI when delivered in groups. The trial aimed to test the eectiveness of a group approach to treatment using outcome measures of symptom severity and quality of life pragmatically applied in the UK National Health Service, and to investigate whether group treatments are more cost-eective than individual management. Outcome data for 174 women provided evidence that a group educational approach to treatment is as clinically eective as an individual educational approach, and that group treatment is more cost-eective than individual treatment. Pelvic oor exercises and bladder retraining are simple, low-cost treatments, and have been shown to be eective. Women should be encouraged to take these up.
Keywords: female urinary incontinence, group intervention, individual intervention, outcome, physiotherapy.
Lesley Hill, a clinical member of a multi-centre team, gave a presentation at the 2006 ACPWH Conference to share the clinically signicant and cost-eective results of this multi-centre randomized controlled trial of group versus individual
intervention in the management of female urinary incontinence. The above is an abstract, and it is hoped to include a more detailed account of her research in the next issue of the Journal.
Correspondence: Lesley Hill, George Eliot Hospital NHS Trust, Lewes House, College Street, Nuneaton CV10 7DJ, UK (e-mail: lesley.hill@geh.nhs.uk).
37
Mammographic breast screening
Breast cancer is the commonest female malignancy, accounting for around 41 000 cases per annum in the UK in 2004, with up to half of these women dying from the disease. There is a gradual upwards trend in its incidence, with registrations of 5064-year-old women increasing by 50% since 1988. The National Health Service Breast Screening Programme (NHSBSP) commenced in 1988. This followed convincing evidence from Scandinavia that showed a reduction in mortality from breast cancer in asymptomatic women who had been given mammographic screening. Initially, women between the ages of 50 and 64 years were oered single-view mammography every 3 years. More recently, this has been extended to women up to the age of 70 years, with older women having screening only on request. Two views of each breast are now obtained, i.e. mediolateral-oblique and craniocaudal images, which increases the detection rate. The majority of women who accept the invitation for screening have their lms taken on mobile trailers staed by experienced mammographers (radiographers with expertise in mammography). The lms are processed back at the screening centre and loaded onto high-capacity roller viewers for reading. Most breast cancers detected by screening are impalpable, and breast cancer has a variety of appearances on mammography: dominant nodule, spiculate density, area of glandular distortion or glandular asymmetry, or microcalcication. Benign lesions may look malignant and vice versa. Women who are thought to have a signicant abnormality are recalled for assessment of the lesion to the screening centre within a few weeks of their initial mammogram. They have further specialized mammograms performed that may
compress or magnify an area of concern. Many women will undergo an ultrasound examination of the area as well. If a biopsy is required, then this is performed using image guidance to accurately sample the focus of concern. A wide-bore needle (14 or 16 French) and mammotomy may be used (11 or 8 French). A breast surgeon will examine the women and assess the lesion for its palpability and possible surgical options, if required. The samples are analysed by specialist breast pathologists, and the clinical teams meet to discuss the results and conclusions. Great importance is attached to the decision-making process in order that the correct diagnosis is reached. Should a biopsied lesion be malignant, the treatment options are decided before discussing the results with the patient. The number of women screened by the programme continues to increase year on year, as do the number of cancers found. In 20022003, 1.3 million women were screened in England, yielding a total of 9849 cancers. Not all of these tumours are invasive, i.e. will spread within the breast and be capable of spreading elsewhere. Around 25% of abnormalities are pre-invasive, but these are still treated by surgery with, or without, radiotherapy. Screened women are a little more likely to be diagnosed with breast cancer than those who are not screened, implying that some screen-detected cancers may be overdiagnosed and might never have become manifest to the women during her lifetime. For every 400 women who are regularly screened over a 10-year term, one fewer woman will die of the disease. The NHSBSP saves around 1400 lives per annum in England. Dr Kate Gower Thomas Consultant radiologist Breast Test Wales Cardi
38
Presentation reections
The following speakers did not submit a paper based on their Conference presentations, but were happy for us to publish details from their abstracts and to reect on their talks. Margie Polden Memorial Lecture: A midwifes perspective Mary Cronk MBE, midwife in independent practice, Chichester, UK Mary Cronk was introduced to Conference by Jeanette Haslam, which was to give us a avour of the presentation to follow. In addition to background information on Marys long career, Jeanette has rst-hand experience of her expertise, having had her in attendance at her own home births. Marys presentation was full of interesting and thought-provoking ideas, demonstrating her commitment to womens health in the most holistic of senses. She recalled how, since her training, practices have changed massively; in particular, the mandatory use of episiotomy (a process she described as a form of female genital mutilation) has, thankfully, become a thing of the past. She remembered her own contact with physiotherapists as a patient and the help that she received from the profession after the birth of her own children. The main theme was that of breech birth, and her belief that Caesarean deliveries are performed far too frequently when safe vaginal delivery is possible. The slides that followed were an amazing insight into how breech presentation babies can be born at home uneventfully. Case histories were presented with this rare opportunity to view the initial presentation and stage-by-stage snapshots of normal breech deliveries. Another theory presented was a proposed explanation of why symphysis pubis dysfunction (SPD) has apparently become a more prevalent condition in recent years. It was suggested that panty girdles might have had a role in preventing the symptoms of pelvic instability in the past. Now that these are no longer commonly worn, the incidence of SPD has consequently
increased. Marys suggestion for clinical practice was the selective use of such undergarments in women who are recognized to have hypermobility syndrome or are otherwise susceptible to developing SPD. The presentation was very well received with a terric round of applause, having kept our interest throughout. Chairman Ros Thomas presented Mary with her Margie Polden certicate and a bouquet. Rachel Kerr GUM clinic: what to look for Linda Furness, health advisor, Genito-Urinary Medicine Clinic, Cardiff and Vale NHS Trust, Cardiff, UK A presentation on genito-urinary medicine (GUM) was, perhaps, a challenging start to Sunday morning following the Conference dinner on Saturday night, but Linda Furness gave a comprehensive and interesting talk on the subject. She explained how the Venereal Disease (VD) Act means that the information that patients give sta at GUM clinics cannot be shared with anyone outside the unit. This, perhaps, contributes to its isolation from mainstream medicine. She went on to say that we should not be judgemental: anyone can be at risk of contracting a sexually transmitted infection (STI). Linda listed viral and bacterial STIs, and reported a recent increase in cases of gonorrhoea and, currently, syphilis. A run-down on signs and symptoms things you see, smell or are told about followed, accompanied by some graphic photographs. She also pointed out that some infections cause no evident symptoms. Chlamydia falls into this category, with 80% of females and 40% of males showing no signs and symptoms, but suerers at risk of major problems such as pelvic inammatory disease or infertility. Linda also discussed HIV, which might present itself in many ways, including myalgia, arthralgia, fever, pharyngitis, lymphadenopathy, skin rash, and mucosal ulceration of the mouth, genitals or oesophagus. 39
This was an interesting and understandable presentation that was, I felt, useful to womens health physiotherapists, especially those working with women experiencing incontinence and other pelvic oor dysfunctions. As Linda said, we are just the type of people empathic practitioners, with more time for women than some healthcare professionals to whom they might divulge a problem. I would not presume to make a diagnosis of a STI, but I will be more vigilant and would have no hesitation in suggesting that a woman should visit a GUM clinic. Linda directed us to the website of the Society of Sexual Health Advisors (www.ssha.info). I have checked this out and it is, indeed, a good source of information on STIs that is accessible to the general public. Gill Brook Hormonal treatment of severe premenstrual syndrome Professor John Studd, consultant gynaecologist, London, UK We were indeed fortunate to hear the thoughts of Professor John Studd, esteemed gynaecologist and founder of the rst menopausal clinic in the UK in 1969. His descriptions of reproductive depression were enlightening, including a redenition of premenstrual syndrome (PMS) as an ovarian cycle dysfunction, rather than one related to the menstrual cycle. As such, PMS cannot be surgically cured by hysterectomy, only by bilateral salpingo-oophorectomy (BSO). Women with severe PMS can often t their symptoms into a pattern of hormone-related depression. Severe PMS symptoms may be completely relieved in pregnancy, but may return as postnatal depression, followed by a return to cyclical depression that worsens with age. Unfortunately, this aggravation of PMS often becomes less regular with the approaching menopause. A good question to gauge symptom severity in a patient may be, How many good days do you have in a month? Some women with postnatal depression respond well to transdermal oestrogen. Current treatments for PMS consist of hormonal therapy alongside psychiatric support, lifestyle changes and alternative therapies. According to Professor Studd, antidepressants do not have a role here. This is a stark contrast to the historical treatments described during his lecture. In days gone by, women with conditions such as menstrual madness, nymphomania, 40
ovarian mania or hysteroepilepsy (PMS) were often sent to the nearest asylum. Here, early gynaecologists pioneered BSO as an eective treatment of PMS. It was so eective for these women that the risky surgery was soon rolled out to many women in asylums, who were particularly popular as subjects for doctors who needed to gain experience in surgery. Fortunately, these practices were eventually stopped. Overall, Professor Studd advocates the use of the best treatment for the individual, which may or may not include surgery. He has found that hormonal manipulation is certainly eective, and often cheaper than the antidepressants promoted by the heavily research-biased literature base. Further information can be found on his website <www.studd.co.uk>. Clair Jones Management of inherited bleeding disorders in pregnancy Dr Peter Collins, consultant haematologist, University Hospital of Wales, Cardiff, UK Inherited bleeding disorders include haemophilia, von Willebrand disease and disorders of platelet function. The management of these disorders during pregnancy requires a multidisciplinary team approach between haemophilia centres, obstetric services and anaesthetists (Lee et al. 2006). Antenatal diagnosis can be oered to most carriers of severe haemophilia from about 10 weeks. Future options will include the use of in vitro fertilization with re-implantation of female or unaected male embryos. Aected women may bleed secondary to trauma associated with vaginal delivery, or invasive procedures such as Caesarean section or epidural anaesthesia. Correction of haemostasis may be required. It is usually not known whether a baby born to a woman who is a carrier of a bleeding disorder is aected until she is tested postnatally. Children with bleeding disorders are at risk of cephalohaematoma and intracranial bleeding at the time of delivery. Therefore, these children should be delivered on the assumption that they have a bleeding disorder. This means avoiding invasive procedures such as ventouse extraction, foetal scalp monitoring and high forceps. Children should be tested for the family disorder at birth. At present, there is no consensus as to whether children born with a severe bleeding
disorder should be treated at birth, and individual centres should have a policy on this. Peter Collins Reference
Lee C. A., Chi C., Pavord S. R., et al. (2006) The obstetric and gynaecological management of women with inher-
ited bleeding disorders review with guidelines produced by a taskforce of UK Haemophilia Centre Doctors Organization. Haemophilia 12 (4), 301336.
41
CLINICAL AUDIT
Assessing outcomes of urinary incontinence treatment using the International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form
C. Jouanny
Urotherapy Clinic, Westmount Assessment and Rehabilitation Centre, Overdale Hospital, St Helier, Jersey, Channel Islands
Abstract Outcome measures should prove to be useful tools in the development of the provision of optimal physiotherapy treatment for women with urinary incontinence (UI). The International Consultation on Incontinence Questionnaire Urinary Incontinence (ICIQ-UI) Short Form was used to assess treatment outcomes, and scores were compared with subjective treatment outcomes. This paper details the outcomes of treatment for the rst 51 women with UI who underwent therapy after the introduction of the ICIQ-UI Short Form in a urotherapy clinic. The audit showed that over 75% of women referred to the clinic had improved after attendance and that the ICIQ-UI Short Form reected the subjective outcomes. It is recommended that use of the questionnaire should be continued as an outcome measure for physiotherapy for UI in clinical practice.
Keywords: audit, outcomes, urinary incontinence.
Introduction Following attendance at a Chartered Physiotherapists Promoting Continence (CPPC) study day in October 2003, the means of assessing treatment outcomes at a urotherapy clinic were reviewed by the present author. The Kings Health Questionnaire (Kelleher et al. 1997) had previously been used in the assessment of women with stress urinary incontinence (SUI), but this had proved to be too unwieldy and timeconsuming for eective use in the clinical setting. The fully validated International Consultation on Incontinence Questionnaire Urinary Incontinence (ICIQ-UI) Short Form (Avery et al. 2004) was presented by its author at the CPPC study day. Womens health physiotherapists were encouraged to consider using it both as an outcome measure for research as well as in routine clinical practice. The higher the score on the questionnaire, the greater the symptom bother.
Correspondence: Mrs Clare Jouanny, Urotherapy Clinic, WARC, Overdale Hospital, Westmount Road, St Helier, Jersey JE1 3UN, Channel Islands (e-mail: c.jouanny@ health.gov.je).
Since 2004, the ICIQ-UI Short Form has been used at the Urotherapy Clinic of the Westmount Assessment and Rehabilitation Centre, Overdale Hospital, St Helier, Jersey, Channel Islands, for any woman referred to the service whose referral suggests that she is incontinent of urine. Patients may have other diagnoses, of course, and incontinence may not always be the primary clinical sign. Subjects and methods Questionnaires were sent with the rst appointment letter to all women who, according to their referral, were suering from urinary incontinence (UI). The questionnaire was collected the rst time that the patient was seen and the information was entered into a computer database. After treatment was completed, women were sent another ICIQ-UI Short Form, along with a return envelope. The present paper describes an audit of the rst 51 ICIQ-UI Short Forms to be completed both before and after treatment at the urotherapy clinic.
42
Urinary incontinence treatment
Figure 1. Subjective outcomes of treatment for urinary incontinence (total n=51).
Figure 3. Group rst appointment: subjective outcomes of treatment for urinary incontinence (total n=29).
Results The number of questionnaires that were not returned, either before or after treatment at the urotherapy clinic, was not documented because of time constraints. The average ICIQ-UI Short Form scores before and after treatment at the urotherapy clinic were 9.2 and 6.4, respectively. The subjective outcomes of treatment are shown in Fig. 1. The information was then analysed further: + Twenty-one (41%) women attended an individual (one-to-one) appointment rst. For these women, the average ICIQ-UI Short Form scores before and after treatment were 8.9 and 5.7, respectively. The subjective outcomes of their treatment are shown in Fig. 2. + Twenty-nine (57%) women attended a group information session rst. Twenty-ve of these subjects were referred with SUI, urge UI (UUI) or mixed UI (MUI), which showed that, in general, the criteria (local criteria based on referral information) for attending a group information session rst were being followed. For these women, the average ICIQ-UI Short Form scores before and after treatment were 9.3 and 7.2, respectively. The
subjective outcomes of treatment are shown in Fig. 3. The outcomes were then analysed according to the secondary diagnosis recorded on the database. Some women may have had more than one diagnosis (e.g. SUI and genital prolapse), in which case the most problematic diagnosis was recorded. Urge urinary incontinence (n=6) The average ICIQ-UI Short Form scores before and after treatment were 10.5 and 6.3, respectively. Half the women were cured. Mixed urinary incontinence (n=17) The average ICIQ-UI Short Form scores before and after treatment were 10.8 and 7.6, respectively. Eleven (64.7%) of these women attended a group information session rst. Eleven (64.7%) women with MUI felt better after treatment (i.e. cured, greatly improved or improved). Four (23.5%) were referred on. Stress urinary incontinence (n=14) The average ICIQ-UI Short Form scores before and after treatment were 8.8 and 7.2, respectively. Nine (64.3%) of these women felt better after treatment (i.e. cured or greatly improved). Other diagnoses Other diagnoses included pelvic pain, anal incontinence, genital prolapse, urinary frequency, post-micturition dribble, pelvic oor muscle (PFM) weakness and urinary urgency. The nal analysis was a comparison of the womens subjective outcome of treatment with the ICIQ-UI Short Form score:
Figure 2. Individual rst appointment: subjective outcomes of treatment for urinary incontinence (total n=21).
+ Eleven (21.6%) of the women considered themselves cured. The average ICIQ-UI Short 43
C. Jouanny
Figure 4. Dierence in pre- and post-treatment International Consultation on Incontinence Questionnaire Urinary Incontinence (ICIQ-UI) Short Form scores compared to subjective urinary incontinence treatment outcomes.
Form scores before and after treatment were 8.8 and 4.2, respectively. Sixteen (31.4%) of the subjects considered themselves greatly improved. The average ICIQ-UI Short Form scores before and after treatment were 8.6 and 6, respectively. Five (9.8%) of the women considered themselves improved. The average ICIQ-UI Short Form scores before and after treatment were 9.4 and 7.2, respectively. Seven (13.7%) of the subjects received a oneo advice session. The average ICIQ-UI Short Form scores before and after treatment were 6.4 and 3.1, respectively, Nine (17.6%) of the women were referred on. The average ICIQ-UI Short Form scores before and after treatment were 11.8 and 10.5, respectively. These results are displayed in Fig. 4.
Discussion The women who attended an individual (one-toone) appointment rst had a greater dierence in ICIQ-UI Short Form pre- and post-treatment scores (3.2) than those who attended a group information session rst (2.1). The 21 women who attended an individual (one-to-one) appointment rst were 11.4% more likely to be cured. Fifteen (71.4%) of these subjects felt better (i.e. cured, greatly improved 44
or improved) compared to 17 (58.6%) of the 29 women who attended a group information session rst. The reason for this dierence is not clear. Grimshaw (2005) audited physiotherapy classes for women with pelvic oor dysfunction, but felt that it would be too dicult to do an audit on medical improvement since there were so many variables in diagnosis, and in extent and type of symptom; therefore, the outcome of the patients symptoms was not audited. Using the ndings of a limited literature review and information gained from womens health physiotherapists, Smith (2004) assessed the advantages and disadvantages of groups. Again, there was no information on the outcomes of symptoms for those attending such a group. Cook (2001) reviewed the evidence relating to the group treatment of female UI, including the eect of group treatment on the strength of the PFMs, bladder training and improvement of patient knowledge. Eight studies were identied, but it was concluded that there is a lack of available evidence and that further research is required. In contrast to the present audit, papers by Demain et al. (2001) and Janssen et al. (2001) found that individual and group treatments were equally eective in improving female UI at 3 and 9 months after treatment. However, it should be noted that subjects in the present audit who
attended a group session rst, then went on to have individual follow-up and did not remain in a group for the duration of their treatment, which could account for the dierence. Vestergaard (1997) aimed to compile guidelines for group sessions rather than assess the outcome of treatment for those attending a group session rst versus an individual session rst, and therefore, did not add to this discussion. It is possible that those women who attended a one-to-one session rst had more individualized treatment from the outset, which motivated them more and led to an improved outcome. However, since the women who attended the group information session were more likely to be referred on, it is possible that the problems that they were referred with were more complex and less likely to respond to physiotherapy intervention in the rst place. In this group of women, although the numbers were small, a main complaint of UUI was the diagnosis with the most successful outcome. Fifty per cent were cured and this corresponded with a considerable dierence in pre- and posttreatment ICIQ-UI Short Form scores. It should be noted that there were only six women with UUI, compared to 14 and 17 for SUI and MUI, respectively; success rates may have been dierent with a larger sample. A systematic review by Hay-Smith & Dumoulin (2006) found that trials in women with SUI that suggested a greater benet recruited a younger population and recommended a longer training period than the one trial in women with detrusor overactivity (urge) incontinence. It would be useful to conduct a further audit to investigate the number of treatment sessions that women with SUI received compared to those with UUI, in order see if this relates to the dierent outcomes. Borello-France et al. (2006) reported a 67.9% reduction in the frequency of episodes of SUI following PFM exercises (PFMEs), regardless of the position adopted. In a review of an earlier cohort of women, B et al. (2005) found that 60% were almost or completely continent 6 months after intensive PFM training, although this was not maintained 15 years later. Dannecker et al. (2005) found that self-reported improvement of incontinence symptoms was 95% for women after an intensive and electromyography-biofeedback-assisted PFM training programme. These more recent papers add to the considerable body of evidence suggesting that physiotherapy is a successful therapy for SUI.
However, in a limited literature review, no studies were found that directly compared the outcomes for SUI versus UUI. This suggests that little has changed since Hay-Smith et al.s (2001) systematic review, which concluded that the role of PFM training for women with UUI alone remains unclear. Women with MUI had a considerable dierence in pre- and post-treatment ICIQ-UI Short Form scores of 3.2, with 11 (64.7%) feeling better. However, there was a high onward referral rate (n=4, 23.5%) for these women, which implies that physiotherapy treatment alone did not make them suciently better. On further investigation of their records, more of these subjects had overactive bladders diagnosed on cystometrogram (after appropriate onward referral), and some also had prolapse as a secondary diagnosis. From the dierence between their pre- and post-treatment scores, physiotherapy would seem to have made these women less bothered about their urinary symptoms. In women whose main complaint was SUI, nine (64.3%) felt better after treatment, but the dierence in pre- and post-treatment ICIQ-UI Short Form scores was only 1.6. This could be because they felt better about their symptoms, even though the symptoms themselves were not much improved. In Hay-Smith et al.s (2001) review of PFMEs versus no treatment, exercises were found to signicantly improve self-reported cure rates, and self-reported cure or improvement rates over 36 months, compared with no treatment. Cure or improvement rates in two randomized controlled trials showed 62/78 (79%) with PFMEs versus 3/86 (3%) with no treatment. Other recent research, already cited above (B et al. 2005; Dannecker et al. 2005; Borello-France et al. 2006), has also suggested a higher cure/ improvement rate than seen in the present audit. Hay-Smith & Dumoulin (2006) undertook a systematic review and found 13 trials involving 714 women (375 doing PFM training; 339 controls) that met the inclusion criteria, but only six trials (403 women) contributed data to the analysis. Overall, the review provided some support for PFM training as rst-line conservative management, but indicated that the treatment eect may be greater in younger women with SUI alone. The subjects in the current audit were of varying ages and reported SUI as their main symptom, but it may be that other symptoms such as urgency and frequency were still bothersome, and this was reected by the ICIQ-UI Short Form score. 45
C. Jouanny
A usable measure to capture how patients feel about their problem after treatment at the urotherapy clinic would be useful. In the past, as mentioned above, the Kings Health Questionnaire was used, and the present author also has experience of the Short Form 36 questionnaire, both of which provide greater detail about quality of life. However, these tools are considered too time-consuming for routine clinical practice, and despite various searches, a more suitable measure has not yet been found. Other diagnoses were too infrequent to allow comment on their treatment outcomes, or did not involve incontinence. The comparison of subjective outcomes with ICIQ-UI Short Form scores did show a correlation: those women who felt that they had been cured had a greater dierence (4.6) in pre- and post-treatment scores on the questionnaire in comparison to those who only felt that they had improved (2.2). The ICIQ-UI Short Form scores of those women who received a one-o advice session (with or without a group information session as well) demonstrated a dierence in pre- and posttreatment ICIQ-UI Short Form scores of 3.3, implying that their symptoms were at least greatly improved. In a literature review, Cook (2001) examined the theoretical framework of group treatment, and commented that the capacity for comparison and support within a group reduces both feelings of isolation and the need for secrecy. This should make women feel better about their symptoms. Cook (2001) also noted that pretraining inuences the eectiveness of group intervention. All women attending the information group session rst do receive a leaet detailing why they have been invited and what the session entails. These factors could have enhanced the outcomes of these women. Keller (1999) examined the occurrence, attitudes and knowledge of UI among older women in a rural setting, and concluded that misconceptions concerning the causes of and the availability of treatment for incontinence [. . .] may have an impact on their decision to seek care for this typically remediable condition. Newman (2004) used a simple mail-in questionnaire to survey 1500 women with bladder control disorders; 422 responded. The survey concluded that these women wanted more information regarding incontinence. This should remind us that the importance of giving women relevant advice should not be underestimated. 46
Conclusions Over 75% of women referred to the present authors urotherapy clinic improved after attendance. The ICIQ-UI Short Form reects the subjective outcomes of cured, greatly improved, improved and referred on, and it is recommended that its use should be continued as an outcome measure for physiotherapy for UI. It is also recommended that new versions of this questionnaire that are being developed as outcome measures for vaginal symptoms and faecal (anal) incontinence are used at the urotherapy clinic, when available, and subsequently audited. The present author considers that many women with UI feel better about their problem after being able to discuss it and understand it during assessment and treatment at the urotherapy clinic, but this is not well captured as an outcome of therapy. Therefore, it is recommended that usable measures to record this important outcome are explored and employed if possible. The following subjective outcomes used need to be reconsidered: + one-o advice session and cancelled or did not attend last session those who attended a one-o advice session did not attend the clinic again, meaning that their subjective outcome could not be recorded, but this could be added to the letter accompanying the ICIQ-UI Short Form sent out after discharge; + more consideration needs to be given to the subjective outcomes of patients who are referred on, many of whom feel better as a result of the treatment they receive, but not better enough; and + there needs to be greater clarity as to whether the subjective outcome is recording the outcome for the treatment as a whole, or only the outcome for the main complaint this may be where an outcome measure of perceived benet would be useful. Therefore, it is recommended that the subjective outcomes recorded should be brought into line with those now used at the Physiotherapy Department, Jersey General Hospital, St Helier, Jersey, Channel Islands, as follows: + + + + + resolved; much better; improved; unchanged; worse;
+ physiotherapy not required (e.g. patient does not perceive any problem, incorrect referral or going privately); and + DNA the patient did not attend (i.e. it cannot be judged whether they beneted or not). If the patient does not attend after their third session, an outcome should be chosen from the rst ve listed above, based on subjective changes recorded in the Subjective, Objective, Analysis, Plan (SOAP) notes. A more accurate record should be kept of the number of ICIQ-UI Short Forms sent out and the number of those returned. Although it would be dicult to follow up women who did not return their ICIQ-UI Short Form posttreatment, it would be interesting to know if they failed to return it because they were no better and, therefore, demoralized, or if they were in fact better and were too busy enjoying a better quality of life to return the questionnaire. Finally, it is recommended that, in future treatment outcome audits, the number of appointments is recorded and analysed in relation to outcome, in order to see whether women who attend more appointments have a better outcome or not. These recommendations should be implemented by June 2006, after discussion with relevant parties, and there will be a follow-up audit in June 2007. Addendum Changes have been implemented since the present audit was completed. The ICIQ Vaginal Symptoms questionnaire has been used with appropriate patients, although it is in long form, and therefore, more time-consuming. The subjective outcomes have been changed to come into line with Jersey General Hospital policy, and this certainly helps to reect a more accurate outcome when a patient cancels or does not attend their last session. A record is now kept of the number of ICIQUI Short Forms sent out and returned. Currently, only approximately 50% of those sent out at discharge are returned, despite an addressed (though not stamped) envelope being included. A usable measure to capture the ways in which women feel better after gaining a greater understanding of their problem is actively being sought. There are many measures available, but none have appeared more suitable so far. Re-audit is due in June 2007.
Acknowledgments Grateful thanks go to Kerry Avery for her permission to use the ICIQ-UI Short Form and her continued interest in its use in this setting, and to Nikki Gardener for her advice on the presentation of this audit, as well as her continued enthusiasm and support. My thanks also go to Yvette Dobin for sending out the initial questionnaires, Gerard Dubras for his technical assistance and Gill Brook for editing the paper.
References
Avery K., Donovan J., Peters T. J., et al. (2004) ICIQ: a brief and robust measure for evaluating the symptoms and impact of urinary incontinence. Neurology and Urodynamics 23 (4), 322330. B K., Kyarstein B. & Nygaard I. (2005) Lower urinary tract symptoms and pelvic oor muscle exercise adherence after 15 years. Obstetrics and Gynecology 105 (5, Pt 1), 9991005. Borello-France D. F., Zyczynski H. M., Downey P. A., Rause C. R. & Wister J. A. (2006) Eect of pelvic-oor muscle exercise position on continence and quality-of-life outcomes in women with stress urinary incontinence. Physical Therapy 86 (7), 974986. Cook T. (2001) Group treatment of female urinary incontinence: literature review. Physiotherapy 87 (5), 226 235. Dannecker C., Wolf V., Raab R., Hepp H. & Anthuber C. (2005) EMG-biofeedback assisted pelvic oor muscle training is an eective therapy of stress urinary or mixed incontinence: a 7-year experience with 390 patients. Archives of Gynecology and Obstetrics 273 (2), 9397. Demain S., Fereday Smith J., Hiller L. & Dziedzic K. (2001) Comparison of group and individual physiotherapy for female urinary incontinence in primary care: pilot study. Physiotherapy 87 (5), 235242. Grimshaw R. (2005) An audit of physiotherapy classes for women with pelvic oor dysfunction. Journal of the Association of Chartered Physiotherapists in Womens Health 96, 6264. Hay-Smith E. J. C., B K., Berghmans L. C. M., Hendriks H. J. M., de Bie R. A. & van Waalwijk van Doorn E. S. C. (2001) Pelvic oor muscle training for urinary incontinence in women (Cochrane Review). In: The Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD001407. DOI: 10.1002/14651858.CD001407. Hay-Smith E. J. C. & Dumoulin C. (2006) Pelvic oor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women (Cochrane Review). In: Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD005654. DOI: 10.1002/ 14651858.CD005654. Janssen C. C. M., Lagro-Janssen A. K. M. & Felling A. J. A. (2001) The eects of physiotherapy for female urinary incontinence: individual compared with group treatment. British Journal of Urology International 87, 201206. Keller S. L. (1999) Urinary incontinence: occurrence, knowledge, and attitudes among women aged 55 and
47
C. Jouanny
older in a rural Midwestern setting. Journal of Wound, Ostomy and Continence Nursing 26 (1), 3038. Kelleher C. J., Cardozo L. D., Khullar V. & Salvatore S. (1997) A new questionnaire to assess the quality of life of urinary incontinent women. British Journal of Obstetrics and Gynaecology 104 (12), 13741379. Newman D. K. (2004) Report of a mail survey of women with bladder control disorders. Urology Nurse 24 (6), 499507. Smith R. (2004) Advice groups for female patients with pelvic oor dysfunction. Journal of the Association of Chartered Physiotherapists in Womens Health 95, 5357. Vestergaard A. (1997) Promoting continence in group sessions. Journal of the Association of Chartered Physiotherapists in Womens Health 80, 2730.
Clare Jouanny is a senior physiotherapist specializing in pelvic oor muscle dysfunction in Jersey, Channel Islands. She works both for the States of Jersey Health Service and in private practice. Clare is an ACPWH area representative and is also a moderator for the ACPWH network on iCSP.
48
Executive committee response to Conference discussion groups
As is practice at each Conference, discussion groups were held. Delegates were invited to join a small group facilitated by an executive committee member. The questions posed, the comments made by members and a response from the executive committee are given below. Business planning working party Should the Association set up a working group to discuss business planning to help members secure funds for service development? There was a unanimous yes in response to this question, and a gratifying number of volunteers said that they would like to be involved. Comments included the feasibility of using Interactive Chartered Society of Physiotherapy (iCSP) and/or area representatives as a contact query medium, and that there should be a realistic approach to setting up and maintaining the service. There was agreement that there should be a risk-management approach. Executive response Members comments will be taken to the next executive committee meeting in January 2006 for discussion about the best way to approach setting up the working party. What are the pros and cons of a move to a biennial conference? 1. Because of current nancial restraints, lack of funding and time-off issues within the National Health Service, the executive committee wonders whether there is any benet to holding our Conference every 2 years instead of annually. This might maximize support and make it better value for money There was a majority in favour of retaining an annual Conference. This topic generated a great deal of discussion, and many general points surrounding conference were raised. Comments for a biennial conference: + funding issues; and
+ implications for an annual general meeting (AGM) (could this be held at Congress?). Comments against: + other training is available, but Conference is good for extras/added value; + some teams take turns attending Conference; + yearly funding may be lost if it is not used; + the support network is essential; + there are fears that the ACPWH could lose prole if there is no annual Conference and that there could be a loss of members interest in their Association; + it is good to have the option of going every year, even if members are unable always to attend; + there would be a long time between Conferences if one is missed; + new members would have a long time to wait before getting involved; + the AGM could be held annually only a small body is needed to look at the constitution between Conferences; + discussion groups are valuable annually; and + for many, Conference is their only update for portfolio/reection. General comments (most were not related to the original question, but reect members thoughts about Conference): + it means giving up a weekend; + Conference could be divided into 2 days, one obstetric and one gynaecological, and delegates could choose which to attend; + many members have trouble getting time o work; + a full Conference could be alternated with a one-day conference; + accommodation not included may be a problem; + some members could cope with less-salubrious surroundings; + the possibility of concentrating the Conference so that members only have to stay for one night was raised; 49
Executive committee response
+ the possibility that the cost of gala dinner could be reduced was mentioned; + sponsorship could be obtained; + some members nd it dicult to get funding for a conference (could it be called something else, e.g. a study weekend?); + an application form to investigate funding was suggested; + the Chartered Physiotherapists Promoting Continence have single study days with a 9.00 a.m. start, but these still require an overnight stay; + the iCSP and/or the ACPWH website forum could be used to canvass opinions and nd out the reasons for decreased attendance; and + a retrospective audit of those attending could be conducted. 2. Plans are already under way for 2007, so 2008 could be the rst year with no Conference. However, 2008 coincides with our sixtieth anniversary, which the Association would presumably like to celebrate. What do members feel? Should we have a Conference in 2008 or celebrate our sixtieth in some other way? Suggestions for 2008: + a 2-day Conference; + do not hold it over a weekend; + holding the Conference on FridaySaturday means using up study leave on a Friday; + it must be celebrated/emotional/involve media; + have a big conference (!); + video-record presentations for departmental use; and + hold it at central location. Further general comments: + this should be discussed again at Preston (is the number applying in 2006 a blip?); + members will have to stay anyway, so the Association should have a 2-day conference; and + it would be a shame to miss our sixtieth anniversary in 2008, so Conference should go ahead. Executive response Many diering issues have been raised. The executive committee will consider all of them and decide how best to please the majority. 50
Acronym There has been a suggestion that we should change the name of our Association to reect the fact that some of our members treat men and children as well as women. The executive committee has discussed this at length and invited comment from the membership prior to Conference There was a virtually unanimous no to a change of name for our association, but some comments were made: + there could be a subgroup for those who treat men; + patient awareness of ACPWH is low anyway; + we have a good website, so men will be directed to the ACPWH; + many men contact us because of mentions womens magazines (!); and + its a local issue. Executive response The executive committee is not in favour of a name change, and this view was reinforced by both the vast majority at Conference and a number of e-mails from members received prior to Conference. Therefore, the acronym will remain as ACPWH. Annual Representatives Conference motion on dyslexia If our motion is put forward in 2007 at the Annual Representatives Conference (ARC), it should read as follows: Conference urges Council to survey the membership, to identify how many are affected by dyslexia and to ascertain from them how the Society can best meet their needs. Do members have further comments? Suggestions: + the British Dyslexia Association and Dyslexia Institute should be contacted; + we need awareness of Equality and Diversity legislation; and + CSP information packs for students. General comments: + ask for CSP guidance (e.g. more time for writing notes); + there are huge issues surrounding lack of support in the workplace; + it is up to the local manager to address this; + this must be considered for ACPWH courses;
Executive committee response
+ other issues that are more clinical should be addressed; + three out of ve people in one group had a child with dyslexia, and for two out of three, this had adversely aected their education; and + one sta member who is known to be dyslexic does not want any special treatment or allowances made. Executive response The executive will ask our diversity ocer to take the suggestions forward for action on behalf of the ACPWH, after further discussion at the next executive committee meeting. This will happen whether or not our motion is accepted at ARC. Papers in other journals The Journal editor would like feedback on whether the Papers in other journals section, which is in each edition, is well received, or not? If so, are there any other journals you would like to see papers from listed in addition to, or instead of, those currently used? This section of the Journal is appreciated by most members. The majority are very happy with Journal at present, especially the most recent edition. Executive response The executive will pass on all the comments received, plus the names of individuals wishing to help with Papers in other journals, to the Journal editor Any other business Many topics were raised, including the following: + Should we, as a womens health association, be encompassing all aspects of womens
health; for example, Ca breast and osteoporosis (future workshops?)? The (previously unconrmed) pelvic girdle pain lecture was removed from Conference, leaving little for obstetric-only physiotherapists. The ARC motion on the CSP guidelines for domestic violence: if the CSP is not interested, then what about the ACPWH? There has been either slow or no feedback on points that have been previously raised (e.g. electrotherapy and symphysis pubis dysfunction guidelines). It is a shame that courses are run without ACPWH approval; for example, ACPWH approval is needed for the 2-day musculoskeletal course, and obstetric courses are needed. The iCSP very useful and very easy to access. The ACPWH website is also useful, but the iCSP forum is probably used more frequently.
Executive response The executive committee thanks members for raising so many valid points. One or two were addressed during the course of the Conference weekend. The remainder will be discussed by the executive and there will be full response/ explanation/update on the website as soon as possible after the next executive meeting. + The most recent issue of the Journal was excellent. + The postgraduate courses are good. + Thanks were given to the committee for their time and the Journal. Executive response The executive committee thanks members for their comments, which are much appreciated. Ros Thomas
51
Conference and course reports
Research Officers Study Day

Chartered Society of Physiotherapy, London, 19 May 2006 The Chartered Society of Physiotherapy (CSP) hosted a study day for research ocers (ROs) from each of the clinical interest/occupational groups (CI/OGs) in May 2006 and about 12 groups were represented. The main aims of the day were to discuss strategies for the development of a research culture in the physiotherapy profession, and also to help the CI/OGs to identify the type of help needed to develop their own research culture. It was an opportunity for CI/OGs to share information on dierent approaches/types of support for physiotherapy research. It was emphasized that a research culture must be clinically driven, and ultimately, be for the patients benet. Much of the day was spent in discussing the new National Physiotherapy Research Network (NPRN) and outlining its purpose. The NPRN was set up in 2005 to support and encourage engagement in physiotherapy research. It is a mutual support network involving a full range of research experience and interests. It supports physiotherapy research in dierent regions throughout the country and aims to develop a research culture in the workplace, particularly in clinical settings rather than the traditional university setting. There are 20 regional research hubs, each one led by a senior researcher based in a university, but with links to clinicians. This enables CSP members to tap into mentorship and research expertise in the region. You can access information via the CSP website at: <www. csp.org.uk/director/eectivepractice/research/ nprn.cfm>, or contact Dr Philippa Lyon, the NPRN research ocer, at <p.lyon@bton.ac.uk>. We had to complete a strengths, weaknesses, opportunities and threats (SWOT) analysis of our CI/OGs research culture, and there were many common themes across the groups. The points most pertinent to ACPWH are summarized below. Strengths: + the ACPWH is associated with postgraduate courses that have a research culture; these are now oered at Bradford and allow the oppor52 +
+ + +
tunity for a full MSc, and thus, new members of ACPWH should have more background in research; the Association is a member of the international womens health group of the World Confederation for Physical Therapy and has links to international researchers; it publishes a partially peer-reviewed journal; the ACPWH runs an annual conference that presents some scientic papers; and it runs evidence-based approved workshops. Weaknesses:
+ the isolation of workers in womens health makes the generation of ideas and implementation of research ideas dicult; + research among ACPWH members is limited to a few people, although numbers are rising slowly; + the Association has only had a RO at executive level for a short time (this was previously a subcommittee post); + a research culture is not built in to clinical practice in the way that it is in higher education; and + there can be some resistance to challenging custom and practice within physiotherapy as a whole. Opportunities: + we could make our Annual Conference more scientic by having some shorter sciencebased presentations and using the Conference to ask for poster presentations; + the RO should have strong links with the Journal committee; + we could increase bursaries to include those supporting research done by members; + we should produce a database of researchers in womens health; + we should foster links with higher education institutes to promote teaching of womens health to undergraduates; and + we should have a page dedicated to research on our website. Threats: + the current lack of resources in the National Health Service (NHS);
+ a shift in culture of the NHS to payment by results, and no mention of research and development; + many members of the Association qualied before the degree was available and so do not have research background; and + there is some opposition from members. This list is not exhaustive, but it gives a loose framework for the development of the role of the research ocer. Other items covered during the day included the development of CI/OGs newsletters and journals to include evidence-based articles. This session highlighted the dierence between CI/OGs, with some having a chatty, newsletterstyle publication and others having a fully peerreviewed journal. It was not suggested or agreed that CI/OGs should move towards a totally peer-reviewed journal, since CI/OG groups are diverse. However, it was felt that CI/OGs should be encouraging the publication of some evidence-based and research articles within the scope of their publication. As this already exists to some extent with the ACPWH Journal, I felt that we were contributing to developing a research culture among our members, and that we were one of the leading CI/OGs with an emphasis on evidence-based practice. There was a short presentation on accessing and sharing research training and development resources through the CSP and the NPRN, and members were encouraged to access the websites of these two groups. Overall, the day had a strong emphasis on the idea that clinicians (rather than academics) should generate clinical research questions, and it was demonstrated that there was support within the physiotherapy profession for clinicians to develop a research culture within their practice. Yvonne Coldron Research ocer
The WellBeing of Women (WoW) Show The Womens Health Show Thats Serious Fun
Royal College of Obstetricians and Gynaecologists, London, 8 July 2006 WellBeing of Women (WoW) is a UK charity dedicated to the funding of research, and to raising awareness of all aspects of womens health across three areas: pregnancy and birth; quality-of-life problems (e.g. the menopause,
endometriosis, polycystic ovary syndrome and incontinence); and gynaecological cancers. If you require more information about the charity you can log onto <www.wellbeingofwomen.org.uk>. Last summer, the Royal College of Obstetricians and Gynaecologists (RCOG) kindly hosted The Big Squeeze, part of the WoW campaign to raise awareness of urinary incontinence and other bladder problems, the importance of preventative action, and the availability of eective treatments. The ACPWH was invited to take part in this exciting event. I have to admit that I expected hundreds of women to attend, but unfortunately, that wasnt the case. This could be for two reasons. On the one hand, it is possible that not enough marketing/advertising was done to promote the show; on the other, urinary incontinence is still a taboo subject, and therefore, it is likely that some women still feel too embarrassed to openly discuss their complaint in an environment that doesnt ensure their privacy. We had a marvellous day in which we gave advice to a few women. All of them were very grateful. We directed women towards their local womens health physiotherapist, advised them on a variety of topics (e.g. constipation and prolapse), taught them how to do pelvic oor muscle exercises (PFMEs) correctly and we showed them dierent gadgets. We had a nice stand with lots of information on it. A few issues were raised by the women. There is a lot of information on stress urinary incontinence, but not enough on urge urinary incontinence. Only a few had been oered physiotherapy as a rst-line treatment. In fact, the majority of women did not know that physiotherapy could help them. Many were not sure what our treatment involved. Very few women were doing PFMEs correctly. Some of the women had a concomitant prolapse and wanted to know more about that. We gave information about the dierent types and degrees of prolapse, and how PFMEs should help them. Women were quite shy about coming to the stand, and some were asking for information for their friends. I think we did a fantastic job; it was a shame that only a few women attended the show. I appreciated the opportunity to be with two other womens health physiotherapists, Julia Muman and Katie Jeitz many of us tend to work on our own, so it was nice to share information and knowledge with Julia and Katie. The downside 53
was that attendance was so low. I hope that the show will be better advertised in the future. Paula Igualada-Martinez Senior womens health physiotherapist Royal London Hospital London
become nation-wide in time. I am still attending, and have made some great friends. For further details, visit the website, <www. pushymothers.com>. Helen Forth
Pushy Mothers
Gladstone Park, London, July 2006 It was with great interest and, dare I say it, excitement that I attended my rst Pushy Mothers session in Gladstone Park, a 5-min walk from home, back in July 2006. At the time, I was about 8 weeks postnatal, following the birth of my rst baby, Chloe, and I was itching to get going. I found out about Pushy Mothers quite by chance. Judy DiFiore, one of the founders, had contacted me asking if I could spread the word with my team at the Royal Free Hospital (RFH), not realizing I was on maternity leave. She knew that we run a postnatal class at RFH, and thought that we might be willing to inform our patients about the existence of Pushy Mothers. It actually proved to be the ideal opportunity for me to do a bit of exercise, meet some other mums in the local area and do some professional spying. Judy set up Pushy Mothers earlier in 2006, along with her colleague Rachel Berg. Both are members of the Guild of Pregnancy and Postnatal Exercise Instructors, and are highly qualied tness and exercise professionals. The ethos of Pushy Mothers is to provide a safe and unique buggy workout, focusing on core stability training and cardiovascular tness for new mums. All Pushy Mothers instructors hold a postnatal exercise qualication and have undergone a 2-day Pushy Mothers training course. I have found Pushy Mothers to be good fun, and good exercise. The exercises are safe, functional and eective, and the classes are very social. It is wonderful to exercise in the open air, and to be able to take your baby along (they tend to sleep in the buggies, which is great!). Our instructor, Karen, is excellent, combining just the right balance of professionalism, motivation and humour. I will not hesitate to recommend these classes to my patients when I return to work. At the time of writing (September 2006), Pushy Mothers has really taken o in the parks of North London, and there are plans for it to 54
Cognitive Behavioural Therapy in the Physical Health Setting

Manchester, 910 September 2006 This course was organized by physiotherapist Chris Irving, and was led by Sister Karen Heslop, respiratory nurse specialist, and Dr Chris Baker, consultant psychologist. Twenty-three physiotherapists and two occupational therapists attended. They worked in a variety of settings, including pain management, cardiac and pulmonary rehabilitation, mental health, and urology. Many therapists see their patients regularly over a number of weeks, during which time they will often discuss their non-physical problems. The aim of cognitive behavioural therapy (CBT) is to change unhelpful thoughtfeeling behaviour patterns by experimenting with alternative patterns of thinking and behaviour. By applying the principles of CBT with some of my patients, I feel I can assist my patients to cope better, and I would recommend this as a most worthwhile course. Geraldine Buckley Senior physiotherapist Mercy University Hospital Cork, Ireland
ACPWH Conference
Copthorne Hotel, Cardiff, 2224 September 2006 This years Annual Conference (Figs 115) was held in the capital of Wales on a beautiful sunny weekend. The theme, Hormones to Happiness, was chosen by the committee, and the aim was to look at the holistic approach of the physiotherapist to womens health. The age range of delegates meant that there was something for everyone! The opening speaker was Dr Annie Evans, who gave a fascinating presentation on the perils of the perimenopause (see pp. 2732). This gave us the scientic reasons behind the changes
Figure 1. Caron James of the Cardi organizing committee with Dr Charlotte Fleming.
Figure 2. Chairman Ros Thomas with Margie Polden lecturer Mary Cronk.
undergone by women. The evening closed with a presentation on domestic abuse and what physiotherapists need to know. Saturday began with the opening of the trade stands exhibition and bookstall. Then Mary Cronk (Fig. 2) delivered the Margie Polden Memorial Lecture (see p. 39). She paid a warm tribute to Margie, and gave us a valuable insight into the expertise of the midwife. This was followed by a succession of fascinating presentation topics, including the management of clotting disorders in pregnancy (see pp. 4041), acupuncture and its use in womens health (see pp. 2126), the hormonal treatment of premenstrual syndrome (see p. 40), postnatal depression (see pp. 413), and breast screening (see p. 38). A very pleasant evening was spent at the gala dinner, where we sampled some Welsh cuisine, accompanied by music from a Welsh harpist. This was followed by presentations of certicates for the long Bradford course, and nally, the transfer of the ACPWH chains of oce from
Figure 3. Michelle Gormley, winner of the Margie Polden student award, with Ros Thomas.
Figure 4. Dr Peter Collins with Carole Board, Cardi organizing committee chairman.
55
Figure 5. Mair Whittall thanks Professor John Studd and Jennie Longbottom.
Figure 7. Caron James with Debra Bick.
Figure 8. Jill Mantle, Ros Thomas and the Right Honourable the Lord Mayor of Cardi enjoy a chat before the gala dinner.
Figure 6. Retiring executive member Sue Brook with Ros Thomas.
Ros Thomas, the outgoing chairman, to Pauline Walsh. Sunday began with a slideshow and a very interesting talk on sexually transmitted infections (see pp. 3940), followed by one of our own womens health physiotherapists, who described research on the eectiveness of classes in the treatment of urinary stress incontinence (see p. 37). The conference drew to a close with two presentations considering motivation and cognitive behavioural therapy (see pp. 1420 and 3336), which left us all with food for thought. 56
Figure 9. Our friends from Slovenia, Lidija, Darija and Gabrijela, enjoy a moment with the Lord Mayor and Lady Mayoress.
Special thanks go to all the sta of Fitwise, the conference organizers used to help us with this years Conference. They gave constant support
Figure 10. Ros Thomas with the Lord Mayor and Lady Mayoress.
Figure 12. Jeanette Haslam presents Romy Tudor with her certicate for completing the Bradford continence course.
Figure 13. The rst words from the new chairman, Pauline Walsh.
Figure 11. Mair Whittall and Dr Annie Evans.
to our event both running up to and over the weekend. Very special thanks go to Blair King, who came down from Edinburgh and spent the whole weekend with us, facilitating and coordinating the Conference.
From the Cardiff organizing committee Everyone felt that the whole Fitwise team, led by Blair King, provided excellent support for our event. He acted eciently as the coordinator between us and his sta. Each member of each team had dedicated roles, which became more apparent as we neared the Conference date and was very useful in ensuring that all queries were being answered. He pursued all enquiries quickly 57
Figure 14. Ex-chairman Jill Mantle.
other accommodation to achieve this, giving delegates an option to stay at cheaper hotels. Analysis of the evaluation forms (only 54 of the 78 delegates attending lled in the form) showed that 46% did stay at the Copthorne, and 44% of these were self-funding. Sponsorship through trade stands proved very dicult to achieve. It may be that the cost to the companies was too high in relation to the number of delegates attending, and this issue needs to be addressed by future Conference organizing committees (92% of the delegates appreciated the trade stands and bookshop). Delegates may not realize the importance of the trade stands, which provide a vital source of income that enables us to balance the books. The bookshop donated 10% of its takings. Finally, 67% of delegates completed the evaluation forms. Ninety-six per cent rated the Conference above 4, with 81% giving it 6 out of 6, so we can call Conference 2006 a success overall. Carole Broad Chair of Conference organizing committee 2006 (retired!)
Figure 15. Linda Furness, health advisor.
and eectively, and was able to suggest realistic options when posed with problems such as keeping the overall cost below 300 and how to use 58
Report from the winner of the Margie Polden Award 2006 Earlier this year, I applied to the Margie Polden Memorial Fund for a place at the ACPWH Annual Conference in Cardi. In doing so, I expressed both my passion for womens health physiotherapy, and my long-term goal to be part of a team that raises awareness of the many womens health issues and decreases the chance of women suering in silence. Thanks to Margie Poldens family funding my place and the ACPWH awarding it, I was able to attend the Conference. It could not have come at a better time. I graduated from Cardi in July 2006 and have been applying for jobs since then, with no luck to date. The Conference was a tonic: inspirational, enchanting, and full of fascinating topics that I could not wait to share with friends, colleagues and future patients. Throughout the 3 days, I met so many wonderful, like-minded womens health physiotherapists from a broad range of organizations. They were full of positive advice and support with regard to my current situation, and all encouraged my love of womens health physiotherapy.
I was never lucky enough to meet Margie Polden, but after attending the Conference, I now have seen the impact that she has had on both individuals and the development womens health. Those I spoke to who knew Margie showed me by their actions that she is a muchloved legend and is greatly missed. They told me that she educated numerous physiotherapists and professionals, and was renowned for inspiring student physiotherapists. How lucky I felt to know that I am one of them. There were 13 guest speakers over the 3 days, all of whom had the audience captivated and inspired. How refreshing it was to hear such serious and worthwhile topics explained in such simple and eective ways, often laced with humour, touching every person in the room, since we all know someone for whom this information would be of great help. The conference had over 100 attendees, including junior physiotherapists, lecturers and members of the ACPWH executive committee. The gala dinner, breakfasts, lunches and breaks were excellent opportunities to meet with, and nally put faces to, well-known names in womens health. In the present climate, when CPD is so important, I was surprised to hear about the nancial implications that may aect the frequency of future Conferences and the levels of attendance. To me, this weekend was priceless because it encouraged physiotherapists to think outside the box, embrace new concepts and let go of old myths. It gives us the opportunity to meet the living legends in womens health, and to learn about their own heroines, from whom we are still beneting today. Michelle Gormley Vagina monologue from a Conference virgin The Annual Conference was greatly anticipated at Saint Marys Hospital, Manchester, with much talk of gin and tonics, and gala dinners! Fortunately, I was able to sit comfortably in my chair this time round in contrast to the other ACPWH courses Ive attended this year, where Ive had to de-robe for the benet of practical learning! The highlight of the Conference, not counting the hotel breakfast, was the Margie Polden Memorial Lecture by the absolutely amazing Mary Cronk. She spoke from a midwifes perspective about issues of signicance to womens health physiotherapists, including sym 2007 Association of Chartered Physiotherapists in Womens Health
physis pubis dysfunction (SPD), and the unnecessarily high incidence of Caesarean sections for breech presentation. As I rushed onto the maternity wards on the Monday morning after Conference, there were ahs amongst the midwives as I spoke of the lecture Marys a true heroine. The other lecture that particularly sticks in my mind is The perils of the perimenopause by Dr Annie Evans (see pp. 2732). She spoke so condently about hormones, dispelling many common myths, and it was clear that most knowledge had been gained as a direct result of listening carefully to and caring for women for many years. I remember dashing up to my room before dinner and phoning my mother, saying, Mum, you really must get some of these oestrogen patches! clearly, the answer to absolutely everything! Conference, in a word, was fantastic. I learned a tremendous amount and it was great being among. like-minded people. As a Conference virgin, I was made to feel so welcome I made lots of contacts with colleagues from across the country and Im looking forward to seeing you all again next year! Hannah Gray
Master Class in Advanced Urogynaecology

Royal College of Surgeons, London, 2 October 2006 The Advanced Urogynaecology Master Class was constructed as a joint national project with the British Society of Urogynaecology, the Association for Continence Advice, the International Continence Society and the Continence Foundation. Twelve patient case studies were presented and discussed by a panel of six experts, including Mr Julian Shah (urology), Mr Dudley Robinson (urogynaecology), Mr Robert Freeman (urogynaecology), Ms Pauline Walsh (physiotherapy), Professor Mike Kirby (primary care and general practice) and Mr Ray Addison (specialist nurse). Professor Linda Cardozo (urogynaecology) acted as chairman to facilitate proceedings. The whole day was a highly interactive exercise, and a wide range of dicult, unusual and problematic clinical cases were discussed in the light of the latest research. Mr Julian Shah played devils advocate, provoking great 59
responses from a very spontaneous audience, with excellent multidisciplinary input that challenged delegates to think laterally and beyond the scope of their own specialty. There were 60 delegates in all, and physiotherapy was well represented by Pauline Walsh, Eva Johnston, Victoria Muir, Ros Thomas, Ritte Vosloo and Shernaz Screwvala. Case studies were presented with history and characteristics, followed by a discussion of investigations and treatment options by the expert panel, with participation from the audience. Consensus was sought on optimal clinical strategy. It was very interesting to hear the dierences of opinion regarding appropriate investigations, surgical options and catheterization between members on the expert panel as well as delegates. However, the patients best interest was always the highest priority in all considerations. The importance of making a diagnosis instead of treating a symptomcomplex was highlighted throughout the day, as was careful consideration of surgery in the view of complications. Multiple sclerosis (MS) proved to be a very interesting topic of discussion, since it is often picked up in urodynamics clinics long before the patient presents with other neurological symptoms. The use of suprapubic catheters versus clean intermittent self-catheterization (CISC), as well as the high cost of single-use catheters for CISC, and the need for it to be single use only, were valid points of discussion. The National Institute for Health and Clinical Excellence guideline statement that cranberry juice should never be recommended to patients who suer from MS also came into question. This recommendation is based solely on the lack of evidence to support the potential benet of cranberry juice in the prevention of urinary tract infections in this specic patient group. The pros and cons of tension-free vaginal tape (TVT) versus colposuspension and TVT versus transobturator tape were discussed in dierent case scenarios. The preferred use of autologous sling procedures in very young women (1421 years) with stress urinary incontinence was very interesting. There were also dierences in opinion about whether Caesarean section would be more protective than vaginal delivery following continence (or prolapse) surgery or not. The use of botox for detrusor overactivity is still very much experimental at this stage, and should be explained as such to patients, together with the relatively high risk of the need for 60
CISC after injections. The eect of botox is not permanent, but wears o within 48 months on average, and according to the literature, botox should not repeated more than seven times. A case study that was of particular interest was a male patient who presented with bladder symptoms following spinal manipulation for back and hip pain. This highlighted the musculoskeletal aspect that is often neglected in the assessment of incontinence, raising concerns about the use of spinal manipulation, and its potential eect on bladder and bowel function. Another area of concern was the policy for the use of indwelling Foley catheters during vaginal delivery. It is not uncommon for a catheter to come out during delivery with the balloon still inated, as happened in one specic case study presented. It would be very dicult to determine whether urinary incontinence after delivery was the result of urethral sphincter damage caused by the balloon coming out inated, or whether it was related to the size of the baby, long second stage of labour, pudendal nerve neuropathy or pelvic oor damage. However, the question remained: should nursing protocols regarding this issue be reviewed? Can an inated catheter balloon cause real damage to the urethral sphincter? Should midwives or nursing sta be expected to do regular intermittent selfcatheterization to prevent over-distension of the bladder when they hardly have time to monitor the mother and babys vital signs? Does the risk of over-distension because of a lack of care outweigh the potential risk of an inated balloon coming out during delivery? Should the balloon be deated when the woman enters the second stage of delivery? Finally, no consensus was reached regarding the use of hormone replacement therapy (HRT) to treat urogenital atrophy and its eect on incontinence or irritative symptoms. Current evidence indicates that HRT may have a negative eect on urinary incontinence, and the Cochrane Incontinence Group meta-analysis (Moehrer et al. 2003) was the only study that showed greater improvement of symptoms in the oestrogen group than in the placebo group. The overall impression was that the prescribing of topical oestrogen (with or without systemic HRT) should be maintained to treat urogenital atrophy, specically if patients have overactive bladder symptoms, but that more research into topical treatments is needed.
As a physiotherapist, I found the master class session most interesting and learned a great deal from the dierent case studies discussed. It gave me a much broader perspective on patient management, and highlighted the importance of multidisciplinary input and interdisciplinary communication. It is about the whole package! Physiotherapy, specically pelvic oor muscle training, was well supported, but also questioned, by members of the expert panel as well as the audience, but Pauline Walsh represented us well. Provided that patients take responsibility for their improvement, are compliant with treatment and adhere to a regular exercise routine, physiotherapy could help to improve their quality of life, and may even help to avoid, or at least postpone, surgery. I would recommend such a master class to all physiotherapists with an interest in womens health. Riette Vosloo Reference
Moehrer B., Hextall A. & Jackson S. (2003) Oestrogens for urinary incontinence in women (Cochrane review). In: Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD001405. DOI: 10.1002/14651858.CD001405.
brains and do short presentations, but with absolutely no pressure or fear of getting it wrong. Here is a photo (Fig. 17) werent we having fun! Gail Stephens and Amanda Savage are great tutors, and we were lucky enough to have the other two tutors present, along with assessors Judith Lee and Diane Stark, and workshop coordinator Ruth Hawkes. I would thoroughly recommend this course, not just as an introduction, but as an update for those with previous experience of Pilates. I hope that the ACPWH will grant approval for the workshop and it will be running in 2007. Please contact Ruth Hawkes for details. Ann Dennis Solent Group area representative
The Unique Role of the Womens Health Physiotherapist in Antenatal Classes

Chorley and South Ribble District General Hospital, Chorley, 23 December 2006 The rst weekend in December was dedicated to the long-awaited and eagerly anticipated pilot of the ACPWH antenatal workshop, the overall aim of which was to evaluate the unique role of the womens health physiotherapist in antenatal classes. The 21 enthusiastic delegates who congregated in the physiotherapy department of Chorley and South Ribble District General Hospital an excellent venue for any course were met each morning by the wonderful aroma of steaming hot coee and delicious Danish pastries! Our grateful thanks are extended to the excellent organizational skills of Michelle Horridge! The friendly and helpful course tutors, Judith Lee and Maggi Saunders, professionally delivered a tightly packed 2-day programme that provided a good mixture of evidence-based theoretical and practical sessions. These included the anatomical and physiological changes associated with pregnancy, the complications and discomforts of pregnancy, and safe core stability exercises. Day 2 comprehensively covered the stages of labour, along with coping skills physiotherapists can teach women and their birthing partners. These skills included positions for labour, relaxation and massage techniques wonderful! 61
An Introduction to Pilates in Womens Health Physiotherapy

Bournemouth Hospital, Bournemouth, 1112 November 2006 The pilot of this ACPWH workshop proved to be an excellent course that all the participants seemed to thoroughly enjoy. It was the perfect mix of theory and practice, with updates on all the latest research. We were made to use our
Figure 17. Pilates class at the ACPWH pilot workshop.

Many delegates commented on the advantages of participating in the class planning scenarios. Networking with peers, exchanging information and sharing practice was highly valued by both the experienced clinicians and those relatively new to womens health services. Overall, this informative and upbeat course is highly recommended to all womens health physiotherapists who are involved in the development and delivery of antenatal classes. Delegates were left in no doubt about the unique and important role of the womens health physiotherapist. However, it was recommended that physiotherapists work collaboratively with our midwifery and medical colleagues. Delivering antenatal physiotherapy services within an interprofessional teamwork culture should provide the ideal opportunity for the true value of physiotherapy input to be more fully appreciated. [It is hoped that the ACPWH will grant approval to this workshop in 2007 Ed.] Jane S. Brazendale Principal physiotherapist Central Lancashire PCT Leyland Lancashire
A Functional Approach to Assessment and Treatment of the Pelvic Girdle in Pregnancy and Postpartum
Great Western Hospital, Swindon, 4 November 2006 I was delighted to attend Yvonne Coldrons day course on pregnancy-related pelvic girdle pain because, although there are many courses on the lumbopelvic region available, there are few covering the particular problems encountered by women during pregnancy and the puerperium. Yvonne began the day with an overview of the biomechanical changes associated with pregnancy, followed by a discussion of the anatomy and biomechanics of the pelvic girdle, with reference to her own research into the role of rectus abdominis and the eects of divarication on pelvic stability. She has a wealth and depth of knowledge about these subjects, and the amount of information presented would benet from a full 62
morning session rather than the allotted hour, but the day-course format required us to move on rapidly to practical physical examination of the pelvic girdle. This included points of caution and positional modications required for the examination of pregnant women, and aimed to achieve a diagnosis in terms of articular, myofascial and/or motor control dysfunction. In the afternoon, Yvonne discussed and demonstrated practical techniques for the management of dysfunction of the symphysis pubis, sacrum and ilium, using articular techniques, myofascial muscle energy techniques, and inhibitory and facilitatory techniques for muscle balance, followed by an opportunity to practice. I was familiar with many of these techniques, but tend to use only a selection of them clinically. Working through them practically with Yvonne gave me more condence to apply additional techniques and understand their role in the management of pelvic girdle dysfunction. It was very helpful to see and practise some of the modications that Yvonne uses for her pregnant patients. This was an informative and relevant daycourse, but I feel and I know Yvonne agrees! that a 2-day course would allow for more reection and practical time for the many strategies covered. However, for most participants, CPD funding (i.e. self-funding in most cases!) favoured one day rather than two. Perhaps a follow-up day in 6 months, to allow us to return with case studies and an opportunity to troubleshoot techniques/consolidate our knowledge, would be a viable alternative format. Paula Riseborough Senior physiotherapist Royal United Hospital Bath
Physiotherapy for Pregnancy Related Pelvic Girdle Pain

Great Western Hospital, Swindon, 4 November 2006 As a relatively new senior 2 in womens health physiotherapy, I thought it would be a good idea to address all my questions about how to treat pregnant ladies suering with SPD and sacroiliac joint (SIJ) pain using more than just a support belt, pelvic oor and core stability exercises. Yvonne Coldrons aptly named study day seemed the ideal learning opportunity.
Prior to attending the day, I was sent an excellent information pack outlining the aims and objectives of the course, the days timetable, and a reference list of two essential books to read. It looked a full and daunting day. How much of the biomechanics was I supposed to understand prior to attending? It would have been easier for me to have a specic outline about how much to read. In the end, this was not something I needed to worry about! The day consisted of an informal lecturebased introduction, and teaching of form and force closure, and the impact of muscles and gait on the joints. It included pregnancy-related musculoskeletal changes, terms, incidence and classications of the dierent types of SPD and SIJ dysfunction, and management of these conditions. It was nice to relearn and clarify some basic knowledge about the joints and relate this to new ndings and evidence from Yvonnes research. The environment was relaxed and open, and it was good to talk to people in the group with varied skill mixes and experience. The practical learning was very informative and well structured, giving each individual a
chance to assess and practise treatment techniques on each other in small groups. The time seemed to y by too quickly to allow me to remember all the techniques, and I was tired by the end of the session. There was a huge amount of information to cover in one go this would denitely be a course I would like to complete over 2 days if I had a choice. The outcome of the day made me challenge and question my practice with regard to the emphasis put on the transversus abdominis when treating divarication, at the expense of the importance of the obliques and rectus abdominis function. I also newly learned about the altered inuence of the gluteal and adductor muscles on the pregnant pelvis in relation to SPD. Thanks to this study day, I feel more condent in my ability to assess and treat manually those patients with pregnancy-related musculoskeletal pain. I look forward to reading Yvonnes research to further consolidate my understanding of her assessment and treatment choices. Alison Crocker
63
From your executive
Chairmans report
Having just returned home from a great Conference in Cardi, I should like to begin by thanking the Cardi team, led by Carole Broad, for organizing the event. They have had the unenviable task of trying to attract delegates who have little or no funding, but I hope those who managed to attend both enjoyed it and learned a lot. Those of you who were at Conference in 2005 will remember that we periodically have to undergo the reaccreditation process to be recognized as a clinical interest group (CIG) by the Chartered Society of Physiotherapy (CSP). This process requires us to be seen to full ve criteria over a 5-year period. At Cardi, I explained briey how we have continued to full those criteria. Category 1: Continuing professional development Demand is high for the urinary incontinence and anorectal workshops, and we are now developing a treatment workshop to include both conditions. The Pilates and antenatal workshops will be piloted in November and December 2006, respectively. If you are unable to access a course, or wish to organize one, please contact Ruth Hawkes, who is both the area representative coordinator and the workshop coordinator (see inside front cover). Our postgraduate courses continue to be popular. Achieving success in one of them continues to be the main way of gaining membership to the ACPWH, and three candidates received their certicates at the gala dinner. Category 2: Inuencing and informing Ruth Hawkes and I had a useful meeting with most of the area representatives in June 2006, and the task of disseminating information to all members nationwide is becoming easier and more ecient. I am delighted that 14 out of 16 areas of the UK are represented. With the retirement of Ann Johnson, Yorkshire is looking for a new area representative and Amanda Savage is looking for replacement in Cambridge. Thank you Ann and Amanda for all you have done. 64
Giving and receiving awards is always a good way to gain attention for the ACPWH. At Conference, the Margie Polden Student Award was presented to Michelle Gormley, who, coincidentally, has just graduated from Cardi. I hope this Conference has inspired her to continue her interest in womens health (see p. 59). Interactive CSP (iCSP) has nally launched, and after a shaky start, seems to be a great success. Our own iCSP moderators came to Cardi to provide some familiarization for some delegates. Our website continues, although it remains to be seen how it will evolve alongside iCSP. The executive committee will monitor its use. Please continue to place your adverts on it for courses and study days. Many of us continue to work with other, outside physiotherapy organizations. Recently, we were approached by the Royal College of Obstetricians and Gynaecologists to peer review a new document on the assessment, surgery and treatment of third- and fourth-degree anal tears in childbirth. Gill Brook continues to act as the treasurer of the International Organization of Physical Therapists in Womens Health (IOPTWH), and next year, we both hope to represent the ACPWH at the World Confederation for Physical Therapy conference in Vancouver, Canada. Two representatives will be attending the CIGs conference in November. Representatives from each CIG are eligible to go, and it is usually a rewarding weekend. The Annual Representative Conference (ARC) was cancelled in 2006, but our motion will be reconsidered for inclusion in 2007 and I have a team of keen people ready to attend on our behalf. These two conferences are open to any of you, so please contact the honorary secretary if you are interested. Category 3: Promoting physiotherapy With more members than ever and, therefore, more voices raising awareness about what we do, womens health issues are becoming generally more talked about. You will read in public relations ocer Ann Maynes report below that we are continually bombarded by requests for comments on various aspects of womens health
From your executive
for inclusion in newspapers, magazines and radio programmes. We do our best to respond to as many of these requests as possible, but the report is often required almost immediately and it is very dicult for many of us to nd time in the middle of a working day. A group of us went for media training in London, and the guidance we produced is available from your area representatives or the website. Some of you will know that Fit for Motherhood has been reviewed and replaces the original version. The Pregnancy-Related Pelvic Girdle Pain leaets, one for health professionals and one for patients, are scheduled to be printed by the end of 2006. These replace the old symphysis pubis dysfunction (SPD) leaet, which has not been available for some time. We are hoping to get the production and printing of our patient leaet sponsored so that it will be free, but in these cash-strapped times, we can only wait and see. All our leaets sell well, and again, raise the public face of the ACPWH in what I hope is a positive and professional manner. Once the new publications are all in stock, we will begin the review of our other leaets. These have remained at the same price since we started with Fit for Motherhood in 2000. Since the postage and packaging rates changed radically last month, Ralph Allen Press are revising their entire costings so please refer to the ACPWH website and the back page of the Journal before making an order. Tidys Physiotherapy has also been reviewed this year, and many ACPWH members have contributed to part of a chapter or written a whole one. Category 4: Quality assurance The education subcommittee (ESC) handles so many of the tasks that take time to achieve. Currently, it is updating and reviewing many of our documents. My thanks to the committee members for all their hard work. By monitoring articles in the press, and by being selective about who we speak and give interviews to, it is possible to maintain quality assurance and high standards of reporting. The Journal continues to go from strength to strength and could probably be included in each of the categories Ive mentioned. The standard is ever higher, so my thanks to Gill Brook for coordinating her team so eciently. Diversity issues are few in number, but it is good to know that we have a trained individual on the executive to manage any that might arise.
Category 5: Research and clinical effectiveness Work continues to evolve the role of the research ocer both in terms of facilitating research and advising on clinical governance issues (see p. 68). Believe it or not, we are still attempting to produce guidance for electrotherapy during pregnancy and labour. It is an ongoing project, but rest assured, the executive and the ESC will not be giving up until it is resolved. We have been massively involved with the National Institute for Health and Clinical Excellence this year. Work continues with the urinary incontinence and the faecal incontinence guidelines. We have been consulted recently on the antenatal guideline review and the antenatal mental health guidelines. Our comments on the intrapartum guidelines were not accepted. If anyone is interested in being more involved in key areas of the ACPWH, such as with the Journal, archives, CIG conference, ARC, joining the executive or belonging to non-committee groups for small tasks that come up from time to time, then please speak to me or one of the executive committee we really would love to hear from you. As always, I would like to acknowledge the hard work done by many people. They are the members of the executive, the members of the ESC, the members of the Journal subcommittee and the area representatives, who all give a great deal of time and commitment to the ACPWH. I cannot name you all, but you know who you are. So, as I come to the end of my 3 years as chairman, I reect on the achievements and experiences we have had during my term of oce. I am sure it is every departing chairmans wish to pass on an Association that better meets the needs of not only its members, but also its wider stakeholders patients, other health professionals and, indeed, the general public. This would be a wonderful legacy for me. One of my personal aims was to involve more of the younger members and I am delighted that four have been nominated this year for election to the committee. This is a tremendous start and I very much I hope the trend will be continued. I have recently worked hard to appoint an administrator to provide help and support by tackling some of the routine day-to-day activity, leaving the executive to concentrate on what it was elected to do. I hope this will make a tremendous dierence to us all and you will be updated regularly during the probationary period. 65
From your executive
We have ve members leaving the executive this year. First, Sue Brook, who has, during her 6 years of service, been willing, reliable and always cheerful, even when tasked with being the minutes secretary. Secondly, Trish Evans, who has served for 4 years, most recently as book and leaet secretary. Thirdly, Alex Welman, who also served on the executive committee for 6 years, and latterly, has taken on the enormous task of membership secretary. During this time, she has also sat on the ESC, and has been a reliable and helpful member, contributing an enormous amount. Fourthly, Rachel Grubb was appointed as secretary soon after joining the executive and then became treasurer 2 years ago. Although this is not a popular job with anyone, she has tackled it cheerfully and eectively. Rachel has been level-headed and sensible throughout, and always quick to respond to important issues. Both Alex and Rachel will be leaving their posts when the new administrator has got to grips with them. And last, but very much not least, Gill Brook, who has been part of the ACPWH for 12 years. She has held the honorary posts of secretary, book and leaet secretary and chairman, and is now retiring as Journal editor. She continues as treasurer to IOPTWH. We owe her an enormous debt of gratitude for all she has done for the Association. She has led us admirably and is the most laid-back person I know, happily taking the p out of panic for me on many an occasion. I thank all ve of them for their massive contributions and support; they will all be sorely missed. Your next chairman, Pauline Walsh, was elected at Conference 2006 in Cardi and I formally handed over the chains of oce at the gala dinner. I know Pauline will make a splendid chairman and I wish her every success leading the ACPWH onwards for the next 3 years. I have found my 3 years at the helm of the Association challenging and enjoyable, both frustrating and rewarding, but most of all, it has simply been a pleasure to work with and for so many lovely people, many of whom have become rm friends. I am looking forward to the next challenge of Journal editorship and hope I can continue the good work which Gill has implemented so well. Ros Thomas 66
Treasurers report
This will, I hope, be my nal report as treasurer. As I outlined to those of you who were at Conference 2006 in Cardi, our association continues to grow, and with it, the workload of committee members. This is a concern not only to the ACPWH, but also to other CIGs. For this reason, the executive committee has decided to pilot the use of paid administrative help; indeed, by the time you read this, it may be under way. The cost of this pilot will be met from existing funds and will be reviewed at the end of one year. The membership will be kept informed via the website and mailings, and of course, will be given notice if this is likely to have an impact on annual subscriptions. Association funds remain reasonably healthy. Our income and expenditure are largely the same from year to year, and I am condent that ACPWH funds can sustain the cost of administrative support in the short term. I am equally sure that this will be a very positive change for the association that will be of benet to the members. Rachel Grubb
Membership secretarys report

Total membership stands at 722 as of 1 October 2006 (Table 1). As I write this, I am in the process of handing over to Blair King at Fitwise Management Ltd. I have thoroughly enjoyed my time as your membership secretary and the time I have spent working for the ACPWH. I have particularly relished welcoming new members into the Association, and in the 3 years that I have been your membership secretary, this has amounted to over 200 new members! I have also thoroughly enjoyed helping members of the public nd a specialist womens health physiotherapist in their local area.
Table 1. Membership of the ACPWH as of 1 October 2005 Membership type Full Aliate Associate Honorary Retired Total Number 316 298 55 6 47 722
From your executive
However, the ACPWH has now become so large that the time has come to amalgamate the membership secretarys and treasurers roles into one, and for the administration of the Association to be all under one roof. By the time you read this, Fitwise should be at the helm. Alex Welman
Public relations officers report

The ACPWH continues to work closely with the CSP press oce and public relations ocer, Prabh Salaman. We had a busy time early in the year and during the summer months with media interest in several womens health issues. Local and national newspapers and several magazines published articles, and all gave our website details, resulting in many requests from the public asking for more information. A project, run by WellBeing of Women (WOW), about stress urinary incontinence and pelvic oor muscle exercises (PFMEs) kept us busy throughout the spring and summer. A nation-wide survey of 1232 women about their knowledge regarding bladder problems and PFMEs came out, with some very interesting results and statistics. Unfortunately, WOW refused to give the ACPWH permission to use any of the data, even though the Association had played a major part in designing and writing the questionnaire. In July, WOW organized The Big Squeeze road show, which was held at the Royal College of Obstetricians and Gynaecologists in London. Unfortunately, the event was not well organized and publicity leading up to the event was poor. Very few people attended and the day was very disappointing. However, thanks must go to Julia Muman, Katie Jeitz and Paula Martinez, who bravely looked after the ACPWH display stand for the day. Please do get in touch with me if you see or hear about interesting womens health stories in the media. A big thank you goes to members who have helped with media events and interviews during the past year. We need to raise our prole still further during 2007. Ann Mayne
been produced as a result of the foresight of its initiator, Alex Welman, who has carried the ag with the rest of the committee until its nal publication. We do all hope that you will nd it useful. This leaet is also going to be adapted and published to make it suitable for those women who sadly have a stillbirth or neonatal death. We hope that this will also become available in the near future. The Pregnancy-Related Pelvic Girdle Pain leaflets (previously known as the SPD leaet), one for the use of health professionals and the other for patients, are now in their nal drafts and should be available very soon. The ACPWH-approved workshops are increasingly popular. Please do visit the Association website frequently to ensure that you dont miss out on any that you may wish to attend. I recommend that you book early since many of them are fully booked quite quickly. However, we did have to cancel the psychosexual workshop because of insucient applicants. We think this may be a result of its higher cost. People have also commented that they are nding it increasingly dicult to get time o work to study; however, most workshops are at weekends. At present, we provide workshops on: + pelvic oor assessment and examination for urinary incontinence; + pelvic oor assessment and examination for anorectal dysfunction; + an introduction to Pilates in womens health physiotherapy; and + the unique role of the womens health physiotherapist in antenatal classes. If you want to organize a workshop in your area on any of these subjects, just let me or workshop coordinator Ruth Hawkes (see inside front cover) know. Another ongoing project is that of formulating an advice leaet for professionals on the use of transcutaneous electrical nerve stimulation (TENS) in pregnancy. It has been proposed that a patient information leaet should then be written when this is completed. We are also pleased to report that there has been successful cooperation between the ACPWH and the Chartered Physiotherapists Promoting Continence to produce a pelvic oor leaet for AGILE, the special interest group for the elderly. They are to launch it later in the year. Julia Herbert is to speak on behalf of the Association at the AGILE session at the CSP conference. 67
Education subcommittee report

The ESC has been hard at work since the last Journal and are delighted to report that the new Fit for Motherhood leaet is now available. It has
From your executive
There have been 15 successful candidates on the University of Bradford continence course this year. We oer them all our heartiest congratulations and look forward to seeing more of them in the future. Jeanette Haslam
Research officers report

Earlier this year, I attended a research ocers study day at the CSP, and information from that day is reported separately (see pp. 5253). However, there was much publicity about the launch of the National Physiotherapy Research Network (NPRN). There are now 20 regional research hubs in the UK and Ireland, and I attended a meeting of the South East hub, partly in my capacity as the research ocer for the ACPWH, but also as a clinical physiotherapist with an interest in research. The meeting was at the University of Brighton (Eastbourne), and participants came from both the academic and clinical sectors. The content of the evening largely consisted of group discussion about the way forward for the hub, as well as discussion regarding the scope and problems of clinical research. The CSP members at the meeting were enthusiastic about the way that research could be undertaken in a clinical setting. It was recognized that academic support may be necessary, and the Physiotherapy Department at the University of Brighton is keen to be involved with clinicians. The South East hub is an active organization and meetings are arranged every 34 months. These regional meetings are open to all CSP members who have an interest in research you do not have to be involved in active research to attend. I found the meeting to be very supportive of clinicians who had had very little experience of research. If you wish to know more about your local research hub or the NPRN, you can access information via the CSP website <http://www. csp.org.uk/director/eectivepractice/research/ nprn.cfm> or contact Dr Philippa Lyon, NPRN Research Ocer at <p.lyon@bton.ac.uk>. I have continued to lead the production of two evidence-based, peer-reviewed, multiprofessional leaets on pregnancy-related pelvic girdle pain (PGP) (encompassing both symphysis pubis and sacroiliac dysfunction). One leaet is aimed at health professionals involved with ante- and postnatal care (including physiothera68
pists, midwives, health visitors, general practitioners and obstetricians), and the other is aimed at women who have experienced PGP. These leaets are in their nal review stages and we hope to have them printed by the New Year. I have continued to support the ESC and we are meeting TENS experts in October to review our current policy on TENS in pregnancy. I have received many queries from members and non-members about various issues relating to research, and this makes for some interesting discussion. However, for general discussion about matters relating to womens health, iCSP is a good resource and I would encourage those members who would like to explore wider issues to sign up! The process is easy just access the CSP website and follow the instructions. For 2007, I am concentrating on developing the role of the research ocer, and shall be particularly exploring issues around research bursaries, development of a research page on our website and gaining information on current research activity from members. Yvonne Coldron
New executive committee members

Becky Aston After qualifying as a physiotherapist from the University of East London (UEL) in 1997, I embarked on a junior rotational programme at the Royal Free Hospital in London. It was during this period that I was lucky enough to be given the opportunity to attend a 3-day course entitled An introduction to womens health, and followed this with a 4-month womens health placement. Since then, I have specialized in womens health, moving to St Georges Hospital in London, where I completed the Bradford course and became a full member of the ACPWH. I moved to the Homerton Hospital in East London in 2002 as a senior I physiotherapist, and then a clinical specialist. I have recently returned to work after maternity leave and embarked on a 2-year research fellow post, investigating dierent aspects of pelvic oor dysfunction and service design models. I have been a member of the Association since 1999 and a full member since 2001. In 2001, I joined the ACPWH Journal subcommittee and have been an active member, responsible for the Papers in other journals section (see pp. 97 103). Furthermore, I have lectured on womens
From your executive
health issues at an undergraduate level at UEL since 2003. I feel that it is important to contribute to an Association which supports us as members in our clinical work. I hope to bring enthusiasm and motivation to the ACPWH executive. Becky Aston Katie Mann Like many of us, pelvic oor physiotherapy fell upon me by accident, having followed my basic postgraduate experience in the usual way (Fig. 1). I qualied from Salford in 1989 and joined Southport District General Hospital. A return to work course in Exeter after the birth of my son reintroduced me to the pelvic oor. I then went on to complete the rst ACPWH continence course in 1996. After several years developing the Physiotherapy Pelvic Floor Clinic, I am now clinical specialist at Southport and Ormskirk Hospitals, with some private work at the local Capio hospital. I currently treat men and women with pelvic oor dysfunction, and work closely with the urogynaecologists and nurse specialists of our trust. I am a clinical supervisor and regional group mentor for the ACPWH course, and have been involved in research with Jo Laycock. I am an active participant in the Mersey region, implementing the governments Integrated Continence
Services White Paper. I teach postgraduate nurses at Edge Hill College and undergraduate midwives at Aintree Hospital, and I am often asked to give talks at various courses and meetings. I look forward to the challenge of being a member of the executive committee of the ACPWH. I can oer 13 years of experience working in the eld of pelvic oor dysfunction. I wish to actively promote the role of physiotherapy in this area and support the work of the Association in continually developing national quality standards. Katie Mann Lesley Southon I have spent many years working in musculoskeletal departments both in England, Scotland and Norway. I started dealing with continence patients about 6 or 7 years ago in a part-time capacity as part of my musculoskeletal caseload, and then about 4 years ago, I was fortunate enough to transfer to work in the Kingsher Clinic in Norwich, which is a multidisciplinary continence clinic, our core team comprising of physiotherapists and nurses. I completed the UELs graduate continence course in 2004 and have acted as a mentor this year for the new Bradford continence course. I have just written a chapter for the second edition of Therapeutic Management of Incontinence and Pelvic Pain edited by J. Laycock & J. Haslam, which is scheduled to be published this year, entitled The athletic woman/women and exercise, based on my groups presentation during the UEL course. I am presently involved in a research project with a medical student from the University of East Anglias medical school. This will look at various aspects of the patients journey and care whilst treated in our clinic. I was keen to stand for the ACPWH executive committee because I would like to become more involved in the continuing development of the Association. I foresee that it will be challenging, but think that the role for the ACPWH is ever-increasing and it is an exciting time to be involved. I believe that any membership group is only as good as its members and that everyone has a responsibility to input into that group in some way. I hope that I will be able to be involved particularly with the aspects of integrated continence care that are constantly evolving in many dierent ways throughout the country. Lesley Southon 69
Figure 1. Katie Mann.

From your executive
forward-thinking, and adapt to a progressive National Health Service and changing society. Gail Stephens
Fitwise Management Ltd

Since Conference 2006 in Cardi, we have made great progress in acquiring administrative assistance for the executive committee. We have decided to pilot using the services of Fitwise Management Ltd, which is based near Edinburgh (Fig. 3). Fitwise already manages our conference for us, and its involvement with ACPWH has now been extended to include management of the membership database, our nance and accounts, and distribution of our stock of books and leaets. Some of you will be familiar with Blair King, one of the directors, who attended the Cardi conference with Lynn Ward. Sandra Rees is our new nancial manager and Gillian Reid manages the membership database. Details of how to contact Fitwise are given on the inside front cover. We are doing our best to ensure a smooth handover to Fitwise, and the benets to the executives workload are already becoming obvious. We will continue to have nominal posts for the specic roles of treasurer (Doreen McClurg), and book and leaet secretary (Clair Jones). If you have any concerns during the handover
Figure 2. Gail Stephens.
Gail Stephens I am a physiotherapist, working in both primary care and the private sector, who specializes in men and women with continence problems, and also pelvic girdle pain (Fig. 2). I qualied from Keele University in 1999, and worked at Addenbrookes Hospital in Cambridge, becoming more interested in womens health before relishing the opportunity to work within primary care in the Continence Service as the sole physiotherapist in 2003. I work closely with continence advisors running joint clinics across Cambridgeshire whilst constantly striving to improve the service oered to patients within primary care. I am actively involved in audit and research, and I am a tutor on the Introduction to Pilates in womens health ACPWH workshop. I am regularly asked to teach and lecture at local and regional events, and have published articles in national journals as well as local publications. I completed the UEL continence course in 2004. I rmly believe in a good work/life balance, since this is fundamental to performing eciently and eectively at work and play. So, when I am not a physiotherapist, I am a Brownie and Guide Guider. Through Girlguiding UK, I have been involved in promoting sexual health through PFMEs, and bladder and bowel health. I strongly believe that organizations such as Girlguiding UK and the ACPWH should be 70
Figure 3. Ros Thomas on a ying visit before Christmas to the Bathgate headquarters of the Fitwise Management team. Back row, left to right: Stacy Martin (ACPWH conference administrator), Ros Thomas, John Matthews (director), Lynn Ward (general administration) and Blair King (director). Front row, left to right: Gillian Reid (ACPWH membership database), Sandra Rees (ACPWH accounts and nance), Anne Ross (sales of trade exhibition space) and Lynne Martin (general administration).
From your executive
period, please contact Doreen or Clair, or for general concerns, contact the secretary, Julia Bray, so that we can deal with issues as they arise. There will be another update on the success of the enterprise in the Autumn 2007 Journal and
at Conference. ACPWH funds will cover the administrative costs for the coming year and the executive will look carefully at any impact on subscription levels in the future. Pauline Walsh & Ros Thomas
71
Round the regions
Channel islands
The audit on Assessing outcomes of urinary incontinence treatment using the International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form is published in this issue of the Journal (pp. 4248)! The recommendations have been implemented and re-audit is scheduled for the middle of 2007. The next audit on the agenda is the Chartered Society of Physiotherapy Standards, and we are planning to do this across womens health. Our obstetric service review is still on the boil these things always seem to take longer than rst thought and we will soon be training the rst line of midwifery care assistants to deliver one-to-one pelvic oor advice to new mums who are at low to medium risk according to the PromoCon Pelvic Floor Risk Assessment Tool. This should free up some time to spend with high-risk women and antenatal care. Clare Jouanny Area representative E-mail: jouanny@localdial.com
London
In April 2006, Elizabeth Emerson and Linda Boston delivered a talk on Incontinence in the athletic woman on behalf of the East England group. This presentation was part of their Graduate Certicate in Professional Development in Health Continence at the University of East London. It was a fascinating review of the literature on incontinence in the elite athlete that revealed a high level of urinary and faecal incontinence. Urinary incontinence is prevalent in gymnasts and athletes, a possible cause being a predominance of type 3 collagen in the connective tissue, resulting in a hypermobile urethra. Low oestrogen levels, combined with increased type 3 collagen bres, and the repeated physical forces generated by repetitive jumping, long jump, running, gymnastics and trampolining, are conducive to urinary incontinence, trampolining producing the greatest incidence of urinary incontinence in girls aged 15 years. Faecal incontinence in long distance runners is not uncommon (3060%). With her reasoning skills and knowledge of physiology, the womens 72
health physiotherapist is well placed to assist athletes to optimize the muscular aspect of the continence mechanism, and take part in health promotion activities with athletics coaches and tness instructors. This was an excellent evening. In June, we hosted a study day at Hammersmith Hospital on The perinatal pelvic girdle: a functional approach to assessment and treatment. The course tutor was Dr Yvonne Coldron. She ran an excellent day that gave us an opportunity to practise our musculoskeletal skills in order to enable us to examine, manage and treat pelvic girdle problems in ante- and postnatal women. We revised the physiological changes in pregnancy, had the altered biomechanics of the spine and pelvic girdle explained to us very clearly, discussed the possible aetiology of these pains, and were shown manual techniques and exercises for the pelvic girdle in pregnancy and following delivery. It was a lot to absorb in one day, but a muchneeded course for those of us who see and treat many patients with symphysis pubis dysfunction/pelvic girdle pain (SPD/PGP) in pregnancy. Thank you, Yvonne. I will be retiring in March 2007, and I am looking forward to nding a successor who will continue to provide the London group with interesting and stimulating study days and workshops, keeping the Margie Polden thirst for knowledge in womens health alive. Avril Hillyard Area representative Email: avrilhillyard@hotmail.com
North East
Over the past year, the north-east group has had two evening meetings. In November 2005, a small group attended a very interesting talk by a midwife on optimal foetal positioning, and the programmes oered to mums and their families, at the large regional hospital in Newcastle upon Tyne. We did not meet again until June, when the same small group brought journal articles for discussion. We agreed to try a new format and held a successful afternoon meeting in September. Lunch was provided by the Lyrinel XL representative. We used the session to report
Round the regions
on Conference 2006 in Cardi and the London scientic updates in urogynaecology. We also viewed the video on erectile dysfunction, postmicturition dribble and urinary incontinence, and decided that we would next meet in the New Year, topics to be arranged. I asked for volunteers for area representative. In February 2006, we hosted the ACPWH anorectal assessment and treatment workshop in North Tyneside. The enthusiasm of lecturers Janette Haslam and Julia Herbert was evident, and the practical session was conducted in a very sensitive yet helpful manner. The demonstration of anorectal physiology tests by the consultant was extremely helpful. The course evaluated very well and ended with the participants feeling the need for a further workshop on physiotherapy treatments for continence problems. Is anyone in the region interested in hosting this? Emilie Nesbit Area representative E-mail: Emilie.Nesbit@northumbria-healthcare.nhs.uk
Two introductory weekend courses on urinary incontinence and faecal incontinence are being run for less-experienced senior sta and juniors interested in womens health by the Continuing Professional Development (CPD) Centre in early 2007. We also plan to run a study day in March 2007 on overactive bladder. Speakers are currently being sought. Thamra Ayton Area representative E-mail: mayton@ukonline.co.uk
Scotland
The Scottish branch meeting took place on 2627 October 2006. Eighteen physiotherapists attended the weekend and there was a waiting list to get on the course! All interested members got places and then we opened it up to outpatients colleagues. It was lovely to see so many younger physiotherapists, and we had two new graduates on their rst rotations, which were in womens health (we hope they will be future members). The course even persuaded two colleagues to travel from the Western Isles to the mainland, and one member made the 8.30 a.m. start from Inverness. The course was run by Helen Thomson, a physiotherapist in private practice who is involved in womens health. She has a downto-earth approach to outpatients, and with her wealth of experience, guided us through the sacroiliac joint, coccyx, lumbar spine, ribs and diaphragm with her insights into the relationship between musculoskeletal dysfunction and continence. Helen gained everyones respect by demonstrating on two pregnant ladies. One of them said, I think youre a white witch. I feel brilliant! At the end of the course, I asked everyone if they would be interested in learning more and all 18 put their hands up! I take it from this that we had a successful meeting! I recommend other members to think of inviting Helen to talk at your meetings. Our next meeting will be in the spring and it will be a day course. The venue and time have still to be arranged. You must be fed up of coming to Wishaw, so come on, I need a volunteer! I also need someone to think about taking on the area representative role next year. Elaine Struthers Area representative E-mail: Elaine_struthers@hotmail.com 73
Northern Ireland
We in Northern Ireland are presently undergoing a period of change. The consultation on the Review of Public Administration has looked at reforming the Health and Personal Social Services structure. From April 2007, the new structure will be made up of fewer (i.e. ve) trusts, which we hope will create new opportunities to integrate services across the existing hospitals in the long term. Furthermore, many of us have been working with our other professional colleagues on introducing Integrated Clinical Assessment and Treatment Services to Northern Ireland. Along with the Agenda for Change, these seem to be causing us a lot of headaches. To keep our spirits up, we all met at the end of September 2006 for a half day to hear a wellpresented, very informative talk on hormone replacement therapy and the menopause by Dr Raymond White. We also planned for the year ahead. Doreen McClurg was elected as chairperson, with Caroline Hackney stepping down. Gail Allen was elected as treasurer, with Paddy Mullan stepping down. Lorraine Johnston has agreed to stay on for another year as secretary. We would like to thank the girls for their help and to congratulate Doreen on the successful completion of her doctorate.
Round the regions
South East
At the time of writing in October 2006, no meetings have been held this year so far because of a lack of response to requests for speakers and venues (we have had only one reply), and sta being very overstretched. The next meeting is planned for November 2006, and will include a talk from a consultant urologist from Brighton on bulking injections, feedback from Conference and arrangements of further meetings. Five members from the region went to Conference this year. Romy Tudor received her membership of the ACPWH following completion of the University of Bradford Postgraduate Continence modules. Our plan for the next 6 months is to get together in November to nd ways of maintaining interest in regional meetings, and to try to encourage more input from the whole of the South East region. Oers of speakers and venues are very welcome! Susannah Staples, Debbie Joice, Romy Tudor & Nadine Ranger Area representatives E-mail: Nadine.ranger@wash.nhs.uk or Susannah.staples@wash.nhs.uk
new to the speciality. The only complaint was that we ran out of time we could have easily lled the whole day. At our next meeting, in May 2006, we listened to an experienced urogynaecology nurse, Sue Larner. She explained to us how urodynamic investigations are carried out and then interpreted graphs pertaining to various bladder problems. A review of the anatomy of the abdominal corset made us put our thinking caps on, and then we broke up into smaller groups to discuss the physiotherapeutic management of weak abdominal musculature in dierent client groups. Finally, we had an informal session discussing when physiotherapy interventions may not be appropriate. Linda Boston Area representative E-mail: linda2004@btinternet.com
West London
There are various groups in the West London area, meeting regularly in Wiltshire, Gloucestershire, Bristol and Ascot. The Wiltshire Group have recently completed work on a matrix of priorities for womens health and continence work that we developed as a local tool to use with managers questioning why we are (or are not) doing certain jobs that might come within our remit (this is particularly useful where there is scant evidence). They are also completing a survey of the benets of splints for carpal tunnel syndrome in pregnancy. At the time of writing, our planned study days are A functional approach to assessment and treatment of the pelvic girdle in pregnancy and postpartum with Yvonne Coldron on Saturday 4 November 2006 at the Great Western Hospital, Swindon (see pp. 6263), and Physiotherapy for bone health, an osteoporosis study day with Meena Sran on Saturday 1 December 2006 in Swindon. We plan to run more local study days or half days, so please contact me with your suggestions or if you want to be e-mailed about upcoming events. Ruth Vidal Area representative E-mail: ruthmvidal@hotmail.com
South Midlands
At our Autumn 2005 meeting, Simon Jackson, consultant urogynaecologist at the John Radclie Hospital in Oxford, started the earlymorning session by giving us an overview of female continence problems and the treatments available. Simon is very supportive of conservative therapies and is always happy to help us with our CPD. The talk was followed by a demonstration by Mike Morter, representing Diagnostic Sonar Ltd, in which he showed us what a real-time ultrasound machine can do, using himself as a model. The session was rounded o by Nicole TudorWilliams, one of our senior physiotherapists at the Womens Centre, who has been very involved in an SPD/PGP audit currently being undertaken in Oxfordshire. The results of the audit were presented, and this was followed by a practical demonstration of manual techniques that may be used on women with pelvic ring pathology in the child-bearing year. Twenty-one delegates attended and it was pleasing to see how many physiotherapists are
74
Area representatives 20062007

In response to requests from members, the following table details the area representatives and how to contact them. N.B. Some postcodes are shared by more than one representative. Ruth Hawkes is both the area representative and workshops coordinator. Queries about either should be addressed to her at Dunston House, Dunston, Lincoln LN4 2ES, or sent by e-mail to <ruthhawkes@uk-consultants.co.uk>.
Name Thamra Ayton
Contact details Northern Ireland
Area and postcodes July 2005
Start date
E-mail: mayton@ukonline.co.uk Linda Boston South Midlands: OX Shared: HP, MK, RG E-mail: linda2004@btinternet.com Carole Broad Wales October 2004 November 2004
E-mail: BroadAP@Cardi.ac.uk Lynne Coates South West: PL, EX, TA, TR, TQ April 2005
E-mail: Lynnecoates2004@yahoo.co.uk/ Lynne.Coates@nepct.cornwall.nhs.uk Ann Dennis Solent: PO, SO, BH, GU, DT E-mail: annpam@btinternet.com Gillian Hawkins Midlands: B, CV, HR, June 2005 NN, TF, WR, WS, WV, DY E-mail: gillian.hawkins@heartofengland.nhs.uk Avril Hillyard London: UB, WD, EN, (retires March Shared: HP, MK E-mail: avrilhillyard@hotmail.com IG, RM, AL Manchester: PR, BL, LA, August 2004 2007) June 2005
Michelle Horridge
September 2002 BB, WN, L, WA, SK, M, CA
(looking for replacement)
E-mail: michelle.horridge@cmmc.nhs.uk
75
Area representatives 20062007

Name Clare Jouanny Contact details Area and postcodes Channel Islands: JE, GY Start date
October 2003 (to continue for further year)
E-mail: jouanny@localdial.com/ c.jouanny@health.gov.je Emilie Nesbit North East: NE, DH, SR, TS, DL E-mail: emilie.nesbit@northumbria-healthcare.nhs.uk Nadine Ranger (see Susannah Staples below South East: BN, RH, TN, CT, ME August 2004 August 2000 (looking for replacement)
E-mail: nadine.ranger@wash.nhs.uk Maggie Saunders Trent: NG, S, LN, DN Shared: LE, DE E-mail: maggie.saunders@nhs.net Susannah Staples (covering for Nadine Rangers maternity leave South East: BN, RH, TN, Maternity cover CT, ME October 2004
E-mail: Susannah.staples@wash.nhs.uk Elaine Struthers Scotland June 2003
E-mail: Elaine_struthers@hotmail.com Ruth Vidal South: SN, BA, BS, GL Shared: RG E-mail: ruthmvidal@hotmail.com/ Ruth.vidal@smnhst.swest.nhs.uk East Anglia: CB, NR, CO, SS, PE, CM, SG, IP Leeds: LS, WF, YO, HD, HX, HG, HU, BD Vacant position Vacant position November 2004
76
PhD thesis reports
Multiple sclerosis and lower urinary tract dysfunction

Coincidence? Referrals of a specialist nature with little evidence to point to eective treatment and the opportunity to undertake research within this population: a combination too good to miss or a nightmare scenario? I will leave you, the reader, to be the judge. As a senior physiotherapist working in gynaecology and urology, referrals had been received concerning people with multiple sclerosis (MS) and lower urinary tract dysfunction. However, there was little evidence as to best practice. Around the same time, the University of Ulster had been awarded a substantial grant by the MS Society of Great Britain and Northern Ireland to undertake research into the relief of symptoms within this population, and bladder and/or bowel dysfunction was one of the proposed studies. I applied, was accepted and took a 3-year career break. The rst few months were spent reviewing the literature. This was a time of adjustment: instead of thinking about patients and hospital life, the computer seemed to devour my time. At the end of the day (and many evenings), it was sometimes dicult to say what you had done and then it always seemed to be the articles that you wanted most that had to be ordered. An outline proposal had already been approved by the Universitys Ethical Committee, so that scenario was negated; however, amendments were discussed, discussed again and approved. A pragmatic pilot study to establish the ecacy of physiotherapy interventions within such a neurological population was proposed. Honorary contracts were established, outcome measures reviewed and training in urodynamic procedures undertaken. Everything was in place, but what about some patients? Consultant neurologists, MS specialist nurses, continence advisors and colleagues all helped with recruitment. Advertisements were also placed in relevant charity magazines and I was able to attend the meetings of these charities one of the most enjoyable aspects of the 3 years was the appreciation shown that someone was taking the time to come and talk
about what is still a taboo subject. Recruitment went well. There were some disappointments, but 9 months later, 30 participants had completed the 9 weeks of treatment, and the 16- and 24-week follow-ups. Then came the dreaded statistics a new language and the many drafts of the rst paper, culminating in its acceptance for publication, another milestone. The rst and second seminars were stressful times, but there were some good laughs with fellow students, and coee became an addiction (it could have been worse). A trip to Vienna, Austria, to present at an International MS conference was a high the thought of the ice cream is making my mouth water while writing this. Based on the results of the pilot study, a double-blind randomized controlled trial (RCT) was undertaken to further establish the use of physiotherapy modalities within this population and to evaluate if the additional benet that was demonstrated in those who received electrical stimulation was real or placebo. Seventy-four participants were recruited and were seen at 12 centres throughout Northern Ireland. A full year was devoted to this study, involving many long hours of travelling and organization. During this time, I had a car accident a wooden pallet fell o an oncoming skip and smashed my windscreen but thankfully, I had no serious injuries. (I also got caught speeding on my way to an assessment clinic, and the eldest of our four daughters was married!) Again, one of the most special things about this study was the opportunity to meet many lovely people with such diverse and sometimes severe disabilities. There were ups and downs, but eventually, all were recruited; and then, almost unbelievably, all the assessments were completed. The statistics and writing up was so much easier the second time around, but the added pressure of the completion date was also looming. Submission was a bit of an anticlimax because it was still dicult to relax. Then came the viva, an experience not to be repeated. Was it all worth it? Would I do it again? Would I advise allied health professionals to undertake a PhD? These are all questions that I have been asked. The answer to all is probably a 77
PhD thesis reports
yes. It may sound inane, but I did it to try to improve the continence services for people with MS, and I hope that the benets will be tangible. Locally, a direct referral system has been established whereby MS nurses, consultant neurologists and rehabilitation physiotherapists can all send us patients, and we hope to establish multidisciplinary classes for those who have been newly diagnosed. Part of the content of these classes will include information on good bladder management, as well as on rehabilitation and other aspects of treatment. I would probably do it again. The learning curve was steep, but I did things, such as presenting, travelling and meeting people from many dierent walks of life, that I would not have done otherwise. If someone was contemplating undertaking a PhD and asked my advice, I would say that you should consider it carefully and make sure that it is something you are really interested in. At times, I felt that the worlds of academics and of clinicians were very dierent, and it is of paramount importance that you have a good working relationship with your supervisors. As someone once told me, a PhD becomes your extra baby, and just like a baby, there are good and bad times, and it can be dicult to extricate yourself in order to have a family life. Then, at the end, it can feel like leaving the child at the school gate with a mixture of sadness, relief, pride and exhaustion. The results of the pilot study have been published in McClurg et al. (2006). The results of the RCT are about to be submitted for publication. Doreen McClurg Clinical specialist physiotherapist Belfast City Hospital Belfast Reference
McClurg D., Ashe R. G., Marshall K. & Lowe-Strong A. S. (2006) Comparison of pelvic oor muscle training, electromyography biofeedback and neuromuscular electrical stimulation for bladder dysfunction in people with multiple sclerosis. Neurology and Urodynamics 25 (4), 337 348.
Characteristics of abdominal and paraspinal muscles in postpartum women

I have often been asked why I decided to do a PhD and how I decided what to investigate. My appetite for research was whetted when I did a Masters degree in 1993 and I was lucky to 78
work with a renowned muscle physiologist Dr Olga Rutherford in her laboratory at St Marys Medical School, London. I considered going on to study for a PhD after this, but an opportunity did not present itself immediately. However, in 1995, I was working as a lecturer/ practitioner at Brunel University and Kingston Hospital in London with a specialist role as a musculoskeletal physiotherapist when I met the dynamic Sarah Murdoch, who, at the time, was senior 1 in womens health. I became interested in her work with pregnant and postnatal women with low back/pelvic girdle pain, and we discussed, examined and treated many women together. At the time, studies on motor control of the abdominal muscles were a new and fastchanging musculoskeletal physiotherapy practice. I wondered whether this new approach would be of benet to Sarahs clients, and we tried dierent strategies with varying degrees of success. I realized that very little was known about the actual physiological changes to the abdominal muscles during pregnancy and postpartum, and therefore, if we were going to use rehabilitation strategies for abdominal muscles in the ante- and postnatal periods, it would be preferable that we understood the changes that occurred during pregnancy. I changed jobs and was fortunate to be given the opportunity to do a part-time PhD, funded for 3 years, at St Georges Medical School, London. Navely, I thought it would be done and dusted in 3 years whilst working part-time: lesson number one, part-time working extends the total length of the project. I also got married 6 months into the project, which added to some of the delay! I decided to study the characteristics of abdominal and multidus muscles in postnatal women in order to inform future studies for clinical practice. Therefore, the project was registered in the eld of neuromuscular physiology at the University of London. I decided that I would use real-time ultrasound imaging to study abdominal and multidus muscle size, plus electromyography (EMG) to study (1) fatigability and (2) recruitment of these muscles in response to trunk perturbation. I had to start from scratch: designing the project, nding willing supervisors, getting ethical approval (a mammoth task), applying for funding for equipment (begging, borrowing and stealing equipment, if necessary!), learning how to use new equipment and doing a pilot study. This took over 12 months to accomplish, and there were many setbacks but also a few golden
PhD thesis reports
moments. A rheumatologist, Dr (now Professor) John Axford, agreed to be my ocial internal supervisor and oered me oce space in his department. Professor Maria Stokes very kindly agreed to be my scientic supervisor. She has always been 100% supportive, and I am so grateful for all her advice and knowledge. During my rst few months, I put the proposal together and it was approved by the ethics committee. I had been promised use of an ultrasound scanner, but it did not materialize, and I realized that my project was in jeopardy. Enter the second person who was to keep me sane during the next 2.5 years: Katy Cook is a specialist ultrasonographer in the foetal medicine department at St Georges and she was allowed to work with me for half a day a week. Katy worked hard to ensure that I had access to an ultrasound machine, and with her help, I gained access to the postnatal wards. I applied for, and was given, funding by the Medical School and the ACPWH (the Dame Josephine Barnes Bursary) to purchase an EMG machine and accessories. I was given further nancial help by the ACPWH during my write-up time and I am very grateful for the support given to me by the Association. During the next few months, I undertook a pilot study using both ultrasound scanning and EMG in order to establish the methodology for the full study, and recruited a small sample of nulliparous female controls and day 1 postpartum women. Part of this pilot study determined that the size of the multidus did not dier whether ultrasound imaging was performed in prone or side-lying (Coldron et al. 2003). This was important to determine because breastfeeding women could not easily lie prone. Measurements of ultrasound imaging of the four abdominal muscles and lumbar multidus were shown to be reliable from intra- and inter-rater reliability studies. I had to learn to use the EMG apparatus and programme the computer to analyse the results. This was a steep learning curve! I was lucky that Professor Di Newham agreed to be my second scientic supervisor, and with her help and that of the technical representative of the EMG company, I learned to use the EMG equipment. Di Newham helped me to develop the exercises to measure fatigue and motor recruitment, and at the end of the pilot study, we realized that we needed more equipment to determine the force output of a maximum voluntary contraction (MVC) of the abdominal muscles and, thus,
calculate the percentage force output necessary to induce fatigue during a one-minute sustained contraction. Professor Stokes worked at the Royal Hospital for Neuro-disability, London, and with the help of their mechanical workshop engineers, we devised a testing chair. This chair allowed two restraining straps to be attached to strain gauges to record force output when women performed an MVC of the abdominal muscles. Sixty per cent of the MVC value was used for the fatiguing one-minute contraction and the EMG signal was recorded. Trunk perturbation exercises in standing were adapted from those of Hodges & Richardson (1996), and again, the EMG signal was recorded. All PhD students registered at St Georges, University of London, are required to undertake a transfer viva to go from MPhil registration to PhD registration. This comprised writing a summary of my pilot studies (10 000 words) and undertaking a viva all good preparation for the real thing! I undertook this successfully 12 months after registering for the PhD, but 18 months into my funding. From then on, it was all systems go to collect my data before the funding ran out. At this point, I was lucky to gain semi-permanent access to a room in the School of Physiotherapy where I could store my equipment (by that time, I had access to an ultrasound machine) and test women at later stages postpartum. (I continued to test day 1 postpartum women on the postnatal wards.) It was decided to make my design mainly cross-sectional, and for the next 18 months, I recruited women at day 1, and at 2, 6 and 12 months postpartum. Some of these women attended on more than one occasion and formed the small longitudinal part of the study. I also continued to recruit nulliparous female controls of childbearing age. One of the joys of this project was meeting so many women who volunteered willingly to undergo the ultrasound scanning and participate in exercise that fatigued their abdominal muscles. I became an expert in juggling a baby with one hand and operating the computer mouse with the other! I left St Georges after 3 years, and decided that I would quickly analyse my results and write up within the year whilst working part-time as a clinician. Another lesson: data analysis and writing up a doctoral thesis take much longer than one thinks. Life traumas, including the prolonged illness and subsequent death of my father, problems with my own health, my husbands redundancy, returning to full-time work, 79
PhD thesis reports
and moving house, meant that I submitted over 2 years later. However, this was still well inside the submission time since part-time students have 7 years in which to submit. During these years, I relied on my husband, Tim, who looked after and supported me (I have totally forgotten how to cook!), and I would advise anyone thinking of undertaking a PhD to look for support outside of work and discuss things fully with their family. One of the most unsupportive things anybody can say during this writing up time is, Havent you nished yet? In order to do a doctoral thesis, one has to be prepared to give up evenings, weekends and holidays for many years, and this is something to consider when embarking on such a project. The viva was a trial, and fortunately, did not have to be repeated. I passed with some revisions and was nally awarded the doctorate in 2006. I learnt that doing doctoral study is much more than just answering the original research question. It is a journey through the research process, learning about writing a proposal, presenting before an ethics committee, recruiting subjects, gaining access to and learning how to use complicated measuring tools, reviewing literature, analysing spreadsheets full of data, and writing scientically. These aspects of research all have value for future studies. The results of my study were interesting, although not necessarily those that might have been expected. I hope that, once further papers are published from the thesis, others may be encouraged to undertake study into appropriate postnatal abdominal exercise or other aspects of postnatal physiotherapy. Life after a PhD is mainly one lived with a sense of relief that it is nished, but there are still papers to be written and presented at conferences. The results of one experimental chapter are currently in press (Coldron et al. 2007).
Would I recommend others to do a PhD? I think it was worth it because I learnt so much not only about postpartum abdominal and multidus muscle characteristics, but also about the research process. However, it can be a lonely process, and it requires stamina and tenacity to nish a thesis. Studying for a PhD ts more easily into the academic way of life than into that of an National Health Service department, but maybe that is because we are still a young profession in research terms and we have not yet managed to nd many ways in which research can be incorporated into clinical practice. For anyone considering undertaking doctoral study, I would advise that you need to love the subject since it will be with you for a very long time. I also know that I could not have undertaken or completed the PhD without the full support of Professors Stokes and Newham, so I would advise that your choice of supervisors is paramount. I hope that I will have scope to use my new research skills in the future in order to inform evidence-based clinical practice. I would hate all the eort to go to waste! Yvonne Coldron Research ocer
References
Coldron Y., Stokes M. & Cook K. (2003) Lumbar multidus muscle size does not dier whether ultrasound imaging is performed in prone or side lying. Manual Therapy 8, 161165. Coldron Y., Stokes M. J., Newham D. J. & Cook K. (2007) Postpartum characteristics of rectus abdominis on ultrasound imaging. Manual Therapy 12, in press. Hodges P. W. & Richardson C. A. (1996) Inecient muscular stabilization of the lumbar spine associated with low back pain. A motor control evaluation of transversus abdominis. Spine 21, 26402650.
80
Visit to the UK
I am an Austrian physiotherapist specializing in womens health and pelvic oor re-education. Having worked in this eld for 12 years, I took the opportunity to share and improve my knowledge with colleagues by starting lecturing courses for pelvic oor re-education in 1999. While presenting my results at the World Confederation for Physical Therapy Congress in Barcelona, Spain, I got to know Gill Brook and Teresa Cook from the UK, who helped me to amend my lectures. The European Union oers the opportunity to undertake working experience in other countries, and so I planned a 9-week trip to the UK, during which I would spend each week in a dierent hospital, shadowing physiotherapists specializing in the eld of womens health and incontinence. Gill helped me to nd 10 dierent places where I could shadow sta. This was a very dicult job: in some places, some sta were on holiday, and others wanted me to pay for my observation. Gill was a great help and it is thanks to her that I could put this project into practice. I started my visit in London, where I observed the treatment of patients with constipation who were taught defecation techniques with Julie Duncan, Brigitte Collins, Lorraine OBrien and Trish Evans at St Marks Hospital. I received lots of the assessment sheets and folders that are used there. I also had the opportunity to see a defecating proctogram, an examination of the colon transit via X-ray, and a manometry and ultrasound examination. After St Marks, I spent 2 weeks in Hammersmith Hospital with Avril Hillyard, Yasmine Ransome, Janine Shaw, Rachel Keeling and Susi Cook. This gave me an opportunity to see work on the wards, pre- and postnatal classes, and individual treatments of women with incontinence problems or prolapse. I also attended gynaecological surgery and a Caesarean section of twins. Avril made it possible for me to participate in a study day with Jeanette Haslam in Ascot, where I got to know 20 other physiotherapists working in the speciality. My next stop was the world-famous Great Ormond Street Hospital childrens hospital, where I had the opportunity to follow the treat 2007 Association of Chartered Physiotherapists in Womens Health
ment of children with bladder or bowel problems. Brid Carr, Laureen, Caren and Kath looked after me there. I saw two videourodynamics, and attended clinics for outpatients and the weekly meeting of all the doctors specializing in that eld, where they discuss dicult cases. After this, I went north to Manchester, where I spent a week in St Marys Hospital with Ann Mayne, Michelle Horridge, Courtney Gum, Hanna Gray, Lisa Roberts and Nicole Needham. It was interesting to see more ward work and outpatient treatments. I also spent a day shadowing Gordon Hosker, a worldrenowned research fellow, who showed me manometry, ultrasound and pudendal nerve latency tests for patients with faecal incontinence. I then visited Cumbria (Fig. 1), where I spent 4 days with Jeanette Haslam. It was fascinating to look at her private library, as well as see how she organizes her lecturing and nds relevant
Figure 1. Elizabeth Pulker with a couple of friends.
81
Visit to the UK
papers when needed. In the lovely countryside of the Lake District, I had long and interesting talks with Jeanette about her years of experience in lecturing and about carrying out studies. My next stop was Bradford Royal Inrmary, where I spent 3 days shadowing colleagues, and this gave me the opportunity to thank Gill Brook personally for all she had done for me. In Bradford, I met Stephanie Knight again (we had previously met at an International Continence Society conference), and I got to know Dianne Naylor, Helen Bryer and Pauline Bibby, whom I shadowed as they carried out pelvic oor reeducation with outpatients. I observed Stephanie performing urodynamics as a physiotherapist, something that would not be possible in Austria because it is only carried out by doctors. After this, I went back to London and the Willesden Centre of Health and Care, where I spent a week with Lizelle Miller, a South African physiotherapist who only works with outpatients. She showed me how to carry out perineal ultrasound for biofeedback. I saw it in use on patients, and we had the opportunity to try it on our own. It was fascinating for both myself and for the patients. I then went up to Scotland where I spent a week in Glasgow with Julie Lang in the Victoria Inrmary and Diane Stark in the Southern
General Hospital. Observing Julie, I saw many treatments performed on patients with anorectal dysfunction, and with Dianne, I found out about the pelvic organ prolapse qualication a study in which Dianne is involved which gave me a broader understanding of the scope of our work as physiotherapists. I spent my last week with colleagues in two dierent London hospitals: Charlotte Lion and Wendy Harper, who work in the Chelsea and Westminster Hospital showed me their work on the wards and with outpatients; and Paula Martinez and her colleague Emily Hoile showed me their work in the Royal London Hospital. In my 9 weeks in the UK, I got to know a total of 46 physiotherapists working in many dierent ways with pelvic oor re-education. I returned home with new ideas and enthusiasm for my work. I was very well looked after, and besides learning better English, I got to see a lot of the beauty of the UK and made many new friends. Elisabeth Pulker Museumstrae 28 6020 Innsbruck Austria E-mail: pulkerliese@yahoo.de
82
Book and DVD reviews
A Headache in the Pelvis: A New Understanding and Treatment for Prostatitis and Chronic Pelvic Pain Syndromes, 3rd edn By David Wise & Rodney Anderson National Center for Pelvic Pain, Occidental, CA, 2003, 333 pages, paperback, $24.95 ISBN 0-9727755-2-8 This book is dedicated to helping both men and women with a variety of chronic pelvic pain syndromes gain a better understanding of the problem of chronic pain, and its causes and treatment. The focus is primarily on male chronic pelvic pain syndrome (CPPS)/chronic prostatitis, since this is the area of work on which the authors research has concentrated. Dr David Wise is a psychologist at Stanford University, CA, USA, and has suered from chronic prostatitis himself. Rodney Anderson is an eminent neurourologist. The regime described in the book originally helped Dr Wise to overcome his own chronic pain, which prompted him to devise the Stanford Protocol, a multidisciplinary treatment approach to CPPS/chronic prostatitis. Headache in the pelvis is the name given to all forms of pelvic pain and dysfunction when no primary pathology is found. The analogy is based on the premise that, when no other cause can be found, CPPS may be the result of chronic tension in the pelvic oor muscles (PFMs), in a similar way to that in which chronic upper back and neck muscle tension may cause headache. The holistic treatment protocol is aimed at teaching the patient to release this tension by using both physical and psychological methods, thus relieving the headache. Because A Headache in the Pelvis is written for the patient, it is written in appropriate laymans language, and contains no references or footnotes. For those interested in reading a more scientic basis for the theory, the authors have published a reasonably robust research study to add weight to the use of their protocol (Anderson et al. 2005). The opening chapter gives denitions and categories of CPPS in both men and women, and in addition to chronic prostatitis, includes conditions such as vulvodynia, urethral syndrome,
proctalgia fugax and interstitial cystitis, all of which may have an underlying element of increased PFM tension. This leads the way into the rest of the book, which explains the Stanford model for explaining chronic pelvic pain. A Headache in the Pelvis is interesting to read because it tells a story, and uses parables and allegory to help the reader gain a better understanding of the reasons why pelvic oor dysfunction may develop. The current model of the multifaceted nature of chronic pain, and the painanxietytension cycle is written in an interesting style, although this sometimes becomes repetitious rather than reinforcing the explanations. Case histories are included amongst the theoretical text to let the reader know that there are many other suerers out there. The methodology of the Stanford Protocol is then outlined. The authors do make it clear from the outset that the treatment is not suitable for everyone, and that thorough diagnostic evaluation is necessary to rule out organic conditions that require dierent treatment. Neither do they make claims for how many, nor which type of patient, will benet from the protocol. Assessment tools are included that may be useful for clinicians, but are not, as yet, validated. Other validated questionnaires are mentioned. The basis of the treatment protocol is a combination of paradoxical relaxation and myofascial/trigger point release. The relaxation techniques are based on Edmund Jacobsons method of Progressive Relaxation. The relaxation techniques are described in detail. Dr Wise, the psychologist, produces a series of relaxation tapes. He emphasizes that the tapes cannot be purchased on a stand-alone basis, but must be bought in conjunction with one-on-one teaching to gain the full benet of achieving deep relaxation of the PFMs. The next part of the protocol is physical. It aims to release trigger points in the pelvic oor, and restore the muscles to their correct length and tension. This part of the treatment is carried out by a physical therapist, although the authors do say that a willing partner may be taught to perform the techniques, since treatment may take many weeks or months, and the patient often lives a long distance from the clinic. Part of 83
the protocol (except for the manual treatment!) is available on the Internet. The chapter on myofascial release is very useful, and contains illustrations of all the possible aected muscles and their trigger points. Stretching exercises are another important part of the overall therapy, and again, good illustrations are included. The book concludes with patients questions in Frequent concerns. These explore issues such as sex and sexuality, faith, Eastern philosophy and alternative therapies in a very colloquial fashion, which is at an appropriate level for the intended readership. There are also many selfreported cases histories, but of course, these only describe the patients who were improved or cured. However, this book is not intended to be a research paper, and it does an excellent job of informing suerers about the possibility of exploring this treatment option. The authors do not adopt a hard sell approach, although many men from Europe do travel to California for an intensive 6-week course of treatment oered by the Stanford team. Not all of these patients get better, and the course is expensive. Many therapists in the UK who specialize in pelvic oor dysfunction are capable of treating these cases following a similar approach; it is merely a question of spreading the word. A Headache in the Pelvis is a must read for any physiotherapist treating men with CPPS/ chronic prostatitis since most well-informed patients will come with the book in their hand and ask for the Stanford Protocol. It is a useful source of information for male CPPS patients, but less useful for women. The Stanford team are happy to share their protocol, and more long-term research is indicated in order to establish who is likely to benet. Stephanie Knight Airedale General Hospital Keighley, West Yorkshire Reference
Anderson R. U., Wise D., Sawyer T. & Chan C. (2005) Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. Journal of Urology 174 (1), 155160.
The Essential Guide to Acupuncture in Pregnancy and Childbirth By Debra Betts Journal of Chinese Medicine Ltd, Hove, 2006, 328 pages, hardback, 35.00 ISBN 0951054694 84
This well-presented clinical textbook is written by Debra Betts, an experienced New Zealand midwife and acupuncturist. Although the book is aimed primarily at midwives, it provides clinical guidance for multi-professional acupuncture practitioners who encounter pregnant and postpartum women. The Essential Guide to Acupuncture in Pregnancy and Childbirth is divided into 26 chapters and nine appendices. Individual sections cover most of the common conditions found in pregnancy, including nausea and vomiting, musculoskeletal conditions, heartburn, fatigue, insomnia, anxiety, depression, and oedema. Several chapters are devoted to birth and the postpartum period, highlighting the role of acupuncture during these times. Each section is clearly written and explains both the Western and traditional Chinese medicine (TCM) approaches to acupuncture for each condition. The pathology of conditions in Western and TCM terms, followed by a discussion on the recommended acupuncture points, are detailed in each chapter. Where possible, the selection of acupuncture points is based on evidence from the literature, but the Betts own wide clinical experience also informs the text. Most clinical chapters include case histories to illustrate the relevance of acupuncture to the given condition/ pathology presented. Importantly, the rst chapter deals with safety of acupuncture treatment for pregnant women, and clearly outlines the acupuncture points that may promote labour, and thus, are contraindicated during pregnancy. Furthermore, there is clear adaptation of needling technique for the pregnant woman, and details of the number of needles used and the method of acupuncture. Several chapters contain information that would be relevant for womens health physiotherapists who practise needling. In particular, Chapter 8 deals with musculoskeletal conditions. I think that the information presented in this chapter would enhance safe practice, as well as encouraging physiotherapists to use acupuncture as a modality to treat pregnant women with upper and lower back pain, pelvic girdle pain, rib pain, and carpal tunnel syndrome. Chapter 26 reviews some of the research evidence underpinning the use of acupuncture in pregnancy. Betts cites only one recent study that investigated acupuncture in low back/pelvic girdle pain, although there have been several papers published in recent years. Unfortunately, the paper cited was physiotherapy generated and
used contraindicated points (although there were no adverse eects), and Betts makes the point that questions should be raised about the way point-prescription acupuncture is used by physiotherapists. Many of the chapters deal with wider issues around pregnancy, and Chapter 27 deals solely with dietary advice during and after pregnancy. The appendices are extensive and informative, and include Western and TCM glossaries that would be useful for physiotherapists practising acupuncture. Of particular value is Appendix 7, which describes the location and needling of points that have been used in the text, and is accompanied by clear illustrations. Overall, this book is clearly presented and the arrangement of each chapter makes it easy to read. There are clear sections on Western and TCM viewpoints, clinical manifestations of conditions, discussion of acupuncture points, case histories, and references. Within each chapter, coloured inset boxes are placed in the wide margins, and used to emphasize key clinical aspects, precautions and acupuncture points. Debra Betts approach to the holistic management of women pre-, ante- and postnatally makes this much more than a textbook of acupuncture points. Her concern for the well-being of women at each stage of pregnancy, birth and afterwards is paramount, and the reader could not fail to improve her or his clinical practice. As a physiotherapist practising acupuncture and dealing with pregnant women, I have no hesitation in recommending The Essential Guide to Acupuncture in Pregnancy and Childbirth to those womens health physiotherapists who wish to undertake further acupuncture training and extend their knowledge into this eld. Yvonne Coldron Mayday Healthcare NHS Trust Croydon
midwife, physiotherapist or doctor working with acupuncture in the eld of gynaecology and obstetrics. Within the realms of physiotherapy, I would fully recommend this text as essential reading matter if practitioners are about to embark on further advanced acupuncture training in womens health, provided they have a fundamental knowledge of TCM philosophy. The Essential Guide to Acupuncture in Pregnancy and Childbirth is divided into sections covering a number of conditions, such as nausea and vomiting, musculoskeletal conditions, insomnia, and anxiety. These are presented at prepartum, during labour and postpartum, with a chapter dedicated to each. Within each chapter, Debra Betts has integrated Western medical diagnosis into a TCM framework. She uses succinct, manageable language something I nd lacking in several other texts on this subject, and something I welcome within our clinical practice. The book has an added advantage in that treatment protocols are provided within each section. The anatomical positions of relevant points are superbly illustrated by Peter Deadman, Mazin Al-Khafaji and Kevin Baker, and indepth clinical reasoning for their use is provided. Chapter 26, citing a review of current research with clinical application to acupuncture in pregnancy, is an added bonus. Each page provides the reader with the authors clinical experience and knowledge of the subject matter. I am grateful for this knowledge and for the easy style in which it has been written, which has the dual benets of enhancing my clinical reasoning and aiding my patients recovery. I welcome texts that augment the clinicians patient care and problem-solving skills within an evidence base that is eective, relevant and pertinent to current healthcare. The Essential Guide to Acupuncture in Pregnancy and Childbirth provides all these qualities and more. Jennie Longbottom Acupuncture Association of Chartered Physiotherapists Peterborough The Pelvic Floor Edited by Beate Carrire & Cynthia Markel Feldt Georg Thieme Verlag, Stuttgart, 2006, 476 pages, paperback, V69.95 ISBN 1-58890-325-7 85
I felt very privileged when asked to review this long-awaited clinical approach to a subject I have particular interest in and I was far from disappointed. Even before opening The Essential Guide to Acupuncture in Pregnancy and Childbirth, the cover is so aesthetically pleasing that it makes the book a must for those wanting to nd out more. As the title announces, this is an essential clinical guide, crossing professional disciplines, and encompassing proven solutions to the management of the mother and the foetus, whether you are a professional acupuncturist,
This book is small in size, but huge in content, boasting contributions from a team of internationally renowned experts, including Kari B, Pauline Chiarelli, Grace Dorey and Paul Hodges, as well as the two main authors, Americans Beate Carrire and Cynthia Markel Feldt. The Pelvic Floor covers in great detail the current state of our knowledge of the pelvic oor, and its contribution to pelvic health and illness. My rst impression on opening the book was overwhelming. The content is very comprehensive, and although small, The Pelvic Floor contains over 500 pages, all very busy with a small typeface and minimal marginal space on each page. However, I appreciate that this keeps the production costs of the book down to an aordable amount. One would expect a text with such comprehensive content to be priced much higher than it is. However, it could have be improved if the dierent sections of the book were more identiable. As it stands, it is dicult to distinguish between dierent parts, and therefore, not so easy to nd things without frequently resorting to the contents for a page number. In my opinion, a quote from the rst section describes the essence of this book: The pelvic oor cannot be viewed in isolation and has to be considered in connection with the surrounding structures, as well as its individual parts. It is a truly holistic account of the treatment of pelvic oor dysfunction. The book encompasses a wide range of conditions that a womens health physiotherapist might be asked to treat. Although the title is The Pelvic Floor, it also includes a section on the management of lymphoedema. Many of the treatment techniques are wellknown amongst physiotherapists and supported by a strong evidence base. However, the book also includes many less-known techniques some that have been used for many years and others much more recent that do not currently have a good evidence base. Indeed, some sections in The Pelvic Floor have no real evidence to support them, being based solely on expert opinion. I think one of the strengths of this book is that all these treatments are included. The authors describe the strength of evidence supporting their statements, and there is an extensive reference list at the end of each section. The Pelvic Floor is divided into six main sections: 86
(1) Basics: anatomy and physiology, nervous system, musculoskeletal chronic pelvic pain, posture and the pelvic oor, low back pain and the pelvic oor, reex incontinence, psychosocial inuences, and evidence-based physiotherapy for stress and urge incontinence. (2) Treatment techniques: manual physiotherapy techniques for pelvic oor disorders, strain and counterstrain for pelvic pain, connective tissue manipulations and other physical therapies, visceral mobilization, PFM training, reex incontinence, and therapy for lymphoedema. (3) Paediatric therapy: enuresis and encopresis (assessment and treatments). (4) Therapy for women: back-to-nature labour, storage and emptying disorders of the bladder, prolapse, and sexual and pelvic oor dysfunctions. (5) Therapy for men: anatomy and physiology, assessment and treatment of incontinence, pelvic pain, and erectile dysfunction. (6) Treatment of anorectal disorders: anal dysfunction after delivery and physiotherapy for anorectal disorders. The diagrams and accompanying photographs throughout the book are of a consistently high quality. However, some parts are very detailed, particularly the anatomy and physiology section at the beginning of the book, and some segments of the treatment sections. In these areas, I think the text would have been more accessible if it had been accompanied by more illustrations. In conclusion, I would strongly recommend The Pelvic Floor to any womens health physiotherapist. It is an up-to-date, aordable, comprehensive guide for the treatment of all conditions associated with pelvic oor dysfunction. It enhances our understanding of the functional signicance of the pelvic oor, and will contribute to better treatment for all our patients. Dianne Naylor Bradford Teaching Hospitals NHS Foundation Trust Bradford Pelvic Dysfunction in Men By Grace Dorey John Wiley & Sons Ltd, Chichester, 2006, 187 pages, paperback, 26.99 ISBN 0-470-2836X This is an updated edition of the authors rst textbook, Conservative Treatment of Male
Urinary Incontinence and Erectile Dysfunction, published in 2001. It is primarily aimed at specialist continence physiotherapists, and as a guide for urology and continence nurses, urologists and general practitioners. This edition contains an abundance of information, beginning with four chapters on the history, symptoms, anatomy and physiology, and nervous control of the urinary tract. An overview of prostate conditions, urinary incontinence and pelvic pain in men is provided, followed by chapters on patient assessment and conservative treatment. Although one has to recognize that it is dicult to provide information about such a large and evolving eld as products within such a book, the relevant section is out of date and lacks information on washable products and urinals, and does not promote the use of information services such as PromoCon. Two chapters deal with the treatment of postprostatectomy problems. The rst is a review of the literature, which is perhaps unnecessary in such a textbook since the following chapter describes the treatments available and references the relevant literature. More information on the risk of incontinence after surgery and the longterm prognosis would have been useful. A further chapter discusses pharmacotherapy for a wide range of conditions from detrusor overactivity to prostate cancer. Thereafter, faecal incontinence is covered, with a further two chapters pertaining to male sexual dysfunction: rst, a description of the condition, and then an outline of the treatment with a review of the relevant literature on physical therapy for erectile dysfunction. Again, it would have been useful if the actual percentage of men experiencing retrograde ejaculation, urethral stricture and/or erectile dysfunction following prostatectomy was documented. The nal chapter is entitled Setting up a continence service, which is perhaps misplaced within such a textbook, although the importance of interdisciplinary collaboration is discussed with a plethora of information on relevant professional and patient literature and specialist groups. However, it is possible for a director of continence services to be any member of the multidisciplinary team, not just a continence nurse specialist or specialist continence physiotherapist. Pelvic Dysfunction in Men is an essential reference book for physiotherapists working in the eld of male pelvic oor disorders. Although it is
not particularly cheap, one of the main things I liked about the book was its simple layout, with each chapter detailing key points at the beginning, and those concerned with treatment ending with a question-and-answer page/case study. Most of the anatomical drawings and gures are relatively simple and appropriate. There are also many up-to-date references and recommendations for further research, and I hope that some of these will taken up. Pelvic Dysfunction in Men is a handy size, and is both a useful addition to the shelves of medical libraries and a helpful guide to other disciplines treating this group of patients. Doreen McClurg Belfast City Hospital Belfast Menstrual Disorders: A Practical Guide By Deborah Ehrenthal, Paula Adams Hillard & Matthew Homan American College of Physicians, Philadelphia, PA (distributed by the Royal Society of Medicine Press, London), 2006, 262 pages, paperback, 30.95 ISBN 1-930513-66-6 This books stated aim is to provide a blend of all the latest information from the elds of internal medicine, gynaecology, adolescent medicine and other subspecialties in order to give a comprehensive overview of menstrual disorders. Menstrual Disorders: A Practical Guide starts with a review of the normal menstrual cycle, followed by a chapter on common menstrual complaints, including abnormal uterine bleeding, amenorrhoea, perimenopausal bleeding, dysmenorrhoea and premenstrual syndrome. It then moves on to medical issues, including polycystic ovary syndrome, menstrual disorders in women with developmental disabilities, bleeding disorders and menstrual disorders, and reproductive issues in women with chronic medical problems. This last is the most useful because it covers, in one chapter, diabetic women, obesity, eating disorders, substance abuse, the female athlete, acute and chronic liver disease, renal disease, lupus, heart disease, and seizure disorders. Menstrual Disorders: A Practical Guide concludes with a chapter on surgical procedures. The main drawback of this book is that it uses jargon whenever possible, making it very dicult 87
to read, especially since the authors can take several pages before they explain the meaning of the terminology. This meant looking up terms in a medical dictionary only to nd them explained later. The authors use American spelling throughout, which can be disconcerting to a British reader. Womens health physiotherapists could nd some of Menstrual Disorders: A Practical Guide quite patronizing. On the plus side, the chapter on chronic medical inuences on menstrual disorders is comprehensive. You might normally have to look through several texts to nd this information. It is also reasonably priced, and available on Amazon. However, I can only see this as a reference book for limited use, and as long as the hospital library is good, I would not particularly want to buy it for my department. Kathleen Vits Southampton University Hospitals NHS Trust Southampton
symptoms such as osteoporosis. There is an informative chapter on complementary therapies, information on managing the menopause when you have other medical conditions, and a useful glossary at the end of the book. As a woman of that certain age myself, I jumped at the chance to review The Menopause: What You Need to Know. I have read many books recently on the menopause, but none written so succinctly or with as much information. As womens health physiotherapists, we are often asked about the menopause and our opinions on HRT. This is an excellent source of information and would be a welcome edition to any physiotherapy department, both for sta and for patient loan. Rachel Grubb Warwick Hospital Warwick Clinics in Motion DVDs
The Menopause: What You Need to Know, 2nd edn Edited by Margaret Rees, David W. Purdie & Sally Hope Royal Society of Medicine Press Ltd and British Menopause Society Publications Ltd, London, 2006, 102 pages, paperback, 10.95 ISBN 1-85315-672-8 The stated aim of the second edition of this guide to the menopause is to provide unbiased and non-promotional information about the menopause and its management to doctors, nurses, their patients and families. The book achieves this dicult task very well. The Menopause: What You Need to Know combines good medical knowledge with information that is easy for the lay person to understand. This is particularly evident in Chapter 8, which covers the controversies over hormone replacement therapy (HRT). It explains the dierent types of clinical trial, how to understand the evidence, what risk means, and in particular, discusses the more recent clinical trials that have made the newspaper headlines. The chapters are well set out and easy to read, and at the end of each, there are sources of information, such as journal articles, books and websites. The Menopause: What You Need to Know explains what the menopause is, its symptoms and long-term eects. It discusses HRT and its alternatives in the treatment of particular 88
Clinics in Motion is an Irish healthcare learning company providing the worlds rst DVD publication and resource centre for physiotherapists [. . .] featuring an internationally developed syllabus [. . .] and online assessment programme. The company has produced six active learning tools in its Neuromusculoskeletal Physiotherapy Series 1. These cover: the lumbar spine; the pelvis and hip; the cervical and thoracic spine; the shoulder; the knee, ankle and foot; and the elbow, wrist and hand. The excellent website (www.clinicsinmotion. com) allows you to sample the series and view the contents of each DVD. You can also try the test! Practical Techniques of Physiotherapy Examination and Treatment, Vol. 2: The Pelvis and Hip By Helen French, Karen McCreesh, Mark Sexton, & Jeremy Walsh Clinics in Motion, Dublin, 2005, interactive DVD, 69.00 I was asked to review this DVD just as a new restriction was placed on our study leave, which highlighted to me what a very useful resource this series should prove to be. For less than the cost of a study day, you can watch techniques on your own television. This is an e-learning package, and a workbook and examination are
available online from when you register your purchase. The contents of the DVD are described in a small accompanying booklet that sets out the aims of the series, i.e. to explain and demonstrate the practical aspects of physiotherapy diagnosis and treatment that are universally and internationally useful in physiotherapy education and continuing professional development (CPD). Practical Techniques of Physiotherapy Examination and Treatment, Vol. 2: The Pelvis and Hip includes surface anatomy, observation tests and techniques. Using the angle button on the DVD remote control gives the viewer close-ups, wide angles and a skeleton shot, which is particularly useful for learning techniques. A case study, some tips and information on applied radiology complete the package. This is a very useful learning and revision aid. I will certainly be watching it again to check up on my basic skills. I would recommend this DVD to any ACPWH members who want to revise this subject. Caroline de Chair Gill Norfolk and Norwich University Trust Hospital Norwich For the inexperienced practitioner, or for those returning to work, this is a comprehensive and informative guide to the manual skills needed for the physical examination of the pelvis and the hip. The logical progression and well-dened order of the chapters makes the information easy to follow and the techniques easily reproducible. The practitioners clearly demonstrate common techniques at a fundamental level, while reinforcing the need for treatment to be clinically reasoned and patient-orientated. However, the graphics and overall presentation of Practical Techniques of Physiotherapy Examination and Treatment, Vol. 2: The Pelvis and Hip could have been enhanced to improve the learning experience. The visual learning tools were a little dated and, although adequate, uninspiring. Better use of computer graphics could have been made to show the relationships of the joints to one another, and to put the techniques in context. There is an opportunity to make use of the workbooks on the Internet, which allows for interactive learning, and this denitely enhances
the learning experience and will assist greatly with CPD. Although it is no substitute for hands on practice, this production would support and complement prior learning for students and practitioners alike, and would be a useful tool to review basic knowledge and skills. Lucy Craig Norfolk and Norwich University Trust Hospital Norwich Practical Techniques of Physiotherapy Examination and Treatment, Vol. 3: The Cervical and Thoracic Spine By Helen French, Karen McCreesh, Mark Sexton, & Jeremy Walsh Clinics in Motion, Dublin, 2005, interactive DVD, 69.00 This DVD consists of 16 chapters that can be selected individually from the main menu, including sections on joint screening, surface anatomy, active movement (including passive physiological intervertebral motions and passive accessory intervertebral motions), neurological examination, treatment techniques and exercise prescription. Each chapter consists of a variable number of sub-chapters that can also be selected individually. The style of Practical Techniques of Physiotherapy Examination and Treatment, Vol. 3: The Cervical and Thoracic Spine is that of an informal lecture delivered in your living room. Repeated references are made to possible variations between individual patients and the importance of relating ndings to the subjective examination. Care is taken to ensure safety in all aspects of assessment and treatment (e.g. cervical vascular insuciency, overpressure indications and contraindications, and ergonomic advice for the physiotherapist). The DVD provides only a general anatomical description, but this is appropriate for the aims of the production. It also assumes knowledge of the principles of assessment, and concepts such as irritability and quadrants of movement. All sections are of an appropriate length; for example, there is a brief discussion of clearing other joints, but there are prudent caveats about when a more detailed examination would be indicated. Careful explanation and demonstration of techniques is enhanced by Multi-Angle Vision. This function enables the viewer to 89
access a split screen demonstrating the technique from another angle and/or performed on a skeleton. This would be invaluable if you were to practice techniques at the same time as they are being demonstrated. Useful tips for checking bony palpation are included. Overall, this is an excellent learning device with clear explanations and demonstrations of an entire cervical and/or thoracic assessment, advice about treatments, and a relevant case study. Although several dierent tutors demonstrate the techniques, any inconsistencies between models are easily overcome. It is a good
revision aid for an experienced physiotherapist, and an eective way to study teaching methods and ne-tune specic techniques. It is dicult to take in the DVD in its entirety: I felt that it would be better used as a modular learning aid, with the viewer choosing particular areas and techniques to review. The basics are covered for each technique, ensuring correct application and meaning that each chapter can stand alone. Clair Jones Norfolk and Norwich University Trust Hospital Norwich
90
Website watch
The rst four websites described in this article are ones that I have been asked to review by members (the remaining two were mentioned at Conference 2006). Please do keep sending me links to sites that you think might be interesting for others. There is so much information on the World Wide Web that it is good to narrow down the search by referring to a review. My e-mail address is <jkin64@aol.com>. www.breastfeeding.nhs.uk I liked this website very much and feel it would be useful to all new mothers. It is simple, clear and unfussy, containing good information in a very easily understood format. A link from the homepage takes you to a section entitled About breastfeeding that lists a few introductory facts about breast-feeding and has a menu divided into How to breastfeed, sections For mums and For health professionals, and Questions and answers. How to breastfeed has an excellent series of pictures showing how best to sit and position the baby, with clear stages of how to get a child to open her or his mouth and correctly latch on, how it should feel when the baby is correctly on the breast, and reassurance that it may not work rst time, but to take baby o and repeat the process until you both succeed. The pictures are backed up by captions, but even if a users English was poor or nonexistent, I still think it would be possible to understand this section. The For mums section contains common questions asked about breast-feeding, along with good, comprehensive answers and a seven-page directory of breast-feeding resources, with lists of books and leaets by such organizations as the United Nations Childrens Fund (UNICEF), the National Childbirth Trust (NCT) and the Leleche League. The titles cover all areas of breast-feeding and weaning, as well as the feeding of infants. Some are specically for health professionals. There is also a section on weaning on the site. This has another series of pictures and captions, and two downloadable booklets in a printable format, one on weaning and one on bottle-feeding. A very good area tells the stories of six womens experiences of breast-feeding. I particu 2007 Association of Chartered Physiotherapists in Womens Health
larly liked the way that they had chosen a selection of primigravidae and multigravidae, single and multiple pregnancies, and dierent ages and races, addressing the resistance that may come from family or friends, or the social or economic situation in which a woman may nd herself. I felt that reading about some womens experiences in this way would give others condence and reassurance that breast-feeding would be worth a try. I hate to admit that it is over 32 years now since I began breast-feeding our rst baby, but I still remember how dicult I found it at rst. It was not the fashion to feed at that time, but my determination to do it, and my mothers reassurance and help because she had successfully fed got me going. The health professionals told me to bottle-feed because it was easier, which seems unbelievable now! Had there been such a thing then, I am sure I would have found this website a boon and a reassurance to be returned to regularly during the early years of feeding that rst child. Use this site yourself if you are expecting your rst baby, or recommend it to patients, friends and family. www.1in3women.co.uk This website is designed by Eli Lilly and was launched this year. It is intended for women suering from urinary incontinence (UI), giving advice on the dierent types of UI, the treatments available, and how to approach your general practitioner (GP) or nurse for help. All the information is downloadable in a printable format. From the homepage, a menu leads you to a description of the symptoms, prevalence and causes of stress UI (SUI). There is a diagram of the anatomy of the bladder, urethra and pelvic oor, but the labelling could have been made clearer. Later in the text, there is a reference to the bladder muscle, but I am not sure that a lay person would understand that this refers to the muscle of the bladder wall. However, I could not get a printout of the information on SUI in anything but a very small type, one probably used so that the information tted onto a single page of A4, but very dicult for those who have a visually impairment. Of even more concern was the fact that the questionnaire to be lled in 91
Website watch
and taken to your doctor or nurse to help with a diagnosis, or to get over the embarrassment of having to discuss your symptoms, was also in very small print, whereas the information on mixed UI and overactive bladder was in very large type. This inconsistency is strange. There is a section on the real life experience of a 47-year-old woman with SUI, and I was delighted to read that she improved her symptoms with pelvic oor muscle exercises, Pilates and maintaining a healthy weight. Rather cynically, I had expected drug treatments to have been recommended rst, given the owners of the website. There is an area detailing the dierent treatments that are available, conservative treatment being given the largest share of the coverage. Pelvic oor muscle exercises are mentioned, but there are no detailed instructions on how to do them. Also mentioned are vaginal cones and electromagnetic (?) stimulation, but again, with no accompanying details as to what they are, how they work, or who would be able to advise a woman or give treatment. Medications are mentioned, but not explained, as are surgical options. There follows a list of frequently asked questions and answers that may be useful, but best of all are the links to the websites and phone numbers for Incontact and the Continence Foundation. On the whole, I felt that this was too supercial to be a good resource for patients. The Continence Foundation has such a good website with excellent, detailed advice and explanations, and extremely good downloadable and printable leaets, why would you bother with this one? I suppose the questionnaire to be lled in and taken to the GP is a good idea, but I hope all concerned have good enough eyesight to read it!
visitors, paediatricians and neonatal nurses, as well as members of the NCT, the Association for Improvements in the Maternity Services and others, so this forum is a broad interest group. The website is fairly basic, with the usual list of whos who, the address, phone and fax numbers of the RSM, and an e-mail link. The coming meetings are advertised and those in London, or anyone else with easy access, should keep an eye on what is coming up since I think the topics look very interesting. I am afraid the website does not explain how to become a member, but no doubt, an e-mail or a phone call will produce that information. The links area, unfortunately, does not appear to work, or did not while I was doing my research or today as I wrote this. The best bit of the site for me was the long list of previous topics from the past few years, and from most recent years, full reports and abstracts of meetings. These make excellent reading and I will now make a regular habit of returning to the site to read these. There is a lot of information and it will take me a while to work my way through, but it is very informative indeed.
www.motherhood.org.uk This site belongs to the Forum for Maternity and the Newborn, which is part of the Royal Society of Medicine (RSM). It is designed to give information to members and guests on future meetings of the Forum, as well as information on past meetings and topics discussed. The meetings are held ve times a year at the RSM headquarters in Wimpole Street, and are generally 2.5-h-long evening meetings, although there are some whole-day seminars. These meetings are free to members and usually take the format of a presentation with a discussion afterwards. Members are typically midwives, GPs, obstetricians, physiotherapists, psychologists, health 92
www.pushymothers.com Pushy Mothers (see also p. 54) is a new exercise system designed for pregnant and postnatal women by pregnancy and postnatal tness professionals. It oers a one-hour buggy workout, although, sadly, it is only available in London at present. What a great idea it is and I do hope that more people will train and take it countrywide. The exercise sessions are arranged in various London parks and a 3-min demonstration video is available on the site to give a taste of what a session involves. The sessions are designed to help mothers get back to tness under the supervision of a well-trained instructor, with the added benet of being out in the fresh air, having baby with you, meeting other mums, and one would hope, making new friends. It looks much more fun than going to the gym and putting baby in a crche! The class workout includes cardiovascular activities to burn o the extra adipose tissue after pregnancy, stretches and toning, and core stability for a healthier back, rmer abdominal and pelvic oor muscles. The joining fee is 15, for which you get a Pushy Mothers tote bag, exercise band, exercise booklet and discount vouchers for Ocado (the Waitrose delivery
Website watch
service), Sweaty Betty sports clothing (15% on purchases of 90 or more!) and Running Needs (only in London). There are 16 people in a class and you must commit to at least four classes, which are booked in advance. Pushy Mothers was the brainchild of Rachel Berg, who was a professional dancer and then became a tness instructor and personal trainer specializing in pregnancy and postnatal tness. She has a lot of impressive experience, as does her business partner, Judy DiFiore, who has written a book called The Complete Guide to Postnatal Fitness, and is one of the founding members of the Guild of Pregnancy and Postnatal Exercise Instructors and a qualied Pilates instructor. Both are mothers, and so have rsthand knowledge and have practiced what they preach. Within the website, there is all the information needed to join, as well as a Pushy Bloggers section containing news of events and a very good section of advice for safe postnatal exercise. I particularly liked the advice to have your feet measured and a new pair of trainers tted after pregnancy because of the changes that may have occurred to your feet during pregnancy. How many postnatal women would have given that a thought? It is also possible to nd out how to become an instructor, and I was pleased to see that anyone interested would need to have an existing ante- or postnatal exercise qualication, although they are happy to arrange this as extra training if necessary. Inevitably, Pushy Mothers is London-based at present and primarily has a middle-class appeal, but it is a very good idea, and I wish them well and hope it catches on.
350 sexual health advisors in the country. Clinics vary in what they have to oer, but commonly include treatment, partner notication/contact tracing, sexual health promotion, teaching and training, counselling, as well as research and audit. Although this website is primarily for members, it does also include a very good public education section. This is a rich source of information on STIs. There are at least 25 of these infections, and there is detailed information on 15 of the commoner varieties. The introduction with general information on STIs and good sexual health advice is followed by details of specic infections with descriptions of symptoms, how common they are, how they are passed on, the treatment necessary and good practice. Some of the conditions mentioned are not actual STIs, but symptoms can be very worrying and it is reassuring to know that many can be treated easily if caught early. There are a few pictures of symptoms of the conditions for ease of identication. This website is a very useful resource for both patients and healthcare professionals.
www.ssha.info During her very interesting, if rather gruesome, Conference talk and slideshow on sexually transmitted infections (STIs) and what to look for, Linda Furness, health advisor for the Cardi and Vale National Health Service (NHS) Trust, gave us this website reference. The Society of Sexual Health Advisors (SSHA) is the professional organization for health advisors working in departments of genito-urinary medicine and sexual health. Sexual health advisors do not need to have a core qualication, but generally come from a variety of professional backgrounds, including nursing, health visiting and social work. Training courses are run by various educational establishments and there are now
www.homebirth.org.uk/marycronk Mary Cronk MBE gave the Margie Polden Memorial Lecture at Conference and I found her talk very interesting (see p. 39). She emanated such knowledge and enthusiasm for her subject, and would instinctively inspire great condence in any woman who chose Mary as an independent midwife for her pregnancy, birth and postnatal care. I typed Mary Cronk into Google and found more than 20 references, although only 10 were related to Mary the midwife. The rest were for Mary Cronk Farrell, who would seem to be a Catholic author of novels and texts, and I dont think this is the same person in another guise! Mary describes herself on her website as a mature midwife who has helped birth 1600 babies! She worked in the NHS for 30 years, mainly as a domiciliary midwife specializing in home births, but left in 1991 to become an independent practitioner because it was increasingly dicult to provide a woman-centred service within the NHS. She will take on clients within an hours drive of Chichester, West Sussex, and oers antenatal care tailored to a womans needs. She delivers the baby with the woman at home, but can arrange honorary contracts to deliver the baby in hospital within her practice area if this is necessary or is what a 93
Website watch
woman wants. She lists an e-mail contact and telephone numbers on the site. The links on the site are excellent, and cover breech birth workshops for midwives (one of Marys particular skills is the normal delivery of breech babies, as she demonstrated with her talk and PowerPoint presentation at Conference) and her list of equipment for a home birth (what she provides and what she requires the parents to provide). This is such a sensible list and nishes with frequent cups of proper building site tea none of this Earl Grey or healthy herbal stu for Mary! Her advice on what to expect if an unplanned or emergency Caesarean section should be necessary would be a good preparatory read for any
pregnant woman and her partner, and her notes for women expecting twins are extremely helpful. Do have a look at Marys website and at other references to her on Google. There is some very interesting and encouraging information. I will certainly remember it for advice when/if I am an expectant grandmother, although I dont think Mary will be able to attend my daughter who lives in New Zealand! (I am reassured, though, because I have it on good authority that maternity care is very much more woman-centred there.) What a shame that so many of our midwives here have become de-skilled because of the prevailing system in the NHS. Jenny Kinahan
ACPWH polo shirts

Following their re-launch at Conference 2003, the ever-popular ACPWH polo shirts are on sale: + Easy-care Pique polo + Twin-needle stitching to sleeves and hems + 50% cotton, 50% polyester + Navy blue or white + ACPWH badge and initials embroidered on left side of chest + Sizes (bust)=32$, 34$, 36$, 38$, 40$, 42$ + Price 10.50 (including P&P per shirt). Cheques payable to ACPWH. For further information, e-mail: robertsonco@btinternet.com or send your orders to: Sue Davies 34 Exeter Road Mapesbury London NW2 4SB
94
Notes and news
Distinguished Service Award

It is my pleasure to inform you that Jane Goudge has been awarded the Distinguished Service Award by the Chartered Society of Physiotherapy for her services to womens health over 30 years. Ros Thomas
Dame Josephine Barnes Bursary

Dame Josephine Barnes was a former president of our association (19771995). The bursary was started through her generosity and is now owned by the ACPWH. It is used for educational and research needs, and for promoting womens health and continence in this country and abroad. The bursary is topped up each year by any prot from the Annual Conference. Up to 2000 will be made available per year for this award and this amount will be reviewed every 2 years by the executive committee. The following constitutes the policy and criteria for the Dame Josephine Barnes Bursary. Jeanette Haslam Chairman Education subcommittee Use of the bursary The bursary will be made available for use in the following ways: (1) Part-funding of courses: (a) to help towards subsidizing up to four places on the validated university courses which are recognized by ACPWH as a route to membership of the Association [In order to qualify for this assistance, the candidate must be a member or aliate member of the ACPWH and will be required to pledge a further years membership on completion of the course. The maximum amount granted will be 250.00 (12.5% of the annual sum).]; (b) to part-fund places on other appropriate courses/conferences in this country or abroad; and (c) to give nancial help to those doing a Masters degree relevant to womens health and continence.
(2) The development of research in womens health and continence: (a) to give funding towards research projects relevant to womens health and continence; (b) to fund/part-fund a course that would enable a project or a piece of research to be undertaken; (c) to encourage evidence-based practice; for example, an ACPWH annual workshop on how to get started with a research project (this would be at the members request); and (d) to promote a project nationally for the benet of physiotherapists working in womens health or continence; for example, standardized outcome measures or research organized country-wide (i.e. small groups bringing information to a central point). (3) Directive of the Association: (a) fund an issue that emerges from the discussion groups at the Annual Conference that the members consider needs addressing; and (b) enable members to travel abroad where they would be acting as an ambassador for the ACPWH, and also promoting womens health and/or continence. Criteria for selection All applicants must: + be paid-up members of the ACPWH; + ll in and complete the necessary pro forma; + provide evidence that they have sought funding elsewhere, whether successful or unsuccessful, including any employers contribution, i.e. study leave; + give concise reasons for application, explaining the benets to womens health, the Association, the patient and/or physiotherapy generally; + provide a curriculum vitae; + explain the relevance to the applicants career development and future continuing professional development; + provide a precise breakdown of expected expenses, i.e. course fees, travel and subsistence; 95
Notes and news
+ seek the cheapest travel and accommodation (within reasonable limits, i.e. block travel bookings by agreed carriers, block hotel bookings, APEX and cheap return tickets); + provide evidence of adequate insurance cover when travelling abroad; + provide a prcis of the course content or research project, or an abstract of the lecture or poster presentation; + provide evidence of acceptance on the course or an invitation to speak; + agree to write up their work for the ACPWH Journal; and + submit the application before the agreed deadline. Application forms are available from the current ACPWH secretary (see the address on the inside front cover of the Journal). Applications will be considered every 6 months and must be submitted before the closing date, which will be published in the Journal or by application to the ACPWH secretary. Applications whether single or as a group can be retrospective or anticipatory, and should be returned to the ACPWH secretary. The implementation of the awards will be overseen by a small group from the executive and the education subcommittee that will include the ACPWH chairperson and treasurer. The next closing date is 1 July 2007.
and completed nominations must be received by 1 July 2007. Ann Johnson was the winner of the Anne Bird Prize 2006. Ann has been an active member of ACPWH for many years, her roles including book and leaet secretary, secretary, and most recently, area representative for Yorkshire. She is also a tutor for the University of Bradford Postgraduate Certicate in Womens Health. Amongst her numerous attributes, Ann is tremendously enthusiastic, hard-working and cheerful. She more than fulls the criteria for the Prize, and exemplies the excellence and professionalism that the ACPWH encourages. The award also recognizes a special contribution to an ACPWH post-registration course, which as a student Ann demonstrated as an excellent tutor group leader, and continues to do from the other side of the fence as a course tutor. Ann is always willing to share her knowledge, and her contribution to any project is given enthusiastically and always thoroughly undertaken. She is measured and fair in her responses and opinions, and therefore, greatly respected by her colleagues and peer group. Ann never seeks personal reward and was the last person to have expected this award, as was evident by the shock she had when I announced the winner. It gave me enormous pleasure to present Ann with her well-deserved prize. Ros Thomas
Anne Bird Prize

The Anne Bird Prize commemorates the life of Anne Bird, chairman of the Association of Chartered Physiotherapists in Obstetrics and Gynaecology from 1985 to 1988, by encouraging those qualities which she herself valued. It will normally be awarded annually to individuals who show overall excellence, professionalism and empathy in their educational development within the ACPWH, and who also make a special contribution to an ACPWH postregistration course or to physiotherapy in womens health. Nominations are invited for the Anne Bird Prize for this year. Each nominee must be nominated by three people, one of whom must be an ACPWH member. Nominations must be condential. Forms are available from the ACPWH secretary (see address on the inside front cover),
World Physical Therapy 2007

The 15th International Congress of the World Confederation of Physical Therapy (WCPT) will be held in Vancouver, Canada, from 2 to 6 June 2007, hosted by the Canadian Physiotherapy Association. Many internationally known and respected speakers will lecture during the Congress on issues concerning practice, research, education and management. Physiotherapists will have an unparallelled opportunity to access a huge range of international expertise under one roof. The programme is both stimulating and thought-provoking, and if you think you would like to attend, further details can be found on the WCPT website <www.wcpt.org/congress> or e-mail <congress@wcpt.org>.
96
Letter
Madam, Re: The Urgent PC Neuromodulation System I am writing to express my concern about the Urgent PC Neuromodulation System distributed by Uroplasty Ltd. The technology of sacral aerent nerve stimulation (SANS) or percutaneous tibial nerve stimulation (PTNS) has been known for some considerable time (Govier et al. 2001), and indeed, there have been other units in circulation (Klinger et al. 2000), although it would never seem to have successfully taken o as a routine treatment for overactive bladder. My concern is that, unless we are acupuncture trained (and I am aware that many of our members are), we will be working outside our scope of practice in using this equipment. The company does not provide training to a certied level of competence, and I would urge (!) members to be cautious if they are considering the use of this modality. That said, it is always exciting to see new products appearing on the market, and despite
its considerable expense, Jersey General Hospital will be setting up a nurse-led clinic to trial the Urgent PC Neuromodulation System for those patients who have intractable urinary urge incontinence. Clare Jouanny Urotherapy Clinic WARC Overdale Hospital Westmount Road St Helier Jersey JE1 3UN Channel Islands E-mail: c.jouanny@health.gov.je References
Govier F. E., Litwiller S., Nitti V., Kreder K. J., Jr & Rosenblatt P. (2001) Percutaneous aerent neuromodulation for the refractory overactive bladder: results of a multicenter study. Journal of Urology 165 (4), 11931198. Klinger H. C., Pycha A., Schmidbauer J. & Marberger M. (2000) Use of peripheral neuromodulation of the S3 region for treatment of detrusor overactivity: a urodynamic-based study. Urology 56 (5), 766771.
97
Papers in other journals

Compiled by Becky Aston, Gill Brook, Roberta Eales, Helen Forth, Rachel Grubb, Georgie Gulliford and Jo Whitehead
Bowel dysfunction
Faltin D. L., Otero M., Petignat P., et al. (2006) Womens health 18 years after rupture of the anal sphincter during childbirth: I. Fecal incontinence. American Journal of Obstetrics and Gynecology 194 (5), 12551259. Gregory W. T., Hamilton Boyles S., Simmons K., Corcoran A. & Clark A. L. (2006) External anal sphincter volume measurements using 3-dimensional endoanal ultrasound. American Journal of Obstetrics and Gynecology 194 (5), 12431248. Mahoney R. & OHerlihy C. (2006) Recent impact of anal sphincter injury on overall Caesarean section incidence. Australian and New Zealand Journal of Obstetrics and Gynaecology 46 (3) 202204. Nichols C. M., Nam M., Ramakrishnan V., Lamb E. H. & Currie N. (2006) Anal sphincter defects and bowel symptoms in women with and without recognized anal sphincter trauma. American Journal of Obstetrics and Gynecology 194 (5), 14501454. Otero M., Boulvain M., Bianchi-Demicheli F., et al. (2006) Womens health 18 years after rupture of the anal sphincter during childbirth: II. Urinary incontinence, sexual function, and physical and mental health. American Journal of Obstetrics and Gynecology 194 (5), 12601265. Soligo M., Salvatore S., Emmanuel A. V., et al. (2006) Patterns of constipation in urogynecology: clinical importance and pathophysiologic insights. American Journal of Obstetrics and Gynecology 195 (1), 5055.
Bladder dysfunction
Amaro J. L., Gameiro M. O., Kawano P. R. & Padovani C. R. (2006) Intravaginal electrical stimulation: a randomized, double-blind study on the treatment of mixed urinary incontinence. Acta Obstetricia et Gynecologica Scandinavica 85 (5), 619622. Atala A., Bauer S. B., Soker S., Yoo J. J. & Retik A. B. (2006) Tissue-engineered autologous bladders for patients needing cystoplasty. Lancet 367 (9518), 12411246. Brubaker L., Chapple C., Coyne K. S. & Kopp Z. (2006) Patient-reported outcomes in over98
active bladder: importance for determining clinical eectiveness of treatment. Urology 68 (2, Suppl. 1), 148. Burgio K., Locher J. L., Goode P. S., Locher J. L. & Roth D. L. (2006) Global ratings of patient satisfaction and perceptions of improvement with treatment for urinary incontinence: validation of three global patient ratings. Neurourology and Urodynamics 25 (5), 411417. Cardozo L. (2006) Duloxetine in the context of current needs and issues in treatment of women with stress urinary incontinence. BJOG: An International Journal of Obstetrics and Gynaecology 113 (Suppl. 1), 14. Coyne K. S., Matza L. S., Thompson C. L., Kopp Z. S. & Khullar V. (2006) Determining the importance of change in the overactive bladder questionnaire. Journal of Urology 176 (2), 627632. Dalpiaz O. & Curti P. (2006) Role of perineal ultrasound in the evaluation of urinary stress incontinence and pelvic organ prolapse: a systematic review. Neurourology and Urodynamics 25 (4), 301306. Daneshgari F., Moore C., Frinjari H. & Babineau D. (2006) Patient related risk factors for recurrent stress urinary incontinence surgery in women treated at a tertiary care center. Journal of Urology 176 (4), 1493 1499. Dietz H. P., Hyland G. & Hay-Smith J. (2006) The assessment of levator trauma: a comparison between palpation and 4D pelvic oor ultrasound. Neurourology and Urodynamics 25 (5), 424427. Dong D., Xu Z., Shi B., et al. (2006) Urodynamic study in the neurogenic bladder dysfunction caused by intervertebral disk hernia. Neurourology and Urodynamics 25 (5), 446 450. Drutz H. (2006) Duloxetine in women awaiting surgery. BJOG: An International Journal of Obstetrics and Gynaecology 113 (Suppl. 1), 1721. Durue A., Petrilli S., Nicolas B., et al. (2006) Eects of pregnancy and child birth on urinary symptoms and urodynamics in women with multiple sclerosis. International Urogynecology Journal 17 (4), 352355.
Ellis-Jones J., Swithinbank L. & Abrams P. (2006) The impact of formal education and training on urodynamic practice in the United Kingdom: a survey. Neurourology and Urodynamics 25 (5), 406410. FitzGerald M. P., Mulligan M. & Parthasarathy S. (2006) Nocturic frequency is related to severity of obstructive sleep apnea, improves with continuous positive airways treatment. American Journal of Obstetrics and Gynecology 194 (5), 13991403. Freeman R. M. (2006) Initial management of stress urinary incontinence: pelvic oor muscle training and duloxetine. BJOG: An International Journal of Obstetrics and Gynaecology 113 (Suppl. 1), 1016. Goldberg R. P., Sand P. K. & Beck H. (2005) Early-stage ovarian carcinoma presenting with irritative voiding symptoms and urge incontinence. International Urogynecology Journal 16 (5), 342344. Goldberg R. P. & Sand P. K. (2006) Electromagnetic pelvic oor stimulation for urinary incontinence and bladder disease. International Urogynecology Journal 16 (5), 401404. Kenton K., Mahajan S., FitzGerald M. P. & Brubaker L. (2006) Recurrent stress incontinence is associated with decreased neuromuscular function in the striated urethral sphincter. American Journal of Obstetrics and Gynecology 194 (5), 14341437. Kim J. C., Park E. Y., Seo S. I., Park Y. H. & Hwang T.-K. (2006) Nerve growth factor and prostaglandins in the urine of female patients with overactive bladder. Journal of Urology 175 (5), 17731776. McClurg D., Ashe R. G., Marshall K. & LoweStrong A. S. (2006) Comparison of pelvic oor muscle training, electromyography biofeedback, and neuromuscular electrical stimulation for bladder dysfunction in people with multiple sclerosis: a randomised pilot study. Neurourology and Urodynamics 25 (4), 337 348. Melville J. L., Katon W., Delaney K. & Newton K. (2006) Urinary incontinence in US women. A population-based study. Journal of Urology 175 (5), 1800. Murphy M., Culligan P. J., Arce C. M., et al. (2006) Construct validity of the Incontinence Severity Index. Neurourology and Urodynamics 25 (5), 418423. Oelke M., Roovers J.-P. W. R. & Michel M. C. (2006) Safety and tolerability of duloxetine in women with stress urinary incontinence. BJOG: An International Journal of Obstetrics and Gynaecology 113 (Suppl. 1), 2226. Oh S. J. & Ku J. H. (2006) Does conditionspecic quality of life correlate with generic
health-related quality of life and objective incontinence severity in women with stress urinary incontinence? Neurourology and Urodynamics 25 (4), 324329. Patel D. A., Xu X., Thomason A. D., et al. (2006) Childbirth and pelvic oor dysfunction: an epidemiologic approach to the assessment of prevention opportunities at delivery. American Journal of Obstetrics and Gynecology 195 (1), 2328. Patki P., Woodhouse J., Hamid R., Shah J. & Craggs M. (2006) Lower urinary tract dysfunction in ambulatory patients with incomplete spinal cord injury. Journal of Urology 175 (5), 17841787. Pauwels E., De Laet K., De Wachter S. & Wyndaele J.-J. (2006) Healthy, middle-aged, history-free, continent women do they strain to void? Journal of Urology 176 (4), 14031407. Psterer M. H.-D., Griths D. J., Rosenberg L., Schaefer W. & Resnick N. M. (2006) The impact of detrusor overactivity on bladder function in younger and older women. Journal of Urology 175 (5), 17771783. Reid G. & Bruce A. W. (2006) Probiotics to prevent urinary tract infections: the rationale and evidence. World Journal of Urology 24 (1), 2832. Rortveit G. & Hunskaar S. (2006) Urinary incontinence and age at the rst and last delivery: the Norwegian HUNT/EPINCONT study. American Journal of Obstetrics and Gynecology 195 (2), 433438. Savaris R. F., Teixeira L. M. & Torres T. G. (2006) Bladder tenderness as a physical sign for diagnosing cystitis in women. International Journal of Gynecology and Obstetrics 93 (3), 256257. Schuessler B. (2006) What do we know about duloxetines mode of action? Evidence from animals to humans. BJOG: An International Journal of Obstetrics and Gynaecology 113 (Suppl. 1), 59. Sinha D., Nallaswamy V. & Arunkalaivanan A. S. (2006) Value of leak point pressure study in women with incontinence. Journal of Urology 176 (1), 186188. Wein A. J. (2006) Voiding function and dysfunction, bladder physiology and pharmacology, and female urology. Journal of Urology 176 (1), 210214. Wein A. J. (2006) Voiding function and dysfunction, bladder physiology and pharmacology, and female urology. Journal of Urology 176 (3), 10571060. Yap T. L., Brown C. T. & Emberton M. (2006) Self-management in lower urinary tract symptoms: the next major therapeutic revolution. World Journal of Urology 24 (4), 371377. 99
Gynaecology
Abrams P., Baranowski A., Berger R. E., et al. (2006) A new classication is needed for pelvic pain syndromes are existing terminologies of spurious diagnostic authority bad for patients? Journal of Urology 175 (6), 1989 1990. B K. (2006) Can pelvic oor muscle training prevent and treat pelvic organ prolapse? Acta Obstetricia et Gynecologica Scandinavica 85 (3), 263268. Constantino S. Esposito F., Nadalini C., et al. (2006) Ultrasound imaging of the female perineum: the eect of vaginal delivery on pelvic oor dynamics. Ultrasound in Obstetrics and Gynecology 27 (2), 183187. Donnay F. & Ramsey K. (2006) Eliminating obstetric stula: progress in partnerships. International Journal of Gynecology and Obstetrics 94 (3), 254261. Elmusharaf S., Elhadi N. & Almroth L. (2006) Reliability of self reported form of female genital mutilation and WHO classication: cross sectional study. British Medical Journal 333 (7559), 124128. Hsu Y., Summers A., Hussain H. K., Guire K. E. & Delancey J. O. L. (2006) Levator plate angle in women with pelvic organ prolapse compared to women with normal support using dynamic MR imaging. American Journal of Obstetrics and Gynecology 194 (5), 1427 1433. Hundley A. F., Yuan L. & Visco A. G. (2006) Skeletal muscle heavy-chain polypeptide 3 and myosin binding protein H in the pubococcygeus muscle in patients with and without pelvic organ prolapse. American Journal of Obstetrics and Gynecology 194 (5), 14041410. Jelovsek J. E. & Barber M. D. (2006) Women seeking treatment for advanced pelvic organ prolapse have decreased body image and quality of life. American Journal of Obstetrics and Gynecology 194 (5), 14551461. Juang C. M., Yen M. S., Twu N. F., et al. (2006) Impact of pregnancy on primary dysmenorrhea. International Journal of Gynecology and Obstetrics 92 (3), 221227. Lorentto C., Petta C. A., Navarro M. J., Bahamondes L. & Matos A. (2006) Depression in women with endometriosis with and without chronic pelvic pain. Acta Obstetricia et Gynecologica Scandinavica 85 (1), 8892. Moreira D. & Paula C. R. (2006) Vulvovaginal candidiasis International Journal of Gynecology and Obstetrics 92 (3), 266267. Price N., Jackson S. R., Avery K., Brookes S. T. & Abrams P. (2006) Development and psychometric evaluation of the ICIQ Vaginal Symptoms Questionnaire: the ICIQ-VS. 100
BJOG: An International Journal of Obstetrics and Gynaecology 113 (6), 700712. Price J., Farmer G., Harris J., et al. (2006) Attitudes of women with chronic pelvic pain to the gynaecological consultation: a qualitative study. BJOG: An International Journal of Obstetrics and Gynaecology 113 (4), 446452. Seehusen D. A., Johnson D. R., Earwood J. S., et al. (2006) Improving womens experience during speculum examinations at routine gynaecological visits: randomised clinical trial. British Medical Journal 333 (7560), 171173. Seo J. T. & Kim J. M. (2006) Pelvic organ support and prevalence by Pelvic Organ Prolapse-Quantication (POP-Q) in Korean Women. Journal of Urology 175 (5), 1769 1772. Simoes J. A., Discacciati M. G., Brolazo E. M., et al. (2006) Clinical diagnosis of bacterial vaginosis. International Journal of Gynecology and Obstetrics 94 (1), 2832. Siwe K., Wijma B. & Berter C. (2006) A stronger and clearer perception of self. Womens experience of being professional patients in teaching the pelvic examination: a qualitative study. BJOG: An International Journal of Obstetrics and Gynaecology 113 (8), 890895. Sogaard M., Kjaer S. K. & Gayther S. (2006) Ovarian cancer and genetic susceptibility in relation to the BRCA1 and BRCA2 genes. Occurrence, clinical importance and intervention. Acta Obstetricia et Gynecologica Scandinavica 85 (1), 93105. Spencer C. & Pakarian F. (2006) The role of childbirth in the aetiology of rectocele. BJOG: An International Journal of Obstetrics and Gynaecology 113 (7), 849849. Summers A., Winkel L. A., Hussain H. K. & DeLancey J. O. L. (2006) The relationship between anterior and apical compartment support. American Journal of Obstetrics and Gynecology 194 (5), 14381443. Swift S. (2005) Pelvic organ prolapse: is it time to dene it? Severity of pelvic organ prolapse associated with measurements of pelvic oor function. International Urogynecology Journal 16 (6), 425427. Topcu S, Caliskan M., Gullu H., et al. (2006) Do women with polycystic ovary syndrome really have predisposition to atherosclerosis? Australian and New Zealand Journal of Obstetrics and Gynaecology 46 (2), 164167. Taylor A. W., Maclennan A. H. & Avery J.C. (2006) Postmenopausal hormone therapy: who now takes it and do they dier from non-users? Australian and New Zealand Journal of Obstetrics and Gynaecology 46 (2), 128135.
Woad K. J., Watkins W. J., Prendergast D. & Shellin A. N. (2006) The genetic basis of premature ovarian failure. International Journal of Gynecology and Obstetrics 93 (2), 242 244. Woodman P. J., Swift S. E., OBoyle A. L., et al. (2006) Prevalence of severe pelvic organ prolapse in relation to job description and socioeconomic status: a multicenter cross-sectional study. International Urogynecology Journal 17 (4), 340345.
Gynaecological surgery
Alessandri F., Mistrangelo E., Lijoi D., Ferrero S. & Ragni N. (2006) A prospective, randomized trial comparing immediate versus delayed catheter removal following hysterectomy. Acta Obstetricia et Gynecologica Scandinavica 85 (6), 716720. Ankardal M., Heiwall B., Lausten-Thomsen N., Carnelid J. & Milsom I. (2006) Short- and long-term results of the tension-free vaginal tape procedure in the treatment of female urinary incontinence. Acta Obstetricia et Gynecologica Scandinavica 85 (8), 986992. Ayhan A., Esin S., Guven S., Salman C. & Ozyuncu O. (2006) The Manchester operation for uterine prolapse. International Journal of Gynecology and Obstetrics 92 (3), 228233. Bakas P., Liapis A., Giner M. & Creatsas G. (2006) Quality of life in relation to TVT procedure for the treatment of stress urinary incontinence. Acta Obstetricia et Gynecologica Scandinavica 85 (6), 748752. Barber M. D., Walters M. D., Cundi G. W. & the PESSRI Trial Group (2006) Responsiveness of the Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ) in women undergoing vaginal surgery and pessary treatment for pelvic organ prolapse. American Journal of Obstetrics and Gynecology 194 (5), 14921498. Carey M. P., Goh J. T., Rosamilia A., et al. (2006) Laparoscopic versus open Burch colposuspension: a randomised controlled trial. BJOG: An International Journal of Obstetrics and Gynaecology 113 (9), 9991006. Collinet P., Belot F., Debodinance F., et al. (2006) Transvaginal mesh technique for pelvic organ prolapse repair: mesh exposure management and risk factors. International Urogynecology Journal 17 (4), 315320. de Tayrac R., Deeux X., Resten A., et al. (2006) A transvaginal ultrasound study comparing transobturator tape and tension-free vaginal tape after surgical treatment of female stress urinary incontinence. International Urogynecology Journal 17 (5), 466471.
Dumville J. C., Manca A., Kitchener H. C., et al. (2006) Cost-eectiveness analysis of open colposuspension versus laparoscopic colposuspension in the treatment of urodynamic stress incontinence. BJOG: An International Journal of Obstetrics and Gynaecology 113 (9), 1014 1022. Engelsen I. B., Woie K. & Hordnes K. (2006) Transcervical endometrial resection: longterm results of 390 procedures. Acta Obstetricia et Gynecologica Scandinavica 85 (1), 8287. Engh M. A. E., Otterlind L., Stjerndahl J. H. & Lofgren M. (2006) Hysterectomy and incontinence: a study from the Swedish national register for gynecological surgery. Acta Obstetricia et Gynecologica Scandinavica 85 (5), 614618. Ghanbari Z., Baratali B. H. & Mireshghi M. S. (2006) Posterior intravaginal slingplasty (infracoccygeal sacropexy) in the treatment of vaginal vault prolapse. International Journal of Gynecology and Obstetrics 94 (2), 147148. Ghezzi F., Serati M., Cromi A., et al. (2006) Tension-free vaginal tape for the treatment of urodynamic stress incontinence with intrinsic sphincteric deciency. International Urogynecology Journal 17 (4), 335339. Giri S. K., Hickey J. P., Sil D., et al. (2006) The long-term results of pubovaginal sling surgery using acellular cross-linked porcine dermis in the treatment of urodynamic stress incontinence. Journal of Urology 175 (5), 1788 1793. Glavind K., Bjork J., Nohr M., Jaquet A. & Glavind L. (2006) A prospective study on whether a tension-free urethropexy procedure aects the residual urine and ow up to 4 years after the operation. Acta Obstetricia et Gynecologica Scandinavica 85 (8), 982985. Howden N. S., Zyczynski H. M., Moalli P. A., et al. (2006) Comparison of autologous rectus fascia and cadaveric fascia in pubovaginal sling continence outcomes. American Journal of Obstetrics and Gynecology 194 (5), 1444 1449. Huang K. H., Kung F.-T., Liang H.-M. & Chang S.-Y. (2005) Management of polypropylene mesh erosion after intravaginal midurethral sling operation for female stress urinary incontinence. International Urogynecology Journal 16 (6), 437440. Huebner M., Hsu Y. & Fenner D. E. (2006) The use of graft materials in vaginal pelvic oor surgery. International Journal of Gynecology and Obstetrics 92 (3), 279288. Jordaan D. J., Prollius A., Cronj H. S. & Nel M. (2006) Posterior intravaginal slingplasty for vaginal prolapse. International Urogynecology Journal 17 (4), 326329. 101
Kitchener H. C., Dunn G., Lawton V., Reid F., Nelson L. & Smith, A. R. B. (2006) Laparoscopic versus open colposuspension results of a prospective randomised controlled trial. BJOG: An International Journal of Obstetrics and Gynaecology 113 (9), 1007 1013. Kleeman S., Vassallo B., Segal J., Hungler M. & Karram M. (2006) The ability of history and a negative cough stress test to detect occult stress incontinence in patients undergoing surgical repair of advanced pelvic organ prolapse. International Urogynecology Journal 17 (1), 2729. Kueck A. S., Gossner G., Burke W. M. & Reynolds R. K. (2006) Laparoscopic technology for the treatment of endometrial cancer. International Journal of Gynecology and Obstetrics 93 (2), 176181. Kuuva N. & Nilsson C. G. (2006) Long-term results of the tension-free vaginal tape operation in an unselected group of 129 stress incontinent women. Acta Obstetricia et Gynecologica Scandinavica 85 (4), 482487. Mattox T. F., Moore S., Stanford E. J. & Mills B. B. (2006) Posterior vaginal sling experience in elderly patients yields poor results. American Journal of Obstetrics and Gynecology 194 (5), 14621466. Persson P., Wijma K., Hammar M. & Kjlhede P. (2006) Psychological wellbeing after laparoscopic and abdominal hysterectomy a randomised controlled multicentre study. BJOG: An International Journal of Obstetrics and Gynaecology 113 (9), 10231030. Rutman M. P., Deng D. Y., Shah S. M., Raz S. & Rodrguez L. V. (2006) Spiral sling salvage anti-incontinence surgery in female patients with a nonfunctional urethra: technique and initial results. Journal of Urology 175 (5), 17941799. Schraordt Koops S. E., Bisseling T. M., Heintz A. P. M. & Vervest H. A. M. (2006) The eectiveness of tension-free vaginal tape (TVT) and quality of life measured in women with previous urogynecologic surgery: analysis from The Netherlands TVT database. American Journal of Obstetrics and Gynecology 195 (2), 439444. Seow K. M., Tsou C. T., Lin Y. H., et al. (2006) Outcomes and complications of laparoscopically assisted vaginal hysterectomy. International Journal of Gynecology and Obstetrics 95 (1), 2934. Somigliana E., Ragni G., Infantino M., et al. (2006) Does laparoscopic removal of nonendometriotic benign ovarian cysts aect ovarian reserve? Acta Obstetricia et Gynecologica Scandinavica 85 (1), 7477. 102
Sung V. W., Weitzen S., Sokol E. R., Rardin C. R. & Myers D. L. (2006) Eect of patient age on increasing morbidity and mortality following urogynecologic surgery. American Journal of Obstetrics and Gynecology 194 (5), 1411 1417. Tincello D. G. (2006) Open or laparoscopic colposuspension for stress incontinence: new evidence too late? BJOG: An International Journal of Obstetrics and Gynaecology 113 (9), 985987. Viereck V., Nebel M., Bader W., et al. (2006) Role of bladder neck mobility and urethral closure pressure in predicting outcome of tension free vaginal tape (TVT) procedure. Ultrasound in Obstetrics and Gynecology 28 (2), 214221. Vierhout M. E., Stoutjesdijk J. & Spruijt J. (2006) A comparison of preoperative and intraoperative evaluation of patients undergoing pelvic reconstructive surgery for pelvic organ prolapse using the pelvic organ prolapse quantication system. International Urogynecology Journal 17 (1), 4649. Wu J. M., Wells E. C., Hundley A. F., et al. (2006) Mesh erosion in abdominal sacral colpopexy with and without concomitant hysterectomy. American Journal of Obstetrics and Gynecology 194 (5), 14181422.
Male incontinence
Azzouzi A.-R., Fourmarier M., Desgrandchamps F., et al. (2006) Other therapies for BPH patients: desmopressin, anti-cholinergic, anti-inammatory drugs, and botulinum toxin. World Journal of Urology 24 (4), 383 388. Kaplan S. A. (2006) Benign prostatic hyperplasia. Journal of Urology 176 (3), 10611063.
Miscellaneous
Chan M. F. & Ko C. Y. (2006) Osteoporosis prevention education programme for women. Journal of Advanced Nursing 54 (2), 159. Chen L., Hsu Y., Ashton-Miller J. A. & DeLancey J. O. (2006) Measurement of the pubic portion of the levator ani muscle in women with unilateral defects in 3-d models from MR images. International Journal of Gynecology and Obstetrics 92 (3), 234241. Gilling-Smith C., Nicopoullos J. D. M., Semprini A. E. & Frodsham L. C. G. (2006) HIV and reproductive care a review of current practice. BJOG: An International Journal of Obstetrics and Gynaecology 113 (8), 869 878. Sambrook P. & Cooper C. (2006) Osteoporosis. Lancet 367 (9527), 20102018.
Swanton A., Iyer L. & Reginald P. W. (2006) Diagnosis, treatment and follow up of women undergoing conscious pain mapping for chronic pelvic pain: a prospective cohort study. BJOG: An International Journal of Obstetrics and Gynaecology 113 (7), 792796. Trybulski J. (2006) Women and abortion: the past reaches into the present. Journal of Advanced Nursing 54 (6) 683. van Brummen H. J., Bruinse H. W., van de Pol G., Heintz A. P. M. & van der Vaart C. H. (2006) Which factors determine the sexual function 1 year after childbirth? BJOG: An International Journal of Obstetrics and Gynaecology 113 (8), 914918. Voorham-van der Zalm P. J., Pelger R. C., van Heeswijk-Faase I. C., et al. (2006) Placement of probes in electrostimulation and biofeedback training in pelvic oor dysfunction. Acta Obstetricia et Gynecologica Scandinavica 85 (7), 850855. WHO Study Group on Female Genital Mutilation and Obstetric Outcome et al. (2006) Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. Lancet 367 (9525), 18351841.
Obstetrics
Albert H. B., Godskesen M., Korsholm L. & Westergaard J. G. (2006) Risk factors in developing pregnancy-related pelvic girdle pain. Acta Obstetricia et Gynecologica Scandinavica 85 (5), 539544. Alehagen S., Wijma B. & Wijma K. (2006) Fear of childbirth before, during, and after childbirth. Acta Obstetricia et Gynecologica Scandinavica 85 (1), 5662. Althaus J., Petersen S., Driggers R., et al. (2006) Cephalopelvic disproportion is associated with an altered uterine contraction shape in the active phase of labor. American Journal of Obstetrics and Gynecology 195 (3), 739742. Aukee P., Sundstrom H. & Kairaluoma M. V. (2006) The role of mediolateral episiotomy during labour. Analysis of risk factors for obstetric anal sphincter tears. Acta Obstetricia et Gynecologica Scandinavica 85 (7), 856860. Barau G., Robillard P.-Y., Hulsey T.C., et al. (2006) Linear association between maternal pre-pregnancy body mass index and risk of caesarean section in term deliveries. BJOG: An International Journal of Obstetrics and Gynaecology 113 (10), 11731177. Constantino S., Esposito F., Nadalini C., et al. (2006) Ultrasound imaging of the female perineum: the eect of vaginal delivery on pelvic oor dynamics. Ultrasound in Obstetrics and Gynecology 27 (2), 183187.
de la Chapelle A., Cahrles M., Gleize V., et al. (2006) Impact of walking epidural analgesia on obstetric outcome of nulliparous women in spontaneous labour. International Journal of Obstetric Anesthesia 15 (2), 104108. Dodd J. M., Crowther C. A. & Robinson J. S. (2006) Oral misoprostol for induction of labour at term: randomised controlled trial. British Medical Journal 332 (7540), 509513. Domingo C., Latorre E., Mirapeix R. M. & Abad J. (2006) Snoring, obstructive sleep apnea syndrome, and pregnancy. International Journal of Gynecology and Obstetrics 93 (1), 5759. Drake E., Drake M., Bird J. & Russell R. (2006) Obstetric regional blocks for women with MS: a survey of UK experience. International Journal of Obstetric Anesthesia 15 (2), 115123. Dresner M., Brocklesby J. & Bamber J. (2006) Audit of the inuence of body mass index on the performance of epidural analgesia in labour and the subsequent mode of delivery. BJOG: An International Journal of Obstetrics and Gynaecology 113 (10), 11781181. Duncombe D., Skouteris H., Wertheim E. H., et al. (2006) Vigorous exercise and birth outcomes in a sample of recreational exercisers: a prospective study across pregnancy. Australian and New Zealand Journal of Obstetrics and Gynaecology 46 (4), 288292. Gherman R. B., Chauhan S., Ouzounian J. G., et al. (2006) Shoulder dystocia: the unpreventable obstetric emergency with empiric management guidelines. American Journal of Obstetrics and Gynecology 195 (3), 657672. Habiba M., Kaminski M., Da Fr M., et al. (2006) Caesarean section on request: a comparison of obstetricians attitudes in eight European countries. BJOG: An International Journal of Obstetrics and Gynaecology 113 (6), 647656. Jerbi M., Hidar S., Ammar A. & Khairi H. (2006) Predictive factors of vaginal birth after cesarean delivery. International Journal of Gynecology and Obstetrics 94 (1), 4344. Kudish B., Blackwell S., McNeeley S. G., et al. (2006) Operative vaginal delivery and midline episiotomy: a bad combination for the perineum. American Journal of Obstetrics and Gynecology 195 (3), 749754. Kung J., Swan A. V. & Arulkumaran S. (2006) Delivery of the posterior arm reduces shoulder dimensions in shoulder dystocia. International Journal of Gynecology and Obstetrics 93 (3), 233237. Latthe P., Mignini L., Gray R., Hills R. & Khan K. (2006) Factors predisposing women to chronic pelvic pain: systematic review. British Medical Journal 322 (7544), 749755. 103
Lund I., Lundeberg T., Lonnberg L. & Svensson E. (2006) Decrease of pregnant womens pelvic pain after acupuncture: a randomized controlled single-blind study. Acta Obstetricia et Gynecologica Scandinavica 85 (1), 1219. Martin S. R. & Foley M. R. (2006) Intensive care in obstetrics: an evidence-based review. American Journal of Obstetrics and Gynecology 195 (3), 673689. Mazouni C., Porcu G., Bretelle F., et al. (2006) Risk factors for forceps delivery in nulliparous patients. Acta Obstetricia et Gynecologica Scandinavica 85 (3), 298301. Mogren I. (2006) Perceived health, sick leave, psychosocial situation, and sexual life in women with low-back pain and pelvic pain during pregnancy. Acta Obstetricia et Gynecologica Scandinavica 85 (6), 647656. Nikkola E., Laara A., Hinkka S., et al. (2006) Patient-controlled epidural analgesia in labor does not always improve maternal satisfaction. Acta Obstetricia et Gynecologica Scandinavica 85 (2), 188194. Poston L., Briley A., Seed P., et al. (2006) Vitamin C and vitamin E in pregnant women at risk for pre-eclampsia (VIP trial): randomised placebo-controlled trial. Lancet 367 (9517), 11451154. Robinson H. S., Eskild A., Heiberg E. & Eberhard-Gran M. (2006) Pelvic girdle pain in pregnancy: the impact on function. Acta Obstetricia et Gynecologica Scandinavica 85 (2), 160164. Rost C. C. M., Jacqueline J., Kaiser A., Verhagen A. P. & Koes B. W. (2006) Prognosis of women with pelvic pain during pregnancy: a long-term follow-up study. Acta Obstetricia et Gynecologica Scandinavica 85 (7), 771777. Sanders J., Campbell R. & Peters T. J. (2006) Eectiveness and acceptability of lidocaine spray in reducing perineal pain during spontaneous vaginal delivery: randomised con-
trolled trial. British Medical Journal 333 (7559), 117119. Saunders T. A., Stein D. J. & Dilger J. P. (2006) Informed consent for labour epidurals: a survey of Society for Obstetrics Anaesthesia and Perinatology anesthesiologists from the United States. International Journal of Obstetric Anesthesia 15 (2), 98103. Thorsen P., Vogel I., Molsted K., et al. (2006) Risk factors for bacterial vaginosis in pregnancy: a population-based study on Danish women. Acta Obstetricia et Gynecologica Scandinavica 85 (8), 906911. Vacca A. (2006) Vacuum-assisted delivery: an analysis of traction force and maternal and neonatal outcomes. Australian and New Zealand Journal of Obstetrics and Gynaecology 46 (2) 124127. Viereck V., Nebel M., Bader W., et al. (2006) Role of bladder neck mobility and urethral closure pressure in predicting outcome of tension free vaginal tape (TVT) procedure. Ultrasound in Obstetrics and Gynecology 28 (2), 214221. Williams M. K. & Chames M. C. (2006) Risk factors for the breakdown of perineal laceration repair after vaginal delivery. American Journal of Obstetrics and Gynecology 195 (3), 755759. Yu C. K. H., Teoh T. G. & Robinson S. (2006) Obesity in pregnancy. BJOG: An International Journal of Obstetrics and Gynaecology 113 (10), 11171125.
Sexual health
Brubaker L. (2006) Partner dyspareunia (hispareunia). [Editorial.] International Urogynecology Journal 17 (4), 311. Mller L. A. & Lose G. (2006) Sexual activity and lower urinary tract symptoms. International Urogynecology Journal 17 (1), 1821.
104
Reading list
The list printed below has been compiled at the request of ACPWH members and is for your benet. It is not comprehensive, but is correct to the best of our knowledge at the time of going to press. The inclusion of any title in this list does not necessarily imply endorsement by the ACPWH. It will be amended in each new edition of the Journal and suggestions are welcome. Please e-mail your recommendations, including full details, to Victoria Muir at <v.muir2@ntlworld.com>. Bibliography
Artal R., Wiswell R. A. & Drinkwater B. L. (1991) Exercise in Pregnancy, 2nd edn. Williams & Wilkins, Baltimore, MD. (ISBN 0683002570.) Balaskas J. (1991) New Active Birth: A Concise Guide to Natural Childbirth, 2nd edn. Thorsons, London. (ISBN 0722525664.) Brayshaw E. (2003) Exercises for Pregnancy and Childbirth: A Guide for Educators. Books for Midwives Press, Oxford. (ISBN 075065600X.) Butler D. S. & Moseley G. L. (2003) Explain Pain 2003. Finsbury Green Printing, Adelaide. (ISBN 097509100X.) Cardozo L. (1997) Urogynecology. Churchill Livingstone, Edinburgh. (ISBN 0-443-05058-9.) Cardozo L. (2000) Textbook of Female Urology and Urogynecology. Isis Medical Media, San Francisco, CA. (ISBN 1901865053.) Cardozo L., Staskin D. & Kirby M. (2000) Urinary Incontinence in Primary Care. Isis Medical Media, San Francisco, CA. (ISBN 1901865681.) Chiarelli P. E. (2002) Womens Waterworks: Curing Incontinence. Gore & Osment, Sydney. (ISBN 1-8755 31009.) Dorey G. (ed.) (2006) Pelvic Dysfunction in Men: Diagnosis and Treatment of Male Incontinence and Erectile Dysfunction. John Wiley & Sons, Chichester. (ISBN 0-470-02836X.) Edwards B. & Sanderson D. (2001) Swiss Ball Systems A Practical Guide. Swiss Ball Systems, Bangor. (ISBN 01248 372828.) Elphinstone J. & Pook P. (2002) The Core Workout Manual. Rugby Science, Fleet. (ISBN 0953985903.) Getlie K. & Dolman M. (2002) Promoting Continence: A Clinical Research Resource, 2nd edn. Baillire Tindall, London. (ISBN 0702026379.)
Heaner M. K. (1995) The 7 Minute Sex Secret. Hodder & Stoughton, London. (ISBN 0-340-62860-X.) Hobbs L. (2001) The Best Labour Possible? Books for Midwives Press, Oxford. (ISBN 0750652004.) King M. (2000) Pure Pilates. Mitchell Beazley, London. (ISBN 1-84000-266-2.) Laycock J. & Haslam J. (eds) (2002) Therapeutic Management of Incontinence and Pelvic Pain: Pelvic Organ Disorders. Springer-Verlag, Berlin. (ISBN 1852332247.) McKenzie R. (1998) Treat Your Own Back. Spinal Publications, Waikanae. (ISBN 0959804927.) MacLean A. & Cardozo L. (eds) (2002) Incontinence in Women. RCOG Press, London. (ISBN 1 900364 67.) Mantle J., Haslam J. & Barton S. (2004) Physiotherapy in Obstetrics and Gynaecology, 2nd edn. Butterworth Heinemann, Oxford. (ISBN 1750622652.) Melzack R. & Wall P. D. (1996) The Challenge of Pain. Penguin Science, London. (ISBN 0140256709.) Nolan M. (1998) Antenatal Education: A Dynamic Approach. Baillire Tindall, London. (ISBN 0-7020-2279-9.) Norton C. & Kamm M. A. (1999) Bowel Control Information and Practical Advice. Beaconseld Publishers, Beaconseld. (ISBN 0906584493.) Payne R. A. (2000) Relaxation Techniques A Practical Handbook for theHealthcare Professional. Churchill Livingstone, Edinburgh. (ISBN 0443062633.) Priest J. & Schott J. (2001) Leading Antenatal Classes: A Practical Guide. Butterworth Heinemann, Oxford. (ISBN 07506498.) Richardson C., Jull G., Hodges P. & Hides J. (1999) Therapeutic Exercise for Spinal Segmental Stabilisation in Low Back Pain: Scientic Basis and Clinical Approach. Churchill Livingstone, Edinburgh. (ISBN 0-443-05802-4.) Robinson L. (2002) The Ocial Body Control Pilates Manual. Pan Books, London. (ISBN 0-333-78202-X.) Royal College of Midwives (2001) Successful Breastfeeding. ChurchillLivingstone, Edinburgh. (ISBN 0443059675.) Sapsford R., Bullock-Saxton J. & Markwell S. (1997) Womens Health: A Textbook for Physiotherapists. W. B. Saunders, Philadelphia, PA. (ISBN 0-7020-2209-8.) Schussler B., Laycock J., Norton P. & Stanton S. (1998) Pelvic Floor Re-education: Principles and Practice. Springer-Verlag, Berlin. (ISBN 3-540-76145-4.) Sweet B. R. (ed.) (2002) Mayes Midwifery: A Textbook for Midwives, 12th edn. Baillire Tindall, London. (ISBN 0 7020 1757.) Yerby M. (2000) Pain Management in Childbearing Key Issues in Management. Baillire Tindall, London. (ISBN 0702022993.)
105
Writing for the ACPWH Journal: guidelines for authors
+ Please always refer to a recent issue of the Journal, and follow the style and layout of an article or item that is similar to your contribution. Manuscripts may be returned to authors if they have not adhered to the guidelines. If necessary, the editor should be consulted in the initial stages for clarication. + If a paper is submitted for publication, then it is assumed that it has not been submitted simultaneously to another journal. All submissions should be original and previously unpublished. + Academic papers are subject to review and may need to be revised before being accepted. The editor reserves the right to edit, amend or revise any submission. + Oprints are available free of charge if notice is given to the editor when the article is submitted. + All published material becomes the copyright of the ACPWH. Preparation of manuscripts All articles must be typed double-spaced, with wide (3-cm) margins all round, on one side of A4-size paper, using Courier New, font size 12. The pages should be numbered consecutively, and two hard copies of the article and a disk version (text saved in Rich Text Format) should be submitted. Articles should be a maximum of 7500 words (excluding the abstract and references). Papers should be arranged as follows: Abstract A summary of not more than 200 words should be submitted on a separate sheet outlining the purpose, scope and conclusions of the paper. This should be followed by a minimum of three, maximum of ve, keywords which best represent the contents. Title The title of the article should be in lower case, bold and ranged left, as in the title above: note that there is no full stop and no underlining. The authors name(s) (initials and surname only) should be given below the articles title in lower 106
case, bold and ranged left. Again, there is no full stop. Below the authors name(s), place(s) of work should be listed in italics, ranged left, no full stop. Text The layout of the Journal is that the heading of each section is in bold lower case. Notice that, again, there is no full stop and no underlining. The rst paragraph is left-justied; subsequent paragraphs in the same section are indented, as is this part of the guidelines. When including tables, diagrams and gures, these should be numbered in the order in which they appear in the text, and must be submitted, in duplicate, on separate sheets, i.e. not embedded in the text. Please indicate their placing in the text (e.g. Fig. 1). Any caption should be left-justied above the table or below the diagram. All gures and tables must be referred to in the text. When using numbers in the text, these should be written out in words up to and including nine, unless they are measurements, numbers in tables or years. Clinical papers: referencing All clinical papers must be fully referenced and the references veried by the author. No exceptions will be made. The reference list must be double-spaced on separate sheets, and arranged alphabetically by the name of the rst author or editor. In the text, give the author(s) and date of publication in brackets [e.g. (Smith 1998)], or if the main authors name is part of a sentence, then only the year is in brackets [e.g. as described by Smith (1998)]. Note the absence of commas and full stops. For more than two authors, reference can be made in the text to Smith et al. (1998); note the italics and full stop. However, when writing the reference list, the convention is as follows: for up to ve authors, write all the authors names; for six or more authors, write the rst three authors names, followed by et al. For journals, give the authors surname with initials, the year of publication in brackets, the title of the paper, the full name of the journal,
Guidelines for authors
the volume number, the issue number in brackets, and the rst and last page numbers of the article (note the correct use of italic, bold, commas and full stops): Laycock J., Knight S. & Naylor D. (1995) Prospective, randomised, controlled clinical trial to compare chronic electrical stimulation in combination therapy for GSI. Neurourology and Urodynamics 14 (5), 425426. For books, give the authors/editors surname and initials, the year of publication in brackets, the book title in italics, and the publisher and city of publication: Williams P. L. & Warwick R. (eds) (1986) Grays Anatomy, 36th edn. Churchill Livingstone, Edinburgh. For a chapter or section in a book by a named author (who may be one of several contributors), both chapter and book title should be given along with the editors name(s), and the rst and last page numbers of the chapter: Robinson K. L. (1996) Bioelectric elds and physical principles. In: Physics in Medicine and Related Fields (eds P. Smith & P. S. Hascombe), pp. 335349. Dekker Publishing, New York, NY. Please adhere strictly to this style of referencing in any contribution to the Journal. Acknowledgements Please state any funding sources, or companies providing technical or equipment support. Photographs These can be colour or monochrome, but must be in sharp focus. Please write any caption on the back in soft pencil since ball-point and felttipped pens smudge. The photographs should be numbered and their placing indicated in the text. All photos will be returned. If digital photographs are submitted, they should be of high resolution (minimum 300 dots per inch), saved to oppy disk or CD, and accompanied by a hard copy.
Case reports The Journal welcomes case reports of up to 2500 words. These should be structured as follows: title, abstract and keywords, a brief introduction, a concise description of the patient and condition, and an explanation of the assessment, treatment and progress, followed nally by a discussion and evaluation of implications for practice. The study must be referenced throughout. Further guidance is available on request. Book reviews At the beginning of the review, give all details of the book including title in bold, the authors/ editors full name(s), publisher, city and year of publication, price, whether hardback or paperback, number of pages, ISBN number and details of how/where to purchase (if appropriate). The reviewers name should appear at the end of the review in bold, right-justied, followed by their title and place of work in italics. General points to note Please enclose your home, work and e-mail addresses, and telephone and fax numbers. It is the authors responsibility to obtain and acknowledge permission to reproduce any material that has appeared in another journal or textbook. A brief biographical note on the author should be included at the end of a clinical paper in italics and should include an address for correspondence, if required. All notes and news should have clinical relevance to our Association. Please refer at all times to the style and layout of previous ACPWH journals for whatever you are writing. Using these guidelines will save time for the Journal team. The copy deadline for the next issue of the Journal is printed in the current one and can be found below the Editorial at the beginning of the Journal. It must be strictly adhered to by all contributors. Any further enquiries should be addressed to the editor, whose name and address appear on the inside front cover of the Journal.
107
InteractiveCSP
The new iCSP website is now up and running. It is an easy-to-use interactive website about physiotherapy and people, not technology. Register and log in at: www.interactivecsp.org.uk To register go to the website and click on register. You need your CSP membership number and an e-mail address. From the homepage, you can access the networks that are of interest to you (e.g. womens health), and direct access to relevant websites, such as the ACPWH, is also possible. iCSP is mainly about sharing knowledge, networking irrespective of location, and tapping into the know-how of your peers. Go on, register today it is there for your benet!
FOR SALE
(limited availability)
Pilates for Mums with Lindsey Jackson 20 per DVD including postage and packing within the UK Chartex Antenatal and Postnatal Exercise and Advice charts 15 per pair of charts (one antenatal and one postnatal) including postage and packing within the UK All prots go to the ACPWH. Please send a cheque made payable to ACPWH to: Gill Brook, Burras Lynd, Burras Lane, Otley, West Yorkshire LS21 3ET, UK. For further information, or to discuss postage costs outside the UK, please e-mail: gill.brook@lineone.net.
IMPORTANT NOTICE
Communication by e-mail
At the Conference 2005 discussion groups, members resoundingly agreed that a move to communication via e-mail would be in the best interest of the Association. If you have an e-mail address that you regularly use, please send it to membership secretary Alex Welman (alexwelman@konekt.co.uk), along with your postal address. Please remember to let her know if you change it.
Advertising rates
Charges apply for advertising courses, study days or workshops, and are as follows: (1) ACPWH-approved courses, study days or workshops, or any other non-prot making ACPWH educational event: Free of charge (2) Other courses or workshops (15% discount for ACPWH members): Full page 90 Half page 60 Quarter page 30 (3) Manufacturers rates: Full page 500 Half page 300 Quarter page 200
Please contact the advertising manager, Sue Brook, in the rst instance

Journal of The ACP in Womens Health

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Journal of The ACP in Womens Health

Uploaded by

Copyright:

Available Formats

Journal of the Association of Chartered Physiotherapists in Womens Health

 2007 Association of Chartered Physiotherapists in Womens Health

ACPWH CONFERENCE 2006

Postnatal maternal mental health

D. Bick & C. Rowan

Postnatal maternal mental health

D. Bick & C. Rowan

Postnatal maternal mental health

D. Bick & C. Rowan

Postnatal maternal mental health

D. Bick & C. Rowan

Postnatal maternal mental health

 2007 Association of Chartered Physiotherapists in Womens Health

ACPWH CONFERENCE 2006

Motivational interviewing and health behaviour change

Motivational interviewing and health behaviour change

Motivational interviewing and health behaviour change

ACPWH CONFERENCE 2006

Quote me happy: can acupuncture make those hormones happy?

Acupuncture and hormones

Acupuncture and hormones

 2007 Association of Chartered Physiotherapists in Womens Health

ACPWH CONFERENCE 2006

Box 2. Symptoms of the perimenopause

Contraceptive and hormonal needs in the perimenopause

Contraceptive and hormonal needs in the perimenopause

 2007 Association of Chartered Physiotherapists in Womens Health

ACPWH CONFERENCE 2006

Multi-convergent therapy in the treatment of medically unexplained symptoms

 2007 Association of Chartered Physiotherapists in Womens Health

ACPWH CONFERENCE 2006

ACPWH CONFERENCE 2006

Mammographic breast screening

 2007 Association of Chartered Physiotherapists in Womens Health

ACPWH CONFERENCE 2006

 2007 Association of Chartered Physiotherapists in Womens Health

Urinary incontinence treatment

Figure 1. Subjective outcomes of treatment for urinary incontinence (total n=51).

Urinary incontinence treatment

 2007 Association of Chartered Physiotherapists in Womens Health

Urinary incontinence treatment

 2007 Association of Chartered Physiotherapists in Womens Health

ACPWH CONFERENCE 2006

Executive committee response to Conference discussion groups

Executive committee response

Executive committee response

 2007 Association of Chartered Physiotherapists in Womens Health

Conference and course reports

Research Officers Study Day

Conference and course reports

Conference and course reports

Cognitive Behavioural Therapy in the Physical Health Setting

Conference and course reports

Conference and course reports

Figure 7. Caron James with Debra Bick.

Figure 6. Retiring executive member Sue Brook with Ros Thomas.

Conference and course reports

Figure 11. Mair Whittall and Dr Annie Evans.

Conference and course reports

Figure 14. Ex-chairman Jill Mantle.

Figure 15. Linda Furness, health advisor.

Conference and course reports

Master Class in Advanced Urogynaecology

2007 Association of Chartered Physiotherapists in Womens Health

2007 Association of Chartered Physiotherapists in Womens Health

2007 Association of Chartered Physiotherapists in Womens Health

2007 Association of Chartered Physiotherapists in Womens Health

2007 Association of Chartered Physiotherapists in Womens Health

2007 Association of Chartered Physiotherapists in Womens Health

2007 Association of Chartered Physiotherapists in Womens Health

2007 Association of Chartered Physiotherapists in Womens Health

2007 Association of Chartered Physiotherapists in Womens Health

2007 Association of Chartered Physiotherapists in Womens Health

2007 Association of Chartered Physiotherapists in Womens Health

2007 Association of Chartered Physiotherapists in Womens Health

2007 Association of Chartered Physiotherapists in Womens Health

2007 Association of Chartered Physiotherapists in Womens Health

2007 Association of Chartered Physiotherapists in Womens Health

2007 Association of Chartered Physiotherapists in Womens Health

2007 Association of Chartered Physiotherapists in Womens Health

2007 Association of Chartered Physiotherapists in Womens Health

2007 Association of Chartered Physiotherapists in Womens Health

2007 Association of Chartered Physiotherapists in Womens Health