Journal of the ACP in Womens Health

Journal of theAssociation ofCharteredPhysiotherapists inWomen’sHealthEditor: Ros Thomas ([email protected])

Production editor: Andrew J. Wilson ([email protected])News editor: Helen Forth ([email protected])Websites editor: Jenny Kinahan ([email protected])Papers in other journals editor: Becky Aston ([email protected])Committee member: Gill Brook ([email protected])Committee member: Kathleen Vits ([email protected])

ContentsEditorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Postnatal maternal mental health: an update on depression and post-traumatic stress disorder following birth by D. Bick & C. Rowan 4Motivational interviewing and health behaviour change: an overview and their relevance to women’s health by C. A. Lane . . . 14‘Quote me happy’: can acupuncture make those hormones happy? by J. Longbottom . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21The perils of the perimenopause: contraceptive and hormonal needs in the perimenopause by A. E. Evans . . . . . . . . . . . . . . . . . 27Multi-convergent therapy in the treatment of medically unexplained symptoms: a brief journey in time by M. Sadlier . . . . . . . . 33Bladders behaving badly: a randomized controlled trial of group versus individual interventions in the management of femaleurinary incontinence by L. A. Hill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Mammographic breast screening (Dr Kate Gower Thomas) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Presentation reflections:

Margie Polden Memorial Lecture: A midwife’s perspective (Rachel Kerr) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39GUM clinic: what to look for (Gill Brook) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Hormonal treatment of severe premenstrual syndrome (Clair Jones) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Management 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Executive committee response to Conference discussion groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49Conference and course reports:

Research Officers’ Study Day (Yvonne Coldron) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52The WellBeing of Women (WoW) Show – The Women’s Health Show That’s Serious Fun (Paula Igualada-Martinez) . . . . . . 53Pushy Mothers (Helen Forth) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54Cognitive Behavioural Therapy in the Physical Health Setting (Geraldine Buckley) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54ACPWH Conference (Carole Broad, Michelle Gormley & Hannah Gray) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54Master Class in Advanced Urogynaecology (Riette Vosloo) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60An Introduction to Pilates in Women’s Health Physiotherapy (Ann Dennis) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61The Unique Role of the Women’s Health Physiotherapist in Antenatal Classes (Jane S. Brazendale) . . . . . . . . . . . . . . . . . . . 61A Functional Approach to Assessment and Treatment of the Pelvic Girdle in Pregnancy and Postpartum (Paula Riseborough) . 62Physiotherapy for Pregnancy Related Pelvic Girdle Pain (Alison Crocker) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

From your executive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64Round the regions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72Area representatives 2006–2007 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75PhD thesis reports:

Multiple sclerosis and lower urinary tract dysfunction (Doreen McLurg) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77Characteristics of abdominal and paraspinal muscles in postpartum women (Yvonne Coldron) . . . . . . . . . . . . . . . . . . . . . . . . 78

Visit to the UK (Elisabeth Pulker) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81Book and DVD reviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83Website watch (Jenny Kinahan) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91Notes and news . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95Letter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97Papers in other journals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98Reading list . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105Writing for ACPWH Journal: guidelines for authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106Price list of publications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . back coverThe 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 Women’s Health 1

Journal of the Association of Chartered Physiotherapists in Women’s Health, Spring 2007, 100, 2–3

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 past3 years in developing our Journal into the veryprofessional and expansive tome that it hasbecome. She has, of course, been well supportedby the expert advice and experience of AndrewWilson, our production editor, and the Journalsubcommittee. I wish her every success in her‘retirement’, but I’m delighted that she’s notdisappearing completely and remaining on theJournal subcommittee to help me into my newrole. I’m very grateful for this because I’mnegotiating a very steep learning curve, but Ihope I can rise to the challenges that are boundto confront me.

The first one was thrust upon me immediatelysince this is our hundredth edition. The Journalsubcommittee decided to mark the anniversaryby reproducing some of the earliest newsletters.Both Andrew Wilson and I had fun lookingat the early newsletters now stored for us inEdinburgh by Fitwise Management Ltd. Sadly,reproduction was not possible, so I have insteadextracted some very early references to the‘birth’ of the idea of an Association newsletterfrom the minutes taken from executive com-mittee meetings from 1949 onwards. These formour cover montage.

To further commemorate the hundredth edi-tion, we present a list (Table 1) of all past editorsof the Journal of the Association of CharteredPhysiotherapists in Women’s Helath (formerlythe Newsletter of the Obstetric Association ofChartered Physiotherapists and then the Associ-ation of Chartered Physiotherapists in Obstetricsand Gynaecology, and the Journal of the Associ-ation of Chartered Physiotherapists in Obstetricsand Gynaecology).

When sitting down to write this, my first edi-torial since taking over in October, I decided tolook back to Gill’s first editorial (Spring 2004),only to find that she had asked Jill Mantle tocontribute instead. Jill used the opportunity as atimely reminder to us of the importance of re-search in women’s health, and of our importantand continuing role in obstetrics – points that arejust as relevant today. The main reason that JillMantle was asked to contribute was that Gill hadjust retried as chairman, and therefore, consid-ered that the issue already featured her quiteheavily. I seem to be following in Gill’s footsteps,but I didn’t have the foresight to ask someoneelse to contribute, so I’m afraid you will have toput up with me both in the editorial and in someof the inside pages as well – but at least I shallhave the authority in future to monitor whichphotographs are used and which are not!

Table 1. Former Journal editors

Editor Numbers Dates

Anonymous* 1–7 1948–1958Mrs Margaret Williams 8–14 March 1958–January 1962Miss J. Common 15–19 January 1962–December 1964Mrs D. Mandelstam 20–26 December 1964–March 1969Mrs P. Boughton 27–28 March 1969–October 1970Mrs Margaret Williams 29–39 October 1970–July 1976Mrs J. W. Cox 40–48 July 1976–Winter 1981Mrs Anne Bird 49–59 Winter 1981–July 1986Mrs Ruth Davidge 60–61 July 1986–July 1987Mrs Christine Campbell & Anne Kite 62–67 July 1987–Summer 1990Mrs Christine Campbell & Mrs Georgina Evans 68–69 Summer 1990–Summer 1991Georgina Evans & Deborah Fry 70–74 Summer 1991–February 1994Deborah Fry 75–78 February 1994–February 1996Pauline Walsh 79–85 February 1996–February 2000Daphne Sidney 86–87 February 2000–Spring 2001Mary Bray 88–93 Spring 2001–Autumn 2003Gill Brook 94–99 Autumn 2003–Autumn 2006

*Probably a team effort.

2 � 2007 Association of Chartered Physiotherapists in Women’s Health

At Conference in Cardiff, which was the lastopportunity for me to wear the ‘chains of office’before handing them over, Jill told me she neverhad a photo of herself wearing them when shewas chairman, so one of my first actions asJournal editor is to rectify that (see p. 58).

The Journal subcommittee met at the end ofNovember 2006. The more observant amongstyou will notice a number of minor changes in theJournal, some of them reflecting the increasinginvolvement which Fitwise Management Ltdhas with ACPWH. Our new chairman, PaulineWalsh, will be bringing you up to date more fullyin the Autumn 2007 issue, when the handover toFitwise is complete. In the meantime, I would lketo draw your attention to the contact details (seethe inside front and back covers) for the teamin the key areas of finance (expenses and sub-scriptions), the membership database, and thedistribution of small quantities of the books andleaflets.

One of the next challenges facing us will beproducing a commemorative edition for the six-tieth anniversay of our Association in Autumn2008. We already have a number of interestingideas. In the meantime, I’m planning two new,regular pages in the Journal dedicated to ‘Edu-cation and research’, and an ‘Honours’ sectionhighlighting member’s achievements such asfellowships, distinguished sevice awards andrecipients of the Anne Bird Prize.

Gill never missed an opportunity to ask you toconsider writing for the Journal, or to encouragesomeone you know or work with to stop ‘hidingtheir light under a bushel’ and share their hardwork with us all, so neither should I. Or you canjust tell me about a course, write me a letter orcontribute in any other suitable way

Please e-mail me with any comments on thecurrent edition or ideas for the future.

Ros Thomas

Cover photograph: Montage of very early references to the idea of an Association newsletter from theminutes taken from executive committee meetings from 1949 onwards.

Copy deadlineCopy (including disks) for the Autumn issue of the Journal (no. 101) must be submitted to the editor by12 April 2007. Please note that academic and clinical articles must be received well before the deadlinesince time must be allowed so that they can be informally reviewed. Manuscripts should be printed on oneside of A4 paper, double-spaced with a wide margin, and adhere to the author’s guidelines found onp. 105. Articles for consideration should be sent to Mrs Ros Thomas, Byway, Chapel Lane, Box, Corsham,Wiltshire SN13 8NU.

Editorial



ACPWH CONFERENCE 2006

Postnatal maternal mental health: an update ondepression and post-traumatic stress disorderfollowing birth

D. Bick & C. RowanCentre for Research in Midwifery and Childbirth, Faculty of Health and Human Sciences, Thames ValleyUniversity, London, UK

AbstractMaternal morbidity after birth can be widespread and persistent. A number ofphysical and mental health problems may be experienced, including backache,stress urinary and faecal incontinence, perineal pain, and depression. Up to halfof all women who have given birth will experience the ‘postnatal blues’, thesymptoms of which should be self-limited and transitory. A more severe healthproblem, depression, is experienced by around 13% of women, and 1–2% mayexperience a traumatic response to their birth. There are concerns that the currentorganization and content of postnatal care fails to identify much of this morbidity.Service evaluations and women’s views of care suggest that mental health servicesfor postnatal women are fragmented and uncoordinated, particularly across thecare sectors. Current evidence does not support the implementation of a nationalscreening programme for depression or the use of single-session debriefinginterventions to prevent psychological trauma. To enhance the care of womenwith mental health needs, relevant healthcare professionals should be aware of thesigns and symptoms of problems after birth, and all women should be offered achance to talk about their birth and to ask questions about their delivery.Management should be planned and tailored to individual need.

Keywords: debriefing, depression, maternal health, postnatal care, post-traumatic stressdisorder.

IntroductionRecent research has shown widespread andpersistent maternal physical and psychologicalmorbidity after childbirth (Brown & Lumley2000; MacArthur et al. 2002). In addition to anumber of chronic physical health problems,such as backache or perineal pain, postnatalwomen are also more vulnerable to mentalhealth problems. A variety of physical, psycho-logical and psychiatric problems may be experi-enced, ranging in severity from transientpsychological symptoms (more often termed the‘postnatal blues’) to depression, anxiety, psycho-sis and post-traumatic stress disorder (PTSD).

Although giving birth is viewed as a positive,life-changing event for a woman, for those whoexperience mental illness after birth, it is an eventthat can trigger a period of isolation and despairthat may impact negatively on their infant’semotional and cognitive development, and theirrelationships with their partner and family(Lovestone & Kumar 1993; Murray & Cooper1997; Boath et al. 1998). Maternal mental healthhas been described as a public health priority(Bick 2003), with suicide now accounting for thehighest number of maternal deaths in the firstyear after birth (Lewis & CEMACH 2004). Thepresent paper describes current research in rela-tion to postnatal mental health illness, with aparticular emphasis on depression and PTSD,issues in relation to the prevention of mentalhealth illness after birth and the need to considerrevision of maternity service provision.

Correspondence: Professor Debra Bick, Centre for Researchin Midwifery and Childbirth, Faculty of Health and HumanSciences, Thames Valley University, 32–38 Uxbridge Road,Ealing, London W5 2BS, UK (e-mail: [email protected]).


Health after birthIt was previously assumed that most womenfully recovered from giving birth within the6–8-week postnatal period (Bick & MacArthur1995). Evidence from large observational studiesundertaken in a number of countries has foundthat this is not the case (MacArthur et al. 1991;Brown & Lumley 1998; Saurel-Cubizolles et al.2000). For some women, health problems can besevere, persisting for months or even years afterthey have given birth (MacArthur et al. 1991;Glazener et al. 1995). Commonly experiencedphysical symptoms include backache, faecal andurinary incontinence, perineal pain, sexualhealth problems, and fatigue (MacArthur et al.1991; Glazener et al. 1995). Symptoms may beassociated with interventions or events duringlabour and birth, such as the use of forceps oremergency Caesarean section (Glazener et al.1995), or personal factors, such as the level ofpostnatal social support available to a woman(MacArthur et al. 1991). What is clear from theresearch to date is that few women voluntarilyreport problems to their healthcare provider, butwill give information on their health if theyare asked (Bick & MacArthur 1995; Brown &Lumley 1998). However, many will have unmethealth needs because the current provision ofcare focuses on routine observations and exami-nations, and increasingly early discharge frompostnatal services does not allow sufficient timeto identify and appropriately manage maternalhealth problems (Bick et al. 2002).

Postnatal mental healthWomen may encounter a number of psychologi-cal and mental health problems following child-birth. The symptoms may be experienced forthe first time after giving birth, or represent arecurrence of a previous mental health problemor an ongoing disorder. Observational studieshave reported that around half of all womenwho have undergone childbirth will experiencethe postnatal blues, symptoms of which shouldbe transitory and self-limiting (Kendall et al.1981; Stein et al. 1991). Maternal depression,which is a more severe illness, has a reportedprevalence of between 4.5% and 28% (SIGN2002). At the most severe end of the range ofmental health problems is psychosis, whichaffects one or two women in every thousand(SIGN 2002), and may be triggered by therecurrence of previous mental health disorderssuch as bipolar disorder or schizophrenia

(Chaudron & Pies 2003). Post-traumatic stressdisorder is an acute anxiety symptom associatedwith exposure to an extreme event, such as beinginvolved in combat, a major disaster or roadtraffic accident. Prior to the inclusion of child-birth as a possible stressor in the fourth editionof the American Psychiatric Association Diag-nostic and Statistical Manual of Mental Disorders(DSM-IV; APA 1994), PTSD was considered tobe a reaction to an event ‘outside’ the range ofnormal experience (Slade 2006).

DepressionDepression is one of the few postnatal maternalhealth problems to have been extensively studied(Gaynes et al. 2005). The wide prevalence ofdepression referred to above (SIGN 2002) is aresult of the range of inclusion criteria used todescribe the study population, the timing ofassessments in relation to the birth, the length offollow-up and the diagnostic criteria used. Somestudies have reported point prevalence, whileothers have described period prevalence. O’Hara& Swain (1996) conducted a meta-analysis thatshowed an average prevalence of depressionafter birth of 13%, based on data on over 12 000women from 59 studies, mostly undertaken indeveloped countries.

There has been some debate as to whetherdepression is more likely to occur followingbirth, or whether rates are similar to those foundin the general population. Depression is reportedtwice as frequently in women as in men (Ebmeieret al. 2006), although this gender difference maynot persist in later life (NCCMH 2004). A studyby Cox et al. (1993) found that the odds ofdepression in the first 5 weeks after the birthwere three times that of a comparison group ofwomen who had not recently given birth.Gaynes et al. (2005) reported that symptoms ofdepression after the birth appear to be greatestat 3 months postpartum, although the dataincluded in this Agency for Healthcare Researchand Quality review had wide confidence intervalsand did not allow conclusions to be reachedas to whether depression was higher in anymonth following the birth, or indeed, during anytrimester of pregnancy.

Women may experience a spectrum of symp-toms, and timely referral and appropriate diag-nosis are essential to ensure that they receiveeffective management tailored to their individualneeds. Two classification systems to guide thediagnosis of mental health problems are avail-able to clinicians and academics working within

Postnatal maternal mental health


the field of perinatal mental health: the DSM-IV(APA 1994) and the tenth edition of the WorldHealth Organization International Classificationof Diseases (ICD-10; WHO 1992). The DSM-IVcriteria for major depression are that the indi-vidual will have experienced one or more epi-sodes of depression lasting for at least 2 weeks,and will report four or more of the followingsymptoms (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 indecisive-

ness;+ loss of interest in sex; and+ recurrent suicidal thoughts.

Minor depression includes one or more epi-sodes of depression lasting for at least 2 weekswith fewer than four of the above symptoms.The ICD-10 (WHO 1992) distinguishes betweennone, minor, moderate and severe depression,and whilst there is some overlap between thesymptoms included within the criteria, there is alack of consensus as to which is the most appro-priate diagnostic criteria to use. Many studieshave used DSM-IV criteria, but anecdotal evi-dence from the UK suggests that clinicians aremore likely to use the ICD-10 in practice. Therecently published guideline on the managementof anxiety from the National Institute for Healthand Clinical Excellence (NICE) used the ICD-10classification (NICE 2004), while the NICEguideline on the management of depression usedDSM-IV criteria (NCCMH 2004). The SIGNguideline on depression and puerperal psychosis(SIGN 2002) did not refer to either classificationin a section on diagnosis.

Around two women in every thousand willbe admitted to hospital with a diagnosis of anon-psychotic condition, usually very severepostnatal depression (Oates 2003). Healthcareprofessionals should also be aware of the factthat a woman may also experience depression inpregnancy (Evans et al. 2001). The systematicreview of studies by Gaynes et al. (2005) foundthat approximately 14% of pregnant women willhave a new episode of major or minor depressionduring pregnancy, a statistic identified using avariety of screening instruments. Consideringonly major depression, 7.5% of women have anew episode during pregnancy (Gaynes et al.2005). These estimates are not significantly

different from the prevalence of depressionreported among women of a similar age in thegeneral population (Cooper et al. 1988; O’Hara& Swain 1996).

Risk factors for the development of depres-sion after birth have been examined in a largenumber of studies that have investigatedpotential associations with maternal, obstetricand sociodemographic characteristics, obstetricinterventions, parity, marital status, hormonaldisorders, previous psychiatric history, and per-sonal relationships (Bick et al. 2002). Because ofthe range of outcome measures assessed, thetimings of the investigations and the instrumentsused to assess the outcomes, these findings arenot conclusive. Nevertheless, some potential riskfactors have been commonly identified. It isapparent that some social factors increase awoman’s risk of becoming depressed. Theseinclude life stresses such as bereavement, unem-ployment, illness, migration and lack of socialsupport networks (O’Hara & Swain 1996; Austin& Lumley 2003). Women who have a history ofabuse, and those with drug and alcohol prob-lems also have higher rates of mental healthproblems after giving birth (Brockington 1996;Buist 1996; O’Hara & Swain 1996). Between20% and 40% of women with a previous historyof postnatal depression are likely to suffer arelapse after a subsequent birth (Cooper &Murray 1995).

Post-traumatic stress disorderResearch on postnatal psychological and psychi-atric morbidity has mainly focused on the effectsof depression, but there has been increasingrecognition that, for a small proportion ofwomen, symptoms of trauma may present aftergiving birth. Post-traumatic stress disorder isestimated to occur in 1–6% of women (Creedyet al. 2000; Czarnocka & Slade 2000; Soet et al.2003; Ayers 2004; White et al. 2006). Traumaticbirth is more often associated with specific physi-cal intervention, such as sustaining an epi-siotomy or severe perineal tear related to aninstrumental vaginal delivery, but childbirth canbe psychologically traumatic for some women.Beck (2004) described a traumatic event in rela-tion to birth as one that occurred during thelabour or birth in which there was actual orthreatened serious injury or death to the motheror her infant, or in which the woman giving birthexperienced intense fear, helplessness, loss ofcontrol and horror. It is important to note that,whilst women may report psychological trauma

D. Bick & C. Rowan


or have symptoms of a stress response afterbirth, not all will go on to experience symptomsthat meet the DSM-IV criteria for acute PTSD.

According to the DSM-IV, PTSD is classifiedas an anxiety disorder that encompasses threeclusters of symptoms: reliving the event (e.g.suffering flashbacks), persistent avoidance ofreminders and hyperarousal. Several characteris-tics have been considered as predictors of PTSD.Robust studies have consistently demonstratedthat a high level of obstetric intervention duringlabour and delivery is associated with a risk ofdeveloping psychological trauma symptoms inthe postnatal period, particularly if an interven-tion (administered either routinely or underemergency situations) happens in the context ofintense pain (Ryding et al. 1998; Creedy et al.2000; Soet et al. 2003). Women who have anemergency Caesarean section or instrumentalvaginal delivery are more likely to report symp-toms of PTSD than those who have a plannedCaesarean section or a normal vaginal delivery(Ryding et al. 1998). However, since an appar-ently normal birth could be traumatic for somewomen, it is difficult to define what constitutestraumatic birth based on mode of delivery orthe extent of obstetric intervention to which awoman is exposed. Some women may be morevulnerable because of previous trauma or per-sonality factors, and there may be mitigatingfactors such as lack of social support.

Can mental health problems after birth beprevented?

ScreeningThere is limited research evidence that primaryprevention of symptoms is clinically or costeffective. Based on the findings of the studiesreported above, it is increasingly important thatwomen and healthcare professionals are awareof the signs and symptoms of mental healthproblems after birth, which may be amenableto treatment (Dennis 2005). One of the mostcommonly used tools to identify women at riskof depression is the Edinburgh PostnatalDepression Scale (EPDS; Cox et al. 1987), a10-item self-report scale on which women whohave recently given birth are asked to rate howthey have felt in the previous 7 days. It has beenused internationally as an outcome measure inresearch studies as well as an intervention inroutine clinical practice. A number of translatedversions are available that have been tested forvalidity and reliability (Affonso et al. 2000). A

maximum score of 30 can be achieved, with ascore of 12–13 considered to identify thosewomen more likely to have depression (Coxet al. 1987). Using this cut-off, the EPDS hasbeen found to have a sensitivity of 68–95% and aspecificity ranging from 78% to 96% at 6 weekspostpartum when compared to a diagnosis ofmajor depression following a psychiatric inter-view (Cox et al. 1987; Murray & Carothers1990).

The EPDS has usually been offered to womenby their health visitors to complete at approxi-mately 6–8 weeks after the birth. There areconcerns that a single administration of theEPDS after birth will not accurately identifythose who are depressed to the extent of requir-ing treatment (Oates 2003). Guidance on opti-mal number of times that the scale should beadministered is not available. Qualitative datasuggests that women who complete the scale onmore than one occasion ‘learn’ how to respondaccordingly (Shakespeare et al. 2003; Thurtle2003), although this was not found to be thecase in a large randomized controlled trial(RCT) of a new model of midwifery-led post-natal care (MacArthur et al. 2003). In addition,other factors that may affect the screening out-come should also be considered, including therelationship between the woman and the health-care professional, the environment in which thewoman was asked to complete the tool, and theway in which the healthcare professional admin-isters the tool (Raynor et al. 2003; Shakespeareet al. 2003). Cultural differences may makeit inappropriate for use with women fromethnic minority groups, since ‘depression’ maybe construed as a Western concept of illness(SIGN 2002), and there is a dearth of evidenceas to its acceptability amongst different ethnicgroups.

Concern has also been expressed that the scalemay actually be measuring two separate entities,i.e. depressive feelings and anxiety (Brouwerset al. 2001), and it has recently been suggestedthat a revised, eight-item version of the EPDSwould provide a more psychometrically robustscale (Pallant et al. 2006). The NICE postnatalcare guideline (NICE 2006) has adopted theNational Screening Committee (NSC) recom-mendation, based on a review by Shakespeare(2001), that suggested that the EPDS shouldnot be used as a routine screening tool, but itmay serve as a checklist for postnatal motherswhen used alongside professional judgment andclinical interview.



Antenatal and postnatal interventionsA number of antenatal or postnatal interven-tions for women deemed to be at risk of depres-sion have been evaluated. In paper based on afull Cochrane Library systematic review, Dennis(2005) assessed the effects of psychosocial andpsychological interventions compared with usualantepartum and postpartum care on a woman’srisk of developing postnatal depression. Fifteenstudies were included in the review, providingdata on 7967 women. The outcome of the reviewwas that diverse psychosocial or psychologicalinterventions did not significantly reduce the riskof postnatal depression. The one interventionthat did show promise was the new model ofmidwifery-led extended postnatal care (referredto above), which focused on the identificationand management of postnatal physical andpsychological health problems. This was associ-ated with a reduction in depression at 4 and 12months (MacArthur et al. 2003); however, fur-ther evaluation of this intervention as part ofroutine National Health Service (NHS) care isrequired. A Cochrane Library systematic reviewwas unable to draw clear conclusions about theeffectiveness of antidepressants given prophylac-tically to prevent postnatal depression in thosewith a previous history of depression or post-natal depression (Howard et al. 2005).

DebriefingA number of studies have evaluated the effec-tiveness of debriefing to prevent mental healthproblems after birth, including depression andPTSD. The term debriefing describes a struc-tured process that is intended for the primaryprevention of acute psychological morbidity asa result of experiencing a traumatic event(Dyregov 1989). Psychological debriefingevolved in the late 1980s as a way of assisting thefirst responders to traumatic incidents, notablyfiremen, to talk in a structured way about whathad happened. It was proposed that a one-offsession of debriefing would help to reducepsychological trauma and prevent PTSD(Mitchell 1983). In the 1990s, debriefing, alsoknown as critical incident stress debriefing, wasadopted as a therapeutic response for peoplewho experienced a wide variety of traumaticevents. Despite the upsurge of interest in imple-menting debriefing after trauma, a CochraneLibrary systematic review (Rose et al. 2002)found no evidence of the effectiveness of single-session debriefing for the prevention of PTSD inthe general population and some potential for

harm. Recent recommendations for the manage-ment of PTSD in primary and secondary careare that ‘watchful waiting’ should be instigatedafter traumatic events, since most people willrecover from trauma experiences with goodsocial support (NCCMH 2005).

To date, eight RCTs have compared postnatalpsychological outcomes following debriefing orcounselling interventions after birth. Two trialsfound a positive association: in one, a midwife-led counselling intervention was compared withcurrent care (Gamble et al. 2005), while the otherdescribed a midwife-led debriefing intervention(Lavender & Walkinshaw 1998). A third RCTreported evidence that the intervention (midwife-led debriefing on the postnatal ward followingoperative birth) resulted in harm in the shorterterm (Small et al. 2000), with no long-termdifferences at 4–6-year follow-up (Small et al.2006). In the other five RCTs (Priest et al. 2003;Tam et al. 2003; Ryding et al. 2004; Kershawet al. 2005; Selkirk et al. 2006), there were nodifferences in outcomes. Methodological issues,in addition to the timing of the interventionassessed and study inclusion criteria, may haveaccounted for differences in the effectiveness ofthe outcomes.

In UK maternity services, the term ‘postnataldebriefing’ has been used to describe a variety ofpost-birth discussions, which are mainly offeredby midwives with the intention of providingwomen with an opportunity to talk about theirbirth experiences. This sometimes less structuredapproach to debriefing in the childbirth arenahas led to some confusion about the purposeand the effectiveness of such interventions(Alexander 1998). A number of evaluations havebeen published of this service provision that doshow that women who use the service value theopportunity to talk about their birth and theevents surrounding to it (Charles & Curtis 1994;Baxter et al. 2003; Dennett 2003). However, noneof the studies published to date has includeddata on clinical outcomes, and further work isrequired on the training needs of midwives toenable them to deliver these interventions, thetiming of offering an intervention, the aims of thisservice provision and whether it meets the needsof women from a range of ethnic backgrounds.

Maternity service care for women whohave mental health needsThere is clearly a need to ensure that the identi-fication of mental health needs becomes part of

D. Bick & C. Rowan


the routine provision of postnatal care offered toall women, which includes appropriate referraland management for women with mental healthneeds, including signs and symptoms of traumaand depression. A recently published survey byMIND (2006) found that most of the 148 womenquestioned attributed the problems that theyexperienced to a lack of understanding by healthprofessionals, and inadequate advice and infor-mation. Women also felt that more supportshould be offered to women’s partners and theirfamilies. Two-thirds of the women surveyed hadto wait over a month or more for treatment, withone in 10 having to wait over a year. Overtwo-thirds of women were admitted to a generalpsychiatric ward rather than a specializedmother and baby unit, and most of these womenwere admitted without their babies. Women alsoreported a lack of communication and coordina-tion between services, an issue highlighted in themost recent Confidential Enquiry into Maternaland Child Health (CEMACH) report (Lewis &CEMACH 2004).

If healthcare professionals are to addresswomen’s mental health needs, they will requireguidance and support, since a number of issueswould have to be addressed. These include beingable to discuss mental health symptoms withwomen, increasing awareness of the signs andsymptoms of mental health problems, and pro-vision of effective care, including timely referralto the most appropriate healthcare professionals.There is a dearth of evidence about the extent towhich guidance is in use in current practice.Tully et al. (2002) undertook a survey to identifythe use of policies and guidelines in relation tothe identification and management of antenataland postnatal depression; 182 units, 86% of thethen total units in England and Wales, providedinformation. Over one-third of units had policiesor guidelines on maternal mental health needs,although only one-fifth indicated that thesecovered postnatal depression and psychosis.Although most respondents indicated thatwomen were routinely asked about their mentalhealth history during their booking visit, fewunits had audited the services offered to womenwith mental health problems. A survey of 78mental health trusts in England (Oluwato &Friedman 2005) found that, although protocolson mental health needs were available in 58%of the trusts, 16 (48%) considered these to beoutdated or inadequate.

A suite of guidelines intended to inform themanagement of mental health needs within the

NHS in England and Wales have been publishedor are in development (www.nice.org.uk). Thereis also a NICE guideline programme for thematernity services, which include recommenda-tions for the care of pregnant and postnatalwomen with mental health needs. The NICEguideline on antenatal care (NCCWCH 2003)recommends that women are asked early inpregnancy if they have had any previous psychi-atric illnesses, and that women who have ahistory of psychiatric disorder should be referredfor a psychiatric assessment. Guidelines for post-natal care (NICE 2006) recommend that allwomen should have an opportunity to discussand ask questions about the birth, and in linewith the Cochrane Library review by Rose et al.(2002), single-session debriefing should not beoffered. A guideline on antenatal and postnataldepression is scheduled for publication in 2007(www.nice.org.uk). The impact of these guide-line programmes, which aim to reduce variationin practice and ensure that the most clinicallyand cost effective care is provided, is as yetunclear, with local services expected to audit theoutcome of service provision.

DiscussionWomen can experience a range of psychologicaland psychiatric health problems after givingbirth that may have a long-term impact on theirhealth and well-being, as well as implications forthe health of their infants and families. Forsome, these will be experienced in addition tophysical morbidity after birth. The present paperhas described some of the mental health symp-toms which may be experienced, focusing ondepression and psychological trauma, as well asissues surrounding prevention and the need toaddress the content and delivery of maternityservices.

Because much maternal physical, psycho-logical and psychiatric morbidity remainsunidentified by healthcare professionals andunreported by women, it is important to increaseawareness of the signs and symptoms of mentalhealth problems after birth, including depressionand PTSD. This should be targeted at users andproviders of the maternity services, given theconcerns raised by the women in the surveyconducted by MIND (2006), i.e. that healthcareprofessionals did not appear to understand men-tal health needs, and as a consequence, wereunable to offer adequate advice and support.Since there is evidence to support the contention



that a personal or family history of depressionor postnatal depression increases the risk ofthese mental health problems (re)occurring aftergiving birth, it is imperative that a woman’smental health history is documented in orderthat appropriate postnatal care can be insti-gated. All women should now be asked abouttheir personal and family mental health historyat their antenatal booking visit (NCCWCH2003), and any current symptoms should beexplored, although there is little informationabout the extent to which this takes place, or if itis making a difference to women’s experiences ofmental health problems. The evidence to dateindicates that, although women with mentalhealth problems may be identified during preg-nancy, appropriate management plans may nothave been put in place (Lewis & CEMACH2004) and communication between the membersof the multidisciplinary team may not have beenoptimum. Therefore, referral pathways need tobe clear.

Universal screening of women who may be atrisk of depression using a tool such as the EPDSis not currently recommended by the NSC,although it is still commonly used in postnatalcare. Some of the issues in relation to the short-comings of the EPDS have been described,including the environment in which it is admin-istered, but much of the data to date has comefrom research studies rather than outcomes ofroutine clinical practice. From the qualitativedata that are available, women may not findcompleting the EPDS acceptable (Shakespeareet al. 2003), suggesting that time to talk aboutfeelings and emotional well-being may be apreferred alternative. If this is to be an option,then there are clearly training needs to beaddressed, including communications skills,for all relevant healthcare professionals(Shakespeare et al. 2003).

The evidence to date does not support the useof interventions during or after birth to preventmental health problems, with the exception thatplanned and tailored midwifery-led care mayreduce the risk of depression (MacArthur et al.2002, 2003; Dennis 2005). Formal debriefingshould not be instigated, and clarity relating tothe content and benefit of debriefing interven-tions currently offered by the maternity servicesis required so as to ensure that outcomes arebeneficial and services directed at the womenmost in need of their support. Healthcare pro-fessionals may continue to focus on physicalsymptoms rather than addressing any mental

health needs a woman may be exhibiting,although there is clearly a complex relationshipbetween physical and psychological symptoms(Brown & Lumley 2000), and women havereported a lack of focus on their emotional needsafter birth (Singh & Newburn 2002). The evi-dence does suggest that women value the oppor-tunity to talk about their birth, which shouldnow be offered as part of routine care withinEngland and Wales (NICE 2006).

There is general agreement that the postnatalservices, particularly those provided by mid-wives, need to be revised to enable women toreceive tailored, individual care based on theirneeds (MacArthur et al. 2002). There are con-cerns that, because of limited resource capacity,postnatal services in the community are beingcut back, with the potential that health needswill remain unmet. Clearly, not all women willrequire intensive postnatal visiting, and it isan important requirement that those who dorequire care are identified and supported effec-tively. Managers, policy-makers and healthcareprofessionals should ensure that postnatal ser-vices receive equal priority with antenatal andintrapartum care.

Concerns about the care of women in the UKhave come to the fore following the report of the2004 CEMACH, where suicide was identified asthe leading direct cause of maternal death. Thisis a devastating outcome for all concerned, andis an extreme consequence of an illness thataffects thousands of women each year. The needsof women with mental health problems are notconsistently identified or addressed, and muchfurther work is required to ensure that com-prehensive service provision is implemented,given its potential to affect the longer-termhealth of the woman, her infant and herfamily.

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Debra Bick BA(Hons) MMedSci PhD RM is aprofessor of Midwifery and Women’s Health atthe Centre for Research in Midwifery and Child-birth, Faculty of Health and Human Sciences,Thames Valley University, London, UK. She hasworked on a number of large studies examiningthe impact of interventions during and after birthon women’s physical and mental health. Debrawas the clinical advisor to the recently publishedNICE guideline on postnatal care for healthywomen and babies, and has written extensively on

issues relating to the organization and content ofservices for women after birth. She is the editor-in-chief of Midwifery: An International Journal.Her current projects include a national clinicalquality improvement programme to enhance theassessment and management of perineal care,revising the content and planning of postnatal carein hospital and on transfer home, and identifyingtraining needs in order to improve care for womenwith mental health needs.





Motivational interviewing and health behaviour change:an overview and their relevance to women’s health

C. A. LaneSchool of Nursing and Midwifery Studies, Cardiff University, Cardiff, UK

AbstractEncouraging patients to make changes to their health behaviour is challengingfor practitioners in most clinical disciplines. In relation to women’s health issues,the challenges facing physiotherapists include encouraging women to adopttreatment/exercise regimes to improve recovery and well-being, as well as main-taining these practices over time. One method that has shown promise infacilitating health behaviour change in a number of clinical settings is motivationalinterviewing, ‘a directive, client-centred counselling style for eliciting behaviourchange by helping clients to explore and resolve ambivalence’. This paper aims toprovide an overview of the method, to present the evidence to date for its efficacyand to discuss its relevance to women’s health.

Keywords: debriefing, depression, maternal health, postnatal care, post-traumatic stressdisorder.

Introduction

‘Bizarrely, after a couch potato lifestyle, Ihave discovered exercise with a vengeance . . .but while the spirit is willing, the body isn’talways and the old muscles down below aren’twhat they were. If I sneeze unexpectedly,laugh or try a particularly energetic movewhilst playing tennis, then I’m likely to suffera ‘‘stress incontinence moment’’. Not great.Do I do the exercises regularly? Do I heck!’

‘I’ve made a good recovery following myankle surgery, but keeping up with the balanc-ing exercises is hard. There’s always somethingmore pressing to do – be that writing papers,preparing for conferences, or simply trying tokeep my home (that my husband continuallymesses up) tidy. I know how important it isto do my ankle exercises – after all I waited5 years for the surgery to put it right – butbuilding them into my everyday life is hard.Ironically, it’s even harder now that I amfeeling a lot better.’

‘As I rumble towards my menopause, I’mhaving to be much more careful about myweight and it’s a huge effort because I reallylike my food! My knees aren’t as good as theywere and I’m waiting for an operation toscrape out the torn cartilage. I’ve had to havephysio and I can’t afford to gain extra weight.If I want to be in good nick, I’ve got to lookafter myself. Hmm, easier said than done.’

Do these stories ring a bell with you? No doubtyou can think of times when you have told apatient what they need to do, yet when thefollow-up comes around, they do not seem tohave taken your advice. How many times has awomen complained that she could not do herexercises because her husband was notsupportive/the kids needed her/there was so muchto do at home/she had people to stay/her job wasso demanding/she was so tired with everythingelse that she had to do over the past fortnight?

In her training sessions, the present authorsometimes asks health professionals, ‘Howwould you feel if you had to see three patientslike this in a row?’ Responses tend to rangefrom ‘exhausted’ and ‘frustrated’ through to‘demoralized’ and ‘disillusioned’. It is perfectlynormal to feel this way. After all, the reason youand your colleagues give advice like this is

Correspondence: Dr Claire Lane, Nursing, Health and SocialCare Research Centre, School of Nursing and MidwiferyStudies, Cardiff University, Fourth Floor, EastGate House,35–43 Newport Road, Cardiff CF24 0AB, UK (e-mail:[email protected]).


because you care, and you want the patient tomake as good a recovery as possible.

On the other hand, the patient is probablyfeeling as frustrated with herself as you are. Shemay feel as though she has failed because she hasnot managed to do something that should be ‘soeasy’, and she may also be worried that she isdoing herself some damage because she has notdone what she was ‘meant to do’. The presentauthor should know – she is the author of thesecond quotation.

Health behaviour change is a challengingarea – for both the patient and the practitioner.The way in which this is addressed by a healthprofessional can make all the difference, andtherefore, it is important to take a flexibleapproach to communication. All patients aredifferent, and some women will already be moti-vated to make the changes or adhere to thetreatment plans that have been suggested forthem. Other patients may be a little more diffi-cult, and there are times when simple instructionand advice does not do the trick. So, what canyou do instead?

What’s your style?There are a number of different styles that we usewhen communicating with others in our dailylives. This was something the present author anda colleague discussed in some detail with a groupof health visitors whom they trained in 2003(Rollnick et al. 2004). For example, on a dailybasis, it might be appropriate at different pointsto either direct, guide or follow (S. Rollnick,personal communication). Directing involves theprovision of information or advice. Guiding usu-ally involves building on somebody’s strengths tohelp them get better at something they alreadyknow a little about. Following involves listeningto and understanding somebody. Imagine thefollowing scenarios that could occur in everydayfamily life, and think about what style would beappropriate 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 andfollowing seem most appropriate. Now imaginerestricting yourself to using just one style ofcommunication for every scenario, or using thewrong style in the wrong situation – imagine theconsequences of directing the child who iscrying/learning to read, or guiding/following the

child who has run into the road. The sameprinciple applies when dealing with patients inclinical practice. When it comes to behaviour-change issues, some patients may require‘direction’ – others may have more pressingissues and need to be ‘followed’. However,many will be most receptive to a ‘guiding’ style(Rollnick et al. 2005). Looking at the psycho-logical processes behind behaviour change canhelp us to understand why this may be the case.

The psychology of behaviour changeThere are many factors that may affect how andwhy patients make changes.

Patients often need to feel a degree of personalchoice with regard to changing their behaviour.Brehm (1966) suggested that, if a person per-ceives that their individual freedom is beingtaken away, this may, in turn, motivate them toactually perform the behaviour they are beingtold not to do (or of course, fail to performthe behaviour they are being told to do!). Putsimply, this describes the patient who reacts toinformation/advice by thinking, No one tells mewhat to do.

Many patients expect to be persuaded to makelifestyle changes, which can, in turn, result inresistance to making changes. Using ‘empathy’ –listening carefully and demonstrating to patient

that they have been understood – can help tolower resistance. For example, Carl Rogers(1959) developed the ‘client-centred counsellingframework’, which draws closely on the use ofempathy, because he found that his psycho-therapy clients often had improved results if helistened more and allowed them to determine therate of treatment. This led him to believe that aflexible attitude to treatment was important,since encouraging the client to be self-aware andto make independent choices appeared to helpthem to understand the problem at hand.

Self-perception can also have an effect on apatient’s motivation to change (Bem 1972). Ifpatients see themselves as smokers, for example,they think they like it and want to continuedoing it. If they hear themselves saying that theydo not want to be smokers and they are going toquit, they may, in some cases, believe it and stopsmoking.

Similarly, Festinger (1957) discussed ‘cogni-tive dissonance’ – people generally feel uncom-fortable when they hold two conflictingbeliefs – for example, ‘I want to be healthy, but Ieat a lot of fatty food, which is bad for me.’ This,

Motivational interviewing and health behaviour change


in turn, may create an urge to resolve theconflict – which could potentially mean that thepatient in the example decides to graduallyreduce the amount of saturated fat in their diet.However, if patients do not believe that they canreduce the amount of fat in their diets veryeasily, it may be easier to despise what they feelthey cannot achieve: ‘Who wants to look like afake supermodel anyway? Let’s forget that idea.’

Another factor that may affect patientmotivation to change is their ‘readiness’ to makechanges. One model commonly used to try tounderstand readiness is the transtheoretical(or ‘stages of change’) model (Prochaska &DiClemente 1983), which describes five possiblestages that individuals may be at in terms ofmaking a change:

+ the precontemplation stage – the person hasnot even considered that she or he might needto make changes at this point;

+ the contemplation stage – the person has con-sidered that there is something that she or heprobably needs to change;

+ the preparation stage – the person makesplans as to how she or he might change;

+ the action stage – the person is actively under-taking behavioural changes; and

+ the maintenance stage – the person maintainsthe changes she or he made in the action stageover a period of time.

The stages are not linear – an individual canrelapse and fall back into former stages at anypoint in time. For example, perhaps the changesmade in the action stage were difficult to imple-ment, causing a patient to fall back into thecontemplation or preparation stage, or a stress-ful life event such as a relationship breakupforced the patient back into the precontempla-tion stage.

Two factors that can influence patients’ readi-ness to make changes are the degree of impor-tance that they attach to making the behaviourchange, and their confidence in their ability toachieve it (Keller & White 1997; Rollnick et al.1997). In general, if importance and confidenceare both high, patients are more likely to feelready to make changes. If importance and confi-dence are both low, patients are not likely to feelat all ready to make changes. If importance andconfidence are somewhere in the middle of therange, or either importance or confidence is high,but the other is low, patients are likely to beambivalent about making changes. Having theconfidence to achieve change is recognized as a

great factor in making lifestyle changes. If indi-viduals believe that they can change, this is oftenhalf the battle. If they do not believe they canchange, they may not even try (Bandura 1995).

To summarize the information above, it isclear that behaviour change is a phenomenonthat is personal and individual to the patient.Motivation to change can be influenced by howmuch freedom of choice patients feel they have,how they view themselves in relation to how theywould like to be, how ready they feel they are tochange, how important they think it is to change,and how confident they feel about their abilityto achieve it. The fact is that we cannot makepatients change or adhere to treatment regimes.That decision is, and always will be, theirs tomake. However, what we can do is have con-structive discussions with patients about makingchanges, help them to explore how they thinkand feel about change, and guide them in think-ing about how and why they might change. Onemethod that can help with this is motivationalinterviewing (MI; Miller & Rollnick 2002). Thefollowing explanation of MI is based closely on aprevious description of the method (Lane 2006).

Motivational interviewingMotivational interviewing originated in theaddictions/psychotherapy field, and has evolvedfrom the work by Rogers (1959) on the ‘client-centred counselling framework’ mentionedabove. The technique is similar to the client-centred counselling framework, in that:

‘[It] does not focus on teaching new copingskills, reshaping cognitions or excavating thepast. It is quite focussed on the person’spresent interests and concerns. Whatever dis-crepancies are explored and developed have todo with incongruities among aspects of theperson’s own experiences and values.’ (Miller& Rollnick 2002)

Motivation for change is drawn from theclient, rather than imposed. However, MI differsfrom the client-centred counselling framework inthat it is purposely directive:

‘Motivational interviewing involves selectiveresponding to speech in a way that resolvesambivalence and moves the person towardchange.’ (Miller & Rollnick 2002)

One misconception about MI is that it is oftenviewed as a set of techniques that can be inflictedon a patient without genuine empathy andunderstanding. Motivational interviewing is a

C. A. Lane


clinical skill, rather than a tool. To further definethe 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 themethod.

The spirit of MI is divided into three com-ponents: collaboration, evocation and autonomy:

+ Collaboration refers to the patient and prac-titioner working together in partnership, notagainst each other (e.g. with the practitioneradvocating change and the patient arguingwhy change is not a good idea).

+ Evocation describes the process of the prac-titioner eliciting the patient’s goals, thoughtsand feelings about behaviour change, ratherthan providing information as to how andwhat they should feel about change.

+ Autonomy signifies practitioner respect forthe patient’s rights as an individual. Patientsknow their own mind, and should be allowedto choose what to do about their behaviour –there is recognition that any changes that

patients do decide to make are entirely theirchoice, and that the practitioner is not thereto force them to do anything. Should patientsdecide that they do not want to make anychanges to their behaviour, the practitioner,in turn, has to respect this decision.The four principles to be followed while con-

ducting MI are to express empathy, developdiscrepancy, roll with resistance and supportself-efficacy (Miller & Rollnick 2002):

+ Expressing empathy describes how the prac-titioner should demonstrate an understandingof the patient’s perspective. This is mainlyachieved through the use of active, reflectivelistening techniques, which demonstrate thatthe practitioner understands what the patienthas told them.

+ Rolling with resistance is the approach takento avoid confrontation with a patient. It couldbe described as ‘going along with what thepatient says for a bit’ while demonstratingunderstanding for resistance as a means ofreducing it.

+ As well as eliciting the patient’s motivation tochange, the practitioner should support thepatient’s self-efficacy (a person’s belief thatthey have the ability to do something) andbuild on the patient’s confidence in achievingchange without telling her or him what to do.

+ Developing discrepancy is the most complexof the principles underlying motivational

interviewing. It involves the practitioner lis-tening carefully to what the patient says abouther or his personal values, and illustratinghow this is at odds with the patient’s currentbehaviour. This is often achieved by high-lighting how the behaviour in question doesnot fit in with the patients’ perception of howshe or he would like to be.

With the spirit and guiding principles of themethod in mind, the practitioner uses a numberof skills to encourage the production of patient‘change talk’ (patient talk about how and whythey might change their behaviour). This isaccomplished through a variety of means, suchas asking permission to talk about the behaviourin question, encouraging the patient to set theagenda for the consultation, assessing a patient’sreadiness to change, asking open-ended ques-tions, making summaries, and the skilful use ofreflective listening to both express empathy andto direct the patient in producing change talk.

Following its success in the psychotherapyfield, MI has generated much interest withinhealthcare settings where behaviour change isoften an issue. For this reason, the method hasbeen adapted for use in these contexts (Rollnicket al. 1999), adhering to the spirit and principlesoutlined above. There are a number of strategiesthat clinicians can use to help implement MI intotheir practice with patients. Although a com-prehensive guide to ‘doing MI’ is not possiblewithin the scope of a conference paper, fourstrategies (i.e. agenda-setting, exploring the prosand cons of change, exploring readiness tochange, and exchanging information) will beoutlined below to give readers an idea of how MIworks in clinical practice.

Agenda-settingIn MI, the patient is encouraged to set theagenda for talking about behaviour change. Thisis particularly important if there are a number ofdifferent lifestyle issues to be addressed. Forexample, a female cardiac rehabilitation patientmay have been identified as having a number ofrisk factors that may have contributed to herheart attack. She may need to make changes toher diet, increase the amount of physical activitythat she does and cut down the amount ofalcohol she consumes. It is often easier to makechanges by trying to do a bit at a time, ratherthan trying to make a number of substantialchanges all in one go. We are all at differentstages of readiness to change over different



issues – and may even be at different stages ofreadiness to change different aspects of onehealth behaviour (Rollnick et al. 1999). Illustrat-ing the point with the example above, thiscardiac rehabilitation patient may be ready tostart going for a half-hour walk a couple of timesa week, but may not feel ready to start goingswimming too. Achieving small changes canincrease self-efficacy (Bandura 1995), making apatient feel more able to make other smallchanges. Therefore, it is important to start wherethe patient feels most comfortable, and encour-age her or him to suggest what area she wouldlike to talk about, rather than selecting what thehealthcare practitioner feels is the most import-ant issue to talk about first. It is also importantto ask permission to talk about lifestyle changes,so that the patient feels that she has a choice inthe matter.

Encouraging the patient to set the agenda canbe initiated through the use of open questions,such as, ‘There are a number of different thingswe can talk about today. I’m just wonderingwhat aspect of your lifestyle you would like totalk about?’ One tool that can help with this taskis an ‘agenda-setting chart’ (a copy of which,along with instructions for its use in clinicalpractice, can be found in Rollnick et al. 1999),which contains a number of circles containingpicture representations of various different life-style factors, and some blank circles for otherfactors to be inserted by the patient. Be preparedfor the patient to raise issues that you might nothave anticipated – drawing again on our cardiacrehabilitation patient, worries about lookingafter her family may be more pressing at thatparticular point.

Exploring importance and confidenceGiven the role that readiness plays in motivationto change behaviour, it can be useful to gain anunderstanding of this. One way this can beachieved within clinical practice is by exploringhow important the patient feels it is to changeher behaviour, and how confident she feels aboutachieving it.

Many practitioners find it useful to ask patientsto rate, on a scale of 0–10, ‘How important is itfor you, right now, to change X?’ and then askthem to rate, on the same scale, ‘How confidentdo you feel of success in changing X?’ Followingon from this, there is the opportunity to ask apatient why she has given herself this score andnot a higher or lower number, or indeed what she

thinks would help her to move up the scale interms of importance and/or confidence.

This strategy can help the practitioner tounderstand the patient’s barriers to change, andtherefore, can start the process of helping thepatient to overcome them.

Exploring pros and consClosely related to the importance/confidencestrategy, exploring the pros and cons of thecurrent behaviour and changing behaviour canhelp the practitioner to understand the patient’sbarriers to change. This strategy simply involvesasking the patient what she likes/doesn’t likeabout her current behaviour, and what she feelsshe would gain/lose from making changes.

Exchanging informationWithin healthcare consultations, there oftencomes a point when we need to stop listening topatients and give them information. Perhaps thepatient needs to know something for her safety/well-being, she has asked you for informationabout what she should do, or she has misunder-stood something with regard to her care orrecovery.

Information-giving within healthcare is usu-ally a process in which the patient is a passiverecipient. A typical example might be: ‘You areeating too much of X. This means that you are ata much higher risk of developing Y. What Isuggest you do is Z.’ This has the advantage ofbeing short, sweet and to the point. However,it has the disadvantage of possibly telling thepatient something she knows already, or that shemay misunderstand in terms of its relevance forher. It also makes the assumption that thepatient will just take the advice and do as she istold (if only it was that easy!).

Within MI, information is exchanged withpatients, rather than given. This involves the useof the ‘elicit–provide–elicit’ method, or first find-ing out what the patient knows already, provid-ing information (after asking if the patient ishappy for you to do this), and then finding outwhat the patient has made of that information.This means that information is given in a neutralmanner, building on what the patient alreadyknows, and the interpretation of the facts is leftto the patient.

Exchanging information in this way canencourage the patient to actively think of howthe information given applies to her as an indi-vidual, and can even save the practitioner time,

C. A. Lane


since it prevents the provision of redundantinformation, or ‘telling the patient what sheknows already’.

Evidence for the effectiveness ofmotivational interviewingA number of recent systematic reviews havepresented growing evidence for the effectivenessof MI as an intervention. The strongest evidenceis 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 arelatively new method, and it entered the generalhealthcare arena much later than the addictionsfield, the evidence for the effectiveness of MIwithin healthcare settings is still somewhatlimited, although it has shown much promise.Rubak et al. (2005) conducted a systematicreview of 72 randomized controlled trials inhealthcare settings, and found that MI interven-tions had a significant effect on reducing BodyMass Index, cholesterol, systolic blood pressure,blood alcohol content and standard ethanol con-tent, although not on the number of cigarettesper day in smokers or glycosylated haemoglobin(HbA1c) in people with diabetes. Vasliaki et al.(2006) systematically reviewed studies that usedbrief alcohol interventions based on MI, andconcluded that the technique was effective inreducing alcohol consumption in the shortterm with mainly risky (rather than alcohol-dependent) drinkers. A recent systematic reviewby Knight et al. (2006) into the effects of MIinterventions on physical activity concluded thatthese interventions do appear to increase exerciseuptake among patients, although the poor qual-ity of the trials made this hard to determine, withjust eight studies being included in the review asa result, mirroring the findings of previousreviews that have attempted to look at MI inrelation to specific health behaviours (Dunnet al. 2001; Burke et al. 2002, 2003; Hettemaet al. 2005). To enhance the quality of such trialsof MI, more attention is being focused on thequality of the intervention actually delivered bypractitioners in a number of different contexts,resulting in the development of instruments tomeasure practitioner skill in delivering MI (Laneet al. 2005; Moyers et al. 2005; Lane 2006).

One of the advantages of MI is that it appearsto be beneficial in helping people of both sexes tochange behaviours that they are ambivalentabout changing. However, a number of studieshave taken an MI approach specifically with

women in various contexts – such as pregnantdrinkers (Handmaker et al. 1999), pregnantsmokers (Stotts et al. 2004), female sex workers(Yahne et al. 2002) and women experiencingmarital dissatisfaction (Kelly et al. 2000;Cordova et al. 2001) – and have found it to behelpful in facilitating behaviour change amongthese women. A fellow MI trainer has com-mented on how using the technique in herclinical practice with women has been useful:

‘I work on a research study in which I runweight-loss groups for women who are over-weight and have urinary incontinence, and theyare very receptive to the lessons on exploringvalues . . . and making themselves a priority. Itis quite gratifying to see the transformationamong these women, who begin to carve outtime to take better care of themselves and loseweight.’ (J. Hecht, personal communication)

ConclusionMotivational interviewing is a method for whichthere is growing evidence that it may be aneffective way to facilitate behaviour change inpatients who are ambivalent about change, orwho are finding it difficult to put changes intopractice. No method of consulting can offer a‘one size fits all’ approach, but given the import-ance of being flexible, and trying to use the beststyle of communication for each individualpatient, MI is one skill that practitioners mayfind useful to include in their ‘toolbox’ of exist-ing skills when employing a guiding style withtheir patients.

Want to find out more about motivationalinterviewing?More information about MI can be found on theWorld Wide Web at <www.motivationalinter-view.org>. Health Behaviour Change: A Guidefor Practitioners by Rollnick et al. (1999) andMotivational Interviewing: Preparing People forChange by Miller & Rollnick (2002) are recom-mended further reading.

AcknowledgementsMany thanks to the Motivational InterviewingNetwork of Trainers (MINT) and their col-leagues for their ideas and support, especially:Majella Greene, Bob Mash, Marlyn Allicock,Marci Campbell, Grant Corbett, Viv Mumby,Donna Spruijtz-Metz, Cheryl Martin, JackiHecht, Gary Latchford, Dee-Dee Stout andIneke Buskens.



References

Bandura A. E. (1995) Self-Efficacy in Changing Societies.Cambridge University Press, Cambridge.

Bem D. J. (1972) Self-perception theory. In: Advancesin Experimental Social Psychology, Vol. 6 (ed. L.Berkowitz), pp. 1–62. 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 efficacy ofmotivational interviewing and its adaptations: what weknow so far. In: Motivational Interviewing: PreparingPeople for Change, 2nd edn (eds W. R. Miller & S.Rollnick), pp. 217–250. Guilford Press, New York, NY.

Burke B., Arkowitz H. & Menchola M. (2003) The efficacyof motivational interviewing: a meta-analysis of con-trolled clinical trials. Journal of Consulting and ClinicalPsychology 71, 843–861.

Cordova J. V., Warren L. Z. & Gee C. B. (2001) Motiva-tional interviewing as an intervention for at-risk couples.Journal of Marital and Family Therapy 27, 315–326.

Dunn C., Deroo L. & Rivara F. (2001) The use of briefinterventions adapted from motivational interview-ing across behavioral domains: a systematic review.Addiction 96, 1725–1742.

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 interviewingwith pregnant drinkers. Journal of Studies on Alcohol 60,285–287.

Hettema J., Steele J. & Miller W. R. (2005) Motivationalinterviewing. Annual Review of Clinical Psychology 1,91–111.

Keller V. & White M. (1997) Choices and changes: a newmodel for influencing patient health behavior. Journal ofClinical Outcomes Management 4, 33–36.

Kelly A. B., Halford W. K. & Young R. M. (2000)Maritally distressed women with alcohol problems: theimpact of a short-term alcohol-focused intervention ondrinking behaviour and marital satisfaction. Addiction95, 1537–1549.

Knight K., McGowan L., Dickens C. & Bundy C. (2006)A systematic review of motivational interviewing inphysical health care settings. British Journal of HealthPsychology 11, 319–332.

Lane C., Huws-Thomas M., Hood K., et al. (2005) Measur-ing adaptations of motivational interviewing: the devel-opment and validation of the Behavior ChangeCounseling Index. Patient Education and Counselling 56,166–173.

Lane C. A. (2006) The Measurement and Acquisitionof Skills in Behaviour Change Counselling. CardiffUniversity, Cardiff.

Miller W. R. & Rollnick S. (eds) (2002) MotivationalInterviewing: Preparing People for Change. GuilfordPress, New York, NY.

Moyers T., Martin T., Manuel J., Hendrikson S. &Miller W. (2005) Assessing competence in the use ofmotivational interviewing. Journal of Substance AbuseTreatment 28, 19–26.

Prochaska J. O. & DiClemente C. C. (1983) Stages andprocesses of self-change of smoking: toward an integra-tive model of change. Journal of Consulting and ClinicalPsychology 51, 390–395.

Rogers C. R. (1959) A theory of therapy, personality andinterpersonal relationships as developed in the client-centered framework. In: Psychology: A Study of aScience, Vol. 3 (ed. S .Koch), pp. 184–256. McGraw-Hill,New York, NY.

Rollnick S., Butler C. C., McCambridge J., et al. (2005)Consultations about changing behaviour. British MedicalJournal 331, 961–963.

Rollnick S., Butler C. C. & Stott N. (1997) Helping smokersmake decisions: the enhancement of brief interventionfor general medical practice. Patient Education andCounseling 31, 191–203.

Rollnick S., Mason P. & Butler C. (1999) Health BehaviourChange: A Guide for Practitioners. Churchill Livingstone,Edinburgh.

Rose G. S., Rollnick S. & Lane C. (2004) What’s your style?A model for helping practitioners to learn about com-munication and motivational interviewing. MotivationalInterviewing Newsletter: Updates, Education and Training11, 3–5.

Rubak S., Sandboek A., Lauritzen T. & Christensen B.(2005) Motivational interviewing: a systematic reviewand meta-analysis. British Journal of General Practice 55,305–312.

Stotts A. L., Delaune K. A. & Schmitz J. M. (2004) Impactof a motivational intervention on mechanisms of changein low-income pregnant smokers. Addictive Behaviors 29,1649–1657.

Vasilaki E., Hosier S. & Cox W. (2006) The efficacy ofmotivational interviewing as a brief intervention forexcessive drinking: a meta-analytic review. Alcohol andAlcoholism 41 (3), 328–335.

Yahne C. E., Miller W. R., Irvin-Vitela L. & Tonigan S.(2002) Magdalena Pilot Project: motivational outreach tosubstance abusing women street sex workers. Journal ofSubstance Abuse Treatment 23, 49–53.

Claire Lane is a research fellow at the Nursing,Health and Social Care Research Centre, CardiffUniversity.

Originally from a linguistics background, sheundertook her PhD in healthcare communicationat the Department of General Practice, CardiffUniversity. Claire’s academic work to date hasfocused on health behaviour change, and morespecifically, motivational interviewing. To thisend, her doctoral studies examined the effects oftraining on practitioner skill in motivational inter-viewing, and involved the development of aninstrument to measure this, the Behaviour ChangeCounselling Index (BECCI).

Claire is currently working on the Transitionfrom Children to Adolescent Diabetic Services(TCADS) project, which aims to investigate whatmethods of progression seem to work well forparticular groups of teenagers. She is a member ofthe trial management group on the Pre-EmptStudy at the Department of General Practice,Cardiff University.

C. A. Lane




‘Quote me happy’: can acupuncture make thosehormones happy?

J. LongbottomPrivate Practice, St Neots, Cambridgeshire, UK

AbstractThe present paper outlines the neurophysiological and neurohumeral effects ofacupuncture with reference to pain modification, and systemic enhancement ofmood, well-being, sleep and quality of life in the specific area of women’s health.The author seeks to integrate Western evidence-based acupuncture research withthe richness of the underlying philosophy of traditional Chinese medicine in orderto enhance patient care and clinical management of the more complicated casepresentations within physiotherapy. The paper attempts to reinforce suggestedprotocols, both within myofascial pain management and systemic dysfunction,with appropriate research, in order to support clinical reasoning and ‘bestpractice’ encompassing a variety of conditions ranging from the more peripheral,superficial gynaecological infections to systemic dysfunction, whilst retaining thescope of physiotherapeutic practice. The paper encompasses musculoskeletaldysfunction, menopausal symptoms, infertility and mild depression as a means ofenhancing the physiotherapist’s clinical toolbox and offering a greater choice ofpatient care to the acupuncture practitioner.

Keywords: acupuncture, hormones, pain, sleep, well-being.

IntroductionThe word ‘hormone’ is derived from the Greekhormon, meaning ‘to excite or to arouse’.

The present paper seeks to excite and arousefurther interest in acupuncture, within the scopeof physiotherapy practice, in order to ‘gobeyond’ (but not ignore) analgesic evidence foracupuncture effectiveness. The paper emphasizesthe integration of acupuncture, within anevidence-based paradigm, with the philosophy oftraditional Chinese medicine (TCM), whileoffering an explanation of neurophysiologicaland neurohumeral effects that may facilitatesystemic and emotional improvement. The effectof acupuncture, from periphery to brain, is pre-sented; we take a journey to outline some con-ditions encountered, some protocols suggestedand the supporting evidence to enhance clinicalreasoning.

RehabilitationAcupuncture is increasingly finding a place inrehabilitation, and although the evidence base isgrowing quickly, prejudice still surrounds its usewithin conventional Western medical systems.This resistance stems in part from acupuncture’sroots in TCM, dating from 200 BC. The prevail-ing belief at that time was of a system of organsand channels (meridians) through which vitalenergy, ‘qi’, flows. Qi is influenced by needlingspecific locations on the body (acupuncturepoints) in order to enhance or reduce qi flow,achieve balance, restore homeostasis, and pro-mote health and healing. These early attempts atunderstanding disease and disharmony persisteduntil fairly recently. There is some stigma thatstill attaches itself to acupuncture, with detrac-tors claiming that it has a placebo effect at best,and is shamanism at worst. This prejudice,coupled with initially unpromising reports(Mendelson et al. 1983), hindered acupuncture’swider acceptance as an effective treatmentfor pain, although recent studies (Carlsson &Sjolund 2001) have been more encouraging.

Correspondence: Jennie Longbottom, 13 Park Avenue, LittlePaxton, St Neots PE19 6PB, UK (e-mail: [email protected]).


At the peripheryAcupuncture for pain control is more widelyaccepted. Needling is a stimulus that releaseshistamine and calcitonin-gene related peptide(CGRP), and causes a local inflammatory reac-tion (Sandberg et al. 2003).

The resulting therapeutic effect of acupunctureis enhanced blood flow (Cao 2002), increasedphagocytic response and enhanced inflammatoryresponse to trauma with consequent tissue heal-ing (Hsieh 1998).

Interpreting the chemical responses at theperiphery into clinical practice leads to acupunc-ture evidence in the field of treatment of inter-stitial cystitis (Tucker 2004), leucorrhoea andvaginitis (Flaws 1986), and Candida albicans(Erconlani 1997).

Illiev et al. (1990) found significant changesin immunoglobulin and lymphocyte prolifer-ation following electro-acupuncture (EA) atlarge intestine (LI) 4 and stomach (ST) 36.Rosted (1994) recommended a standard proto-col for skin diseases, demonstrating significanteffects using lung and large intestine points.In short, there are optimistic studies for theuse of acupuncture in a variety of superficialskin conditions, providing evidence of a strongphagocytic reaction and antihistaminic effectin healthy volunteers, but there is muchroom for further well-controlled studies in thisarea.

At the spinal cordSmall afferent A�-fibres are stimulated by theacupuncture needle, causing the release of�-endorphin and leu-enkephalin in the dorsalhorn of the affected spinal cord segment (Han2004). These substances block the transmissionof small C-fibre-mediated nociceptive input tothe ascending sensory columns through themechanism of ‘pain gating’ (Han & Terenius1982), thus reducing the experience of pain.Segmental mechanisms of pain control are mostlikely to act locally, and are probably respon-sible for the analgesic effects of needling close tothe site of pain.

Clinical research suggests that pain modula-tion for musculoskeletal management is en-hanced by the use of acupuncture and manualtherapy, compared with manual therapy alone(Furlan et al. 2001), for lumbar pain and pelvicpain as an adjunct to stabilization exercises(Cummings 2003), and for sacroiliac dysfunction(Betts 2005).

Myofascial painRecent evidence from the USA on endometriosispain and dysfunction (Lyttleton 1998; WhyteFerguson & Gerwin 2005) has suggested thatthere is an 80% correlation in pain patternsbetween active abdominal muscle trigger pointsand the diagnosis of ‘endometriosis’. Thisfurther supports previous work by Simonset al. (1999), who suggested that the externalabdominal oblique muscle may cause abdominalpain and reflux; the lateral abdominal musclescausing pain and diarrhoea, and pyramidalis,mirroring endometrial pain.

These active trigger points are capable ofreproducing strong somatovisceral and viscero-somatic interactions, suggesting that the triggerpoints are activated by the visceral component,but persist after this component has resolved(Simons et al. 1999). This may result in mislead-ing diagnoses and treatment regimes. Simonset al. (1999) proposed the ‘energy crisis’ hypoth-esis, according to which the crisis energy leads toincreased production of acetylcholine at a dys-functional motor end plate, which increases actinand myosin filament contraction, resulting intight bands within the muscle fibre. The conse-quence of this is increased pressure on surround-ing blood vessels, with resulting ischaemicsymptoms of pain and paraesthesia, which aremade worse by muscle loading and enhancedsympathetic responses, such as anxiety or stress.

Research has demonstrated that symptomssuch as projectile vomiting, anorexia, intestinalcolic, diarrhoea, bladder and bowel sphincterdysfunction, and dysmenorrhoea (Simons et al.1999) can result from active abdominal triggerpoints.

Assessment and palpation of all abdominalmuscles should be a mandatory componentof physiotherapy management when treatingpatients who demonstrate these symptoms.Appropriate trigger-point needling (WhyteFerguson & Gerwin 2005) should be undertaken,followed by myofascial release techniques(Chaitow 2001) and accompanying muscleimbalance re-education (Wedenberg et al. 2000).

Brain and limbic systemThe action of de qi, and the classic description ofa ‘heavy’, ‘numb’ or ‘sore’ sensation mediatedby the activation of the small C-fibres are essen-tial components of acupuncture effectiveness(Abad-Alegria & Giaz 2004). It is essential forproducing analgesia (Lundeberg 1995) via the

J. Longbottom


endogenous opiate system. Ascending C-fibremediates nociceptive input and stimulates theperiaquaductal grey, hypothalamus and pitu-itary (Wang et al. 1990), which in turn stimulatethe release of serotonin, norepinephrine, hista-mine, bradykinin, endorphin, dopamine andadrenocorticotrophic hormone (ACTH) (Chen& Han 1992). These chemicals modulate painby both pre- and post-synaptic inhibition.Endorphin-like substances also appear in thecerebrospinal fluid after needling (Shen 2001);ACTH passes to the kidneys and stimulates therelease of cortisol (Han et al. 1992), a powerfulsystemic anti-inflammatory.

At the hypothalamus–pituitary axis, we seeenhanced levels of oxytocin release followingacupuncture, leading to improved mood state,relaxation and general quality of life, whilstreducing anxiety and sympathetic hyperalgesia(Alison et al. 2003).

The stimulation of �-endorphin is known todeactivate norepinephrine, which is known to beresponsible for increased climacteric responses inmenopausal flashes, improving stamina and per-sonal drive (Sandberg 2002; Cohen 2003). This iswell presented in TCM gynaecology texts, wherecalming of liver and heart qi and enhancementof spleen and kidney qi (Maciocia 1998) aresuggested protocols for the treatment of meno-pausal syndrome (Jang et al. 2003).

Beyond painThe practitioner should look beyond pain inorder to encompass the TCM philosophy ofhomeostasis and balance, especially in the areaof hormonal response.

Acupuncture does not stop at the hypothala-mus. The hippocampus, which is thought to beinvolved in memory, cognitive problem-solvingskills, and the storing and processing of physicaland spatial information, is believed to becomehighly susceptible to fluctuations in oestrogenand progesterone levels. This is often reportedby patients during periods of fluctuation, such asthe menopause, and the premenstrual and post-natal periods. In a study by Dong et al. (2001),acupuncture significantly improved vasomotorsymptoms at the end of treatment (P=0.0001)and at 3-month follow-up (P=0.003). It didnot change psychosocial or sexual symptoms.Sandberg et al. (2002) found significant changesin mood scale in the EA group over superficialacupuncture needling. Quah-Smith et al. (2005)conducted a study of mild to moderate depres-

sion in postnatal patients in a primary caresetting. A low-level laser was used and patientswere randomized to active or inactive laseracupuncture. Beck Depression Inventory (BDI)scores revealed significant falls (P=0.007) 12weeks after treatment, although this studyinvolved a small sample size and a short post-trial follow-up period. The improvement in BDIscores was not significant at 4 weeks, but becameso at 12 weeks, which may be a result of naturalresolution of the disorder.

Betts (2005) suggested that acupuncture maybe valuable as an emotional support for post-natal patients experiencing depression that per-sists for more than 2 weeks. Postnatal depressionis often accompanied by poor appetite, insom-nia, and feelings of hopelessness and violence.Deficiencies of qi, blood and yin, accompaniedby stasis of blood, are important concepts inTCM diagnosis. Acupuncture is aimed at liftingqi, resolving stasis, and aiding recovery andreturn to homeostasis, thereby enabling thepatient to manage this interim period. Flaws(2006) indicated its use in mild to moderatepremenstrual tension (PMT) as a means ofrestoring homeostasis and preventing large dosesof antidepressant therapy. Bosco Guerreiro daSilva et al. (2005) compared the effects of acu-puncture on a group of pregnant women withthose undergoing conventional treatment forinsomnia. Statistical difference was demon-strated in the acupuncture group (P=0.0028),with a 50% decrease in insomnia scores for theacupuncture group in comparison to the con-trols. Increased levels of the serum concentrationof melatonin in the blood were demonstratedafter acupuncture, levels that are often loweredin pregnant women.

Blitzer et al. (2004) looked at the effects ofacupuncture on treatment of ‘major depressivedisorder’ using the Structured Clinical Interviewfor the Diagnostic and Statistical Manual ofMental Disorders criteria, as well as the BDII and II, and Reynolds Depression SurveyInventory (RDSI), which indicated significantimprovements following acupuncture treatment(BDI, P=0.01; RDSI, P=0.03). More signifi-cantly, none of the participants in the grouptreated with acupuncture met the criteria for amajor depressive disorder at the conclusion ofthe study.

Magnetic resonance imaging evidence suggestsenhanced activity in the hippocampus followingacupuncture (Wu et al. 1999), while acupunctureappears to modulate the limbic system (Hui et al.

Acupuncture and hormones


2002). The latter study by Hui et al. (2002)reinforces the need to attain de qi stimulation inorder to moderate activity in the limbic system,with particular attention needing to be paid tothe area of the anterior cingulate nucleus, whichis thought to be responsible for expectations andattention (Abad-Algeria & Pomaron 2004).

Does this mean that acupuncture may justhelp us find those things we keep losing,especially during the premenstrual and meno-pausal periods . . . or even at normal times of theday?

ReproductionIn terms of fertility and the development of ahealthy foetus, it is known that healthy levelsof progesterone are required for maintenanceof pregnancy and stimulation of leutinizinghormone (LH) for the continued developmentof the corpora lutea. Recent research usingacupuncture before embryo transplant and afterin vitro fertilization (Paulus 2002; Lyttleton2004; Stener-Victorin 2004) has demonstratedimproved clinical pregnancy rates (42.5% in theacupuncture group compared with 26.3% in thecontrols; P=0.03).

The use of acupuncture in the treatment ofblood flow impedance in uterine arteries result-ing in infertility (Stener-Victorin et al. 2003) hasalways been referred to as a ‘cold uterus’ inTCM (Betts 2005). In a group of infertile womendiagnosed with polycystic ovary syndrome,acupuncture resulted in the induction of normalovulatory cycles in one-third of the group receiv-ing acupuncture, compared with no ovulation inthe group with hormonal implants.

We must not forget the males . . .In a group of healthy, non-fertile men, acupunc-ture was seen to increase the viability of livesperm after acupuncture (P=0.05), as well asincreasing 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 enhancesrapid eye movement during deep sleep whilestimulating normal circadian rhythms, releasingincreased levels of growth hormone and stimu-lation of follicle stimulating hormone (FSH).This is thought to induce deeper, dream sleep,which enhances cartilage growth via chondro-

cytes, osteoclasts for bone repair and myoblastsfor muscle repair. It is thought to have a modi-fying effect on joint and muscle pain associatedwith sleep deprivation in patients with fibromy-algia and chronic fatigue (Bosco Guerreiro daSilva et al. 2005).

Urinary dysfunctionAcupuncture has been used extensively in thetreatment of incontinence and pelvic floor re-habilitation, increasing levels of arginine vaso-pressin as a means of controlling urine volume inorder to facilitate the rehabilitation and retrain-ing of urinary urge incontinence (Liu et al. 2002).

Vasopressin causes the kidneys to conservewater and concentrates urine, reducing the urinevolume (Yang et al. 2003; Kelleher et al. 1994).Kelleher et al. (1994) suggested a given protocolto lift kidney and bladder qi, in an attempt tohold fluid within the bladder and help in pelvicfloor retraining.

And finally, the menopause . . .This is a subject that is currently very dear to theheart of the present author, and one that oftencauses angst and embarrassment for patients.According to TCM (Maciocia 1998), the meno-pause is a time when blood and qi, which havebeen previously required within the pelvic basinfor reproduction, are taken away from the uterusand converge on the brain. Menstruation ceasesand subsequent body changes take place. InTCM philosophy, wisdom and insight come withthis change, and the ‘wise woman of the village’emerges. Within a Western paradigm, this is notan easy concept to embrace, but we do see vastchanges in body mass index, shape, hair andskin. We also see huge fluctuations in emotionalresponses, raging from a state of euphoria todepression, memory loss and anxiety. The meno-pause offers a period of mourning for somewomen, with children leaving home, loss ofattractiveness and emotional lability. For others,it may offer a period of enhanced liberation . . .

The essential problem encountered at this timeis the onset of climacteric symptoms (hot flushes)owing to a fall in oestradiol, progesterone, FSHand 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 to3 months following the trial. There was noimprovement in psychosexual symptoms or

J. Longbottom


measured reproductive hormones. Again, inTCM philosophy, the aim is to boost kidney andspleen qi as a means of relieving exhaustion,calming liver and heart fire so as to relieveheightened sympathetic hyperaemia and hotflushes.

ConclusionThe present paper seeks to offer the practitionera variety of clinical tools that go beyond pain,but that may contribute to improved quality oflife and well-being in some patients. It is by nomeans a definitive model, and there are manyareas that have not been covered. The authorhopes that it has offered the reader a greaterinsight into this powerful modality, which we asphysiotherapists are privileged to have withinour clinical toolbox.

In the UK, physiotherapists are able to usethis skill to enhance their practice, while invarious other countries, acupuncture it is notavailable to these clinicians, remaining in thedomain of physicians and consultants.

Acupuncture is a powerful modality whenused with knowledge, clinical reasoning skills,and against a background of evidence to supportthe choice of points and treatment diagnosis. Itspower should not be abused and should never beused as a mere adjunct when other modalitiesfail to produce results.

It is hoped that the present paper may changepractice, and stimulate a desire to know moreand seek further training in acupuncture in theexciting challenge of women’s health.

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Jennie Longbottom is chair of the AcupunctureAssociation of Chartered Physiotherapists(AACP), a member of the British AcupunctureCouncil and runs a private practice. She lecturesat undergraduate, postgraduate and MSc level.Her special interest is chronic pain, with a particu-lar focus on chronic pelvic pain and complex painsyndromes.

J. Longbottom




The perils of the perimenopause: contraceptive andhormonal needs in the perimenopause

A. E. EvansBristol Royal Infirmary and Bristol Nuffield Hospital, Bristol, UK

AbstractThe perimenopause is poorly understood by women and healthcare professionalsalike. It is a time of hormonal instability, resulting in altered menstrual patterns,worsening premenstrual syndrome, and for many women, multiple symptomatol-ogy, which is often misdiagnosed and treated as depression. The contraceptiveneeds of older women have never been more important than they are today in ourchanging society, nor have their choices ever been so great. Sadly, many womenover 35 years of age are not having these needs met, and unplanned pregnancy andtermination rates are rising. Many women in their late thirties, and even morein their mid-forties, are experiencing the effects of their fluctuating hormonalenvironment. Many of the hormonal contraceptive options available would helpto stabilize this and ameliorate early symptoms. For those not seeking or needingcontraception, there are various techniques for stabilizing a woman’s underlyinghormonal environment: principally, transdermal or percutaneous luteal phaseoestradiol, and intrauterine levonorgestrel. These techniques are little-used, andmerit further exploration and validation. The present paper seeks to address someof the problems of the perimenopause and their possible solutions.

Keywords: hormonal instability, levonorgestrel intrauterine system, non-contraceptivebenefits, percutaneous oestradiol, perimenopause.

IntroductionThe contraceptive needs of older women havenever been more important than they are todayin our changing society, nor have their choicesever been so great. Sadly, many women over35 years of age are not having these needs met,and unplanned pregnancy and termination ratesare rising (ONS 2002).

Many women in their late thirties, and evenmore in their mid-forties, are experiencing theeffects of their fluctuating hormonal environ-ment. Many of the available hormonal contra-ceptive options would help to stabilize this andameliorate early symptoms. However, mostwomen – and their general practitioners – areunaware of this, or indeed, believe that they are‘too old to use hormones’ or that it would berisky in some way. For a few, there might be

genuine medical risk, but most could benefitsubstantially from efficient contraception andhormonal stabilization. It should be the role ofthe doctor or practice nurse to proactively initi-ate discussion at various stages in a woman’slife – after childbirth, and during her late thirtiesand forties – when many women or couples maybe considering sterilization.

Changes in societyWith divorce rates in the UK running at around41% of all marriages (ONS 2002), many womenin their ‘middle youth’ find themselves ‘back outin the sexual market-place’. Not only must theycope with the demands of their growing children,they often form new relationships, and therefore,must start dealing once more with the issues ofcontraception and sexual health. If, as so often isthe case, their ex-husband has had a vasectomy,they have not had to face these considera-tions for many years, and are often unaware ofmodern choices.

Correspondence: Dr Annie Evans, Senior Clinical MedicalOfficer in Sexual Health, Women’s Health Specialist, BristolRoyal Infirmary and Bristol Nuffield Hospital, 3 Clifton Hill,Bristol BS8 1BP, UK (e-mail: [email protected]).


The perimenopauseIt is becoming increasingly apparent that thetransition into the menopause, specifically theperimenopausal period, is a gradual process thathappens over many years. The age of onset andthe duration of this perimenopausal phase canvary greatly (Li et al. 1996). Most women do notmove from regular menstruation to suddenamenorrhoea, but rather, experience a time ofmenstrual irregularity, often with shortenedor irregular cycles. Many women reportincreased premenstrual symptomatology, includ-ing headaches and migraine (MacGregor 1997),increased menstrual flow, and more painfulperiods.

This is a time of huge hormonal variability,with hormone levels fluctuating more intenselythan at any other stage of a woman’s life. Forsome, this leads to a variety of problems, includ-ing insomnia, emotional lability, forgetfulness,poor concentration, joint aches and tiredness.This is a time, above all others, when a womanmay turn for advice to the medical profession.To the unwary, this constellation of symptomscould be misinterpreted as depression and it iscertain that significant numbers of women areinappropriately labelled in this way. Many willbe offered antidepressant medication unneces-sarily. Unfortunately, at the present time, clini-cal trial data are insufficient to establishevidence-based treatment standards and clini-cians may need to rely on experience whenconsidering management options (Rebar et al.2000). The need to include the woman herself inthe decision-making process is self-evident. Theproblem is to balance her need for contraceptionwith that for hormonal support and to allow herto make an informed choice.

The perimenopause as an entity has only beenrecognized recently and little reference ismade to it in standard gynaecological texts,making its management challenging (see Boxes1 & 2).

Decreasing fertility ratesMany women assume that it is impossible toconceive in their mid-forties, and althoughfertility declines with age, risks of unplannedconception are much greater than expected.Reliable methods of contraception are stillneeded to avoid unintended pregnancy. Half ofall women are still fertile at 40 years of age (seeTable 1).

Termination of pregnancyWomen aged over 40 years in the UK have thehighest termination of pregnancy rate pernumber of conceptions (40%) of any age groupof women, including teenagers (ONS 2002). Thisis an indication that most pregnancies in thisgroup are unplanned and unwanted. It wouldbe infinitely preferable to avoid this situationby allowing women sufficient knowledge ofavailable contraceptive options.

What methods do older women use?There is a steady transition in the UK away fromhormonal methods and towards sterilizationwith advancing age (see Fig. 1). By the age of35 years, only about one in three women usehormonal methods. At least 40% of couples overthe age of 40 years rely on female or malesterilization, but there are now increasingnumbers of highly effective, reversible methodsavailable. The Royal College of Obstetriciansand Gynaecologists sterilization guidelines(RCOG 1999) recommended that ‘all couples

Box 1. Challenges in the perimenopause

+ Y Fertility+ [ Hormonal instability+ Y Termination of pregnancy rate+ Y Miscarriage rate+ Y Risk of foetal abnormality+ Y Maternal morbidity+ Y Perinatal mortality+ [ Sexual frequency+ Y Delaying first pregnancy+ Y Women with new partners

Box 2. Symptoms of the perimenopause

+ Heavier menstrual loss+ Reduced cycle length+ Increased premenstrual syndrome, irritation, paranoia,

panic+ Premenstrual and menstrual migraine+ Insomnia, tiredness+ Joint aches, flu-like symptoms+ Breast tenderness+ Poor concentration, verbal memory+ Loss of libido, loss of drive+ Inability to multitask+ Inability to cope!

Table 1. Fertility rate (i.e. pregnancies per 100 women-years) by age (adapted from Evans 2000)

Variable

Age (years)

<25 40 45

Fertility rate (%) 85 45 15

A. E. Evans


should be fully counselled about all suchalternatives, before proceeding to sterilisation’.

More than just contraception: positivehealth benefitsMany women would more than welcome thechance to eliminate some of their perimenopau-sal symptoms, and these possibilities should bediscussed with them. The ability to stabilize awoman’s hormonal environment, perhaps by useof the combined Pill, in a non-smoker with noother risk factors, may well enhance the qualityof her life.

Combined oral contraceptive use in theperimenopauseMany women who stop the combined Pill to besterilized experience unwelcome hormonal andmenstrual changes, and conversely, those whodo continue the combined oral contraceptive(COC) into their forties report that they con-tinue to feel well. There are many fears andmisconceptions about using the Pill, and theduration of its use in this older age group, thatneed to be addressed.

Modern, 20-�g COCs offer first-rate contra-ception, along with the benefits of regular, pre-dictable light withdrawal bleeds and maskingof early menopausal symptoms. This can be ofparticular advantage to those women developingmenorrhagia and dysmenorrhoea at this stage intheir lives, where previously hysterectomy mighthave been considered the best option. It can alsohelp to control worsening perimenopausal pres-menstrual syndrome (PMS) and mood change,and give back a sense of control to many women

whose lives are being made more difficult by theunpredictability of these perimenopausal years.

Our job is to ensure that COCs are not givento ‘risky women’. So long as a woman is ahealthy, migraine-free, a non-smoker and has noother risk factors for arterial disease, the term‘contraceptive gap’ no longer applies, and at herrequest, the COC may legitimately be takenthrough to the menopause. Age alone is nolonger considered a contraindication (see Box 3).

The consensus of opinion is that lower oestro-gen doses should probably be used be used overthe age of 40 years if the COC is to be continued(Poulter et al. 1999). It would appear that themodern progestogens (usually to be found in20-�g preparations) are indeed less likely tocause cerebrothrombotic events than thosefound in older-generation Pills (Lidegaard &Kreiner 2002). Thus, ‘risky’ women in this agegroup would also include those with risk factorsfor venous thromboembolism (see Box 4).

Although a recent study by Marchbanks et al.(2002) found no increased risk of breast canceramong women who were current users of low-dose COCs in the 45–54-year-old age group, theabove authors concluded that their findings maynot be conclusive, and further investigation ofthis question is merited. It is no longer disputedthat the COC provides protection from cancer ofthe ovary and endometrium, whose incidencerises particularly above the age 40 years.

Overall, the balance would appear to be infavour of COC use in risk-free older womenbeing beneficial. It provides reliable contra-ception, along with the ‘add-on benefits’ of

Figure 1. Patterns of UK contraceptive use by ageand method in 2002 (information on file at ScheringHealth Care Ltd, Burgess Hill, UK): (IUD) intra-uterine device.

Box 3. Risk factors for arterial disease contraindicatingcombined oral contraceptive use in women over 35 years ofage: (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 forVTE: (BMI) Body Mass Index

+ Previous deep vein thrombosis/pulmonary embolism+ Family history of unprovoked VTE in a first-degree

relative <45 years of age+ Obesity (BMI>39)+ Immobility+ Extensive varicose veins

Contraceptive and hormonal needs in the perimenopause


cycle-control, symptom relief and protectionfrom osteoporosis.

The combined oral contraceptive/hormonereplacement therapy overlapAfter the menopause (or leading up to it, ifcontraception is not an issue), ‘natural’ oestro-gen (17�-oestradiol) is sufficient for symptomrelief; however, it is not contraceptive. If womenstay on the COC ‘until the menopause’, howcan this event be diagnosed and infertility beassured?

One method is to try measuring the folliclestimulating hormone (FSH) at the end of thePill-free week in a woman of 50 years of age. If itis still normal, she cannot be advised to stopusing contraception, but nor would it seem wiseto continue the COC indefinitely, and therefore,a switch to an oestrogen-free method might beadvisable. If the FSH is at menopausal levels ontwo to three occasions, she might be advised toswitch, if she chooses, straight to hormonereplacement therapy (HRT).

Hormonal stabilization without use ofcombined oral contraceptiveThe most effective method of ameliorating thepremenstrual symptoms encountered in the peri-menopause (whether these are predominantlyphysical, such as migraine, or mood-related) isto attempt to stabilize the hormonal milieu inthe luteal phase. In a woman whose menstrualpattern is still regular, this is achieved by deliv-ering a stable dose of oestradiol via a trans-dermal patch or percutaneous gel for the secondhalf of each cycle. Oral dosage of oestrogenproduces fluctuating levels and may exacerbatethe symptoms. This treatment has been shownto be effective in preventing both premenstrual/menstrual migraine (MacGregor et al. 2003)and perimenopause-related depression (Schmidtet al. 2000).

However, a prediction of the timing of theluteal phase cannot be made in women withirregular cycles, and oestrogen must be deliveredcontinuously. This necessitates opposition withprogestogen, since there may be a risk of endo-metrial thickening otherwise. Adding a cyclicalprogesterone, as in ‘conventional’ HRT, mayreproduce many of the premenstrual symptomsalready exacerbated by the perimenopause itself.The better option is to use a locally deliveredprogestogen to protect the endometrium, using aprogestogen-loaded intrauterine system (IUS).

Contraceptive choices with add-onbenefits in older womenThe levonorgestrel IUS (LNG-IUS) has beenhailed as one of the major advances in the fieldof contraception since the introduction of thePill. It is not only a highly effective and revers-ible method, but it also has other non-contraceptive benefits.

Local release of LNG produces an inactiveand atrophic endometrium, and therefore,normal menstrual flow is reduced. In turn, thisleads to less endometrial prostaglandin produc-tion, and therefore, less dysmenorrhoea. Studieshave shown an objective reduction in menstrualloss (86% and 97% after 3 and 12 months,respectively; Andersson & Rybo 1990). Seven-teen per cent of users are amenorrhoeic after oneyear of use (Ronnerdag & Odlind 1999), 27%by the end of the first 5 years and up to 60%after another 5 years. The number of bleedingdays per cycle also gradually diminishes. Within30 days of removal, the endometrium hasreturned to normal and menstruation occurs(Silverberg et al. 1986). Thus, the LNG-IUS iseasily and completely reversible.

Lack of systemic side-effects withintrauterine system useThe systemic absorption of LNG is extremelylow (two progestogen-only Pills per week;Guillebaud 1997), thus minimizing side-effectssuch as breast tenderness, greasy skin and hair,headaches, and abdominal bloating. The plasmaoestradiol of users remains within the normalrange (Luukkainen et al. 1990), which is import-ant for perimenopausal women.

Other benefits of intrauterine system useThe ectopic pregnancy rate in users is exception-ally low, being ten times less than the ectopicrate for Nova-T users (0.02 versus 0.25 per 100women-years; Andersson et al. 1994). The inci-dence of pelvic inflammatory disease is alsomuch lower than for copper intrauterine devices,because of a combination of factors includingthickening of the cervical mucus, endometrialsuppression and reduced bleeding (Toivonenet al. 1991).

Efficient reversible contraceptionThe pregnancy rate in LNG-IUS users hasbeen shown to be exceptionally low (Pearlindex=0.16). The gross cumulative pregnancy

A. E. Evans


rate at 3 years is 0.3 per 100 users. Given that the‘real use’ failure rate of many contraceptivemethods reliant on committed use and usermemory are considerably higher than theirquoted method failure rates (or even the ratesachieved in trial circumstances), it is importantto recognize that real use and method failurerates are almost equivalent in the case of the IUS(Trussell 1998).

User acceptabilityThe extremely low side-effect profile, combinedwith the obvious benefits of reduced or absentmenstrual flow, less dysmenorrhoea and animprovement in PMS, are all reflected inextremely high continuation rates, with onestudy showing 81% at 3 years and 65% at 5 years(Backman et al. 2000).

Long-term use of the intrauterine systemAn important study of long-term IUS use wasreported by Ronnerdag & Odlind (1999). Theabove authors followed 82 women in Uppsala,Sweden, who were offered a second IUS afterprolonged, 7-year use of a first device. Thewomen were seen annually over the subsequent5 years. There were no reported pregnanciesand 77% of these women reported no healthproblems at all during the study period.

At the start of the study, 26% of women hadno bleeding, 70% had regular, scanty bleeds, and4% had irregular, scanty bleeds.

At the end of the second, 5-year period, 60%reported amenorrhoea, 28% regular, scantybleeds, and 12% irregular, scanty bleeds.

Overall, haemoglobin levels rose. Mean bodyweight rose by 0.5 kg per year (which is equal tonon-hormonal users).

Seven women became postmenopausal duringthe follow-up period, but there was no change inbleeding pattern following the introduction ofHRT.

Long-term benefits of the intrauterinesystem in the perimenopauseThe LNG-IUS also provides an effective methodof delivering progestogenic opposition tooestrogen in hormone replacement therapy(Wolter-Svensson et al. 1997), especially in theperimenopausal age group, in whom the inci-dence of dysfunctional uterine bleeding is highand there is still a need for contraception(Suvanto-Luukkonen et al. 1997).

ConclusionOur aim as health professionals should be toguide each woman towards informed choices,while dispelling myths along the way. We shouldnot miss this golden opportunity to control thehormonal milieu and help improve quality of lifein the perimenopause.

References

Andersson K. & Rybo G. (1990) Levonorgestrel-releasingintrauterine 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 comparativetrial. Contraception 49, 56–72.

Backman T., Huhtala S., Tuominen J., et al. (2000) Lengthof use and symptoms associated with premature removalof levonorgestrel-releasing intrauterine system: a nation-wide study of 17,360 users. British Journal of Obstetricsand Gynaecology 107, 335–339.

Evans A. (2000) The contraceptive needs of women over 30.Trends in Urology, Gynaecology and Sexual Health 5(Suppl.), 2–6.

Guillebaud J. (1997) The Pill, 5th edn. Oxford UniversityPress, Oxford.

Li S., Lanuza D., Gulanick M., et al. (1996) Perimeno-pause: the transition into menopause. Health Care forWomen International 17, 293–306.

Lidegaard O. & Kreiner S. (2002) Oral contraceptives andcerebral thrombosis: a five-year national case-controlstudy. Contraception 65, 197–205.

Luukkainen T., Lahteenmaki P. & Toivonen J. (1990)Levonorgestrel-releasing intrauterine system. Annals ofMedicine 22, 85–90.

MacGregor E. A. (1997) Menstruation, sex hormones andmigraine. Headache 15, 125–141.

MacGregor E. A., Frith A., Ellis J. & Aspinall L. (2003)Estrogen ‘withdrawal’: a trigger for migraine? A double-blind placebo-controlled study of estrogen supplementsin the late luteal phase in women with menstrually-related 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, 2025–2032.

Office for National Statistics (ONS) (2002) Social TrendsDocument, No. 32. The Stationery Office, London.

Poulter N., Chang C. L., Farley T. M. M., et al. (1999)Effect on stroke of different progestogens in low-doseoestrogen oral contraceptives. Lancet 354, 301–302.

Rebar R. W., Natchigall L. E., Avis N. E., et al. (2000)Clinical challenges in the perimenopause: consensusopinion of the North American Menopause Society.Menopause 7, 5–13.

Ronnerdag M. & Odlind V. (1999) Health effects of long-term 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

Contraceptive and hormonal needs in the perimenopause


and Female Sterilisation. Royal College of Obstetriciansand Gynaecologists, London.

Schmidt P. J., Lynette N., Danaceau M. A., et al. (2000)Estrogen replacement in perimenopause-related depres-sion: a preliminary report. American Journal of Obstetricsand Gynecology 183, 414–420.

Silverberg S. G., Haukkkamaa M., Arko H., Nilsson C. G.& Luukkainen T. (1986) Endometrial morphology dur-ing long-term use of levonorgestrel-releasing devices.International Journal of Gynecological Pathology 5 (3),235–241.

Suvanto-Luukkonen E., Sundstrom H., Penittinen J., et al.(1997) Percutaneous estradiol gel with an intrauterinelevonorgestrel releasing device or natural progesterone inhormone replacement therapy. Maturitas 26, 211–217.

Toivonen J., Luukkainen T. & Allonen H. (1991) Protectiveeffect of intrauterine release of levonorgestrel on pelvicinfection: three year’s comparative experience of

levonorgestrel- and copper-releasing devices. Obstetricsand Gynecology 77, 261–264.

Trussell J. (1998) Contraceptive efficacy. In: ContraceptiveTechnology, 17th edn (eds R. A. Hatcher, J. Trussell, R.Stewart, et al.), pp. 800–801. Ardent Media, New York,NY.

Wolter-Svensson L., Stadberg E., Andersson K., et al.(1997) Intrauterine administration of levonorgestrel inperimenopausal hormone replacement therapy. ActaObstetricia et Gynecologica Scandinavica 76, 449–454.

Dr Annie Evans is a women’s health specialist atthe Bristol Royal Infirmary and Bristol NuffieldHospital. This article is based on lectures givennationally and internationally, some of which havebeen supported by educational grants by Schering,Organon and Janssen Cilag.

A. E. Evans




Multi-convergent therapy in the treatment of medicallyunexplained symptoms: a brief journey in time

M. SadlierDepartment of Physiotherapy, University Hospital of Wales, Cardiff, UK

AbstractMedically unexplained symptoms (MUS), which mostly occur in women, aregenerally chronic and disabling conditions that present with extensive subjectivesymptoms, although objective findings or causal explanations are lacking. Notonly are MUS very disabling, but these incur a high cost to both patients andhealth providers. Multi-convergent therapy (MCT), which blends aspects ofcognitive behavioural and physical therapy in a seamless way, is one approach todealing with conditions that defy certainty. Its emphasis is on how our percep-tions, behaviours and life influences shape or evolve us into who and what we areby way of neuroplastic adaptation. Multi-convergent therapy can not only beadapted to different conditions, but is also adaptable between patients within thesame 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 inthe development of the strategy from the beginning. Flexibility of repertoire andthe dynamic of the interpersonal relationship rather than the application of agiven procedure or technique is probably more predictive of positive outcome andis the hallmark of MCT. Triangulated evaluation has shown this approach to beacceptable and cost-effective.

Keywords: gender differences, medically unexplained symptoms, multi-convergent therapy.

IntroductionPatients with medically unexplained symptoms(MUS) tend to be characterized more by symp-toms, disability and handicap than by anyconsistently demonstrable tissue abnormality(Table 1). They are often refractory to reassur-ance, explanation or conventional medical treat-ment (Barsky & Borus 1999). The same patientsare frequent attendees at general practitionersurgeries (Hamilton et al. 2001) and outpatientclinics, and are responsible for a high proportionof healthcare costs (Zook & Moore 1980;Garfinkel et al. 1988). Patients with MUS makeup 15–30% of all consultations at the primarycare level (Kirmayer et al. 2004). These con-ditions are noted for their overlap, often sharingdemographic, clinical and psychosocial features.

Indeed, it has been said that, given the overlapbetween these disorders, the label that isassigned is more to do with the chief complaintand clinical speciality than with the actual illnesssettings (Buchwald & Garrity 1994; Wessely et al.1999; Aaron & Buchwald 2001). Comparative

Correspondence: Michael Sadlier, Department of Physio-therapy, University Hospital of Wales, Heath Park, CardiffCF14 4XW, UK (e-mail: [email protected]).

Table 1. Functional somatic syndromes by speciality

Specialty Functional somatic syndrome

Gastroenterology Irritable bowel syndromeGynaecology Premenstrual syndrome, chronic

pelvic painRheumatology FibromyalgiaCardiology Atypical or non-cardiac chest painRespiratory medicine Hyperventilation syndromeInfectious diseases (Chronic postviral) fatigue

syndromeNeurology Tension headacheDentistry Temporomandibular joint

dysfunction, atypical facial painEar, nose and throat Globus syndromeAllergy Multiple chemical sensitivity


investigations in populations from referral clinicshave reported that 70% of patients with fibromy-algia (FM) meet the case definition for chronicfatigue syndrome (CFS), as do 18% of those withtemporomandibular disorders. Furthermore,80% of patients with FM, 92% of those withCFS and 64% of patients with temporomandibu-lar disorders meet the criteria for irritable bowelsyndrome (IBS) (Aaron & Buchwald 2001).Aronowitz (2001) and Sharpe & Carson (2001)have argued that a price has been paid for thisemphasis on measurable, objective pathology, tothe detriment of a sizeable minority.

GenderThe rates for MUS are much higher in womenthan in men. With a prevalence rate of between10% and 15%, IBS is four times more common inwomen, with a threefold increase in cholecystec-tomy, and a twofold increase in appendectomyand hysterectomy. Chronic fatigue syndrome istwice as common in women and headaches arethree times more frequent. Chronic pelvic painaffects 12–25% of women at any given time.Approximately one-third of women with chronicpelvic pain have IBS (Williams et al. 2005).

Women with MUS form a substantial part ofthe workload of gynaecologists, gastroenterolo-gists and surgeons. Each specialist investigateswith their own diagnostic bias, but the source ofdysfunction or pain often remains obscure, witha lack of abnormal findings or failure of symp-tom resolution despite treatment of the identifiedpathology. The patient’s physical and social dis-ability may become compounded by diagnosticconfusion, and by prolonged and ineffectivetreatments, including surgery. The end result isoften a sense of helplessness in both the patientand the physician.

Adding to the complexity is the presence ofdepression. As a co-morbid presentation, depres-sion may worsen the prognosis of other medicalillnesses, including heart disease (Frasure-Smithet al. 1993).

The prevalence of major depression is doublethe rate in women in comparison to men. Thiscan have a dramatic long-term effect in thatwomen who develop major depression in thepostpartum period are more likely to have recur-rent episodes over the following 5 years andbeyond, and their babies are more likely todevelop cognitive, social and mood problems(McKinlay et al. 1987). This situation is made allthe worse for women by the failure at times to

recognize that the peaks of depression occur attimes of hormonal fluctuation in the premen-strual, postpartum and perimenopausal phases.For example, a woman in the perimenopausalphase who has depression but is still having herperiods, albeit with fairly low oestrogen levels,may end up been treated with antidepressantsrather than oestrogens (Studd & Panay 2004).

The predominance of female-to-male ratios isalso influenced by genetic differences, vulnerabil-ity to psychosocial factors related to the stressresponse, gender roles, and the experience ofphysical, mental and sexual abuse (Payne 2004).

Paradigm shiftThe deductive approach to patient presentationhas made great strides in the field of medicine,while bringing great benefit to patient suffering.However, it runs into difficulties when the prob-lem presentation is not so clear or when theobjective findings do not match the symptompresentation. This is the realm of MUS or dis-orders of function. These sizable minorities ofpresentations involve complex brain–body inter-faces. It crosses over the traditional dividebetween medicine and psychology into the areaof neuropsychology, where a network of inter-acting systems demonstrates bi-directional com-munication with the central nervous system,which mediates the effects of psychosocialfactors, perceptions and behaviours on theproduction of physical symptoms (Weiner 1992).

These processes are all the more importantwhen it comes to understanding symptom pres-entation and narrative in women, given thegreater depth of the limbic system (which influ-ences the formation of memory by integratingemotional states with stored memories of physi-cal sensations), the high integration with the leftand right sides of brain, the profound influencesof the oestrogen cycle, and the more sensitivehypothalamic pituitary adrenal axis. Therapy forwomen has to acknowledge these differences,exploring the predisposing, precipitating andperpetuating variables to case presentation. Thesetting on which this exploration takes place isfundamental to outcome.

Therapeutic allianceCommunication is essential to maintain trustand credibility. However, the window of oppor-tunity within therapy is limited, especially forpatients who are already distressed. Such is itsimportance that patients can be lost or gained

M. Sadlier


within the first meeting. The establishment of anequal partnership with the patient on a briefjourney together facilitates this trust and cred-ibility, which lies at the heart of the therapeuticrelationship.

Therefore, the therapeutic alliance is the set-ting in which an exploration of problems, beliefs,fears and emotions, and the facilitation of posi-tive change, can take place between the therapistand the patient. Its prerequisites are empathicunderstanding, trust in the therapist and thetherapeutic process, freedom of expression, anda multiplicity of perspective empirically sup-ported treatments, such as cognitive, behav-ioural and cognitive behaviour therapy.

It is of note that different forms of psycho-therapy have been shown to provide effectiverelief for similar conditions, despite the fact thatthese therapies are treatment-specific (Chambless& Ollendick 2001). There is nothing new in all ofthis. In the mid-eighteenth century, Dr SamuelTissot highlighted the importance of the thera-peutic relationship. Paul Mobius proposed thatthe therapist’s personality was an essential toolto effect a change in the patient in 1888, while in1891, P. Dubois pinpointed the importance ofpatient and therapist as partners. More recently,Horvath & Symonds (1991) stated that a solidtherapeutic alliance was more predictive of out-come than either the type or length of therapy.This is consolidated by Luborsky et al. (2002)and Wampold (2001) in their empirical studyof 225 depressed patients. The above authorsfound that the therapeutic bond formed betweentherapist and patient was a leading influence ona patient’s recovery, regardless of the type oftreatment modality used.

Multi-convergent therapyMulti-convergent therapy (MCT), which incor-porates cognitive behaviour therapy, gradedexercise, mindfulness meditation, hypnotherapy,connective tissue massage and appropriateadvice on antidepressants, is a biopsychosocialapproach that is intended to reduce uncertaintyin areas of MUS, thereby facilitating success.Deale et al. (1997) echoed this philosophy ofapproach with their comment that, given theheterogeneous nature of some of these syn-dromes, what is called for is a pragmatic andflexible use of a range of behavioural and cogni-tive techniques, closely tailored to the individualpatient, rather than adherence to a rigid protocol(Deale et al. 1997) (Table 2).

Therapy actively interacts with the patient,changing course whenever the need arises.Flexibility of repertoire and the dynamic of theinterpersonal relationship rather than the appli-cation of a given procedure or technique areprobably more predictive of positive outcome(Krupnick et al. 1996), and are the hallmark ofMCT.

The heterogeneous nature of patient presen-tation, as seen in disorders such as CFS/myalgic encephalomyelitis, FM, IBS and non-inflammatory pelvic pain, necessitates that thetherapist has the flexibility of repertoire tosuit each individual patient on their journey, ajourney interspersed with many crossroads andalternative pathways. It is for this reason thatMCT embraces the underlying tenets of suchevidence-based practice as cognitive behaviourtherapy, mindfulness meditation and gradedexercise therapy, adopting a synthesized genericapproach that is disease-specific.

Triangulated evaluation over 18 years, includ-ing randomized controlled trials has shown thisapproach to be cost-effective and acceptable toall the major stakeholders (Shaw et al. 1991;Sadlier & Stephens 1995; Sadlier et al. 2000;Thomas et al. 2006).

ConclusionMulti-convergent therapy can be seen as a mind–body approach in which the physical andpsychological aspects are seamless. Its inherentflexibility in dealing with the physical and psy-chosocial aspects of female presentation is itsunique selling point. There is nothing new aboutthe different aspects of MCT. What is different ishow it is used and integrated by the individualtherapist.

References

Aaron L. & Buchwald D. (2001) A review of the evidencefor overlap among unexplained clinical conditions.Annals of Internal Medicine 134 (9), 868–879.

Table 2. Ordinary versus extraordinary management

Ordinary management Extraordinary management

Clear stages Reflection in actionProducer-pushed Consumer-ledAuthority drives

interactionsTherapeutic alliance drives

interactionsOutcomes by prior

intentionOutcomes emerge in time

and are articulated laterJoint action emerges from

policy and strategyPolicy and strategy emerge

from joint action

Multi-convergent therapy in the treatment of medically unexplained symptoms


Aronowitz R. A. (2001) When do symptoms become adisease? Annals of Internal Medicine 134, 803–808.

Barsky J. & Borus F. (1999) Functional somatic syndrome.Annals of Internal Medicine 130 (11), 910–921.

Buchwald D. & Garrity D.(1994) Comparison of patientswith chronic fatigue syndrome, fibromyalgia and mul-tiple chemical sensitivities. Archives of Internal Medicine154 (18), 2049–2053.

Chambless D. & Ollendick T. (2001) Empirically supportedpsychological interventions: controversies and evidence.Annual Review of Psychology 52, 85–716.

Deale A., Chalder T. & Wessely S. (1997) Cognitive behav-ioural therapy for chronic fatigue syndrome: a random-ised controlled trial. American Journal of Psychiatry 154(3), 408–414.

Frasure-Smith N., Lesperance F. & Talajic M. (1993)Depression following myocardial infarction. Impact on6-month survival. Journal of the American MedicalAssociation 270, 1819–1825. [Erratum published inJournal of the American Medical Association 271,1082.]

Garfinkel S., Riley G. & Iannacchinoe V. (1988) High-costusers of medical care. Health Care Financing Review 9,41–52.

Hamilton W. T., Hall G. H. & Round A. P. (2001)Frequency of attendance in general practice and symp-toms before development of chronic fatigue syndrome: acase-control study. British Journal of General Practice 51,553–558.

Horvath A. & Symonds B. (1991) Relation between work-ing alliance and outcome in psychotherapy: a meta-analysis. Journal of Counseling Psychology 38, 139–149.

Kirmayer L., Groleau D., Looper K. & Dao M. (2004)Explaining medically unexplained symptoms. CanadianJournal of Psychiatry 49, 663–672.

Krupnick J., Sotsky S., Simmens S. & Moyer J. (1996) Therole of the therapeutic alliance in psychotherapy andpharmacotherapy outcome: findings in the NationalInstitute of Mental Health Treatment of DepressionCollaborative Research Program. Journal of Consultingand Clinical Psychology 64 (3), 532–539.

Luborsky L., Rosenthal R., Diguer L., et al. (2002) Thedodo bird verdict is alive and well mostly. ClinicalPsychology 9, 2–12.

McKinlay J., McKinlay S. & Brambilla D. (1987) Therelative contributions of endocrine changes and socialcircumstances to depression in mid-aged women. Journalof Health and Social Behavior 28, 345–363.

Payne S. (2004) Sex, gender, and irritable bowel syndrome:making the connections. Gender Medicine 1 (1), 18–28.

Sadlier M. (1997) Triangulated Evaluation of the MCTClinic. M.Ba. thesis, Cardiff University, Cardiff.

Sadlier M., Evans R., Phillips C. & Broad A. (2000) Apreliminary study into the effectiveness of Multi-Convergent Therapy in the treatment of heterogeneouspatients with chronic fatigue syndrome. Journal ofChronic Fatigue Syndrome 7 (1), 93–101.

Sharpe M. & Carson A. (2001) ‘Unexplained’ somaticsymptoms, functional syndromes, and somatization: dowe need a paradigm shift? Annals of Internal Medicine134, 926–930.

Shaw G., Srivastava E. D., Sadlier M., et al. (1991) Stressmanagement for irritable bowel syndrome: a controlledtrial. Digestion 50 (1), 36–42.

Studd J. & Panay N. (2004) Hormones and depression inwomen. Climacteric 7 (4), 338–346.

Thomas M., Sadlier M. & Smith A. (2006) The effect ofMulti Convergent Therapy on the psychopathology,mood and performance of Chronic Fatigue Syndromepatients: a preliminary study. Counselling and Psycho-therapy Research 6 (2), 91–99.

Wampold B. (2001) The Great Psychotherapy Debate: Mod-els, Methods, and Findings. Lawrence Erlbaum Associ-ates, Hillsdale, NJ.

Weiner H. (1992) Perturbing the Organism: The Biology ofStressful Experience. University of Chicago Press, Chi-cago, IL.

Wessely S., Nimnuan C. & Sharpe M. (1999) Functionalsomatic syndromes: one or many? Lancet 354, 936–939.

Williams R., Hartmann K., Sandler R., et al. (2005) Rec-ognition and treatment of irritable bowel syndromeamong women with chronic pelvic pain. AmericanJournal of Obstetrics and Gynecology 192, 761–767.

Zook C. J. & Moore F. (1980) High-cost users of medicalcare. New England Journal of Medicine 302, 996–1002.

Michael Sadlier works as a physiotherapist at theUniversity Hospital of Wales, Cardiff, and is thedirector of the multi-convergent therapy clinic.His primary research interests are in chronicfatigue syndrome, irritable bowel syndrome andtinnitus. He works clinically in both the NationalHealth Service and the private sector. His mainfocus is on medically unexplained symptoms,particularly among women.

M. Sadlier


Journal of the Association of Chartered Physiotherapists in Women’s Health, Spring 2007, 100, 37


Bladders behaving badly: a randomized controlled trialof group versus individual interventions in themanagement of female urinary incontinence

L. A. HillGeorge Eliot Hospital NHS Trust, Nuneaton, UK

AbstractIncontinence 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, andit is one of the most common chronic diseases. A multi-centre randomizedcontrolled trial of group versus individual management of urinary incontinence in180 women was undertaken over a 2-year period. The views of women with femaleurinary incontinence (FUI) were sought on the acceptability and efficacy ofphysiotherapy as a treatment method for FUI when delivered in groups. The trialaimed to test the effectiveness of a group approach to treatment using outcomemeasures of symptom severity and quality of life pragmatically applied in the UKNational Health Service, and to investigate whether group treatments are morecost-effective than individual management. Outcome data for 174 women pro-vided evidence that a group educational approach to treatment is as clinicallyeffective as an individual educational approach, and that group treatment is morecost-effective than individual treatment. Pelvic floor exercises and bladder retrain-ing are simple, low-cost treatments, and have been shown to be effective. Womenshould be encouraged to take these up.

Keywords: female urinary incontinence, group intervention, individual intervention,outcome, physiotherapy.

Lesley Hill, a clinical member of a multi-centreteam, gave a presentation at the 2006 ACPWHConference to share the clinically significant andcost-effective results of this multi-centre random-ized controlled trial of group versus individual

intervention in the management of female urinaryincontinence.

The above is an abstract, and it is hoped toinclude a more detailed account of her research inthe next issue of the Journal.

Correspondence: Lesley Hill, George Eliot Hospital NHSTrust, Lewes House, College Street, Nuneaton CV10 7DJ,UK (e-mail: [email protected]).




Mammographic breast screening

Breast cancer is the commonest female malig-nancy, accounting for around 41 000 cases perannum in the UK in 2004, with up to half ofthese women dying from the disease. There is agradual upwards trend in its incidence, withregistrations of 50–64-year-old women increas-ing by 50% since 1988.

The National Health Service Breast ScreeningProgramme (NHSBSP) commenced in 1988.This followed convincing evidence fromScandinavia that showed a reduction in mor-tality from breast cancer in asymptomaticwomen who had been given mammographicscreening.

Initially, women between the ages of 50 and 64years were offered single-view mammographyevery 3 years. More recently, this has beenextended to women up to the age of 70 years,with older women having screening only onrequest. Two views of each breast are nowobtained, i.e. mediolateral-oblique and cranio-caudal images, which increases the detectionrate.

The majority of women who accept the invi-tation for screening have their films taken onmobile trailers staffed by experienced mammog-raphers (radiographers with expertise in mam-mography). The films are processed back at thescreening centre and loaded onto high-capacityroller viewers for reading. Most breast cancersdetected by screening are impalpable, and breastcancer has a variety of appearances on mam-mography: dominant nodule, spiculate density,area of glandular distortion or glandular asym-metry, or microcalcification. Benign lesions maylook malignant and vice versa.

Women who are thought to have a significantabnormality are recalled for assessment of thelesion to the screening centre within a few weeksof their initial mammogram. They have furtherspecialized mammograms performed that may

compress or magnify an area of concern. Manywomen will undergo an ultrasound examinationof the area as well. If a biopsy is required, thenthis is performed using image guidance to accu-rately sample the focus of concern. A wide-boreneedle (14 or 16 French) and mammotomy maybe used (11 or 8 French).

A breast surgeon will examine the women andassess the lesion for its palpability and possiblesurgical options, if required.

The samples are analysed by specialist breastpathologists, and the clinical teams meet todiscuss the results and conclusions. Great impor-tance is attached to the decision-making processin order that the correct diagnosis is reached.

Should a biopsied lesion be malignant, thetreatment options are decided before discussingthe results with the patient.

The number of women screened by the pro-gramme continues to increase year on year, as dothe number of cancers found. In 2002–2003, 1.3million women were screened in England, yield-ing a total of 9849 cancers. Not all of thesetumours are invasive, i.e. will spread within thebreast and be capable of spreading elsewhere.Around 25% of abnormalities are pre-invasive,but these are still treated by surgery with, orwithout, radiotherapy.

Screened women are a little more likely to bediagnosed with breast cancer than those who arenot screened, implying that some screen-detectedcancers may be overdiagnosed and might neverhave become manifest to the women during herlifetime. For every 400 women who are regularlyscreened over a 10-year term, one fewer womanwill die of the disease. The NHSBSP savesaround 1400 lives per annum in England.

Dr Kate Gower ThomasConsultant radiologist

Breast Test WalesCardiff




Presentation reflections

The following speakers did not submit a paperbased on their Conference presentations, but werehappy for us to publish details from their abstractsand to reflect on their talks.

Margie Polden Memorial Lecture: Amidwife’s perspective

Mary Cronk MBE, midwife in independentpractice, Chichester, UKMary Cronk was introduced to Conference byJeanette Haslam, which was to give us a flavourof the presentation to follow. In addition tobackground information on Mary’s long career,Jeanette has first-hand experience of her exper-tise, having had her in attendance at her ownhome births.

Mary’s presentation was full of interesting andthought-provoking ideas, demonstrating hercommitment to women’s health in the mostholistic of senses. She recalled how, since hertraining, practices have changed massively; inparticular, the mandatory use of episiotomy (aprocess she described as a form of female genitalmutilation) has, thankfully, become a thing ofthe past. She remembered her own contact withphysiotherapists as a patient and the help thatshe received from the profession after the birthof her own children.

The main theme was that of breech birth, andher belief that Caesarean deliveries are per-formed far too frequently when safe vaginaldelivery is possible. The slides that followed werean amazing insight into how breech presentationbabies can be born at home uneventfully. Casehistories were presented with this rare oppor-tunity to view the initial presentation andstage-by-stage snapshots of normal breechdeliveries.

Another theory presented was a proposedexplanation of why symphysis pubis dysfunction(SPD) has apparently become a more prevalentcondition in recent years. It was suggested thatpanty girdles might have had a role in preventingthe symptoms of pelvic instability in the past.Now that these are no longer commonlyworn, the incidence of SPD has consequently

increased. Mary’s suggestion for clinical practicewas the selective use of such undergarments inwomen who are recognized to have hypermobil-ity syndrome or are otherwise susceptible todeveloping SPD.

The presentation was very well received with aterrific round of applause, having kept our inter-est throughout. Chairman Ros Thomas pre-sented Mary with her Margie Polden certificateand a bouquet.

Rachel Kerr

GUM clinic: what to look for

Linda Furness, health advisor, Genito-UrinaryMedicine Clinic, Cardiff and Vale NHS Trust,Cardiff, UKA presentation on genito-urinary medicine(GUM) was, perhaps, a challenging start toSunday morning following the Conferencedinner on Saturday night, but Linda Furnessgave a comprehensive and interesting talk on thesubject.

She explained how the Venereal Disease (VD)Act means that the information that patientsgive staff at GUM clinics cannot be shared withanyone outside the unit. This, perhaps, contrib-utes to its isolation from mainstream medicine.She went on to say that we should not bejudgemental: anyone can be at risk of contract-ing a sexually transmitted infection (STI).

Linda listed viral and bacterial STIs, andreported a recent increase in cases of gonorrhoeaand, currently, syphilis.

A run-down on signs and symptoms – thingsyou see, smell or are told about – followed,accompanied by some graphic photographs. Shealso pointed out that some infections cause noevident symptoms. Chlamydia falls into thiscategory, with 80% of females and 40% of malesshowing no signs and symptoms, but sufferers atrisk of major problems such as pelvic inflamma-tory disease or infertility. Linda also discussedHIV, which might present itself in many ways,including myalgia, arthralgia, fever, pharyngitis,lymphadenopathy, skin rash, and mucosalulceration of the mouth, genitals or oesophagus.


This was an interesting and understandablepresentation that was, I felt, useful to women’shealth physiotherapists, especially those workingwith women experiencing incontinence and otherpelvic floor dysfunctions. As Linda said, we arejust the type of people – empathic practitioners,with more time for women than some healthcareprofessionals – to whom they might divulge aproblem. I would not presume to make a diag-nosis of a STI, but I will be more vigilant andwould have no hesitation in suggesting that awoman should visit a GUM clinic.

Linda directed us to the website of the Societyof Sexual Health Advisors (www.ssha.info). Ihave checked this out and it is, indeed, a goodsource of information on STIs that is accessibleto the general public.

Gill Brook

Hormonal treatment of severepremenstrual syndrome

Professor John Studd, consultant gynaecolo-gist, London, UKWe were indeed fortunate to hear the thoughtsof Professor John Studd, esteemed gynaecologistand founder of the first menopausal clinic in theUK in 1969. His descriptions of ‘reproductivedepression’ were enlightening, including a redefi-nition of premenstrual syndrome (PMS) as anovarian cycle dysfunction, rather than onerelated to the menstrual cycle. As such, PMScannot be surgically cured by hysterectomy, onlyby bilateral salpingo-oophorectomy (BSO).

Women with severe PMS can often fit theirsymptoms into a pattern of hormone-relateddepression. Severe PMS symptoms may be com-pletely relieved in pregnancy, but may return aspostnatal depression, followed by a return tocyclical depression that worsens with age. Unfor-tunately, this aggravation of PMS often becomesless regular with the approaching menopause. Agood question to gauge symptom severity in apatient may be, ‘How many good days doyou have in a month?’ Some women with post-natal depression respond well to transdermaloestrogen.

Current treatments for PMS consist ofhormonal therapy alongside psychiatric support,lifestyle changes and alternative therapies.According to Professor Studd, antidepressantsdo not have a role here. This is a stark contrastto the historical treatments described during hislecture. In days gone by, women with conditionssuch as ‘menstrual madness, nymphomania,

ovarian mania or hysteroepilepsy’ (PMS) wereoften sent to the nearest asylum. Here, earlygynaecologists pioneered BSO as an effectivetreatment of PMS. It was so effective for thesewomen that the risky surgery was soon rolledout to many women in asylums, who wereparticularly popular as subjects for doctorswho needed to gain experience in surgery.Fortunately, these practices were eventuallystopped.

Overall, Professor Studd advocates the use ofthe best treatment for the individual, which mayor may not include surgery. He has found thathormonal manipulation is certainly effective,and often cheaper than the antidepressants pro-moted by the heavily research-biased literaturebase. Further information can be found on hiswebsite <www.studd.co.uk>.

Clair Jones

Management of inherited bleedingdisorders in pregnancy

Dr Peter Collins, consultant haematologist,University Hospital of Wales, Cardiff, UKInherited bleeding disorders include haemo-philia, von Willebrand disease and disorders ofplatelet function. The management of thesedisorders during pregnancy requires a multi-disciplinary team approach between haemo-philia centres, obstetric services and anaesthet-ists (Lee et al. 2006).

Antenatal diagnosis can be offered to mostcarriers of severe haemophilia from about 10weeks. Future options will include the use ofin vitro fertilization with re-implantation offemale or unaffected male embryos.

Affected women may bleed secondary totrauma associated with vaginal delivery, orinvasive procedures such as Caesarean section orepidural anaesthesia. Correction of haemostasismay be required.

It is usually not known whether a baby bornto a woman who is a carrier of a bleedingdisorder is affected until she is tested postnatally.Children with bleeding disorders are at risk ofcephalohaematoma and intracranial bleeding atthe time of delivery. Therefore, these childrenshould be delivered on the assumption that theyhave a bleeding disorder. This means avoidinginvasive procedures such as ventouse extraction,foetal scalp monitoring and high forceps. Chil-dren should be tested for the family disorder atbirth. At present, there is no consensus as towhether children born with a severe bleeding



disorder should be treated at birth, and individ-ual centres should have a policy on this.

Peter Collins

Reference

Lee C. A., Chi C., Pavord S. R., et al. (2006) The obstetricand gynaecological management of women with inher-

ited bleeding disorders – review with guidelines producedby a taskforce of UK Haemophilia Centre Doctors’Organization. Haemophilia 12 (4), 301–336.




CLINICAL AUDIT

Assessing outcomes of urinary incontinence treatmentusing the International Consultation on IncontinenceQuestionnaire – Urinary Incontinence Short Form

C. JouannyUrotherapy Clinic, Westmount Assessment and Rehabilitation Centre, Overdale Hospital, St Helier, Jersey,Channel Islands

AbstractOutcome measures should prove to be useful tools in the development of theprovision of optimal physiotherapy treatment for women with urinary inconti-nence (UI). The International Consultation on Incontinence Questionnaire –Urinary Incontinence (ICIQ-UI) Short Form was used to assess treatmentoutcomes, and scores were compared with subjective treatment outcomes. Thispaper details the outcomes of treatment for the first 51 women with UI whounderwent therapy after the introduction of the ICIQ-UI Short Form in aurotherapy clinic. The audit showed that over 75% of women referred to the clinichad improved after attendance and that the ICIQ-UI Short Form reflected thesubjective outcomes. It is recommended that use of the questionnaire should becontinued as an outcome measure for physiotherapy for UI in clinical practice.

Keywords: audit, outcomes, urinary incontinence.

IntroductionFollowing attendance at a Chartered Physio-therapists Promoting Continence (CPPC) studyday in October 2003, the means of assessingtreatment outcomes at a urotherapy clinic werereviewed by the present author. The King’sHealth Questionnaire (Kelleher et al. 1997) hadpreviously been used in the assessment of womenwith stress urinary incontinence (SUI), but thishad proved to be too unwieldy and time-consuming for effective use in the clinicalsetting.

The fully validated International Consultationon Incontinence Questionnaire – Urinary Incon-tinence (ICIQ-UI) Short Form (Avery et al.2004) was presented by its author at the CPPCstudy day. Women’s health physiotherapistswere encouraged to consider using it both as anoutcome measure for research as well as inroutine clinical practice. The higher the scoreon the questionnaire, the greater the ‘symptombother’.

Since 2004, the ICIQ-UI Short Form has beenused at the Urotherapy Clinic of the WestmountAssessment and Rehabilitation Centre, OverdaleHospital, St Helier, Jersey, Channel Islands, forany woman referred to the service whose referralsuggests that she is incontinent of urine. Patientsmay have other diagnoses, of course, and incon-tinence may not always be the primary clinicalsign.

Subjects and methodsQuestionnaires were sent with the first appoint-ment letter to all women who, according to theirreferral, were suffering from urinary inconti-nence (UI). The questionnaire was collected thefirst time that the patient was seen and theinformation was entered into a computer data-base.

After treatment was completed, women weresent another ICIQ-UI Short Form, along with areturn envelope.

The present paper describes an audit of thefirst 51 ICIQ-UI Short Forms to be completedboth before and after treatment at the uro-therapy clinic.

Correspondence: Mrs Clare Jouanny, Urotherapy Clinic,WARC, Overdale Hospital, Westmount Road, St Helier,Jersey JE1 3UN, Channel Islands (e-mail: [email protected]).


ResultsThe number of questionnaires that were notreturned, either before or after treatment at theurotherapy clinic, was not documented becauseof time constraints.

The average ICIQ-UI Short Form scoresbefore and after treatment at the urotherapyclinic were 9.2 and 6.4, respectively. The subjec-tive outcomes of treatment are shown in Fig. 1.

The information was then analysed further:

+ Twenty-one (41%) women attended an indi-vidual (one-to-one) appointment first. Forthese women, the average ICIQ-UI ShortForm scores before and after treatment were8.9 and 5.7, respectively. The subjective out-comes of their treatment are shown in Fig. 2.

+ Twenty-nine (57%) women attended a groupinformation session first. Twenty-five of thesesubjects were referred with SUI, urge UI(UUI) or mixed UI (MUI), which showedthat, in general, the criteria (local criteriabased on referral information) for attendinga group information session first were beingfollowed. For these women, the averageICIQ-UI Short Form scores before and aftertreatment were 9.3 and 7.2, respectively. The

subjective outcomes of treatment are shownin Fig. 3.

The outcomes were then analysed accordingto the secondary diagnosis recorded on the data-base. Some women may have had more than onediagnosis (e.g. SUI and genital prolapse), inwhich case the most problematic diagnosis wasrecorded.

Urge urinary incontinence (n=6)The average ICIQ-UI Short Form scores beforeand after treatment were 10.5 and 6.3, respect-ively. Half the women were cured.

Mixed urinary incontinence (n=17)The average ICIQ-UI Short Form scores beforeand after treatment were 10.8 and 7.6, respect-ively. Eleven (64.7%) of these women attended agroup information session first. 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 beforeand after treatment were 8.8 and 7.2, respect-ively. Nine (64.3%) of these women felt betterafter treatment (i.e. cured or greatly improved).

Other diagnosesOther diagnoses included pelvic pain, analincontinence, genital prolapse, urinary fre-quency, post-micturition dribble, pelvic floormuscle (PFM) weakness and urinary urgency.

The final analysis was a comparison of thewomen’s subjective outcome of treatment withthe ICIQ-UI Short Form score:

+ Eleven (21.6%) of the women consideredthemselves cured. The average ICIQ-UI Short

Figure 1. Subjective outcomes of treatment for uri-nary incontinence (total n=51).

Figure 2. Individual first appointment: subjective out-comes of treatment for urinary incontinence (totaln=21).

Figure 3. Group first appointment: subjective out-comes of treatment for urinary incontinence (totaln=29).

Urinary incontinence treatment


Form scores before and after treatment were8.8 and 4.2, respectively.

+ Sixteen (31.4%) of the subjects consideredthemselves greatly improved. The averageICIQ-UI Short Form scores before and aftertreatment were 8.6 and 6, respectively.

+ Five (9.8%) of the women considered them-selves improved. The average ICIQ-UI ShortForm scores before and after treatment were9.4 and 7.2, respectively.

+ Seven (13.7%) of the subjects received a one-off advice session. The average ICIQ-UIShort Form scores before and after treatmentwere 6.4 and 3.1, respectively,

+ Nine (17.6%) of the women were referred on.The average ICIQ-UI Short Form scoresbefore and after treatment were 11.8 and 10.5,respectively.

These results are displayed in Fig. 4.

DiscussionThe women who attended an individual (one-to-one) appointment first had a greater difference inICIQ-UI Short Form pre- and post-treatmentscores (3.2) than those who attended a groupinformation session first (2.1).

The 21 women who attended an individual(one-to-one) appointment first were 11.4% morelikely to be cured. Fifteen (71.4%) of thesesubjects felt better (i.e. cured, greatly improved

or improved) compared to 17 (58.6%) of the29 women who attended a group informationsession first.

The reason for this difference is not clear.Grimshaw (2005) audited physiotherapy classesfor women with pelvic floor dysfunction, but feltthat it would be too difficult to do an audit onmedical improvement since there were so manyvariables in diagnosis, and in extent and type ofsymptom; therefore, the outcome of the patient’ssymptoms was not audited. Using the findings ofa limited literature review and informationgained from women’s health physiotherapists,Smith (2004) assessed the advantages and dis-advantages of groups. Again, there was no infor-mation on the outcomes of symptoms for thoseattending such a group.

Cook (2001) reviewed the evidence relating tothe group treatment of female UI, including theeffect of group treatment on the strength of thePFMs, bladder training and improvement ofpatient knowledge. Eight studies were identified,but it was concluded that there is a lack ofavailable evidence and that further research isrequired.

In contrast to the present audit, papers byDemain et al. (2001) and Janssen et al. (2001)found that individual and group treatments wereequally effective in improving female UI at 3 and9 months after treatment. However, it should benoted that subjects in the present audit who

Figure 4. Difference in pre- and post-treatment International Consultation on Incontinence Questionnaire – UrinaryIncontinence (ICIQ-UI) Short Form scores compared to subjective urinary incontinence treatment outcomes.

C. Jouanny


attended a group session first, then went on tohave individual follow-up and did not remainin a group for the duration of their treat-ment, which could account for the difference.Vestergaard (1997) aimed to compile guidelinesfor group sessions rather than assess the out-come of treatment for those attending a groupsession first versus an individual session first,and therefore, did not add to this discussion.

It is possible that those women who attended aone-to-one session first had more individualizedtreatment from the outset, which motivatedthem more and led to an improved outcome.However, since the women who attended thegroup information session were more likely to bereferred on, it is possible that the problems thatthey were referred with were more complex andless likely to respond to physiotherapy interven-tion in the first place.

In this group of women, although the numberswere small, a main complaint of UUI was thediagnosis with the most successful outcome.Fifty per cent were cured and this correspondedwith a considerable difference in pre- and post-treatment ICIQ-UI Short Form scores. It shouldbe noted that there were only six women withUUI, compared to 14 and 17 for SUI and MUI,respectively; success rates may have been differ-ent with a larger sample.

A systematic review by Hay-Smith & Dumoulin(2006) found that trials in women with SUI thatsuggested a greater benefit recruited a youngerpopulation and recommended a longer trainingperiod than the one trial in women with detrusoroveractivity (urge) incontinence. It would be use-ful to conduct a further audit to investigate thenumber of treatment sessions that women withSUI received compared to those with UUI, inorder see if this relates to the different outcomes.

Borello-France et al. (2006) reported a 67.9%reduction in the frequency of episodes of SUIfollowing PFM exercises (PFMEs), regardlessof the position adopted. In a review of anearlier cohort of women, Bø et al. (2005) foundthat 60% were almost or completely continent6 months after intensive PFM training,although this was not maintained 15 years later.Dannecker et al. (2005) found that self-reportedimprovement of incontinence symptoms was95% for women after an intensive andelectromyography-biofeedback-assisted PFMtraining programme. These more recent papersadd to the considerable body of evidencesuggesting that physiotherapy is a successfultherapy for SUI.

However, in a limited literature review, nostudies were found that directly compared theoutcomes for SUI versus UUI. This suggeststhat little has changed since Hay-Smith et al.’s(2001) systematic review, which concluded thatthe role of PFM training for women with UUIalone remains unclear.

Women with MUI had a considerable differ-ence in pre- and post-treatment ICIQ-UI ShortForm scores of 3.2, with 11 (64.7%) feelingbetter. However, there was a high onward refer-ral rate (n=4, 23.5%) for these women, whichimplies that physiotherapy treatment alone didnot make them sufficiently better. On furtherinvestigation of their records, more of thesesubjects had overactive bladders diagnosedon cystometrogram (after appropriate onwardreferral), and some also had prolapse as a sec-ondary diagnosis. From the difference betweentheir pre- and post-treatment scores, physi-otherapy would seem to have made these womenless bothered about their urinary symptoms.

In women whose main complaint was SUI,nine (64.3%) felt better after treatment, but thedifference in pre- and post-treatment ICIQ-UIShort Form scores was only 1.6. This could bebecause they felt better about their symptoms,even though the symptoms themselves were notmuch improved. In Hay-Smith et al.’s (2001)review of PFMEs versus no treatment, exerciseswere found to significantly improve self-reportedcure rates, and self-reported cure or improve-ment rates over 3–6 months, compared with notreatment. Cure or improvement rates in tworandomized controlled trials showed 62/78 (79%)with PFMEs versus 3/86 (3%) with no treatment.Other recent research, already cited above (Bøet al. 2005; Dannecker et al. 2005; Borello-Franceet al. 2006), has also suggested a higher cure/improvement rate than seen in the present audit.

Hay-Smith & Dumoulin (2006) undertook asystematic review and found 13 trials involving714 women (375 doing PFM training; 339 con-trols) that met the inclusion criteria, but only sixtrials (403 women) contributed data to theanalysis. Overall, the review provided some sup-port for PFM training as first-line conservativemanagement, but indicated that the treatmenteffect may be greater in younger women withSUI alone. The subjects in the current audit wereof varying ages and reported SUI as their mainsymptom, but it may be that other symptomssuch as urgency and frequency were still bother-some, and this was reflected by the ICIQ-UIShort Form score.



A usable measure to capture how patients feelabout their problem after treatment at the uro-therapy clinic would be useful. In the past, asmentioned above, the King’s Health Question-naire was used, and the present author also hasexperience of the Short Form 36 questionnaire,both of which provide greater detail about qual-ity of life. However, these tools are consideredtoo time-consuming for routine clinical practice,and despite various searches, a more suitablemeasure has not yet been found.

Other diagnoses were too infrequent to allowcomment on their treatment outcomes, or didnot involve incontinence.

The comparison of subjective outcomes withICIQ-UI Short Form scores did show a corre-lation: those women who felt that they had beencured had a greater difference (4.6) in pre- andpost-treatment scores on the questionnaire incomparison to those who only felt that they hadimproved (2.2).

The ICIQ-UI Short Form scores of thosewomen who received a one-off advice session(with or without a group information session aswell) demonstrated a difference in pre- and post-treatment ICIQ-UI Short Form scores of 3.3,implying that their symptoms were at leastgreatly improved.

In a literature review, Cook (2001) examinedthe theoretical framework of group treatment,and commented that the capacity for compari-son and support within a group reduces bothfeelings of isolation and the need for secrecy.This should make women feel better about theirsymptoms. Cook (2001) also noted that pre-training influences the effectiveness of groupintervention. All women attending the infor-mation group session first do receive a leafletdetailing why they have been invited and whatthe session entails. These factors could haveenhanced the outcomes of these women.

Keller (1999) examined the occurrence, atti-tudes and knowledge of UI among older womenin a rural setting, and concluded that ‘miscon-ceptions concerning the causes of and the avail-ability of treatment for incontinence [. . .] mayhave an impact on their decision to seek care forthis typically remediable condition’. Newman(2004) used a simple mail-in questionnaire tosurvey 1500 women with bladder control dis-orders; 422 responded. The survey concludedthat these women wanted more informationregarding incontinence. This should remind usthat the importance of giving women relevantadvice should not be underestimated.

ConclusionsOver 75% of women referred to the presentauthor’s urotherapy clinic improved afterattendance.

The ICIQ-UI Short Form reflects the subjec-tive outcomes of cured, greatly improved,improved and referred on, and it is recom-mended that its use should be continued as anoutcome measure for physiotherapy for UI.

It is also recommended that new versions ofthis questionnaire that are being developed asoutcome measures for vaginal symptoms andfaecal (anal) incontinence are used at the uro-therapy clinic, when available, and subsequentlyaudited.

The present author considers that manywomen with UI feel better about their problemafter being able to discuss it and understand itduring assessment and treatment at the uro-therapy clinic, but this is not well captured as anoutcome of therapy. Therefore, it is recom-mended that usable measures to record thisimportant outcome are explored and employed ifpossible.

The following subjective outcomes used needto be reconsidered:

+ ‘one-off advice session’ and ‘cancelled or didnot attend last session’ – those who attendeda one-off advice session did not attend theclinic again, meaning that their subjectiveoutcome could not be recorded, but this couldbe added to the letter accompanying theICIQ-UI Short Form sent out after discharge;

+ more consideration needs to be given to thesubjective outcomes of patients who arereferred on, many of whom feel better as aresult of the treatment they receive, but notbetter enough; and

+ there needs to be greater clarity as to whetherthe subjective outcome is recording the out-come for the treatment as a whole, or only theoutcome for the main complaint – this maybe where an outcome measure of perceivedbenefit would be useful.Therefore, it is recommended that the subjec-

tive outcomes recorded should be brought intoline with those now used at the PhysiotherapyDepartment, Jersey General Hospital, St Helier,Jersey, Channel Islands, as follows:

+ resolved;+ much better;+ improved;+ unchanged;+ worse;

C. Jouanny


+ physiotherapy not required (e.g. patient doesnot perceive any problem, incorrect referralor going privately); and

+ DNA – the patient did not attend (i.e. it can-not be judged whether they benefited or not).If the patient does not attend after their thirdsession, an outcome should be chosen fromthe first five listed above, based on subjectivechanges recorded in the Subjective, Objective,Analysis, Plan (SOAP) notes.

A more accurate record should be kept of thenumber of ICIQ-UI Short Forms sent out andthe number of those returned. Although it wouldbe difficult to follow up women who did notreturn their ICIQ-UI Short Form post-treatment, it would be interesting to know if theyfailed to return it because they were no betterand, therefore, demoralized, or if they were infact better and were too busy enjoying a betterquality of life to return the questionnaire.

Finally, it is recommended that, in futuretreatment outcome audits, the number ofappointments is recorded and analysed in rela-tion to outcome, in order to see whether womenwho attend more appointments have a betteroutcome or not.

These recommendations should be imple-mented by June 2006, after discussion with rel-evant parties, and there will be a follow-up auditin June 2007.

AddendumChanges have been implemented since thepresent audit was completed.

The ICIQ – Vaginal Symptoms questionnairehas been used with appropriate patients,although it is in long form, and therefore, moretime-consuming.

The subjective outcomes have been changed tocome into line with Jersey General Hospitalpolicy, and this certainly helps to reflect a moreaccurate outcome when a patient cancels or doesnot attend their last session.

A record is now kept of the number of ICIQ-UI Short Forms sent out and returned. Cur-rently, only approximately 50% of those sent outat discharge are returned, despite an addressed(though not stamped) envelope being included.

A usable measure to capture the ways in whichwomen feel better after gaining a greater under-standing of their problem is actively beingsought. There are many measures available, butnone have appeared more suitable so far.

Re-audit is due in June 2007.

AcknowledgmentsGrateful thanks go to Kerry Avery for herpermission to use the ICIQ-UI Short Form andher continued interest in its use in this setting,and to Nikki Gardener for her advice on thepresentation of this audit, as well as her contin-ued enthusiasm and support. My thanks alsogo to Yvette Dobin for sending out the initialquestionnaires, Gerard Dubras for his tech-nical assistance and Gill Brook for editing thepaper.

References

Avery K., Donovan J., Peters T. J., et al. (2004) ICIQ: abrief and robust measure for evaluating the symptomsand impact of urinary incontinence. Neurology andUrodynamics 23 (4), 322–330.

Bø K., Kyarstein B. & Nygaard I. (2005) Lower urinarytract symptoms and pelvic floor muscle exercise adher-ence after 15 years. Obstetrics and Gynecology 105 (5, Pt1), 999–1005.

Borello-France D. F., Zyczynski H. M., Downey P. A.,Rause C. R. & Wister J. A. (2006) Effect of pelvic-floormuscle exercise position on continence and quality-of-lifeoutcomes in women with stress urinary incontinence.Physical Therapy 86 (7), 974–986.

Cook T. (2001) Group treatment of female urinary in-continence: literature review. Physiotherapy 87 (5), 226–235.

Dannecker C., Wolf V., Raab R., Hepp H. & Anthuber C.(2005) EMG-biofeedback assisted pelvic floor muscletraining is an effective therapy of stress urinary or mixedincontinence: a 7-year experience with 390 patients.Archives of Gynecology and Obstetrics 273 (2), 93–97.

Demain S., Fereday Smith J., Hiller L. & Dziedzic K.(2001) Comparison of group and individual physio-therapy for female urinary incontinence in primary care:pilot study. Physiotherapy 87 (5), 235–242.

Grimshaw R. (2005) An audit of physiotherapy classes forwomen with pelvic floor dysfunction. Journal of theAssociation of Chartered Physiotherapists in Women’sHealth 96, 62–64.

Hay-Smith E. J. C., Bø K., Berghmans L. C. M., HendriksH. J. M., de Bie R. A. & van Waalwijk van Doorn E. S.C. (2001) Pelvic floor muscle training for urinary incon-tinence in women (Cochrane Review). In: The CochraneDatabase of Systematic Reviews, Issue 1. Art. No.:CD001407. DOI: 10.1002/14651858.CD001407.

Hay-Smith E. J. C. & Dumoulin C. (2006) Pelvic floormuscle training versus no treatment, or inactive controltreatments, for urinary incontinence in women(Cochrane Review). In: Cochrane Database of SystematicReviews, 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 effects of physiotherapy for female urinaryincontinence: individual compared with group treatment.British Journal of Urology International 87, 201–206.

Keller S. L. (1999) Urinary incontinence: occurrence,knowledge, and attitudes among women aged 55 and



older in a rural Midwestern setting. Journal of Wound,Ostomy and Continence Nursing 26 (1), 30–38.

Kelleher C. J., Cardozo L. D., Khullar V. & Salvatore S.(1997) A new questionnaire to assess the quality of life ofurinary incontinent women. British Journal of Obstetricsand Gynaecology 104 (12), 1374–1379.

Newman D. K. (2004) Report of a mail survey of womenwith bladder control disorders. Urology Nurse 24 (6),499–507.

Smith R. (2004) Advice groups for female patients withpelvic floor dysfunction. Journal of the Association ofChartered Physiotherapists in Women’s Health 95, 53–57.

Vestergaard A. (1997) Promoting continence in groupsessions. Journal of the Association of Chartered Physio-therapists in Women’s Health 80, 27–30.

Clare Jouanny is a senior physiotherapist special-izing in pelvic floor muscle dysfunction in Jersey,Channel Islands. She works both for the States ofJersey Health Service and in private practice.Clare is an ACPWH area representative and isalso a moderator for the ACPWH network oniCSP.

C. Jouanny




Executive committee response to Conferencediscussion groups

As is practice at each Conference, discussiongroups were held. Delegates were invited tojoin a small group facilitated by an executivecommittee member. The questions posed, thecomments made by members and a responsefrom the executive committee are given below.

Business planning working party

Should the Association set up a working groupto discuss business planning to help memberssecure funds for service development?There was a unanimous ‘yes’ in response to thisquestion, and a gratifying number of volun-teers said that they would like to be involved.Comments included the feasibility of usingInteractive Chartered Society of Physiotherapy(iCSP) and/or area representatives as a contactquery medium, and that there should be a real-istic approach to setting up and maintaining theservice. There was agreement that there shouldbe a risk-management approach.

Executive responseMembers’ comments will be taken to the nextexecutive committee meeting in January 2006for discussion about the best way to approachsetting up the working party.

What are the pros and cons of a move to abiennial conference?

1. Because of current financial restraints, lackof funding and time-off issues within theNational Health Service, the executive com-mittee wonders whether there is any benefit toholding our Conference every 2 years insteadof annually. This might maximize support andmake it better value for moneyThere was a majority in favour of retaining anannual Conference. This topic generated a greatdeal of discussion, and many general pointssurrounding 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 isgood 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

profile if there is no annual Conference andthat there could be a loss of members’ interestin their Association;

+ it is good to have the option of going everyyear, even if members are unable always toattend;

+ there would be a long time between Confer-ences if one is missed;

+ new members would have a long time to waitbefore getting involved;

+ the AGM could be held annually – only asmall body is needed to look at the constitu-tion between Conferences;

+ discussion groups are valuable annually; and+ for many, Conference is their only update for

portfolio/reflection.

General comments (most were not relatedto the original question, but reflect members’thoughts about Conference):

+ it means giving up a weekend;+ Conference could be divided into 2 days,

one obstetric and one gynaecological, anddelegates could choose which to attend;

+ many members have trouble getting time offwork;

+ a full Conference could be alternated with aone-day conference;

+ accommodation not included may be aproblem;

+ some members could cope with less-salubrioussurroundings;

+ the possibility of concentrating the Confer-ence so that members only have to stay forone night was raised;


+ the possibility that the cost of gala dinnercould be reduced was mentioned;

+ sponsorship could be obtained;+ some members find it difficult to get funding

for a ‘conference’ (could it be called some-thing else, e.g. a ‘study weekend?);

+ an application form to investigate fundingwas suggested;

+ the Chartered Physiotherapists PromotingContinence have single study days with a9.00 a.m. start, but these still require an over-night stay;

+ the iCSP and/or the ACPWH website forumcould be used to canvass opinions and findout the reasons for decreased attendance;and

+ a retrospective audit of those attending couldbe conducted.

2. Plans are already under way for 2007, so2008 could be the first year with noConference. However, 2008 coincides withour sixtieth anniversary, which the Associationwould presumably like to celebrate. What domembers feel? Should we have a Conferencein 2008 or celebrate our sixtieth in some otherway?Suggestions for 2008:

+ a 2-day Conference;+ do not hold it over a weekend;+ holding the Conference on Friday–Saturday

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 (isthe number applying in 2006 a ‘blip’?);

+ members will have to stay anyway, so theAssociation should have a 2-day conference;and

+ it would be a shame to miss our sixtiethanniversary in 2008, so Conference should goahead.

Executive responseMany differing issues have been raised. Theexecutive committee will consider all of themand decide how best to please the majority.

Acronym

There has been a suggestion that we shouldchange the name of our Association to reflectthe fact that some of our members treat menand children as well as women. The executivecommittee has discussed this at length andinvited comment from the membership prior toConferenceThere was a virtually unanimous ‘no’ to achange of name for our association, but somecomments were made:

+ there could be a subgroup for those who treatmen;

+ 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

women’s magazines (!); and+ it’s a local issue.

Executive responseThe executive committee is not in favour of aname change, and this view was reinforced byboth the vast majority at Conference and anumber of e-mails from members received priorto Conference. Therefore, the acronym willremain as ACPWH.

Annual Representatives Conferencemotion on dyslexia

If our motion is put forward in 2007 at theAnnual Representatives Conference (ARC), itshould read as follows: ‘Conference urgesCouncil to survey the membership, to identifyhow many are affected by dyslexia and toascertain from them how the Society can bestmeet their needs.’ Do members have furthercomments?Suggestions:

+ the British Dyslexia Association and DyslexiaInstitute should be contacted;

+ we need awareness of Equality and Diversitylegislation; and

+ CSP information packs for students.

General comments:

+ ask for CSP guidance (e.g. more time forwriting notes);

+ there are huge issues surrounding lack ofsupport 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 beaddressed;

+ three out of five people in one group had achild with dyslexia, and for two out of three,this had adversely affected their education;and

+ one staff member who is known to be dyslexicdoes not want any special treatment or allow-ances made.

Executive responseThe executive will ask our diversity officer totake the suggestions forward for action on behalfof the ACPWH, after further discussion at thenext executive committee meeting. This willhappen whether or not our motion is accepted atARC.

Papers in other journals

The Journal editor would like feedback onwhether the ‘Papers in other journals’ section,which is in each edition, is well received, ornot? If so, are there any other journals youwould like to see papers from listed in additionto, or instead of, those currently used?This section of the Journal is appreciated bymost members. The majority are very happywith Journal at present, especially the mostrecent edition.

Executive responseThe executive will pass on all the commentsreceived, plus the names of individuals wishingto help with ‘Papers in other journals’, to theJournal editor

Any other businessMany topics were raised, including the follow-ing:

+ Should we, as a women’s health association,be encompassing all aspects of women’s

health; for example, Ca breast and osteoporo-sis (future workshops?)?

+ The (previously unconfirmed) pelvic girdlepain lecture was removed from Conference,leaving little for obstetric-only physiothera-pists.

+ The ARC motion on the CSP guidelines fordomestic violence: if the CSP is not interested,then what about the ACPWH?

+ There has been either slow or no feedback onpoints that have been previously raised (e.g.electrotherapy and symphysis pubis dysfunc-tion guidelines).

+ It is a shame that courses are run withoutACPWH approval; for example, ACPWHapproval is needed for the 2-day musculo-skeletal course, and obstetric courses areneeded.

+ The iCSP very useful and very easy to access.The ACPWH website is also useful, but theiCSP forum is probably used more frequently.

Executive responseThe executive committee thanks members forraising so many valid points. One or two wereaddressed during the course of the Conferenceweekend. The remainder will be discussed bythe executive and there will be full response/explanation/update on the website as soon aspossible after the next executive meeting.

+ The most recent issue of the Journal wasexcellent.

+ The postgraduate courses are good.+ Thanks were given to the committee for their

time and the Journal.

Executive responseThe executive committee thanks members fortheir comments, which are much appreciated.

Ros Thomas

Executive committee response



Conference and course reports

Research Officers’ Study DayChartered Society of Physiotherapy,London, 19 May 2006The Chartered Society of Physiotherapy (CSP)hosted a study day for research officers (ROs)from each of the clinical interest/occupationalgroups (CI/OGs) in May 2006 and about 12groups were represented. The main aims of theday were to discuss strategies for the develop-ment of a research culture in the physiotherapyprofession, and also to help the CI/OGs toidentify the type of help needed to develop theirown research culture. It was an opportunity forCI/OGs to share information on differentapproaches/types of support for physiotherapyresearch. It was emphasized that a researchculture must be clinically driven, and ultimately,be for the patients’ benefit.

Much of the day was spent in discussing thenew National Physiotherapy Research Network(NPRN) and outlining its purpose. The NPRNwas set up in 2005 to support and encourageengagement in physiotherapy research. It is amutual support network involving a full rangeof research experience and interests. It supportsphysiotherapy research in different regionsthroughout the country and aims to develop aresearch culture in the workplace, particularly inclinical settings rather than the traditional uni-versity setting. There are 20 regional researchhubs, each one led by a senior researcher basedin a university, but with links to clinicians. Thisenables CSP members to tap into mentorship andresearch expertise in the region. You can accessinformation via the CSP website at: <www.csp.org.uk/director/effectivepractice/research/nprn.cfm>, or contact Dr Philippa Lyon, theNPRN research officer, at <[email protected]>.

We had to complete a strengths, weaknesses,opportunities and threats (SWOT) analysis ofour CI/OG’s research culture, and there weremany common themes across the groups. Thepoints most pertinent to ACPWH are summa-rized below.

Strengths:

+ the ACPWH is associated with postgraduatecourses that have a research culture; these arenow offered at Bradford and allow the oppor-

tunity for a full MSc, and thus, new membersof ACPWH should have more background inresearch;

+ the Association is a member of the inter-national women’s health group of the WorldConfederation for Physical Therapy and haslinks to international researchers;

+ it publishes a partially peer-reviewed journal;+ the ACPWH runs an annual conference that

presents some scientific papers; and+ it runs evidence-based approved workshops.

Weaknesses:

+ the isolation of workers in women’s healthmakes the generation of ideas and implemen-tation of research ideas difficult;

+ research among ACPWH members is limitedto a few people, although numbers are risingslowly;

+ the Association has only had a RO at execu-tive level for a short time (this was previouslya subcommittee post);

+ a research culture is not ‘built in’ to clinicalpractice in the way that it is in higher educa-tion; and

+ there can be some resistance to challengingcustom and practice within physiotherapy asa whole.

Opportunities:

+ we could make our Annual Conference morescientific by having some shorter science-based presentations and using the Conferenceto ask for poster presentations;

+ the RO should have strong links with theJournal committee;

+ we could increase bursaries to include thosesupporting research done by members;

+ we should produce a database of researchersin women’s health;

+ we should foster links with higher educationinstitutes to promote teaching of women’shealth to undergraduates; and

+ we should have a page dedicated to researchon our website.

Threats:

+ the current lack of resources in the NationalHealth Service (NHS);


+ a shift in culture of the NHS to paymentby results, and no mention of research anddevelopment;

+ many members of the Association qualifiedbefore the degree was available and so do nothave research background; and

+ there is some opposition from members.

This list is not exhaustive, but it gives a looseframework for the development of the role of theresearch officer.

Other items covered during the day includedthe development of CI/OGs’ newsletters andjournals to include evidence-based articles. Thissession highlighted the difference betweenCI/OGs, with some having a chatty, newsletter-style publication and others having a fully peer-reviewed journal. It was not suggested or agreedthat CI/OGs should move towards a totallypeer-reviewed journal, since CI/OG groupsare diverse. However, it was felt that CI/OGsshould be encouraging the publication of someevidence-based and research articles within thescope of their publication. As this already existsto some extent with the ACPWH Journal, I feltthat we were contributing to developing aresearch culture among our members, and thatwe were one of the leading CI/OGs with anemphasis on evidence-based practice.

There was a short presentation on accessingand sharing research training and developmentresources through the CSP and the NPRN, andmembers were encouraged to access the websitesof these two groups. Overall, the day had astrong emphasis on the idea that clinicians(rather than academics) should generate clinicalresearch questions, and it was demonstrated thatthere was support within the physiotherapyprofession for clinicians to develop a researchculture within their practice.

Yvonne ColdronResearch officer

The WellBeing of Women (WoW)Show – The Women’s HealthShow That’s Serious FunRoyal College of Obstetricians andGynaecologists, London, 8 July 2006WellBeing of Women (WoW) is a UK charitydedicated to the funding of research, and toraising awareness of all aspects of women’shealth across three areas: pregnancy and birth;quality-of-life problems (e.g. the menopause,

endometriosis, polycystic ovary syndrome andincontinence); and gynaecological cancers. If yourequire more information about the charity youcan log onto <www.wellbeingofwomen.org.uk>.

Last summer, the Royal College of Obstetri-cians and Gynaecologists (RCOG) kindly hostedThe Big Squeeze, part of the WoW campaign toraise awareness of urinary incontinence andother bladder problems, the importance of pre-ventative action, and the availability of effectivetreatments. The ACPWH was invited to takepart in this exciting event.

I have to admit that I expected hundreds ofwomen to attend, but unfortunately, that wasn’tthe case. This could be for two reasons. Onthe one hand, it is possible that not enoughmarketing/advertising was done to promote theshow; on the other, urinary incontinence is stilla taboo subject, and therefore, it is likely thatsome women still feel too embarrassed to openlydiscuss their complaint in an environment thatdoesn’t ensure their privacy.

We had a marvellous day in which we gaveadvice to a few women. All of them were verygrateful. We directed women towards their localwomen’s health physiotherapist, advised themon a variety of topics (e.g. constipation andprolapse), taught them how to do pelvic floormuscle exercises (PFMEs) correctly and weshowed them different gadgets. We had a nicestand with lots of information on it.

A few issues were raised by the women. Thereis a lot of information on stress urinary in-continence, but not enough on urge urinaryincontinence. Only a few had been offeredphysiotherapy as a first-line treatment. In fact,the majority of women did not know thatphysiotherapy could help them. Many were notsure what our treatment involved. Very fewwomen were doing PFMEs correctly. Some ofthe women had a concomitant prolapse andwanted to know more about that. We gaveinformation about the different types anddegrees of prolapse, and how PFMEs shouldhelp them.

Women were quite shy about coming to thestand, and some were asking for information for‘their friends’.

I think we did a fantastic job; it was a shamethat only a few women attended the show. Iappreciated the opportunity to be with two otherwomen’s health physiotherapists, Julia Mumanand Katie Jeitz – many of us tend to work onour own, so it was nice to share information andknowledge with Julia and Katie. The downside



was that attendance was so low. I hope that theshow will be better advertised in the future.

Paula Igualada-MartinezSenior women’s health physiotherapist

Royal London HospitalLondon

Pushy Mothers

Gladstone Park, London, July 2006

It was with great interest and, dare I say it,excitement that I attended my first PushyMothers session in Gladstone Park, a 5-minwalk from home, back in July 2006. At the time,I was about 8 weeks postnatal, following thebirth of my first baby, Chloe, and I was itchingto get going.

I found out about Pushy Mothers quite bychance. Judy DiFiore, one of the founders, hadcontacted 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 knewthat we run a postnatal class at RFH, andthought that we might be willing to inform ourpatients about the existence of Pushy Mothers.It actually proved to be the ideal opportunityfor me to do a bit of exercise, meet some othermums in the local area and do some professional‘spying’.

Judy set up Pushy Mothers earlier in 2006,along with her colleague Rachel Berg. Both aremembers of the Guild of Pregnancy and Post-natal Exercise Instructors, and are highly quali-fied fitness and exercise professionals. The ethosof Pushy Mothers is to provide a safe and uniquebuggy workout, focusing on core stability train-ing and cardiovascular fitness for new mums. AllPushy Mothers instructors hold a postnatal exer-cise qualification and have undergone a 2-dayPushy Mothers training course.

I have found Pushy Mothers to be good fun,and good exercise. The exercises are safe, func-tional and effective, and the classes are verysocial. It is wonderful to exercise in the open air,and to be able to take your baby along (theytend to sleep in the buggies, which is great!). Ourinstructor, Karen, is excellent, combining just theright balance of professionalism, motivation andhumour. I will not hesitate to recommend theseclasses to my patients when I return to work.

At the time of writing (September 2006),Pushy Mothers has really taken off in the parksof North London, and there are plans for it to

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

Cognitive Behavioural Therapy inthe Physical Health Setting

Manchester, 9–10 September 2006

This course was organized by physiotherapistChris Irving, and was led by Sister KarenHeslop, respiratory nurse specialist, and DrChris Baker, consultant psychologist.

Twenty-three physiotherapists and two occu-pational therapists attended. They worked in avariety of settings, including pain management,cardiac and pulmonary rehabilitation, mentalhealth, and urology.

Many therapists see their patients regularlyover a number of weeks, during which time theywill often discuss their non-physical problems.The aim of cognitive behavioural therapy(CBT) is to change unhelpful thought–feeling–behaviour patterns by experimenting with alter-native patterns of thinking and behaviour.

By applying the principles of CBT with someof my patients, I feel I can assist my patients tocope better, and I would recommend this as amost worthwhile course.

Geraldine BuckleySenior physiotherapist

Mercy University HospitalCork, Ireland

ACPWH Conference

Copthorne Hotel, Cardiff, 22–24 September2006

This year’s Annual Conference (Figs 1–15) washeld in the capital of Wales on a beautiful sunnyweekend. The theme, ‘Hormones to Happiness’,was chosen by the committee, and the aim wasto look at the holistic approach of the physio-therapist to women’s health. The age range ofdelegates meant that there was something foreveryone!

The opening speaker was Dr Annie Evans,who gave a fascinating presentation on the perilsof the perimenopause (see pp. 27–32). This gaveus the scientific reasons behind the changes



undergone by women. The evening closed witha presentation on domestic abuse and whatphysiotherapists need to know.

Saturday began with the opening of the tradestands exhibition and bookstall. Then MaryCronk (Fig. 2) delivered the Margie PoldenMemorial Lecture (see p. 39). She paid a warmtribute to Margie, and gave us a valuable insightinto the expertise of the midwife. This wasfollowed by a succession of fascinating presen-tation topics, including the management ofclotting disorders in pregnancy (see pp. 40–41),acupuncture and its use in women’s health (seepp. 21–26), the hormonal treatment of premen-strual syndrome (see p. 40), postnatal depression(see pp. 4–13), and breast screening (see p. 38).

A very pleasant evening was spent at the galadinner, where we sampled some Welsh cuisine,accompanied by music from a Welsh harpist.This was followed by presentations of certificatesfor the long Bradford course, and finally, thetransfer of the ACPWH chains of office from

Figure 1. Caron James of the Cardiff organizingcommittee with Dr Charlotte Fleming.

Figure 2. Chairman Ros Thomas with Margie Poldenlecturer Mary Cronk.

Figure 3. Michelle Gormley, winner of the MargiePolden student award, with Ros Thomas.

Figure 4. Dr Peter Collins with Carole Board, Cardifforganizing committee chairman.



Ros Thomas, the outgoing chairman, to PaulineWalsh.

Sunday began with a slideshow and a veryinteresting talk on sexually transmitted infec-tions (see pp. 39–40), followed by one of ourown women’s health physiotherapists, whodescribed research on the effectiveness of classesin the treatment of urinary stress incontinence(see p. 37). The conference drew to a close withtwo presentations considering motivation andcognitive behavioural therapy (see pp. 14–20and 33–36), which left us all with food forthought.

Special thanks go to all the staff of Fitwise, theconference organizers used to help us with thisyear’s Conference. They gave constant support

Figure 5. Mair Whittall thanks Professor John Studdand Jennie Longbottom.

Figure 6. Retiring executive member Sue Brook withRos Thomas.

Figure 7. Caron James with Debra Bick.

Figure 8. Jill Mantle, Ros Thomas and the RightHonourable the Lord Mayor of Cardiff enjoy a chatbefore the gala dinner.

Figure 9. Our friends from Slovenia, Lidija, Darijaand Gabrijela, enjoy a moment with the Lord Mayorand Lady Mayoress.



to our event both running up to and over theweekend. Very special thanks go to Blair King,who came down from Edinburgh and spent thewhole weekend with us, facilitating and coordi-nating the Conference.

From the Cardiff organizing committeeEveryone felt that the whole Fitwise team, led byBlair King, provided excellent support for ourevent. He acted efficiently as the coordinatorbetween us and his staff. Each member of eachteam had dedicated roles, which became moreapparent as we neared the Conference date andwas very useful in ensuring that all queries werebeing answered. He pursued all enquiries quickly

Figure 10. Ros Thomas with the Lord Mayor andLady Mayoress.

Figure 11. Mair Whittall and Dr Annie Evans.

Figure 12. Jeanette Haslam presents Romy Tudorwith her certificate for completing the Bradford con-tinence course.

Figure 13. The first words from the new chairman,Pauline Walsh.



and effectively, and was able to suggest realisticoptions when posed with problems such as keep-ing the overall cost below £300 and how to use

other accommodation to achieve this, givingdelegates an option to stay at cheaper hotels.Analysis of the evaluation forms (only 54 of the78 delegates attending filled in the form) showedthat 46% did stay at the Copthorne, and 44% ofthese were self-funding.

Sponsorship through trade stands proved verydifficult to achieve. It may be that the cost to thecompanies was too high in relation to thenumber of delegates attending, and this issueneeds to be addressed by future Conferenceorganizing committees (92% of the delegatesappreciated the trade stands and bookshop).

Delegates may not realize the importance ofthe trade stands, which provide a vital source ofincome that enables us to balance the books. Thebookshop donated 10% of its takings.

Finally, 67% of delegates completed the evalu-ation forms. Ninety-six per cent rated theConference above 4, with 81% giving it 6 outof 6, so we can call Conference 2006 a successoverall.

Carole BroadChair of Conference organizing committee 2006

(retired!)

Report from the winner of the Margie PoldenAward 2006Earlier this year, I applied to the Margie PoldenMemorial Fund for a place at the ACPWHAnnual Conference in Cardiff. In doing so, Iexpressed both my passion for women’s healthphysiotherapy, and my long-term goal to be partof a team that raises awareness of the manywomen’s health issues and decreases the chanceof women suffering in silence.

Thanks to Margie Polden’s family funding myplace and the ACPWH awarding it, I was able toattend the Conference. It could not have come ata better time. I graduated from Cardiff in July2006 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 Icould not wait to share with friends, colleaguesand future patients.

Throughout the 3 days, I met so many won-derful, like-minded women’s health physio-therapists from a broad range of organizations.They were full of positive advice and sup-port with regard to my current situation, andall encouraged my love of women’s healthphysiotherapy.

Figure 14. Ex-chairman Jill Mantle.

Figure 15. Linda Furness, health advisor.



I was never lucky enough to meet MargiePolden, but after attending the Conference, Inow have seen the impact that she has had onboth individuals and the development women’shealth. Those I spoke to who knew Margieshowed me by their actions that she is a much-loved legend and is greatly missed. They told methat she educated numerous physiotherapistsand professionals, and was renowned for inspir-ing student physiotherapists. How lucky I felt toknow that I am one of them.

There were 13 guest speakers over the 3 days,all of whom had the audience captivated andinspired. How refreshing it was to hear suchserious and worthwhile topics explained in suchsimple and effective ways, often laced withhumour, touching every person in the room,since we all know someone for whom this infor-mation would be of great help.

The conference had over 100 attendees,including junior physiotherapists, lecturers andmembers of the ACPWH executive committee.The gala dinner, breakfasts, lunches and breakswere excellent opportunities to meet with, andfinally put faces to, well-known names inwomen’s health.

In the present climate, when CPD is soimportant, I was surprised to hear about thefinancial implications that may affect the fre-quency of future Conferences and the levels ofattendance. To me, this weekend was pricelessbecause it encouraged physiotherapists to thinkoutside the box, embrace new concepts and letgo of old myths. It gives us the opportunity tomeet the living legends in women’s health, and tolearn about their own heroines, from whom weare still benefiting today.

Michelle Gormley

Vagina monologue from a ‘Conference virgin’The Annual Conference was greatly anticipatedat Saint Mary’s Hospital, Manchester, withmuch talk of gin and tonics, and gala dinners!Fortunately, I was able to sit comfortably in mychair this time round – in contrast to the otherACPWH courses I’ve attended this year, whereI’ve had to ‘de-robe’ for the benefit of practicallearning!

The highlight of the Conference, not countingthe hotel breakfast, was the Margie PoldenMemorial Lecture by the absolutely amazingMary Cronk. She spoke from a midwife’sperspective about issues of significance towomen’s health physiotherapists, including sym-

physis pubis dysfunction (SPD), and the un-necessarily high incidence of Caesarean sectionsfor breech presentation. As I rushed onto thematernity wards on the Monday morning afterConference, there were ‘ahs’ amongst the mid-wives as I spoke of the lecture – Mary’s a trueheroine.

The other lecture that particularly sticks in mymind is ‘The perils of the perimenopause’ byDr Annie Evans (see pp. 27–32). She spoke soconfidently about hormones, dispelling manycommon myths, and it was clear that mostknowledge had been gained as a direct resultof listening carefully to and caring for womenfor many years. I remember dashing up to myroom before dinner and phoning my mother,saying, ‘Mum, you really must get some ofthese oestrogen patches!’ – clearly, the answer toabsolutely everything!

Conference, in a word, was fantastic. I learneda tremendous amount and it was great beingamong. like-minded people. As a Conferencevirgin, I was made to feel so welcome – I madelots of contacts with colleagues from across thecountry and I’m looking forward to seeing youall again next year!

Hannah Gray

Master Class in AdvancedUrogynaecology

Royal College of Surgeons, London,2 October 2006The Advanced Urogynaecology Master Classwas constructed as a joint national project withthe British Society of Urogynaecology, theAssociation for Continence Advice, the Inter-national Continence Society and the ContinenceFoundation. Twelve patient case studies werepresented and discussed by a panel of six experts,including Mr Julian Shah (urology), Mr DudleyRobinson (urogynaecology), Mr Robert Freeman(urogynaecology), Ms Pauline Walsh (physio-therapy), Professor Mike Kirby (primary careand general practice) and Mr Ray Addison(specialist nurse). Professor Linda Cardozo(urogynaecology) acted as chairman to facilitateproceedings.

The whole day was a highly interactive exer-cise, and a wide range of difficult, unusual andproblematic clinical cases were discussed in thelight of the latest research. Mr Julian Shahplayed devil’s advocate, provoking great



responses from a very spontaneous audience,with excellent multidisciplinary input that chal-lenged delegates to think laterally and beyondthe scope of their own specialty. There were 60delegates in all, and physiotherapy was wellrepresented by Pauline Walsh, Eva Johnston,Victoria Muir, Ros Thomas, Riëtte Vosloo andShernaz Screwvala.

Case studies were presented with history andcharacteristics, followed by a discussion of inves-tigations and treatment options by the expertpanel, with participation from the audience.Consensus was sought on optimal clinicalstrategy. It was very interesting to hear thedifferences of opinion regarding appropriateinvestigations, surgical options and catheteriza-tion between members on the expert panel aswell as delegates. However, the patient’s bestinterest was always the highest priority in allconsiderations. The importance of making adiagnosis instead of treating a symptom-complex was highlighted throughout the day, aswas careful consideration of surgery in the viewof complications.

Multiple sclerosis (MS) proved to be a veryinteresting topic of discussion, since it is oftenpicked up in urodynamics clinics long before thepatient presents with other neurological symp-toms. The use of suprapubic catheters versusclean intermittent self-catheterization (CISC), aswell as the high cost of single-use catheters forCISC, and the need for it to be single use only,were valid points of discussion. The NationalInstitute for Health and Clinical Excellenceguideline statement that cranberry juice shouldnever be recommended to patients who sufferfrom MS also came into question. This recom-mendation is based solely on the lack of evidenceto support the potential benefit of cranberryjuice in the prevention of urinary tract infectionsin this specific patient group.

The pros and cons of tension-free vaginal tape(TVT) versus colposuspension and TVT versustransobturator tape were discussed in differentcase scenarios. The preferred use of autologoussling procedures in very young women (14–21years) with stress urinary incontinence wasvery interesting. There were also differences inopinion about whether Caesarean section wouldbe more protective than vaginal delivery follow-ing continence (or prolapse) surgery or not.

The use of botox for detrusor overactivity isstill very much experimental at this stage, andshould be explained as such to patients, togetherwith the relatively high risk of the need for

CISC after injections. The effect of botox is notpermanent, but wears off within 4–8 monthson average, and according to the literature,botox should not repeated more than seventimes.

A case study that was of particular interestwas a male patient who presented with bladdersymptoms following spinal manipulation forback and hip pain. This highlighted themusculoskeletal aspect that is often neglectedin the assessment of incontinence, raising con-cerns about the use of spinal manipulation,and its potential effect on bladder and bowelfunction.

Another area of concern was the policy for theuse of indwelling Foley catheters during vaginaldelivery. It is not uncommon for a catheter tocome out during delivery with the balloon stillinflated, as happened in one specific case studypresented. It would be very difficult to determinewhether urinary incontinence after delivery wasthe result of urethral sphincter damage causedby the balloon coming out inflated, or whether itwas related to the size of the baby, long secondstage of labour, pudendal nerve neuropathyor pelvic floor damage. However, the questionremained: should nursing protocols regardingthis issue be reviewed? Can an inflated catheterballoon cause real damage to the urethralsphincter? Should midwives or nursing staffbe expected to do regular intermittent self-catheterization to prevent over-distension of thebladder when they hardly have time to monitorthe mother and baby’s vital signs? Does the riskof over-distension because of a lack of careoutweigh the potential risk of an inflated ballooncoming out during delivery? Should the balloonbe deflated when the woman enters the secondstage of delivery?

Finally, no consensus was reached regardingthe use of hormone replacement therapy (HRT)to treat urogenital atrophy and its effect onincontinence or irritative symptoms. Current evi-dence indicates that HRT may have a negativeeffect on urinary incontinence, and the CochraneIncontinence Group meta-analysis (Moehreret al. 2003) was the only study that showedgreater improvement of symptoms in the oestro-gen group than in the placebo group. The overallimpression was that the prescribing of topicaloestrogen (with or without systemic HRT)should be maintained to treat urogenital atrophy,specifically if patients have overactive bladdersymptoms, but that more research into topicaltreatments is needed.



As a physiotherapist, I found the master classsession most interesting and learned a greatdeal from the different case studies discussed. Itgave me a much broader perspective on patientmanagement, and highlighted the importanceof multidisciplinary input and interdisciplinarycommunication. It is about the whole package!Physiotherapy, specifically pelvic floor muscletraining, was well supported, but also ques-tioned, by members of the expert panel as well asthe audience, but Pauline Walsh represented uswell. Provided that patients take responsibilityfor their improvement, are compliant with treat-ment and adhere to a regular exercise routine,physiotherapy could help to improve their qual-ity of life, and may even help to avoid, or at leastpostpone, surgery.

I would recommend such a master class to allphysiotherapists with an interest in women’shealth.

Riette Vosloo

Reference

Moehrer B., Hextall A. & Jackson S. (2003) Oestrogens forurinary incontinence in women (Cochrane review). In:Cochrane Database of Systematic Reviews, Issue 2. Art.No.: CD001405. DOI: 10.1002/14651858.CD001405.

An Introduction to Pilates inWomen’s Health PhysiotherapyBournemouth Hospital, Bournemouth,11–12 November 2006The pilot of this ACPWH workshop proved tobe an excellent course that all the participantsseemed to thoroughly enjoy. It was the perfectmix of theory and practice, with updates on allthe latest research. We were made to use our

brains and do short presentations, but withabsolutely no pressure or fear of ‘getting itwrong’. Here is a photo (Fig. 17) – weren’t wehaving fun!

Gail Stephens and Amanda Savage are greattutors, and we were lucky enough to have theother two tutors present, along with assessorsJudith Lee and Diane Stark, and workshopcoordinator Ruth Hawkes.

I would thoroughly recommend this course,not just as an introduction, but as an update forthose with previous experience of Pilates.

I hope that the ACPWH will grant approvalfor the workshop and it will be running in2007. Please contact Ruth Hawkes fordetails.

Ann DennisSolent Group area representative

The Unique Role of the Women’sHealth Physiotherapist inAntenatal ClassesChorley and South Ribble District GeneralHospital, Chorley, 2–3 December 2006The first weekend in December was dedicated tothe long-awaited and eagerly anticipated pilot ofthe ACPWH antenatal workshop, the overallaim of which was to evaluate the unique role ofthe women’s health physiotherapist in antenatalclasses. The 21 enthusiastic delegates who con-gregated in the physiotherapy department ofChorley and South Ribble District GeneralHospital – an excellent venue for any course –were met each morning by the wonderful aromaof steaming hot coffee and delicious Danishpastries! Our grateful thanks are extended tothe excellent organizational skills of MichelleHorridge!

The friendly and helpful course tutors, JudithLee and Maggi Saunders, professionally deliv-ered a tightly packed 2-day programme thatprovided a good mixture of evidence-basedtheoretical and practical sessions. These includedthe anatomical and physiological changesassociated with pregnancy, the complicationsand discomforts of pregnancy, and safe corestability exercises. Day 2 comprehensively cov-ered the stages of labour, along with copingskills physiotherapists can teach women andtheir birthing partners. These skills includedpositions for labour, relaxation and massagetechniques – wonderful!

Figure 17. Pilates class at the ACPWH pilot work-shop.



Many delegates commented on the advantagesof participating in the class planning scenarios.Networking with peers, exchanging informationand sharing practice was highly valued by boththe experienced clinicians and those relativelynew to women’s health services.

Overall, this informative and upbeat course ishighly recommended to all women’s healthphysiotherapists who are involved in the devel-opment and delivery of antenatal classes.

Delegates were left in no doubt about theunique and important role of the women’s healthphysiotherapist. However, it was recommendedthat physiotherapists work collaboratively withour midwifery and medical colleagues. Deliver-ing antenatal physiotherapy services withinan interprofessional teamwork culture shouldprovide the ideal opportunity for the truevalue of physiotherapy input to be more fullyappreciated.

[It is hoped that the ACPWH will grant approvalto this workshop in 2007 – Ed.]

Jane S. BrazendalePrincipal physiotherapistCentral Lancashire PCT

LeylandLancashire

A Functional Approach toAssessment and Treatment of thePelvic Girdle in Pregnancy andPostpartumGreat Western Hospital, Swindon,4 November 2006I was delighted to attend Yvonne Coldron’s daycourse on pregnancy-related pelvic girdle painbecause, although there are many courses onthe lumbopelvic region available, there are fewcovering the particular problems encounteredby women during pregnancy and thepuerperium.

Yvonne began the day with an overview of thebiomechanical changes associated with preg-nancy, followed by a discussion of the anatomyand biomechanics of the pelvic girdle, with ref-erence to her own research into the role of rectusabdominis and the effects of divarication onpelvic stability.

She has a wealth and depth of knowledgeabout these subjects, and the amount of infor-mation presented would benefit from a full

morning session rather than the allotted hour,but the day-course format required us to moveon rapidly to practical physical examination ofthe pelvic girdle. This included points of cautionand positional modifications required for theexamination of pregnant women, and aimed toachieve a diagnosis in terms of articular, myo-fascial and/or motor control dysfunction.

In the afternoon, Yvonne discussed and dem-onstrated practical techniques for the manage-ment of dysfunction of the symphysis pubis,sacrum and ilium, using articular techniques,myofascial muscle energy techniques, and in-hibitory and facilitatory techniques for musclebalance, followed by an opportunity to practice.I was familiar with many of these techniques, buttend to use only a selection of them clinically.Working through them practically with Yvonnegave me more confidence to apply additionaltechniques and understand their role in themanagement of pelvic girdle dysfunction. It wasvery helpful to see and practise some of themodifications that Yvonne uses for her pregnantpatients.

This was an informative and relevant day-course, but I feel – and I know Yvonne agrees! –that a 2-day course would allow for morereflection and practical time for the many strat-egies covered. However, for most participants,CPD funding (i.e. self-funding in most cases!)favoured one day rather than two. Perhaps afollow-up day in 6 months, to allow us to returnwith case studies and an opportunity to ‘trouble-shoot’ techniques/consolidate our knowledge,would be a viable alternative format.

Paula RiseboroughSenior physiotherapistRoyal United Hospital

Bath

Physiotherapy for PregnancyRelated Pelvic Girdle Pain

Great Western Hospital, Swindon,4 November 2006As a relatively new senior 2 in women’s healthphysiotherapy, I thought it would be a good ideato address all my questions about how to treatpregnant ladies suffering with SPD and sacro-iliac joint (SIJ) pain using more than just asupport belt, pelvic floor and core stability exer-cises. Yvonne Coldron’s aptly named study dayseemed the ideal learning opportunity.



Prior to attending the day, I was sent anexcellent information pack outlining the aimsand objectives of the course, the day’s timetable,and a reference list of two essential books toread. It looked a full and daunting day. Howmuch of the biomechanics was I supposed tounderstand prior to attending? It would havebeen easier for me to have a specific outlineabout how much to read. In the end, this was notsomething I needed to worry about!

The day consisted of an informal lecture-based introduction, and teaching of form andforce closure, and the impact of muscles andgait on the joints. It included pregnancy-relatedmusculoskeletal changes, terms, incidence andclassifications of the different types of SPD andSIJ dysfunction, and management of these con-ditions. It was nice to relearn and clarify somebasic knowledge about the joints and relate thisto new findings and evidence from Yvonne’sresearch. The environment was relaxed andopen, and it was good to talk to people in thegroup with varied skill mixes and experience.

The practical learning was very informativeand well structured, giving each individual a

chance to assess and practise treatment tech-niques on each other in small groups. The timeseemed to fly by too quickly to allow me toremember all the techniques, and I was tired bythe end of the session. There was a huge amountof information to cover in one go – this woulddefinitely be a course I would like to completeover 2 days if I had a choice.

The outcome of the day made me challengeand question my practice with regard to theemphasis put on the transversus abdominis whentreating divarication, at the expense of theimportance of the obliques and rectus abdominisfunction. I also newly learned about the alteredinfluence of the gluteal and adductor muscles onthe pregnant pelvis in relation to SPD.

Thanks to this study day, I feel more confidentin my ability to assess and treat manually thosepatients with pregnancy-related musculoskeletalpain. I look forward to reading Yvonne’sresearch to further consolidate my understand-ing of her assessment and treatment choices.

Alison Crocker




From your executive

Chairman’s reportHaving just returned home from a great Confer-ence in Cardiff, I should like to begin by thank-ing the Cardiff team, led by Carole Broad, fororganizing the event. They have had the un-enviable task of trying to attract delegates whohave little or no funding, but I hope those whomanaged to attend both enjoyed it and learned alot.

Those of you who were at Conference in 2005will remember that we periodically have toundergo the reaccreditation process to be recog-nized as a clinical interest group (CIG) by theChartered Society of Physiotherapy (CSP). Thisprocess requires us to be seen to fulfil five criteriaover a 5-year period. At Cardiff, I explainedbriefly how we have continued to fulfil thosecriteria.

Category 1: Continuing professionaldevelopmentDemand is high for the urinary incontinenceand anorectal workshops, and we are now devel-oping a treatment workshop to include bothconditions.

The Pilates and antenatal workshops will bepiloted in November and December 2006,respectively. If you are unable to access a course,or wish to organize one, please contact RuthHawkes, who is both the area representativecoordinator and the workshop coordinator (seeinside front cover).

Our postgraduate courses continue to bepopular. Achieving success in one of them con-tinues to be the main way of gaining membershipto the ACPWH, and three candidates receivedtheir certificates at the gala dinner.

Category 2: Influencing and informingRuth Hawkes and I had a useful meeting withmost of the area representatives in June 2006,and the task of disseminating information to allmembers nationwide is becoming easier andmore efficient. I am delighted that 14 out of 16areas of the UK are represented. With the retire-ment of Ann Johnson, Yorkshire is looking for anew area representative and Amanda Savage islooking for replacement in Cambridge. Thankyou Ann and Amanda for all you have done.

Giving and receiving awards is always a goodway to gain attention for the ACPWH. AtConference, the Margie Polden Student Awardwas presented to Michelle Gormley, who, co-incidentally, has just graduated from Cardiff. Ihope this Conference has inspired her to con-tinue her interest in women’s health (see p. 59).

Interactive CSP (iCSP) has finally launched,and after a shaky start, seems to be a great success.Our own iCSP moderators came to Cardiff toprovide some familiarization for some delegates.

Our website continues, although it remains tobe seen how it will evolve alongside iCSP. Theexecutive committee will monitor its use. Pleasecontinue to place your adverts on it for coursesand study days.

Many of us continue to work with other,‘outside physiotherapy’ organizations. Recently,we were approached by the Royal College ofObstetricians and Gynaecologists to peer reviewa new document on the assessment, surgery andtreatment of third- and fourth-degree anal tearsin childbirth.

Gill Brook continues to act as the treasurerof the International Organization of PhysicalTherapists in Women’s Health (IOPTWH),and next year, we both hope to represent theACPWH at the World Confederation for Physi-cal Therapy conference in Vancouver, Canada.

Two representatives will be attending theCIGs’ conference in November. Representativesfrom each CIG are eligible to go, and it is usuallya rewarding weekend. The Annual Represen-tative Conference (ARC) was cancelled in 2006,but our motion will be reconsidered for inclusionin 2007 and I have a team of keen people readyto attend on our behalf.

These two conferences are open to any of you,so please contact the honorary secretary if youare interested.

Category 3: Promoting physiotherapyWith more members than ever and, therefore,more voices raising awareness about what we do,women’s health issues are becoming generallymore talked about. You will read in publicrelations officer Ann Mayne’s report below thatwe are continually bombarded by requests forcomments on various aspects of women’s health


for inclusion in newspapers, magazines andradio programmes. We do our best to respond toas many of these requests as possible, but thereport is often required almost immediately andit is very difficult for many of us to find time inthe middle of a working day.

A group of us went for media training inLondon, and the guidance we produced isavailable from your area representatives or thewebsite.

Some of you will know that Fit for Mother-hood has been reviewed and replaces the originalversion. The Pregnancy-Related Pelvic GirdlePain leaflets, one for health professionals andone for patients, are scheduled to be printed bythe end of 2006. These replace the old symphysispubis dysfunction (SPD) leaflet, which has notbeen available for some time. We are hoping toget the production and printing of our patientleaflet sponsored so that it will be free, but inthese cash-strapped times, we can only wait andsee. All our leaflets sell well, and again, raise thepublic face of the ACPWH in what I hope is apositive and professional manner. Once the newpublications are all in stock, we will begin thereview of our other leaflets. These have remainedat the same price since we started with Fit forMotherhood in 2000. Since the postage andpackaging rates changed radically last month,Ralph Allen Press are revising their entire cost-ings so please refer to the ACPWH website andthe back page of the Journal before makingan order. Tidy’s Physiotherapy has also beenreviewed this year, and many ACPWH membershave contributed to part of a chapter or writtena whole one.

Category 4: Quality assuranceThe education subcommittee (ESC) handles somany of the tasks that take time to achieve.Currently, it is updating and reviewing many ofour documents. My thanks to the committeemembers for all their hard work.

By monitoring articles in the press, and bybeing selective about who we speak and giveinterviews to, it is possible to maintain qualityassurance and high standards of reporting.

The Journal continues to go from strength tostrength and could probably be included in eachof the categories I’ve mentioned. The standard isever higher, so my thanks to Gill Brook forcoordinating her team so efficiently.

Diversity issues are few in number, but it isgood to know that we have a trained individualon the executive to manage any that might arise.

Category 5: Research and clinicaleffectivenessWork continues to evolve the role of the researchofficer both in terms of facilitating research andadvising on clinical governance issues (see p. 68).

Believe it or not, we are still attempting toproduce guidance for electrotherapy duringpregnancy and labour. It is an ongoing project,but rest assured, the executive and the ESC willnot be giving up until it is resolved.

We have been massively involved with theNational Institute for Health and Clinical Excel-lence this year. Work continues with the urinaryincontinence and the faecal incontinence guide-lines. We have been consulted recently on theantenatal guideline review and the antenatalmental health guidelines. Our comments on theintrapartum guidelines were not accepted.

If anyone is interested in being more involvedin key areas of the ACPWH, such as with theJournal, archives, CIG conference, ARC, joiningthe executive or belonging to non-committeegroups for small tasks that come up from timeto time, then please speak to me or one of theexecutive committee – we really would love tohear from you.

As always, I would like to acknowledge thehard work done by many people. They arethe members of the executive, the members ofthe ESC, the members of the Journal subcom-mittee and the area representatives, who all givea great deal of time and commitment to theACPWH. I cannot name you all, but you knowwho you are.

So, as I come to the end of my 3 years aschairman, I reflect on the achievements andexperiences we have had during my term ofoffice. I am sure it is every departing chairman’swish to pass on an Association that better meetsthe needs of not only its members, but also itswider stakeholders – patients, other health pro-fessionals and, indeed, the general public. Thiswould be a wonderful legacy for me. One of mypersonal aims was to involve more of theyounger members and I am delighted that fourhave been nominated this year for election to thecommittee. This is a tremendous start and I verymuch I hope the trend will be continued. I haverecently worked hard to appoint an administra-tor to provide help and support by tackling someof the routine day-to-day activity, leaving theexecutive to concentrate on what it was electedto do. I hope this will make a tremendousdifference to us all and you will be updatedregularly during the probationary period.

From your executive


We have five members leaving the executivethis year.

First, Sue Brook, who has, during her 6 yearsof service, been willing, reliable and alwayscheerful, even when tasked with being the min-utes secretary.

Secondly, Trish Evans, who has served for4 years, most recently as book and leafletsecretary.

Thirdly, Alex Welman, who also served on theexecutive committee for 6 years, and latterly, hastaken on the enormous task of membershipsecretary. During this time, she has also sat onthe ESC, and has been a reliable and helpfulmember, contributing an enormous amount.

Fourthly, Rachel Grubb was appointed assecretary soon after joining the executive andthen became treasurer 2 years ago. Although thisis not a popular job with anyone, she has tackledit cheerfully and effectively. Rachel has beenlevel-headed and sensible throughout, andalways quick to respond to important issues.Both Alex and Rachel will be leaving their postswhen the new administrator has got to grips withthem.

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 leaflet secretary and chairman, and isnow retiring as Journal editor. She continues astreasurer to IOPTWH. We owe her an enormousdebt of gratitude for all she has done for theAssociation. She has led us admirably and is themost laid-back person I know, happily takingthe ‘p’ out of panic for me on many an occasion.

I thank all five of them for their massivecontributions and support; they will all be sorelymissed.

Your next chairman, Pauline Walsh, waselected at Conference 2006 in Cardiff and Iformally handed over the chains of office at thegala dinner. I know Pauline will make a splendidchairman and I wish her every success leadingthe ACPWH onwards for the next 3 years.

I have found my 3 years at the helm of theAssociation challenging and enjoyable, bothfrustrating and rewarding, but most of all, it hassimply been a pleasure to work with and forso many lovely people, many of whom havebecome firm friends. I am looking forward to thenext challenge of Journal editorship and hope Ican continue the good work which Gill hasimplemented so well.

Ros Thomas

Treasurer’s reportThis will, I hope, be my final report as treasurer.As I outlined to those of you who were atConference 2006 in Cardiff, our associationcontinues to grow, and with it, the workload ofcommittee members. This is a concern not onlyto the ACPWH, but also to other CIGs. For thisreason, the executive committee has decided topilot 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 existingfunds and will be reviewed at the end of oneyear. The membership will be kept informed viathe website and mailings, and of course, will begiven notice if this is likely to have an impact onannual subscriptions.

Association funds remain reasonably healthy.Our income and expenditure are largely the samefrom year to year, and I am confident thatACPWH funds can sustain the cost of adminis-trative support in the short term. I am equallysure that this will be a very positive change forthe association that will be of benefit to themembers.

Rachel Grubb

Membership secretary’s reportTotal membership stands at 722 as of 1 October2006 (Table 1).

As I write this, I am in the process of handingover to Blair King at Fitwise Management Ltd.

I have thoroughly enjoyed my time as yourmembership secretary and the time I have spentworking for the ACPWH. I have particularlyrelished welcoming new members into theAssociation, and in the 3 years that I have beenyour membership secretary, this has amountedto over 200 new members! I have also thor-oughly enjoyed helping members of the publicfind a specialist women’s health physiotherapistin their local area.

Table 1. Membership of the ACPWH as of 1 October 2005

Membership type Number

Full 316Affiliate 298Associate 55Honorary 6Retired 47

Total 722

From your executive


However, the ACPWH has now become solarge that the time has come to amalgamate themembership secretary’s and treasurer’s roles intoone, and for the administration of the Associ-ation to be all under one roof. By the time youread this, Fitwise should be at the helm.

Alex Welman

Public relations officer’s reportThe ACPWH continues to work closely with theCSP press office and public relations officer,Prabh Salaman. We had a busy time early in theyear and during the summer months with mediainterest in several women’s health issues. Localand national newspapers and several magazinespublished articles, and all gave our websitedetails, resulting in many requests from thepublic asking for more information.

A project, run by WellBeing of Women(WOW), about stress urinary incontinence andpelvic floor muscle exercises (PFMEs) kept usbusy throughout the spring and summer. Anation-wide survey of 1232 women about theirknowledge regarding bladder problems andPFMEs came out, with some very interestingresults and statistics. Unfortunately, WOWrefused to give the ACPWH permission to useany of the data, even though the Association hadplayed a major part in designing and writing thequestionnaire.

In July, WOW organized ‘The Big Squeeze’road show, which was held at the Royal Collegeof Obstetricians and Gynaecologists in London.Unfortunately, the event was not well organizedand publicity leading up to the event was poor.Very few people attended and the day was verydisappointing. However, thanks must go to JuliaMuman, Katie Jeitz and Paula Martinez, whobravely looked after the ACPWH display standfor the day.

Please do get in touch with me if you see orhear about interesting women’s health stories inthe media. A big thank you goes to memberswho have helped with media events and inter-views during the past year. We need to raise ourprofile still further during 2007.

Ann Mayne

Education subcommittee reportThe ESC has been hard at work since the lastJournal and are delighted to report that the newFit for Motherhood leaflet is now available. It has

been produced as a result of the foresight of itsinitiator, Alex Welman, who has carried the flagwith the rest of the committee until its finalpublication. We do all hope that you will find ituseful. This leaflet is also going to be adaptedand published to make it suitable for thosewomen who sadly have a stillbirth or neonataldeath. We hope that this will also become avail-able in the near future.

The Pregnancy-Related Pelvic Girdle Pain leaf-lets (previously known as the SPD leaflet), onefor the use of health professional’s and the otherfor patients, are now in their final drafts andshould be available very soon.

The ACPWH-approved workshops areincreasingly popular. Please do visit the Associ-ation website frequently to ensure that you don’tmiss out on any that you may wish to attend. Irecommend that you book early since many ofthem are fully booked quite quickly. However,we did have to cancel the psychosexual work-shop because of insufficient applicants. We thinkthis may be a result of its higher cost. Peoplehave also commented that they are finding itincreasingly difficult to get time off work tostudy; however, most workshops are at week-ends. At present, we provide workshops on:

+ pelvic floor assessment and examination forurinary incontinence;

+ pelvic floor assessment and examination foranorectal dysfunction;

+ an introduction to Pilates in women’s healthphysiotherapy; and

+ the unique role of the women’s health physio-therapist in antenatal classes.

If you want to organize a workshop in yourarea on any of these subjects, just let me orworkshop coordinator Ruth Hawkes (see insidefront cover) know.

Another ongoing project is that of formulat-ing an advice leaflet for professionals on the useof transcutaneous electrical nerve stimulation(TENS) in pregnancy. It has been proposed thata patient information leaflet should then bewritten when this is completed.

We are also pleased to report that there hasbeen successful cooperation between theACPWH and the Chartered PhysiotherapistsPromoting Continence to produce a pelvic floorleaflet for AGILE, the special interest group forthe elderly. They are to launch it later in theyear. Julia Herbert is to speak on behalf of theAssociation at the AGILE session at the CSPconference.

From your executive


There have been 15 successful candidates onthe University of Bradford continence coursethis year. We offer them all our heartiest con-gratulations and look forward to seeing more ofthem in the future.

Jeanette Haslam

Research officer’s reportEarlier this year, I attended a research officers’study day at the CSP, and information from thatday is reported separately (see pp. 52–53). How-ever, there was much publicity about the launchof the National Physiotherapy Research Net-work (NPRN). There are now 20 regionalresearch hubs in the UK and Ireland, and Iattended a meeting of the South East hub, partlyin my capacity as the research officer for theACPWH, but also as a clinical physiotherapistwith an interest in research. The meeting wasat the University of Brighton (Eastbourne),and participants came from both the academicand clinical sectors. The content of the eveninglargely consisted of group discussion about theway forward for the hub, as well as discussionregarding the scope and problems of clinicalresearch. The CSP members at the meeting wereenthusiastic about the way that research couldbe undertaken in a clinical setting. It was recog-nized that academic support may be necessary,and the Physiotherapy Department at theUniversity of Brighton is keen to be involvedwith clinicians.

The South East hub is an active organizationand meetings are arranged every 3–4 months.These regional meetings are open to all CSPmembers who have an interest in research – youdo not have to be involved in active research toattend. I found the meeting to be very supportiveof clinicians who had had very little experienceof research.

If you wish to know more about your localresearch hub or the NPRN, you can accessinformation via the CSP website <http://www.csp.org.uk/director/effectivepractice/research/nprn.cfm> or contact Dr Philippa Lyon, NPRNResearch Officer at <[email protected]>.

I have continued to lead the productionof two evidence-based, peer-reviewed, multi-professional leaflets on pregnancy-related pelvicgirdle pain (PGP) (encompassing both symphy-sis pubis and sacroiliac dysfunction). One leafletis aimed at health professionals involved withante- and postnatal care (including physiothera-

pists, midwives, health visitors, general prac-titioners and obstetricians), and the other isaimed at women who have experienced PGP.These leaflets are in their final review stages andwe hope to have them printed by the New Year.

I have continued to support the ESC and weare meeting TENS experts in October to reviewour current policy on TENS in pregnancy.

I have received many queries from membersand non-members about various issues relatingto research, and this makes for some interestingdiscussion. However, for general discussionabout matters relating to women’s health, iCSPis a good resource and I would encourage thosemembers who would like to explore wider issuesto sign up! The process is easy – just access theCSP website and follow the instructions.

For 2007, I am concentrating on developingthe role of the research officer, and shall beparticularly exploring issues around researchbursaries, development of a research page on ourwebsite and gaining information on currentresearch activity from members.

Yvonne Coldron

New executive committeemembersBecky AstonAfter qualifying as a physiotherapist from theUniversity of East London (UEL) in 1997, Iembarked on a junior rotational programme atthe Royal Free Hospital in London. It wasduring this period that I was lucky enough to begiven the opportunity to attend a 3-day courseentitled ‘An introduction to women’s health’,and followed this with a 4-month women’shealth placement. Since then, I have specializedin women’s health, moving to St George’sHospital in London, where I completed theBradford course and became a full member ofthe ACPWH. I moved to the HomertonHospital in East London in 2002 as a senior Iphysiotherapist, and then a clinical specialist. Ihave recently returned to work after maternityleave and embarked on a 2-year research fellowpost, investigating different aspects of pelvicfloor dysfunction and service design models.

I have been a member of the Association since1999 and a full member since 2001. In 2001, Ijoined the ACPWH Journal subcommittee andhave been an active member, responsible for the‘Papers in other journals’ section (see pp. 97–103). Furthermore, I have lectured on women’s

From your executive


health issues at an undergraduate level at UELsince 2003. I feel that it is important to contrib-ute to an Association which supports us asmembers in our clinical work. I hope to bringenthusiasm and motivation to the ACPWHexecutive.

Becky Aston

Katie MannLike many of us, pelvic floor physiotherapy fellupon me by accident, having followed my basicpostgraduate experience in the usual way (Fig.1). I qualified from Salford in 1989 and joinedSouthport District General Hospital. A ‘returnto work’ course in Exeter after the birth ofmy son reintroduced me to the pelvic floor. Ithen went on to complete the first ACPWHcontinence course in 1996.

After several years developing the Physio-therapy Pelvic Floor Clinic, I am now clinicalspecialist at Southport and Ormskirk Hospitals,with some private work at the local Capiohospital.

I currently treat men and women with pelvicfloor dysfunction, and work closely with theurogynaecologists and nurse specialists of ourtrust. I am a clinical supervisor and regionalgroup mentor for the ACPWH course, and havebeen involved in research with Jo Laycock. I aman active participant in the Mersey region, imple-menting the government’s Integrated Continence

Services White Paper. I teach postgraduate nursesat Edge Hill College and undergraduate midwivesat Aintree Hospital, and I am often asked to givetalks at various courses and meetings.

I look forward to the challenge of being amember of the executive committee of theACPWH. I can offer 13 years of experienceworking in the field of pelvic floor dysfunction. Iwish to actively promote the role of physio-therapy in this area and support the work of theAssociation in continually developing nationalquality standards.

Katie Mann

Lesley SouthonI have spent many years working in musculo-skeletal departments both in England, Scotlandand Norway. I started dealing with continencepatients about 6 or 7 years ago in a part-timecapacity as part of my musculoskeletal caseload,and then about 4 years ago, I was fortunateenough to transfer to work in the KingfisherClinic in Norwich, which is a multidisciplinarycontinence clinic, our core team comprising ofphysiotherapists and nurses.

I completed the UEL’s graduate continencecourse in 2004 and have acted as a mentor thisyear for the new Bradford continence course. Ihave just written a chapter for the second editionof Therapeutic Management of Incontinence andPelvic Pain edited by J. Laycock & J. Haslam,which is scheduled to be published this year,entitled ‘The athletic woman/women and exer-cise’, based on my group’s presentation duringthe UEL course. I am presently involved ina research project with a medical student fromthe University of East Anglia’s medical school.This will look at various aspects of the patient’sjourney and care whilst treated in our clinic.

I was keen to stand for the ACPWH executivecommittee because I would like to become moreinvolved in the continuing development of theAssociation. I foresee that it will be challenging,but think that the role for the ACPWH isever-increasing and it is an exciting time to beinvolved.

I believe that any membership group is only asgood as its members and that everyone has aresponsibility to input into that group in someway. I hope that I will be able to be involvedparticularly with the aspects of integrated conti-nence care that are constantly evolving in manydifferent ways throughout the country.

Lesley SouthonFigure 1. Katie Mann.

From your executive


Gail StephensI am a physiotherapist, working in both primarycare and the private sector, who specializes inmen and women with continence problems, andalso pelvic girdle pain (Fig. 2).

I qualified from Keele University in 1999,and worked at Addenbrooke’s Hospital inCambridge, becoming more interested inwomen’s health before relishing the opportunityto work within primary care in the ContinenceService as the sole physiotherapist in 2003. Iwork closely with continence advisors runningjoint clinics across Cambridgeshire whilst con-stantly striving to improve the service offered topatients within primary care.

I am actively involved in audit and research,and I am a tutor on the ‘Introduction to Pilatesin women’s health’ ACPWH workshop. I amregularly asked to teach and lecture at local andregional events, and have published articles innational journals as well as local publications. Icompleted the UEL continence course in 2004.

I firmly believe in a good work/life balance,since this is fundamental to performingefficiently and effectively at work and play. So,when I am not a physiotherapist, I am a Brownieand Guide Guider. Through Girlguiding UK, Ihave been involved in promoting sexual healththrough PFMEs, and bladder and bowel health.I strongly believe that organizations such asGirlguiding UK and the ACPWH should be

forward-thinking, and adapt to a progressiveNational Health Service and changing society.

Gail Stephens

Fitwise Management LtdSince Conference 2006 in Cardiff, we have madegreat progress in acquiring administrative assist-ance for the executive committee. We have de-cided to pilot using the services of FitwiseManagement Ltd, which is based near Edinburgh(Fig. 3). Fitwise already manages our conferencefor us, and its involvement with ACPWH hasnow been extended to include management ofthe membership database, our finance andaccounts, and distribution of our stock of booksand leaflets.

Some of you will be familiar with Blair King,one of the directors, who attended the Cardiffconference with Lynn Ward. Sandra Rees is ournew financial manager and Gillian Reid man-ages the membership database. Details of how tocontact Fitwise are given on the inside frontcover.

We are doing our best to ensure a smoothhandover to Fitwise, and the benefits to the execu-tive’s workload are already becoming obvious.

We will continue to have nominal posts for thespecific roles of treasurer (Doreen McClurg),and book and leaflet secretary (Clair Jones). Ifyou have any concerns during the handover

Figure 2. Gail Stephens.

Figure 3. Ros Thomas on a flying visit beforeChristmas to the Bathgate headquarters of theFitwise 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 mem-bership database), Sandra Rees (ACPWH accountsand finance), Anne Ross (sales of trade exhibitionspace) and Lynne Martin (general administration).

From your executive


period, please contact Doreen or Clair, or forgeneral concerns, contact the secretary, JuliaBray, so that we can deal with issues as theyarise.

There will be another update on the success ofthe enterprise in the Autumn 2007 Journal and

at Conference. ACPWH funds will cover theadministrative costs for the coming year and theexecutive will look carefully at any impact onsubscription levels in the future.

Pauline Walsh & Ros Thomas

From your executive



Round the regions

Channel islandsThe audit on ‘Assessing outcomes of urinaryincontinence treatment using the InternationalConsultation on Incontinence Questionnaire –Urinary Incontinence Short Form’ is publishedin this issue of the Journal (pp. 42–48)! Therecommendations have been implemented andre-audit is scheduled for the middle of 2007.

The next audit on the agenda is the CharteredSociety of Physiotherapy Standards, and we areplanning to do this across women’s health.

Our obstetric service review is still on theboil – these things always seem to take longerthan first thought – and we will soon be trainingthe first line of midwifery care assistants todeliver one-to-one pelvic floor advice to newmums who are at low to medium risk accordingto the PromoCon Pelvic Floor Risk AssessmentTool. This should free up some time to spendwith high-risk women and antenatal care.

Clare JouannyArea representative

E-mail: [email protected]

LondonIn April 2006, Elizabeth Emerson and LindaBoston delivered a talk on ‘Incontinence in theathletic woman’ on behalf of the East Englandgroup. This presentation was part of theirGraduate Certificate in Professional Develop-ment in Health Continence at the Universityof East London. It was a fascinating review ofthe literature on incontinence in the elite athletethat revealed a high level of urinary and faecalincontinence. Urinary incontinence is prevalentin gymnasts and athletes, a possible cause beinga predominance of type 3 collagen in the connec-tive tissue, resulting in a hypermobile urethra.Low oestrogen levels, combined with increasedtype 3 collagen fibres, and the repeated physicalforces generated by repetitive jumping, longjump, running, gymnastics and trampolining, areconducive to urinary incontinence, trampoliningproducing the greatest incidence of urinaryincontinence in girls aged 15 years. Faecal in-continence in long distance runners is notuncommon (30–60%). With her reasoning skillsand knowledge of physiology, the women’s

health physiotherapist is well placed to assistathletes to optimize the muscular aspect of thecontinence mechanism, and take part in healthpromotion activities with athletics coachesand fitness instructors. This was an excellentevening.

In June, we hosted a study day at Hammer-smith Hospital on ‘The perinatal pelvic girdle:a functional approach to assessment and treat-ment’. The course tutor was Dr YvonneColdron. She ran an excellent day that gave usan opportunity to practise our musculoskeletalskills in order to enable us to examine, manageand treat pelvic girdle problems in ante- andpostnatal women. We revised the physiologicalchanges in pregnancy, had the altered bio-mechanics of the spine and pelvic girdleexplained to us very clearly, discussed the poss-ible aetiology of these pains, and were shownmanual techniques and exercises for the pelvicgirdle in pregnancy and following delivery. Itwas a lot to absorb in one day, but a much-needed course for those of us who see andtreat many patients with symphysis pubisdysfunction/pelvic girdle pain (SPD/PGP) inpregnancy. Thank you, Yvonne.

I will be retiring in March 2007, and I amlooking forward to finding a successor who willcontinue to provide the London group withinteresting and stimulating study days and work-shops, keeping the Margie Polden thirst forknowledge in women’s health alive.

Avril HillyardArea representative

Email: [email protected]

North EastOver the past year, the north-east group has hadtwo evening meetings. In November 2005, asmall group attended a very interesting talk by amidwife on optimal foetal positioning, and theprogrammes offered to mums and their families,at the large regional hospital in Newcastle uponTyne. We did not meet again until June, whenthe same small group brought journal articlesfor discussion. We agreed to try a new formatand held a successful afternoon meeting inSeptember. Lunch was provided by the LyrinelXL representative. We used the session to report


on Conference 2006 in Cardiff and the Londonscientific updates in urogynaecology. We alsoviewed the video on erectile dysfunction, post-micturition dribble and urinary incontinence,and decided that we would next meet in the NewYear, topics to be arranged. I asked for volun-teers for area representative.

In February 2006, we hosted the ACPWHanorectal assessment and treatment workshop inNorth Tyneside. The enthusiasm of lecturersJanette Haslam and Julia Herbert was evident,and the practical session was conducted in a verysensitive yet helpful manner. The demonstrationof anorectal physiology tests by the consultantwas extremely helpful. The course evaluated verywell and ended with the participants feeling theneed for a further workshop on physiotherapytreatments for continence problems. Is anyone inthe region interested in hosting this?

Emilie NesbitArea representative

E-mail:[email protected]

Northern IrelandWe in Northern Ireland are presently undergo-ing a period of change.

The consultation on the Review of PublicAdministration has looked at reforming theHealth and Personal Social Services structure.From April 2007, the new structure will bemade up of fewer (i.e. five) trusts, which we hopewill create new opportunities to integrate ser-vices across the existing hospitals in the longterm.

Furthermore, many of us have been workingwith our other professional colleagues on intro-ducing Integrated Clinical Assessment andTreatment Services to Northern Ireland. Alongwith the Agenda for Change, these seem to becausing us a lot of headaches.

To keep our spirits up, we all met at the end ofSeptember 2006 for a half day to hear a well-presented, very informative talk on hormonereplacement therapy and the menopause by DrRaymond White. We also planned for the yearahead. Doreen McClurg was elected as chair-person, with Caroline Hackney stepping down.Gail Allen was elected as treasurer, with PaddyMullan stepping down. Lorraine Johnston hasagreed to stay on for another year as secretary.We would like to thank the girls for their helpand to congratulate Doreen on the successfulcompletion of her doctorate.

Two introductory weekend courses on urinaryincontinence and faecal incontinence are beingrun for less-experienced senior staff and juniorsinterested in women’s health by the ContinuingProfessional Development (CPD) Centre in early2007.

We also plan to run a study day in March2007 on overactive bladder. Speakers are cur-rently being sought.

Thamra AytonArea representative


ScotlandThe Scottish branch meeting took place on26–27 October 2006. Eighteen physiotherapistsattended the weekend and there was a waitinglist to get on the course! All interested membersgot places and then we opened it up to out-patients colleagues. It was lovely to see so manyyounger physiotherapists, and we had two newgraduates on their first rotations, which were inwomen’s health (we hope they will be futuremembers). The course even persuaded two col-leagues to travel from the Western Isles to themainland, and one member made the 8.30 a.m.start from Inverness.

The course was run by Helen Thomson, aphysiotherapist in private practice who isinvolved in women’s health. She has a down-to-earth approach to outpatients, and with herwealth of experience, guided us through thesacroiliac joint, coccyx, lumbar spine, ribs anddiaphragm with her insights into the relation-ship between musculoskeletal dysfunction andcontinence. Helen gained everyone’s respect bydemonstrating on two pregnant ladies. One ofthem said, ‘I think you’re a white witch. I feelbrilliant!’ At the end of the course, I askedeveryone if they would be interested in learningmore and all 18 put their hands up! I take it fromthis that we had a successful meeting! I recom-mend other members to think of inviting Helento talk at your meetings.

Our next meeting will be in the spring andit will be a day course. The venue and timehave still to be arranged. You must be fed upof coming to Wishaw, so come on, I need avolunteer!

I also need someone to think about taking onthe area representative role next year.

Elaine StruthersArea representative


Round the regions


South EastAt the time of writing in October 2006, nomeetings have been held this year so far becauseof a lack of response to requests for speakers andvenues (we have had only one reply), and staffbeing very overstretched. The next meeting isplanned for November 2006, and will include atalk from a consultant urologist from Brightonon bulking injections, feedback from Conferenceand arrangements of further meetings.

Five members from the region went to Con-ference this year. Romy Tudor received hermembership of the ACPWH following comple-tion of the University of Bradford PostgraduateContinence modules.

Our plan for the next 6 months is to gettogether in November to find ways of maintain-ing interest in regional meetings, and to try toencourage more input from the whole of theSouth East region. Offers of speakers and venuesare very welcome!Susannah Staples, Debbie Joice, Romy Tudor &

Nadine RangerArea representatives

E-mail: [email protected] [email protected]

South MidlandsAt our Autumn 2005 meeting, Simon Jackson,consultant urogynaecologist at the JohnRadcliffe Hospital in Oxford, started the early-morning session by giving us an overview offemale continence problems and the treatmentsavailable. Simon is very supportive of conserva-tive therapies and is always happy to help uswith our CPD. The talk was followed by ademonstration by Mike Morter, representingDiagnostic Sonar Ltd, in which he showed uswhat a real-time ultrasound machine can do,using himself as a model.

The session was rounded off by Nicole Tudor-Williams, one of our senior physiotherapistsat the Women’s Centre, who has been veryinvolved in an SPD/PGP audit currently beingundertaken in Oxfordshire. The results of theaudit were presented, and this was followed by apractical demonstration of manual techniquesthat may be used on women with pelvic ringpathology in the child-bearing year.

Twenty-one delegates attended and it waspleasing to see how many physiotherapists are

new to the speciality. The only complaint wasthat we ran out of time – we could have easilyfilled the whole day.

At our next meeting, in May 2006, we listenedto an experienced urogynaecology nurse, SueLarner. She explained to us how urodynamicinvestigations are carried out and then inter-preted graphs pertaining to various bladderproblems. A review of the anatomy of theabdominal corset made us put our thinking capson, and then we broke up into smaller groups todiscuss the physiotherapeutic management ofweak abdominal musculature in different clientgroups. Finally, we had an informal sessiondiscussing when physiotherapy interventionsmay not be appropriate.

Linda BostonArea representative


West LondonThere are various groups in the West Londonarea, meeting regularly in Wiltshire, Gloucester-shire, Bristol and Ascot. The Wiltshire Grouphave recently completed work on a matrix ofpriorities for women’s health and continencework that we developed as a local tool to usewith managers questioning why we are (or arenot) doing certain jobs that might come withinour remit (this is particularly useful where thereis scant evidence). They are also completing asurvey of the benefits of splints for carpal tunnelsyndrome in pregnancy.

At the time of writing, our planned study daysare ‘A functional approach to assessment andtreatment of the pelvic girdle in pregnancy andpostpartum’ with Yvonne Coldron on Saturday4 November 2006 at the Great Western Hospi-tal, Swindon (see pp. 62–63), and ‘Physiotherapyfor bone health’, an osteoporosis study day withMeena Sran on Saturday 1 December 2006 inSwindon.

We plan to run more local study days or halfdays, so please contact me with your suggestionsor if you want to be e-mailed about upcomingevents.

Ruth VidalArea representative


Round the regions



Area representatives 2006–2007

In response to requests from members, the following table details the area representatives and how tocontact 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 shouldbe addressed to her at Dunston House, Dunston, Lincoln LN4 2ES, or sent by e-mail to<[email protected]>.

Name Contact details Area and postcodes Start date

Thamra Ayton Northern Ireland July 2005


Linda Boston South Midlands: OX November 2004 Shared: HP, MK, RG


Carole Broad Wales October 2004


Lynne Coates South West: PL, EX, TA, April 2005 TR, TQ

E-mail: [email protected]/[email protected]

Ann Dennis Solent: PO, SO, BH, GU, June 2005 DT


Gillian Hawkins Midlands: B, CV, HR, June 2005 NN, TF, WR, WS, WV, DY


Avril Hillyard London: UB, WD, EN, August 2004IG, RM, AL (retires March Shared: HP, MK 2007)E-mail: [email protected]

Michelle Horridge Manchester: PR, BL, LA, September 2002 BB, WN, L, WA, SK, M, (looking for CA replacement)



Name Contact details Area and postcodes Start date

Clare Jouanny Channel Islands: October 2003 JE, GY (to continue for further year)

E-mail: [email protected]/[email protected]

Emilie Nesbit North East: NE, DH, August 2000 SR, TS, DL (looking for replacement)

E-mail:[email protected]

Nadine Ranger South East: BN, RH, TN, August 2004(see SusannahStaples below

CT, ME


Maggie Saunders Trent: NG, S, LN, DN October 2004 Shared: LE, DE


Susannah Staples South East: BN, RH, TN, Maternity cover(covering forNadine Ranger’smaternity leave


CT, ME

Elaine Struthers Scotland June 2003


Ruth Vidal South: SN, BA, BS, GL November 2004 Shared: RG

E-mail: [email protected]/[email protected]ást.nhs.uk

– – East Anglia: CB, NR, Vacant positionCO, SS, PE, CM, SG, IP

– – Leeds: LS, WF, YO, HD, Vacant positionHX, HG, HU, BD

Area representatives 2006–2007



PhD thesis reports

Multiple sclerosis and lowerurinary tract dysfunctionCoincidence? Referrals of a specialist naturewith little evidence to point to effective treatmentand the opportunity to undertake researchwithin this population: a combination too goodto miss or a nightmare scenario? I will leave you,the reader, to be the judge.

As a senior physiotherapist working in gynae-cology and urology, referrals had been receivedconcerning 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 Ulsterhad been awarded a substantial grant by the MSSociety of Great Britain and Northern Ireland toundertake research into the relief of symptomswithin this population, and bladder and/orbowel dysfunction was one of the proposedstudies. I applied, was accepted and took a3-year career break.

The first few months were spent reviewing theliterature. This was a time of adjustment: insteadof thinking about patients and hospital life, thecomputer seemed to devour my time. At the endof the day (and many evenings), it was some-times difficult to say what you had done andthen it always seemed to be the articles that youwanted most that had to be ordered. An outlineproposal had already been approved by theUniversity’s Ethical Committee, so that scenariowas negated; however, amendments were dis-cussed, discussed again and approved. A prag-matic pilot study to establish the efficacy ofphysiotherapy interventions within such a neu-rological population was proposed. Honorarycontracts were established, outcome measuresreviewed and training in urodynamic proceduresundertaken.

Everything was in place, but what about somepatients? Consultant neurologists, MS specialistnurses, continence advisors and colleagues allhelped with recruitment. Advertisements werealso placed in relevant charity magazines and Iwas able to attend the meetings of thesecharities – one of the most enjoyable aspects ofthe 3 years was the appreciation shown thatsomeone was taking the time to come and talk

about what is still a taboo subject. Recruitmentwent well. There were some disappointments,but 9 months later, 30 participants had com-pleted the 9 weeks of treatment, and the 16- and24-week follow-ups.

Then came the dreaded statistics – a newlanguage – and the many drafts of the firstpaper, culminating in its acceptance for publica-tion, another milestone. The first and secondseminars were stressful times, but there weresome good laughs with fellow students, andcoffee became an addiction (it could have beenworse). A trip to Vienna, Austria, to present atan International MS conference was a high – thethought of the ice cream is making my mouthwater while writing this.

Based on the results of the pilot study, adouble-blind randomized controlled trial (RCT)was undertaken to further establish the use ofphysiotherapy modalities within this populationand to evaluate if the additional benefit that wasdemonstrated in those who received electricalstimulation was real or placebo. Seventy-fourparticipants were recruited and were seen at 12centres throughout Northern Ireland. A full yearwas devoted to this study, involving many longhours of travelling and organization. Duringthis time, I had a car accident – a wooden palletfell off an oncoming skip and smashed mywindscreen – but thankfully, I had no seriousinjuries. (I also got caught speeding on my wayto an assessment clinic, and the eldest of our fourdaughters was married!) Again, one of the mostspecial things about this study was the oppor-tunity to meet many lovely people with suchdiverse and sometimes severe disabilities. Therewere ups and downs, but eventually, all wererecruited; and then, almost unbelievably, all theassessments were completed. The statistics andwriting up was so much easier the second timearound, but the added pressure of the comple-tion date was also looming. Submission was a bitof an anticlimax because it was still difficult torelax. Then came the viva, an experience not tobe repeated.

Was it all worth it? Would I do it again?Would I advise allied health professionals toundertake a PhD? These are all questions that Ihave been asked. The answer to all is probably a


yes. It may sound inane, but I did it to try toimprove the continence services for people withMS, and I hope that the benefits will be tangible.Locally, a direct referral system has been estab-lished whereby MS nurses, consultant neurolo-gists and rehabilitation physiotherapists can allsend us patients, and we hope to establish multi-disciplinary classes for those who have beennewly diagnosed. Part of the content of theseclasses will include information on good bladdermanagement, as well as on rehabilitation andother aspects of treatment.

I would probably do it again. The learningcurve was steep, but I did things, such as pre-senting, travelling and meeting people frommany different walks of life, that I would nothave done otherwise. If someone was contem-plating undertaking a PhD and asked my advice,I would say that you should consider it carefullyand make sure that it is something you are reallyinterested in. At times, I felt that the worlds ofacademics and of clinicians were very different,and it is of paramount importance that youhave a good working relationship with yoursupervisors. As someone once told me, a PhDbecomes your extra ‘baby’, and just like a baby,there are good and bad times, and it can bedifficult to extricate yourself in order to have afamily life. Then, at the end, it can feel likeleaving the child at the school gate with amixture of sadness, relief, pride and exhaustion.

The results of the pilot study have been pub-lished in McClurg et al. (2006). The results of theRCT are about to be submitted for publication.

Doreen McClurgClinical specialist physiotherapist

Belfast City HospitalBelfast

Reference

McClurg D., Ashe R. G., Marshall K. & Lowe-Strong A. S.(2006) Comparison of pelvic floor muscle training, elec-tromyography biofeedback and neuromuscular electricalstimulation for bladder dysfunction in people with mul-tiple sclerosis. Neurology and Urodynamics 25 (4), 337–348.

Characteristics of abdominal andparaspinal muscles inpostpartum womenI have often been asked why I decided to do aPhD and how I decided what to investigate. Myappetite for research was whetted when I dida Master’s degree in 1993 and I was lucky to

work with a renowned muscle physiologist DrOlga Rutherford in her laboratory at St Mary’sMedical School, London. I considered going onto study for a PhD after this, but an opportunitydid not present itself immediately.

However, in 1995, I was working as a lecturer/practitioner at Brunel University and KingstonHospital in London with a specialist role as amusculoskeletal physiotherapist when I met thedynamic Sarah Murdoch, who, at the time, wassenior 1 in women’s health. I became interestedin her work with pregnant and postnatal womenwith low back/pelvic girdle pain, and we dis-cussed, examined and treated many womentogether. At the time, studies on motor controlof the abdominal muscles were a new and fast-changing musculoskeletal physiotherapy prac-tice. I wondered whether this new approachwould be of benefit to Sarah’s clients, and wetried different strategies with varying degrees ofsuccess. I realized that very little was knownabout the actual physiological changes to theabdominal muscles during pregnancy and post-partum, and therefore, if we were going to userehabilitation strategies for abdominal musclesin the ante- and postnatal periods, it would bepreferable that we understood the changes thatoccurred during pregnancy.

I changed jobs and was fortunate to be giventhe opportunity to do a part-time PhD, fundedfor 3 years, at St George’s Medical School,London. Naı̈vely, I thought it would be doneand dusted in 3 years whilst working part-time:lesson number one, part-time working extendsthe total length of the project. I also got married6 months into the project, which added to someof the delay! I decided to study the characteris-tics of abdominal and multifidus muscles in post-natal women in order to inform future studiesfor clinical practice. Therefore, the project wasregistered in the field of ‘neuromuscular physi-ology’ at the University of London. I decidedthat I would use real-time ultrasound imagingto study abdominal and multifidus muscle size,plus electromyography (EMG) to study (1) fati-gability and (2) recruitment of these muscles inresponse to trunk perturbation.

I had to start from scratch: designing theproject, finding willing supervisors, getting ethi-cal approval (a mammoth task), applying forfunding for equipment (begging, borrowing andstealing equipment, if necessary!), learning howto use new equipment and doing a pilot study.This took over 12 months to accomplish, andthere were many setbacks but also a few golden

PhD thesis reports


moments. A rheumatologist, Dr (now Professor)John Axford, agreed to be my official internalsupervisor and offered me office space in hisdepartment. Professor Maria Stokes very kindlyagreed to be my scientific supervisor. She hasalways been 100% supportive, and I am sograteful for all her advice and knowledge.

During my first few months, I put the pro-posal together and it was approved by the ethicscommittee. I had been promised use of an ultra-sound scanner, but it did not materialize, and Irealized that my project was in jeopardy. Enterthe second person who was to keep me saneduring the next 2.5 years: Katy Cook is a special-ist ultrasonographer in the foetal medicinedepartment at St George’s and she was allowedto work with me for half a day a week. Katyworked hard to ensure that I had access to anultrasound machine, and with her help, I gainedaccess to the postnatal wards. I applied for,and was given, funding by the Medical Schooland the ACPWH (the Dame Josephine BarnesBursary) to purchase an EMG machine andaccessories. I was given further financial help bythe ACPWH during my write-up time and I amvery grateful for the support given to me by theAssociation.

During the next few months, I undertook apilot study using both ultrasound scanning andEMG in order to establish the methodology forthe full study, and recruited a small sample ofnulliparous female controls and day 1 postpar-tum women. Part of this pilot study determinedthat the size of the multifidus did not differwhether ultrasound imaging was performed inprone or side-lying (Coldron et al. 2003). Thiswas important to determine because breast-feeding women could not easily lie prone.Measurements of ultrasound imaging of the fourabdominal muscles and lumbar multifidus wereshown to be reliable from intra- and inter-raterreliability studies.

I had to learn to use the EMG apparatus andprogramme the computer to analyse the results.This was a steep learning curve! I was lucky thatProfessor Di Newham agreed to be my secondscientific supervisor, and with her help and thatof the technical representative of the EMGcompany, I learned to use the EMG equipment.Di Newham helped me to develop the exercisesto measure fatigue and motor recruitment, andat the end of the pilot study, we realized that weneeded more equipment to determine the forceoutput of a maximum voluntary contraction(MVC) of the abdominal muscles and, thus,

calculate the percentage force output necessaryto induce fatigue during a one-minute sustainedcontraction. Professor Stokes worked at theRoyal Hospital for Neuro-disability, London,and with the help of their mechanical workshopengineers, we devised a testing chair. This chairallowed two restraining straps to be attached tostrain gauges to record force output whenwomen performed an MVC of the abdominalmuscles. Sixty per cent of the MVC value wasused for the fatiguing one-minute contractionand the EMG signal was recorded. Trunk per-turbation exercises in standing were adaptedfrom those of Hodges & Richardson (1996), andagain, the EMG signal was recorded.

All PhD students registered at St George’s,University of London, are required to undertakea transfer viva to go from MPhil registrationto PhD registration. This comprised writing asummary of my pilot studies (10 000 words) andundertaking a viva – all good preparation forthe real thing! I undertook this successfully 12months after registering for the PhD, but 18months into my funding.

From then on, it was all systems go to collectmy data before the funding ran out. At thispoint, I was lucky to gain semi-permanent accessto a room in the School of Physiotherapy whereI could store my equipment (by that time, I hadaccess to an ultrasound machine) and testwomen at later stages postpartum. (I continuedto test day 1 postpartum women on the post-natal wards.) It was decided to make my designmainly cross-sectional, and for the next 18months, I recruited women at day 1, and at 2, 6and 12 months postpartum. Some of thesewomen attended on more than one occasion andformed the small longitudinal part of the study.I also continued to recruit nulliparous femalecontrols of childbearing age. One of the joys ofthis project was meeting so many women whovolunteered willingly to undergo the ultrasoundscanning and participate in exercise that fatiguedtheir abdominal muscles. I became an expert injuggling a baby with one hand and operating thecomputer mouse with the other!

I left St George’s after 3 years, and decidedthat I would quickly analyse my results and writeup within the year whilst working part-time asa clinician. Another lesson: data analysis andwriting up a doctoral thesis take much longerthan one thinks. Life traumas, including theprolonged illness and subsequent death of myfather, problems with my own health, my hus-band’s redundancy, returning to full-time work,

PhD thesis reports


and moving house, meant that I submitted over2 years later. However, this was still well insidethe submission time since part-time studentshave 7 years in which to submit.

During these years, I relied on my husband,Tim, who looked after and supported me (I havetotally forgotten how to cook!), and I wouldadvise anyone thinking of undertaking a PhD tolook for support outside of work and discussthings fully with their family. One of the mostunsupportive things anybody can say during thiswriting up time is, ‘Haven’t you finished yet?’In order to do a doctoral thesis, one has to beprepared to give up evenings, weekends andholidays for many years, and this is something toconsider when embarking on such a project. Theviva was a trial, and fortunately, did not have tobe repeated. I passed with some revisions andwas finally awarded the doctorate in 2006.

I learnt that doing doctoral study is muchmore than just answering the original researchquestion. It is a journey through the researchprocess, learning about writing a proposal, pre-senting before an ethics committee, recruitingsubjects, gaining access to and learning how touse complicated measuring tools, reviewing lit-erature, analysing spreadsheets full of data, andwriting scientifically. These aspects of researchall have value for future studies. The results ofmy study were interesting, although not neces-sarily those that might have been expected. Ihope that, once further papers are publishedfrom the thesis, others may be encouraged toundertake study into appropriate postnatalabdominal exercise or other aspects of postnatalphysiotherapy.

Life after a PhD is mainly one lived with asense of relief that it is finished, but there are stillpapers to be written and presented at confer-ences. The results of one experimental chapterare currently in press (Coldron et al. 2007).

Would I recommend others to do a PhD? Ithink it was worth it because I learnt so muchnot only about postpartum abdominal andmultifidus muscle characteristics, but also aboutthe research process. However, it can be a lonelyprocess, and it requires stamina and tenacity tofinish a thesis. Studying for a PhD fits moreeasily into the academic way of life than intothat of an National Health Service department,but maybe that is because we are still a youngprofession in research terms and we have not yetmanaged to find many ways in which researchcan be incorporated into clinical practice. Foranyone considering undertaking doctoral study,I would advise that you need to love the subjectsince it will be with you for a very long time. Ialso know that I could not have undertaken orcompleted the PhD without the full supportof Professors Stokes and Newham, so I wouldadvise that your choice of supervisors is para-mount. I hope that I will have scope to use mynew research skills in the future in order toinform evidence-based clinical practice. I wouldhate all the effort to go to waste!

Yvonne ColdronResearch officer

References

Coldron Y., Stokes M. & Cook K. (2003) Lumbar multi-fidus muscle size does not differ whether ultrasoundimaging is performed in prone or side lying. ManualTherapy 8, 161–165.

Coldron Y., Stokes M. J., Newham D. J. & Cook K. (2007)Postpartum characteristics of rectus abdominis on ultra-sound imaging. Manual Therapy 12, in press.

Hodges P. W. & Richardson C. A. (1996) Inefficientmuscular stabilization of the lumbar spine associatedwith low back pain. A motor control evaluation oftransversus abdominis. Spine 21, 2640–2650.

PhD thesis reports



Visit to the UK

I am an Austrian physiotherapist specializing inwomen’s health and pelvic floor re-education.Having worked in this field for 12 years, I tookthe opportunity to share and improve myknowledge with colleagues by starting lecturingcourses for pelvic floor re-education in 1999.While presenting my results at the World Con-federation for Physical Therapy Congress inBarcelona, Spain, I got to know Gill Brook andTeresa Cook from the UK, who helped me toamend my lectures.

The European Union offers the opportunity toundertake working experience in other countries,and so I planned a 9-week trip to the UK, duringwhich I would spend each week in a differenthospital, shadowing physiotherapists specializ-ing in the field of women’s health and inconti-nence. Gill helped me to find 10 different placeswhere I could shadow staff. This was a verydifficult job: in some places, some staff were onholiday, and others wanted me to pay for myobservation. Gill was a great help and it isthanks to her that I could put this project intopractice.

I started my visit in London, where I observedthe treatment of patients with constipation whowere taught defecation techniques with JulieDuncan, Brigitte Collins, Lorraine O’Brien andTrish Evans at St Mark’s Hospital. I receivedlots of the assessment sheets and folders that areused there. I also had the opportunity to see adefecating proctogram, an examination of thecolon transit via X-ray, and a manometry andultrasound examination.

After St Mark’s, I spent 2 weeks in Hammer-smith Hospital with Avril Hillyard, YasmineRansome, Janine Shaw, Rachel Keeling and SusiCook. This gave me an opportunity to see workon the wards, pre- and postnatal classes, andindividual treatments of women with inconti-nence problems or prolapse. I also attendedgynaecological surgery and a Caesarean sectionof twins. Avril made it possible for me to par-ticipate in a study day with Jeanette Haslam inAscot, where I got to know 20 other physio-therapists working in the speciality.

My next stop was the world-famous GreatOrmond Street Hospital children’s hospital,where I had the opportunity to follow the treat-

ment of children with bladder or bowel prob-lems. Brid Carr, Laureen, Caren and Kathlooked after me there. I saw two videouro-dynamics, and attended clinics for outpatientsand the weekly meeting of all the doctorsspecializing in that field, where they discussdifficult cases.

After this, I went north to Manchester, whereI spent a week in St Mary’s Hospital with AnnMayne, Michelle Horridge, Courtney Gum,Hanna Gray, Lisa Roberts and NicoleNeedham. It was interesting to see more wardwork and outpatient treatments. I also spent aday shadowing Gordon Hosker, a world-renowned research fellow, who showed me man-ometry, ultrasound and pudendal nerve latencytests for patients with faecal incontinence.

I then visited Cumbria (Fig. 1), where I spent4 days with Jeanette Haslam. It was fascinatingto look at her private library, as well as see howshe organizes her lecturing and finds relevant

Figure 1. Elizabeth Pulker with a couple offriends.


papers when needed. In the lovely countryside ofthe Lake District, I had long and interestingtalks with Jeanette about her years of experiencein lecturing and about carrying out studies.

My next stop was Bradford Royal Infirmary,where I spent 3 days shadowing colleagues, andthis gave me the opportunity to thank GillBrook personally for all she had done for me. InBradford, I met Stephanie Knight again (we hadpreviously met at an International ContinenceSociety conference), and I got to know DianneNaylor, Helen Bryer and Pauline Bibby, whom Ishadowed as they carried out pelvic floor re-education with outpatients. I observed Stephanieperforming urodynamics as a physiotherapist,something that would not be possible in Austriabecause it is only carried out by doctors.

After this, I went back to London and theWillesden Centre of Health and Care, where Ispent a week with Lizelle Miller, a South Africanphysiotherapist who only works with out-patients. She showed me how to carry out peri-neal ultrasound for biofeedback. I saw it in useon patients, and we had the opportunity to try iton our own. It was fascinating for both myselfand for the patients.

I then went up to Scotland where I spent aweek in Glasgow with Julie Lang in the VictoriaInfirmary and Diane Stark in the Southern

General Hospital. Observing Julie, I saw manytreatments performed on patients with anorectaldysfunction, and with Dianne, I found out aboutthe pelvic organ prolapse qualification – a studyin which Dianne is involved – which gave me abroader understanding of the scope of our workas physiotherapists.

I spent my last week with colleagues in twodifferent London hospitals: Charlotte Lion andWendy Harper, who work in the Chelsea andWestminster Hospital showed me their workon the wards and with outpatients; and PaulaMartinez and her colleague Emily Hoile showedme their work in the Royal London Hospital.

In my 9 weeks in the UK, I got to know a totalof 46 physiotherapists working in many differentways with pelvic floor re-education. I returnedhome with new ideas and enthusiasm for mywork. I was very well looked after, and besideslearning better English, I got to see a lot ofthe beauty of the UK and made many newfriends.

Elisabeth PulkerMuseumstraße 28

6020 InnsbruckAustria


Visit to the UK



Book and DVD reviews

A Headache in the Pelvis: A NewUnderstanding and Treatment forProstatitis and Chronic Pelvic PainSyndromes, 3rd ednBy David Wise & Rodney AndersonNational Center for Pelvic Pain, Occidental, CA,2003, 333 pages, paperback, $24.95ISBN 0-9727755-2-8

This book is dedicated to helping both men andwomen with a variety of chronic pelvic painsyndromes gain a better understanding of theproblem of chronic pain, and its causes andtreatment. The focus is primarily on malechronic pelvic pain syndrome (CPPS)/chronicprostatitis, since this is the area of work onwhich the authors’ research has concentrated. DrDavid Wise is a psychologist at Stanford Uni-versity, CA, USA, and has suffered from chronicprostatitis himself. Rodney Anderson is an emi-nent neurourologist. The regime described in thebook originally helped Dr Wise to overcome hisown chronic pain, which prompted him to devisethe ‘Stanford Protocol’, a multidisciplinarytreatment approach to CPPS/chronic prostatitis.

‘Headache in the pelvis’ is the name given toall forms of pelvic pain and dysfunction whenno primary pathology is found. The analogy isbased on the premise that, when no other causecan be found, CPPS may be the result of chronictension in the pelvic floor muscles (PFMs), in asimilar way to that in which chronic upper backand neck muscle tension may cause headache.The holistic treatment protocol is aimed atteaching the patient to release this tension byusing both physical and psychological methods,thus relieving the ‘headache’.

Because A Headache in the Pelvis is written forthe patient, it is written in appropriate layman’slanguage, and contains no references or foot-notes. For those interested in reading a morescientific basis for the theory, the authors havepublished a reasonably robust research studyto add weight to the use of their protocol(Anderson et al. 2005).

The opening chapter gives definitions andcategories of CPPS in both men and women, andin addition to chronic prostatitis, includes con-ditions such as vulvodynia, urethral syndrome,

proctalgia fugax and interstitial cystitis, all ofwhich may have an underlying element ofincreased PFM tension. This leads the way intothe rest of the book, which explains the Stanfordmodel for explaining chronic pelvic pain.

A Headache in the Pelvis is interesting to readbecause it tells a story, and uses parables andallegory to help the reader gain a better under-standing of the reasons why pelvic floor dysfunc-tion may develop. The current model of themultifaceted nature of chronic pain, and thepain–anxiety–tension cycle is written in an inter-esting style, although this sometimes becomesrepetitious rather than reinforcing the explana-tions. Case histories are included amongst thetheoretical text to let the reader know that thereare many other sufferers out there.

The methodology of the Stanford Protocol isthen outlined. The authors do make it clear fromthe outset that the treatment is not suitable foreveryone, and that thorough diagnostic evalu-ation is necessary to rule out organic conditionsthat require different treatment. Neither do theymake claims for how many, nor which type ofpatient, will benefit from the protocol. Assess-ment tools are included that may be useful forclinicians, but are not, as yet, validated. Othervalidated questionnaires are mentioned.

The basis of the treatment protocol is acombination of paradoxical relaxation andmyofascial/trigger point release. The relaxationtechniques are based on Edmund Jacobson’smethod of ‘Progressive Relaxation’. The relaxa-tion techniques are described in detail. Dr Wise,the psychologist, produces a series of relaxationtapes. He emphasizes that the tapes cannot bepurchased on a stand-alone basis, but must bebought in conjunction with one-on-one teachingto gain the full benefit of achieving deep relaxa-tion of the PFMs.

The next part of the protocol is physical. Itaims to release trigger points in the pelvic floor,and restore the muscles to their correct lengthand tension. This part of the treatment is carriedout by a physical therapist, although the authorsdo say that a ‘willing partner’ may be taught toperform the techniques, since treatment maytake many weeks or months, and the patientoften lives a long distance from the clinic. Part of


the protocol (except for the manual treatment!)is available on the Internet. The chapter onmyofascial release is very useful, and containsillustrations of all the possible affected musclesand their trigger points. Stretching exercises areanother important part of the overall therapy,and again, good illustrations are included.

The book concludes with patients’ questionsin ‘Frequent concerns’. These explore issues suchas sex and sexuality, faith, Eastern philosophyand alternative therapies in a very colloquialfashion, which is at an appropriate level for theintended readership. There are also many self-reported cases histories, but of course, these onlydescribe the patients who were improved orcured. However, this book is not intended to bea research paper, and it does an excellent jobof informing sufferers about the possibility ofexploring this treatment option.

The authors do not adopt a ‘hard sell’approach, although many men from Europe dotravel to California for an intensive 6-weekcourse of treatment offered by the Stanfordteam. Not all of these patients get better, andthe course is expensive. Many therapists in theUK who specialize in pelvic floor dysfunctionare capable of treating these cases following asimilar approach; it is merely a question of‘spreading the word’.

A Headache in the Pelvis is a ‘must read’ forany physiotherapist treating men with CPPS/chronic prostatitis since most well-informedpatients will come with the book in their handand ask for the Stanford Protocol. It is a usefulsource of information for male CPPS patients,but less useful for women. The Stanford teamare happy to share their protocol, and morelong-term research is indicated in order to estab-lish who is likely to benefit.

Stephanie KnightAiredale General HospitalKeighley, West Yorkshire

Reference

Anderson R. U., Wise D., Sawyer T. & Chan C. (2005)Integration of myofascial trigger point release and para-doxical relaxation training treatment of chronic pelvicpain in men. Journal of Urology 174 (1), 155–160.

The Essential Guide to Acupuncture inPregnancy and ChildbirthBy Debra BettsJournal of Chinese Medicine Ltd, Hove, 2006,328 pages, hardback, £35.00ISBN 0951054694

This well-presented clinical textbook is writtenby Debra Betts, an experienced New Zealandmidwife and acupuncturist. Although the bookis aimed primarily at midwives, it provides clini-cal guidance for multi-professional acupuncturepractitioners who encounter pregnant and post-partum women.

The Essential Guide to Acupuncture in Preg-nancy and Childbirth is divided into 26 chap-ters and nine appendices. Individual sectionscover most of the common conditions found inpregnancy, including nausea and vomiting,musculoskeletal conditions, heartburn, fatigue,insomnia, anxiety, depression, and oedema.Several chapters are devoted to birth and thepostpartum period, highlighting the role ofacupuncture during these times. Each sectionis clearly written and explains both the Westernand traditional Chinese medicine (TCM)approaches to acupuncture for each condition.The pathology of conditions in Western andTCM terms, followed by a discussion on therecommended acupuncture points, are detailedin each chapter. Where possible, the selection ofacupuncture points is based on evidence fromthe literature, but the Bett’s own wide clinicalexperience also informs the text. Most clinicalchapters include case histories to illustrate therelevance of acupuncture to the given condition/pathology presented.

Importantly, the first chapter deals with safetyof acupuncture treatment for pregnant women,and clearly outlines the acupuncture points thatmay promote labour, and thus, are contraindi-cated during pregnancy. Furthermore, there isclear adaptation of needling technique for thepregnant woman, and details of the number ofneedles used and the method of acupuncture.Several chapters contain information that wouldbe relevant for women’s health physiotherapistswho practise needling. In particular, Chapter 8deals with musculoskeletal conditions. I thinkthat the information presented in this chapterwould enhance safe practice, as well as encour-aging physiotherapists to use acupuncture as amodality to treat pregnant women with upperand lower back pain, pelvic girdle pain, rib pain,and carpal tunnel syndrome.

Chapter 26 reviews some of the research evi-dence underpinning the use of acupuncture inpregnancy. Betts cites only one recent study thatinvestigated acupuncture in low back/pelvicgirdle pain, although there have been severalpapers published in recent years. Unfortunately,the paper cited was physiotherapy generated and



used contraindicated points (although therewere no adverse effects), and Betts makes thepoint that questions should be raised about theway point-prescription acupuncture is used byphysiotherapists. Many of the chapters deal withwider issues around pregnancy, and Chapter 27deals solely with dietary advice during and afterpregnancy. The appendices are extensive andinformative, and include Western and TCMglossaries that would be useful for physiothera-pists practising acupuncture. Of particular valueis Appendix 7, which describes the location andneedling of points that have been used in thetext, and is accompanied by clear illustrations.

Overall, this book is clearly presented and thearrangement of each chapter makes it easy toread. There are clear sections on Western andTCM viewpoints, clinical manifestations of con-ditions, discussion of acupuncture points, casehistories, and references. Within each chapter,coloured inset boxes are placed in the widemargins, and used to emphasize key clinicalaspects, precautions and acupuncture points.

Debra Betts’ approach to the holistic manage-ment of women pre-, ante- and postnatallymakes this much more than a textbook of acu-puncture points. Her concern for the well-beingof women at each stage of pregnancy, birth andafterwards is paramount, and the reader couldnot fail to improve her or his clinical practice. Asa physiotherapist practising acupuncture anddealing with pregnant women, I have no hesita-tion in recommending The Essential Guide toAcupuncture in Pregnancy and Childbirth tothose women’s health physiotherapists who wishto undertake further acupuncture training andextend their knowledge into this field.

Yvonne ColdronMayday Healthcare NHS Trust

Croydon

I felt very privileged when asked to review thislong-awaited clinical approach to a subject Ihave particular interest in and I was far fromdisappointed. Even before opening The EssentialGuide to Acupuncture in Pregnancy and Child-birth, the cover is so aesthetically pleasing that itmakes the book a must for those wanting to findout more. As the title announces, this is anessential clinical guide, crossing professional dis-ciplines, and encompassing proven solutions tothe management of the mother and the foetus,whether you are a professional acupuncturist,

midwife, physiotherapist or doctor working withacupuncture in the field of gynaecology andobstetrics.

Within the realms of physiotherapy, I wouldfully recommend this text as essential readingmatter if practitioners are about to embarkon further advanced acupuncture training inwomen’s health, provided they have a funda-mental knowledge of TCM philosophy.

The Essential Guide to Acupuncture in Preg-nancy and Childbirth is divided into sectionscovering a number of conditions, such as nauseaand vomiting, musculoskeletal conditions,insomnia, and anxiety. These are presented atprepartum, during labour and postpartum, witha chapter dedicated to each. Within each chap-ter, Debra Betts has integrated Western medicaldiagnosis into a TCM framework. She usessuccinct, manageable language – something Ifind lacking in several other texts on this subject,and something I welcome within our clinicalpractice.

The book has an added advantage in thattreatment protocols are provided within each sec-tion. The anatomical positions of relevant pointsare superbly illustrated by Peter Deadman,Mazin Al-Khafaji and Kevin Baker, and in-depth clinical reasoning for their use is provided.Chapter 26, citing a review of current researchwith clinical application to acupuncture in preg-nancy, is an added bonus.

Each page provides the reader with theauthor’s clinical experience and knowledge ofthe subject matter. I am grateful for this knowl-edge and for the easy style in which it has beenwritten, which has the dual benefits of enhancingmy clinical reasoning and aiding my patients’recovery. I welcome texts that augment the cli-nician’s patient care and problem-solving skillswithin an evidence base that is effective, rele-vant and pertinent to current healthcare. TheEssential Guide to Acupuncture in Pregnancy andChildbirth provides all these qualities and more.

Jennie LongbottomAcupuncture Association of Chartered

PhysiotherapistsPeterborough

The Pelvic FloorEdited by Beate Carrière & Cynthia MarkelFeldtGeorg Thieme Verlag, Stuttgart, 2006, 476pages, paperback, V69.95ISBN 1-58890-325-7



This book is small in size, but huge in content,boasting contributions from a team of inter-nationally renowned experts, including KariBø, Pauline Chiarelli, Grace Dorey and PaulHodges, as well as the two main authors,Americans Beate Carrière and Cynthia MarkelFeldt. The Pelvic Floor covers in great detail thecurrent state of our knowledge of the pelvicfloor, and its contribution to pelvic health andillness.

My first impression on opening the book was‘overwhelming’. The content is very comprehen-sive, and although small, The Pelvic Floor con-tains over 500 pages, all very busy with a smalltypeface and minimal marginal space on eachpage. However, I appreciate that this keeps theproduction costs of the book down to an afford-able amount. One would expect a text with suchcomprehensive content to be priced much higherthan it is. However, it could have be improvedif the different sections of the book were moreidentifiable. As it stands, it is difficult to dis-tinguish between different parts, and therefore,not so easy to find things without frequentlyresorting to the contents for a page number.

In my opinion, a quote from the first sectiondescribes the essence of this book:

‘The pelvic floor cannot be viewed in isolationand has to be considered in connection withthe surrounding structures, as well as its indi-vidual parts.’

It is a truly holistic account of the treatment ofpelvic floor dysfunction.

The book encompasses a wide range of con-ditions that a women’s health physiotherapistmight be asked to treat. Although the title is ThePelvic Floor, it also includes a section on themanagement of lymphoedema.

Many of the treatment techniques are well-known amongst physiotherapists and supportedby a strong evidence base. However, the bookalso includes many less-known techniques –somethat have been used for many years and othersmuch more recent – that do not currently havea good evidence base. Indeed, some sections inThe Pelvic Floor have no real evidence to sup-port them, being based solely on expert opinion.I think one of the strengths of this book is thatall these treatments are included. The authorsdescribe the strength of evidence supportingtheir statements, and there is an extensive refer-ence list at the end of each section.

The Pelvic Floor is divided into six mainsections:

(1) Basics: anatomy and physiology, nervoussystem, musculoskeletal chronic pelvic pain,posture and the pelvic floor, low back pain andthe pelvic floor, reflex incontinence, psycho-social influences, and evidence-based physio-therapy for stress and urge incontinence.

(2) Treatment techniques: manual physiotherapytechniques for pelvic floor disorders, strainand counterstrain for pelvic pain, connectivetissue manipulations and other physicaltherapies, visceral mobilization, PFM train-ing, reflex incontinence, and therapy forlymphoedema.

(3) Paediatric therapy: enuresis and encopresis(assessment and treatments).

(4) Therapy for women: back-to-nature labour,storage and emptying disorders of the blad-der, prolapse, and sexual and pelvic floordysfunctions.

(5) Therapy for men: anatomy and physiology,assessment and treatment of incontinence,pelvic pain, and erectile dysfunction.

(6) Treatment of anorectal disorders: anal dys-function after delivery and physiotherapy foranorectal disorders.

The diagrams and accompanying photographsthroughout the book are of a consistently highquality. However, some parts are very detailed,particularly the anatomy and physiology sectionat the beginning of the book, and some segmentsof the treatment sections. In these areas, I thinkthe text would have been more accessible if ithad been accompanied by more illustrations.

In conclusion, I would strongly recommendThe Pelvic Floor to any women’s health physio-therapist. It is an up-to-date, affordable, com-prehensive guide for the treatment of all con-ditions associated with pelvic floor dysfunction.It enhances our understanding of the functionalsignificance of the pelvic floor, and will contrib-ute to better treatment for all our patients.

Dianne NaylorBradford Teaching Hospitals NHS Foundation

TrustBradford

Pelvic Dysfunction in MenBy Grace DoreyJohn Wiley & Sons Ltd, Chichester, 2006,187 pages, paperback, £26.99ISBN 0-470-2836X

This is an updated edition of the author’sfirst textbook, Conservative Treatment of Male



Urinary Incontinence and Erectile Dysfunction,published in 2001. It is primarily aimed atspecialist continence physiotherapists, and as aguide for urology and continence nurses, urolo-gists and general practitioners.

This edition contains an abundance of infor-mation, beginning with four chapters on thehistory, symptoms, anatomy and physiology,and nervous control of the urinary tract. Anoverview of prostate conditions, urinary inconti-nence and pelvic pain in men is provided, fol-lowed by chapters on patient assessment andconservative treatment.

Although one has to recognize that it is diffi-cult to provide information about such a largeand evolving field as products within such abook, the relevant section is out of date andlacks information on washable products andurinals, and does not promote the use of infor-mation services such as PromoCon.

Two chapters deal with the treatment of post-prostatectomy problems. The first is a review ofthe literature, which is perhaps unnecessary insuch a textbook since the following chapterdescribes the treatments available and referencesthe relevant literature. More information on therisk of incontinence after surgery and the long-term prognosis would have been useful.

A further chapter discusses pharmacotherapyfor a wide range of conditions from detrusoroveractivity to prostate cancer. Thereafter,faecal incontinence is covered, with a further twochapters pertaining to male sexual dysfunction:first, a description of the condition, and then anoutline of the treatment with a review of therelevant literature on physical therapy for erec-tile dysfunction. Again, it would have been use-ful if the actual percentage of men experiencingretrograde ejaculation, urethral stricture and/orerectile dysfunction following prostatectomy wasdocumented.

The final chapter is entitled ‘Setting up acontinence service’, which is perhaps misplacedwithin such a textbook, although the importanceof interdisciplinary collaboration is discussedwith a plethora of information on relevant pro-fessional and patient literature and specialistgroups. However, it is possible for a directorof continence services to be any member of themultidisciplinary team, not just a continencenurse specialist or specialist continence physio-therapist.

Pelvic Dysfunction in Men is an essential ref-erence book for physiotherapists working in thefield of male pelvic floor disorders. Although it is

not particularly cheap, one of the main things Iliked about the book was its simple layout, witheach chapter detailing key points at the begin-ning, and those concerned with treatment endingwith a question-and-answer page/case study.Most of the anatomical drawings and figures arerelatively simple and appropriate. There are alsomany up-to-date references and recommenda-tions for further research, and I hope that someof these will taken up. Pelvic Dysfunction in Menis a handy size, and is both a useful addition tothe shelves of medical libraries and a helpfulguide to other disciplines treating this group ofpatients.

Doreen McClurgBelfast City Hospital

Belfast

Menstrual Disorders: A Practical GuideBy Deborah Ehrenthal, Paula Adams Hillard &Matthew HoffmanAmerican College of Physicians, Philadelphia,PA (distributed by the Royal Society of Medi-cine Press, London), 2006, 262 pages, paper-back, £30.95ISBN 1-930513-66-6

This book’s stated aim is to provide a blend ofall the latest information from the fields ofinternal medicine, gynaecology, adolescentmedicine and other subspecialties in order togive a comprehensive overview of menstrualdisorders.

Menstrual Disorders: A Practical Guide startswith a review of the normal menstrual cycle,followed by a chapter on common menstrualcomplaints, including abnormal uterine bleed-ing, amenorrhoea, perimenopausal bleeding,dysmenorrhoea and premenstrual syndrome.

It then moves on to medical issues, includingpolycystic ovary syndrome, menstrual disordersin women with developmental disabilities, bleed-ing disorders and menstrual disorders, andreproductive issues in women with chronic medi-cal problems. This last is the most useful becauseit covers, in one chapter, diabetic women,obesity, eating disorders, substance abuse, thefemale athlete, acute and chronic liver disease,renal disease, lupus, heart disease, and seizuredisorders.

Menstrual Disorders: A Practical Guide con-cludes with a chapter on surgical procedures.

The main drawback of this book is that it usesjargon whenever possible, making it very difficult



to read, especially since the authors can takeseveral pages before they explain the meaning ofthe terminology. This meant looking up terms ina medical dictionary only to find them explainedlater. The authors use American spellingthroughout, which can be disconcerting to aBritish reader.

Women’s health physiotherapists could findsome of Menstrual Disorders: A Practical Guidequite patronizing. On the plus side, the chapteron chronic medical influences on menstrual dis-orders is comprehensive. You might normallyhave to look through several texts to find thisinformation. It is also reasonably priced, andavailable on Amazon. However, I can only seethis as a reference book for limited use, and aslong as the hospital library is good, I would notparticularly want to buy it for my department.

Kathleen VitsSouthampton University Hospitals NHS Trust

Southampton

The Menopause: What You Need to Know,2nd ednEdited by Margaret Rees, David W. Purdie &Sally HopeRoyal Society of Medicine Press Ltd and BritishMenopause Society Publications Ltd, London,2006, 102 pages, paperback, £10.95ISBN 1-85315-672-8

The stated aim of the second edition of this guideto the menopause is ‘to provide unbiased andnon-promotional information about the meno-pause and its management to doctors, nurses,their patients and families’. The book achievesthis difficult task very well. The Menopause:What You Need to Know combines good medicalknowledge with information that is easy for thelay person to understand. This is particularlyevident in Chapter 8, which covers the contro-versies over hormone replacement therapy(HRT). It explains the different types of clinicaltrial, how to understand the evidence, what riskmeans, and in particular, discusses the morerecent clinical trials that have made the news-paper headlines.

The chapters are well set out and easy to read,and at the end of each, there are sources ofinformation, such as journal articles, books andwebsites. The Menopause: What You Need toKnow explains what the menopause is, its symp-toms and long-term effects. It discusses HRTand its alternatives in the treatment of particular

symptoms such as osteoporosis. There is aninformative chapter on complementary thera-pies, information on managing the menopausewhen you have other medical conditions, and auseful glossary at the end of the book.

As a woman ‘of that certain age’ myself, Ijumped at the chance to review The Menopause:What You Need to Know. I have read manybooks recently on the menopause, but nonewritten so succinctly or with as much infor-mation. As women’s health physiotherapists, weare often asked about the menopause and ouropinions on HRT. This is an excellent source ofinformation and would be a welcome edition toany physiotherapy department, both for staffand for patient loan.

Rachel GrubbWarwick Hospital

Warwick

Clinics in Motion DVDs

Clinics in Motion is an Irish healthcare learningcompany providing the ‘world’s first DVD pub-lication and resource centre for physiotherapists[. . .] featuring an internationally developed syl-labus [. . .] and online assessment programme’.The company has produced six active learningtools in its Neuromusculoskeletal PhysiotherapySeries 1. These cover: the lumbar spine; thepelvis and hip; the cervical and thoracic spine;the shoulder; the knee, ankle and foot; and theelbow, wrist and hand.

The excellent website (www.clinicsinmotion.com) allows you to sample the series and viewthe contents of each DVD. You can also try thetest!

Practical Techniques of PhysiotherapyExamination and Treatment, Vol. 2: ThePelvis and HipBy Helen French, Karen McCreesh, MarkSexton, & Jeremy WalshClinics in Motion, Dublin, 2005, interactiveDVD, £69.00

I was asked to review this DVD just as a newrestriction was placed on our study leave, whichhighlighted to me what a very useful resourcethis series should prove to be. For less than thecost of a study day, you can watch techniqueson your own television. This is an e-learningpackage, and a workbook and examination are



available online from when you register yourpurchase.

The contents of the DVD are described in asmall accompanying booklet that sets out theaims of the series, i.e. ‘to explain and demon-strate the practical aspects of physiotherapydiagnosis and treatment that are universally andinternationally useful in physiotherapy educa-tion and continuing professional development(CPD)’.

Practical Techniques of Physiotherapy Exami-nation and Treatment, Vol. 2: The Pelvis and Hipincludes surface anatomy, observation tests andtechniques. Using the angle button on the DVDremote control gives the viewer close-ups, wideangles and a ‘skeleton shot’, which is particularlyuseful for learning techniques. A case study,some tips and information on applied radiologycomplete the package.

This is a very useful learning and revision aid.I will certainly be watching it again to check upon my basic skills.

I would recommend this DVD to anyACPWH members who want to revise thissubject.

Caroline de Chair GillNorfolk and Norwich University Trust Hospital

Norwich

For the inexperienced practitioner, or for thosereturning to work, this is a comprehensive andinformative guide to the manual skills needed forthe physical examination of the pelvis and thehip.

The logical progression and well-defined orderof the chapters makes the information easy tofollow and the techniques easily reproducible.The practitioners clearly demonstrate commontechniques at a fundamental level, while rein-forcing the need for treatment to be clinicallyreasoned and patient-orientated.

However, the graphics and overall presenta-tion of Practical Techniques of PhysiotherapyExamination and Treatment, Vol. 2: The Pelvisand Hip could have been enhanced to improvethe learning experience. The visual learning toolswere a little dated and, although adequate, un-inspiring. Better use of computer graphics couldhave been made to show the relationships of thejoints to one another, and to put the techniquesin context.

There is an opportunity to make use of theworkbooks on the Internet, which allows forinteractive learning, and this definitely enhances

the learning experience and will assist greatlywith CPD.

Although it is no substitute for ‘hands on’practice, this production would support andcomplement prior learning for students andpractitioners alike, and would be a useful tool toreview basic knowledge and skills.

Lucy CraigNorfolk and Norwich University Trust Hospital

Norwich

Practical Techniques of PhysiotherapyExamination and Treatment, Vol. 3: TheCervical and Thoracic SpineBy Helen French, Karen McCreesh, MarkSexton, & Jeremy WalshClinics in Motion, Dublin, 2005, interactiveDVD, £69.00

This DVD consists of 16 chapters that can beselected individually from the main menu,including sections on joint screening, surfaceanatomy, active movement (including passivephysiological intervertebral motions and passiveaccessory intervertebral motions), neurologicalexamination, treatment techniques and exerciseprescription. Each chapter consists of a variablenumber of sub-chapters that can also be selectedindividually.

The style of Practical Techniques of Physio-therapy Examination and Treatment, Vol. 3:The Cervical and Thoracic Spine is that of aninformal lecture delivered in your living room.Repeated references are made to possiblevariations between individual patients and theimportance of relating findings to the subjectiveexamination. Care is taken to ensure safety in allaspects of assessment and treatment (e.g. cervicalvascular insufficiency, overpressure indicationsand contraindications, and ergonomic advice forthe physiotherapist).

The DVD provides only a general anatomicaldescription, but this is appropriate for the aimsof the production. It also assumes knowledge ofthe principles of assessment, and concepts suchas irritability and quadrants of movement. Allsections are of an appropriate length; forexample, there is a brief discussion of clearingother joints, but there are prudent caveats aboutwhen a more detailed examination would beindicated.

Careful explanation and demonstration oftechniques is enhanced by ‘Multi-AngleVision�’. This function enables the viewer to



access a split screen demonstrating the techniquefrom another angle and/or performed on a skel-eton. This would be invaluable if you were topractice techniques at the same time as they arebeing demonstrated. Useful tips for checkingbony palpation are included.

Overall, this is an excellent learning devicewith clear explanations and demonstrations ofan entire cervical and/or thoracic assessment,advice about treatments, and a relevant casestudy. Although several different tutors demon-strate the techniques, any inconsistenciesbetween models are easily overcome. It is a good

revision aid for an experienced physiotherapist,and an effective way to study teaching methodsand fine-tune specific techniques. It is difficult totake in the DVD in its entirety: I felt that itwould be better used as a modular learning aid,with the viewer choosing particular areas andtechniques to review. The basics are covered foreach technique, ensuring correct application andmeaning that each chapter can stand alone.

Clair JonesNorfolk and Norwich University Trust Hospital

Norwich




Website watch

The first four websites described in this articleare ones that I have been asked to review bymembers (the remaining two were mentioned atConference 2006). Please do keep sending melinks to sites that you think might be interestingfor others. There is so much information on theWorld Wide Web that it is good to narrow downthe search by referring to a review. My e-mailaddress is <[email protected]>.

www.breastfeeding.nhs.ukI liked this website very much and feel it wouldbe useful to all new mothers. It is simple, clearand unfussy, containing good information in avery easily understood format. A link from thehomepage takes you to a section entitled ‘Aboutbreastfeeding’ that lists a few introductory factsabout breast-feeding and has a menu dividedinto ‘How to breastfeed’, sections ‘For mums’and ‘For health professionals’, and ‘Questionsand answers’. ‘How to breastfeed’ has an excel-lent series of pictures showing how best to sitand position the baby, with clear stages of howto get a child to open her or his mouth andcorrectly latch on, how it should feel when thebaby is correctly on the breast, and reassurancethat it may not work first time, but to take babyoff and repeat the process until you both suc-ceed. The pictures are backed up by captions,but even if a user’s English was poor or non-existent, I still think it would be possible tounderstand this section.

The ‘For mums’ section contains commonquestions asked about breast-feeding, along withgood, comprehensive answers and a seven-pagedirectory of breast-feeding resources, with listsof books and leaflets by such organizations asthe United Nations Children’s Fund (UNICEF),the National Childbirth Trust (NCT) and theLeleche League. The titles cover all areas ofbreast-feeding and weaning, as well as the feed-ing of infants. Some are specifically for healthprofessionals.

There is also a section on weaning on the site.This has another series of pictures and captions,and two downloadable booklets in a printableformat, one on weaning and one on bottle-feeding.

A very good area tells the stories of sixwomen’s experiences of breast-feeding. I particu-

larly liked the way that they had chosen aselection of primigravidae and multigravidae,single and multiple pregnancies, and differentages and races, addressing the resistance thatmay come from family or friends, or the social oreconomic situation in which a woman may findherself. I felt that reading about some women’sexperiences in this way would give others confi-dence and reassurance that breast-feeding wouldbe worth a try.

I hate to admit that it is over 32 years nowsince I began breast-feeding our first baby, but Istill remember how difficult I found it at first. Itwas not the ‘fashion’ to feed at that time, but mydetermination to do it, and my mother’s reassur-ance and help – because she had successfullyfed – got me going. The health professionals toldme to bottle-feed because it was ‘easier’, whichseems unbelievable now! Had there been such athing then, I am sure I would have found thiswebsite a boon and a reassurance to be returnedto regularly during the early years of feeding thatfirst child. Use this site yourself if you areexpecting your first baby, or recommend it topatients, friends and family.

www.1in3women.co.ukThis website is designed by Eli Lilly and waslaunched this year. It is intended for womensuffering from urinary incontinence (UI), givingadvice on the different types of UI, the treat-ments available, and how to approach yourgeneral practitioner (GP) or nurse for help. Allthe information is downloadable in a printableformat. From the homepage, a menu leads youto a description of the symptoms, prevalence andcauses of stress UI (SUI). There is a diagram ofthe anatomy of the bladder, urethra and pelvicfloor, but the labelling could have been madeclearer. Later in the text, there is a reference to‘the bladder muscle’, but I am not sure that a layperson would understand that this refers to themuscle of the bladder wall. However, I could notget a printout of the information on SUI inanything but a very small type, one probablyused so that the information fitted onto a singlepage of A4, but very difficult for those who havea visually impairment. Of even more concernwas the fact that the questionnaire to be filled in


and taken to your doctor or nurse to help with adiagnosis, or to get over the embarrassment ofhaving to discuss your symptoms, was also invery small print, whereas the information onmixed UI and overactive bladder was in verylarge type. This inconsistency is strange.

There is a section on the ‘real life’ experienceof a 47-year-old woman with SUI, and I wasdelighted to read that she improved her symp-toms with pelvic floor muscle exercises, Pilatesand maintaining a healthy weight. Rather cyni-cally, I had expected drug treatments to havebeen recommended first, given the owners of thewebsite. There is an area detailing the differenttreatments that are available, conservative treat-ment being given the largest share of the cover-age. Pelvic floor muscle exercises are mentioned,but there are no detailed instructions on how todo them. Also mentioned are vaginal cones andelectromagnetic (?) stimulation, but again, withno accompanying details as to what they are,how they work, or who would be able to advisea woman or give treatment. Medications arementioned, but not explained, as are surgicaloptions. There follows a list of frequently askedquestions and answers that may be useful, butbest of all are the links to the websites and phonenumbers for Incontact and the ContinenceFoundation.

On the whole, I felt that this was too superfi-cial to be a good resource for patients. TheContinence Foundation has such a good websitewith excellent, detailed advice and explanations,and extremely good downloadable and printableleaflets, why would you bother with this one? Isuppose the questionnaire to be filled in andtaken to the GP is a good idea, but I hope allconcerned have good enough eyesight to read it!

www.motherhood.org.ukThis site belongs to the Forum for Maternityand the Newborn, which is part of the RoyalSociety of Medicine (RSM). It is designed to giveinformation to members and guests on futuremeetings of the Forum, as well as informationon past meetings and topics discussed. The meet-ings are held five times a year at the RSMheadquarters in Wimpole Street, and are gener-ally 2.5-h-long evening meetings, although thereare some whole-day seminars. These meetingsare free to members and usually take the formatof a presentation with a discussion afterwards.Members are typically midwives, GPs, obstetri-cians, physiotherapists, psychologists, health

visitors, paediatricians and neonatal nurses, aswell as members of the NCT, the Association forImprovements in the Maternity Services andothers, so this forum is a broad interest group.

The website is fairly basic, with the usual listof who’s who, the address, phone and fax num-bers of the RSM, and an e-mail link. The comingmeetings are advertised and those in London, oranyone else with easy access, should keep an eyeon what is coming up since I think the topicslook very interesting. I am afraid the websitedoes not explain how to become a member, butno doubt, an e-mail or a phone call will producethat information.

The links area, unfortunately, does not appearto work, or did not while I was doing myresearch or today as I wrote this.

The best bit of the site for me was the longlist of previous topics from the past few years,and from most recent years, full reports andabstracts of meetings. These make excellentreading and I will now make a regular habit ofreturning to the site to read these. There is a lotof information and it will take me a while towork my way through, but it is very informativeindeed.

www.pushymothers.comPushy Mothers� (see also p. 54) is a new exer-cise system designed for pregnant and postnatalwomen by pregnancy and postnatal fitness pro-fessionals. It offers a one-hour buggy workout,although, sadly, it is only available in Londonat present. What a great idea it is and I do hopethat more people will train and take it country-wide. The exercise sessions are arranged in vari-ous London parks and a 3-min demonstrationvideo is available on the site to give a tasteof what a session involves. The sessions aredesigned to help mothers get back to fitnessunder the supervision of a well-trained instruc-tor, with the added benefit of being out in thefresh air, having baby with you, meeting othermums, and one would hope, making newfriends. It looks much more fun than going tothe gym and putting baby in a crèche!

The class workout includes cardiovascularactivities to burn off the extra adipose tissueafter pregnancy, stretches and toning, and corestability for a healthier back, firmer abdominaland pelvic floor muscles. The joining fee is £15,for which you get a Pushy Mothers� tote bag,exercise band, exercise booklet and discountvouchers for Ocado (the Waitrose delivery

Website watch


service), Sweaty Betty sports clothing (15% onpurchases of £90 or more!) and Running Needs(only in London). There are 16 people in a classand you must commit to at least four classes,which are booked in advance.

Pushy Mothers� was the brainchild ofRachel Berg, who was a professional dancer andthen became a fitness instructor and personaltrainer specializing in pregnancy and postnatalfitness. She has a lot of impressive experience,as does her business partner, Judy DiFiore, whohas written a book called The Complete Guide toPostnatal Fitness, and is one of the foundingmembers of the Guild of Pregnancy and Post-natal Exercise Instructors and a qualified Pilatesinstructor. Both are mothers, and so have first-hand knowledge and have practiced what theypreach.

Within the website, there is all the informationneeded to join, as well as a ‘Pushy Bloggers’section containing news of events and a verygood section of advice for safe postnatal exer-cise. I particularly liked the advice to have yourfeet measured and a new pair of trainers fittedafter pregnancy because of the changes that mayhave occurred to your feet during pregnancy.How many postnatal women would have giventhat a thought? It is also possible to find out howto become an instructor, and I was pleased to seethat anyone interested would need to have anexisting ante- or postnatal exercise qualification,although they are happy to arrange this as extratraining if necessary.

Inevitably, Pushy Mothers is London-based atpresent and primarily has a middle-class appeal,but it is a very good idea, and I wish them welland hope it catches on.

www.ssha.infoDuring her very interesting, if rather gruesome,Conference talk and slideshow on sexually trans-mitted infections (STIs) and what to look for,Linda Furness, health advisor for the Cardiffand Vale National Health Service (NHS) Trust,gave us this website reference. The Society ofSexual Health Advisors (SSHA) is the pro-fessional organization for health advisors work-ing in departments of genito-urinary medicineand sexual health. Sexual health advisors do notneed to have a core qualification, but generallycome from a variety of professional back-grounds, including nursing, health visiting andsocial work. Training courses are run by variouseducational establishments and there are now

350 sexual health advisors in the country. Clinicsvary in what they have to offer, but commonlyinclude treatment, partner notification/contacttracing, sexual health promotion, teaching andtraining, counselling, as well as research andaudit.

Although this website is primarily for mem-bers, it does also include a very good publiceducation section. This is a rich source of infor-mation on STIs. There are at least 25 of theseinfections, and there is detailed information on15 of the commoner varieties. The introductionwith general information on STIs and goodsexual health advice is followed by details ofspecific infections with descriptions of symp-toms, how common they are, how they arepassed on, the treatment necessary and goodpractice. Some of the conditions mentioned arenot actual STIs, but symptoms can be veryworrying and it is reassuring to know that manycan be treated easily if caught early. There are afew pictures of symptoms of the conditions forease of identification.

This website is a very useful resource for bothpatients and healthcare professionals.

www.homebirth.org.uk/marycronkMary Cronk MBE gave the Margie PoldenMemorial Lecture at Conference and I found hertalk very interesting (see p. 39). She emanatedsuch knowledge and enthusiasm for her subject,and would instinctively inspire great confidencein any woman who chose Mary as an indepen-dent midwife for her pregnancy, birth and post-natal care. I typed ‘Mary Cronk’ into Googleand found more than 20 references, althoughonly 10 were related to Mary the midwife. Therest were for Mary Cronk Farrell, who wouldseem to be a Catholic author of novels and texts,and I don’t think this is the same person inanother guise! Mary describes herself on herwebsite as a mature midwife who has helpedbirth 1600 babies! She worked in the NHS for 30years, mainly as a domiciliary midwife specializ-ing in home births, but left in 1991 to becomean independent practitioner because it was in-creasingly difficult to provide a woman-centredservice within the NHS. She will take on clientswithin an hour’s drive of Chichester, WestSussex, and offers antenatal care tailored to awoman’s needs. She delivers the baby with thewoman at home, but can arrange honorarycontracts to deliver the baby in hospital withinher practice area if this is necessary or is what a

Website watch


woman wants. She lists an e-mail contact andtelephone numbers on the site.

The links on the site are excellent, and coverbreech birth workshops for midwives (one ofMary’s particular skills is the normal delivery ofbreech babies, as she demonstrated with her talkand PowerPoint presentation at Conference) andher list of equipment for a home birth (what sheprovides and what she requires the parents toprovide). This is such a sensible list and finisheswith ‘frequent cups of proper building site tea’ –none of this Earl Grey or healthy herbal stuff forMary!

Her advice on what to expect if an unplannedor emergency Caesarean section should be nec-essary would be a good preparatory read for any

pregnant woman and her partner, and her notesfor women expecting twins are extremely helpful.

Do have a look at Mary’s website and at otherreferences to her on Google. There is some veryinteresting and encouraging information. I willcertainly remember it for advice when/if I am anexpectant grandmother, although I don’t thinkMary will be able to attend my daughter wholives in New Zealand! (I am reassured, though,because I have it on good authority that mater-nity care is very much more woman-centredthere.) What a shame that so many of ourmidwives here have become ‘de-skilled’ becauseof the prevailing system in the NHS.

Jenny Kinahan

ACPWH polo shirts

Following their re-launch at Conference2003, the ever-popular ACPWH poloshirts 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:[email protected]

or send your orders to:Sue Davies34 Exeter RoadMapesburyLondon NW2 4SB

Website watch



Notes and news

Distinguished Service AwardIt is my pleasure to inform you that JaneGoudge has been awarded the DistinguishedService Award by the Chartered Society ofPhysiotherapy for her services to women’s healthover 30 years.

Ros Thomas

Dame Josephine Barnes BursaryDame Josephine Barnes was a former presidentof our association (1977–1995). The bursary wasstarted through her generosity and is now ownedby the ACPWH. It is used for educational andresearch needs, and for promoting women’shealth and continence in this country andabroad. The bursary is topped up each year byany profit from the Annual Conference. Up to£2000 will be made available per year for thisaward and this amount will be reviewed every2 years by the executive committee.

The following constitutes the policy and cri-teria for the Dame Josephine Barnes Bursary.

Jeanette HaslamChairman

Education subcommittee

Use of the bursaryThe bursary will be made available for use in thefollowing ways:

(1) Part-funding of courses:(a) to help towards subsidizing up to four

places on the validated university courseswhich are recognized by ACPWH as aroute to membership of the Association[In order to qualify for this assistance,the candidate must be a member oraffiliate member of the ACPWH and willbe required to pledge a further year’smembership on completion of thecourse. The maximum amount grantedwill be £250.00 (12.5% of the annualsum).];

(b) to part-fund places on other appropriatecourses/conferences in this country orabroad; and

(c) to give financial help to those doing aMaster’s degree relevant to women’shealth and continence.

(2) The development of research in women’shealth and continence:(a) to give funding towards research proj-

ects relevant to women’s health andcontinence;

(b) to fund/part-fund a course that wouldenable a project or a piece of research tobe undertaken;

(c) to encourage evidence-based practice; forexample, an ACPWH annual workshopon how to get started with a researchproject (this would be at the members’request); and

(d) to promote a project nationally for thebenefit of physiotherapists working inwomen’s health or continence; forexample, standardized outcome meas-ures or research organized country-wide(i.e. small groups bringing informationto a central point).

(3) Directive of the Association:(a) fund an issue that emerges from the

discussion groups at the Annual Confer-ence that the members consider needsaddressing; and

(b) enable members to travel abroad wherethey would be acting as an ambassadorfor the ACPWH, and also promotingwomen’s health and/or continence.

Criteria for selectionAll applicants must:

+ be paid-up members of the ACPWH;+ fill in and complete the necessary pro forma;+ provide evidence that they have sought

funding elsewhere, whether successful orunsuccessful, including any employer’s contri-bution, i.e. study leave;

+ give concise reasons for application, ex-plaining the benefits to women’s health, theAssociation, the patient and/or physiotherapygenerally;

+ provide a curriculum vitae;+ explain the relevance to the applicant’s career

development and future continuing pro-fessional development;

+ provide a precise breakdown of expectedexpenses, i.e. course fees, travel and subsist-ence;


+ seek the cheapest travel and accommodation(within reasonable limits, i.e. block travelbookings by agreed carriers, block hotelbookings, APEX and cheap return tickets);

+ provide evidence of adequate insurance coverwhen travelling abroad;

+ provide a précis of the course content orresearch project, or an abstract of the lectureor poster presentation;

+ provide evidence of acceptance on the courseor an invitation to speak;

+ agree to write up their work for the ACPWHJournal; and

+ submit the application before the agreeddeadline.

Application forms are available from the cur-rent ACPWH secretary (see the address on theinside front cover of the Journal). Applicationswill be considered every 6 months and must besubmitted before the closing date, which will bepublished in the Journal or by application tothe ACPWH secretary. Applications – whethersingle or as a group – can be retrospective oranticipatory, and should be returned to theACPWH secretary.

The implementation of the awards will beoverseen by a small group from the executiveand the education subcommittee that willinclude the ACPWH chairperson and treasurer.

The next closing date is 1 July 2007.

Anne Bird PrizeThe Anne Bird Prize commemorates the lifeof Anne Bird, chairman of the Association ofChartered Physiotherapists in Obstetrics andGynaecology from 1985 to 1988, by encouragingthose qualities which she herself valued. It willnormally be awarded annually to individualswho show overall excellence, professionalismand empathy in their educational developmentwithin the ACPWH, and who also make aspecial contribution to an ACPWH post-registration course or to physiotherapy inwomen’s health.

Nominations are invited for the Anne BirdPrize for this year. Each nominee must be nomi-nated by three people, one of whom must be anACPWH member. Nominations must be confi-dential. Forms are available from the ACPWHsecretary (see address on the inside front cover),

and completed nominations must be received by1 July 2007.

Ann Johnson was the winner of the Anne BirdPrize 2006. Ann has been an active member ofACPWH for many years, her roles includingbook and leaflet secretary, secretary, and mostrecently, area representative for Yorkshire. Sheis also a tutor for the University of BradfordPostgraduate Certificate in Women’s Health.

Amongst her numerous attributes, Ann istremendously enthusiastic, hard-working andcheerful. She more than fulfils the criteria for thePrize, and exemplifies the excellence and profes-sionalism that the ACPWH encourages. Theaward also recognizes ‘a special contribution toan ACPWH post-registration course’, which – asa student – Ann demonstrated as an excellenttutor group leader, and continues to do – fromthe other side of the fence – as a course tutor.

Ann is always willing to share her knowledge,and her contribution to any project is givenenthusiastically and always thoroughly under-taken. She is measured and fair in her responsesand opinions, and therefore, greatly respected byher colleagues and peer group.

Ann never seeks personal reward and was thelast person to have expected this award, as wasevident by the shock she had when I announcedthe winner. It gave me enormous pleasure topresent Ann with her well-deserved prize.

Ros Thomas

World Physical Therapy 2007The 15th International Congress of the WorldConfederation of Physical Therapy (WCPT) willbe held in Vancouver, Canada, from 2 to 6 June2007, hosted by the Canadian PhysiotherapyAssociation.

Many internationally known and respectedspeakers will lecture during the Congress onissues concerning practice, research, educationand management. Physiotherapists will have anunparallelled opportunity to access a huge rangeof international expertise under one roof.

The programme is both stimulating andthought-provoking, and if you think you wouldlike to attend, further details can be found onthe WCPT website <www.wcpt.org/congress> ore-mail <[email protected]>.

Notes and news



Letter

Madam,Re: The Urgent PC Neuromodulation SystemI am writing to express my concern about theUrgent PC Neuromodulation System distributedby Uroplasty Ltd.

The technology of sacral afferent nerve stimu-lation (SANS) or percutaneous tibial nervestimulation (PTNS) has been known for someconsiderable time (Govier et al. 2001), and in-deed, there have been other units in circulation(Klinger et al. 2000), although it would neverseem to have successfully ‘taken off’ as a routinetreatment for overactive bladder.

My concern is that, unless we are acupuncturetrained (and I am aware that many of ourmembers are), we will be working outside ourscope of practice in using this equipment. Thecompany does not provide training to a certifiedlevel of competence, and I would urge (!) mem-bers to be cautious if they are considering the useof this modality.

That said, it is always exciting to see newproducts appearing on the market, and despite

its considerable expense, Jersey General Hospi-tal will be setting up a nurse-led clinic to trial theUrgent PC Neuromodulation System for thosepatients who have intractable urinary urgeincontinence.

Clare JouannyUrotherapy Clinic

WARCOverdale HospitalWestmount Road

St HelierJersey JE1 3UNChannel Islands


References

Govier F. E., Litwiller S., Nitti V., Kreder K. J., Jr &Rosenblatt P. (2001) Percutaneous afferent neuromodu-lation for the refractory overactive bladder: results of amulticenter study. Journal of Urology 165 (4), 1193–1198.

Klinger H. C., Pycha A., Schmidbauer J. & Marberger M.(2000) Use of peripheral neuromodulation of the S3region for treatment of detrusor overactivity: aurodynamic-based study. Urology 56 (5), 766–771.




Compiled by Becky Aston, Gill Brook, Roberta Eales, Helen Forth, Rachel Grubb,Georgie Gulliford and Jo Whitehead

Bowel dysfunctionFaltin D. L., Otero M., Petignat P., et al. (2006)

Women’s health 18 years after rupture of theanal sphincter during childbirth: I. Fecalincontinence. American Journal of Obstetricsand Gynecology 194 (5), 1255–1259.

Gregory W. T., Hamilton Boyles S., SimmonsK., Corcoran A. & Clark A. L. (2006) Exter-nal anal sphincter volume measurements using3-dimensional endoanal ultrasound. AmericanJournal of Obstetrics and Gynecology 194 (5),1243–1248.

Mahoney R. & O’Herlihy C. (2006) Recentimpact of anal sphincter injury on overallCaesarean section incidence. Australian andNew Zealand Journal of Obstetrics and Gynae-cology 46 (3) 202–204.

Nichols C. M., Nam M., Ramakrishnan V.,Lamb E. H. & Currie N. (2006) Anal sphincterdefects and bowel symptoms in women withand without recognized anal sphinctertrauma. American Journal of Obstetrics andGynecology 194 (5), 1450–1454.

Otero M., Boulvain M., Bianchi-Demicheli F.,et al. (2006) Women’s health 18 years afterrupture of the anal sphincter during child-birth: II. Urinary incontinence, sexual func-tion, and physical and mental health.American Journal of Obstetrics and Gynecol-ogy 194 (5), 1260–1265.

Soligo M., Salvatore S., Emmanuel A. V., et al.(2006) Patterns of constipation in urogynecol-ogy: clinical importance and pathophysiologicinsights. American Journal of Obstetrics andGynecology 195 (1), 50–55.

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Dietz H. P., Hyland G. & Hay-Smith J. (2006)The assessment of levator trauma: a compari-son between palpation and 4D pelvic floorultrasound. Neurourology and Urodynamics 25(5), 424–427.

Dong D., Xu Z., Shi B., et al. (2006) Uro-dynamic study in the neurogenic bladder dys-function caused by intervertebral disk hernia.Neurourology and Urodynamics 25 (5), 446–450.

Drutz H. (2006) Duloxetine in women awaitingsurgery. BJOG: An International Journal ofObstetrics and Gynaecology 113 (Suppl. 1),17–21.

Durufle A., Petrilli S., Nicolas B., et al. (2006)Effects of pregnancy and child birth on uri-nary symptoms and urodynamics in womenwith multiple sclerosis. International Urogyne-cology Journal 17 (4), 352–355.


Ellis-Jones J., Swithinbank L. & Abrams P.(2006) The impact of formal education andtraining on urodynamic practice in the UnitedKingdom: a survey. Neurourology and Uro-dynamics 25 (5), 406–410.

FitzGerald M. P., Mulligan M. & ParthasarathyS. (2006) Nocturic frequency is related toseverity of obstructive sleep apnea, improveswith continuous positive airways treatment.American Journal of Obstetrics and Gynecol-ogy 194 (5), 1399–1403.

Freeman R. M. (2006) Initial management ofstress urinary incontinence: pelvic floor muscletraining and duloxetine. BJOG: An Inter-national Journal of Obstetrics and Gynaecology113 (Suppl. 1), 10–16.

Goldberg R. P., Sand P. K. & Beck H. (2005)Early-stage ovarian carcinoma presentingwith irritative voiding symptoms and urgeincontinence. International UrogynecologyJournal 16 (5), 342–344.

Goldberg R. P. & Sand P. K. (2006) Electromag-netic pelvic floor stimulation for urinary in-continence and bladder disease. InternationalUrogynecology Journal 16 (5), 401–404.

Kenton K., Mahajan S., FitzGerald M. P. &Brubaker L. (2006) Recurrent stress inconti-nence is associated with decreased neuro-muscular function in the striated urethralsphincter. American Journal of Obstetrics andGynecology 194 (5), 1434–1437.

Kim J. C., Park E. Y., Seo S. I., Park Y. H. &Hwang T.-K. (2006) Nerve growth factor andprostaglandins in the urine of female patientswith overactive bladder. Journal of Urology175 (5), 1773–1776.

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Oelke M., Roovers J.-P. W. R. & Michel M. C.(2006) Safety and tolerability of duloxetine inwomen with stress urinary incontinence.BJOG: An International Journal of Obstetricsand Gynaecology 113 (Suppl. 1), 22–26.

Oh S. J. & Ku J. H. (2006) Does condition-specific quality of life correlate with generic

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Rortveit G. & Hunskaar S. (2006) Urinaryincontinence and age at the first and lastdelivery: the Norwegian HUNT/EPINCONTstudy. American Journal of Obstetrics andGynecology 195 (2), 433–438.

Savaris R. F., Teixeira L. M. & Torres T. G.(2006) Bladder tenderness as a physical signfor diagnosing cystitis in women. InternationalJournal of Gynecology and Obstetrics 93 (3),256–257.

Schuessler B. (2006) What do we know aboutduloxetine’s mode of action? Evidence fromanimals to humans. BJOG: An InternationalJournal of Obstetrics and Gynaecology 113(Suppl. 1), 5–9.

Sinha D., Nallaswamy V. & Arunkalaivanan A.S. (2006) Value of leak point pressure study inwomen with incontinence. Journal of Urology176 (1), 186–188.

Wein A. J. (2006) Voiding function and dysfunc-tion, bladder physiology and pharmacology,and female urology. Journal of Urology 176(1), 210–214.

Wein A. J. (2006) Voiding function and dysfunc-tion, bladder physiology and pharmacology,and female urology. Journal of Urology 176(3), 1057–1060.

Yap T. L., Brown C. T. & Emberton M. (2006)Self-management in lower urinary tract symp-toms: the next major therapeutic revolution.World Journal of Urology 24 (4), 371–377.



GynaecologyAbrams P., Baranowski A., Berger R. E., et al.

(2006) A new classification is needed for pelvicpain syndromes – are existing terminologiesof spurious diagnostic authority bad forpatients? Journal of Urology 175 (6), 1989–1990.

Bø K. (2006) Can pelvic floor muscle trainingprevent and treat pelvic organ prolapse? ActaObstetricia et Gynecologica Scandinavica 85(3), 263–268.

Constantino S. Esposito F., Nadalini C., et al.(2006) Ultrasound imaging of the female peri-neum: the effect of vaginal delivery on pelvicfloor dynamics. Ultrasound in Obstetrics andGynecology 27 (2), 183–187.

Donnay F. & Ramsey K. (2006) Eliminatingobstetric fistula: progress in partnerships.International Journal of Gynecology andObstetrics 94 (3), 254–261.

Elmusharaf S., Elhadi N. & Almroth L. (2006)Reliability of self reported form of femalegenital mutilation and WHO classification:cross sectional study. British Medical Journal333 (7559), 124–128.

Hsu Y., Summers A., Hussain H. K., Guire K.E. & Delancey J. O. L. (2006) Levator plateangle in women with pelvic organ prolapsecompared to women with normal supportusing dynamic MR imaging. American Journalof Obstetrics and Gynecology 194 (5), 1427–1433.

Hundley A. F., Yuan L. & Visco A. G. (2006)Skeletal muscle heavy-chain polypeptide 3 andmyosin binding protein H in the pubococcy-geus muscle in patients with and withoutpelvic organ prolapse. American Journal ofObstetrics and Gynecology 194 (5), 1404–1410.

Jelovsek J. E. & Barber M. D. (2006) Womenseeking treatment for advanced pelvic organprolapse have decreased body image and qual-ity of life. American Journal of Obstetrics andGynecology 194 (5), 1455–1461.

Juang C. M., Yen M. S., Twu N. F., et al. (2006)Impact of pregnancy on primary dysmenor-rhea. International Journal of Gynecology andObstetrics 92 (3), 221–227.

Lorentto C., Petta C. A., Navarro M. J.,Bahamondes L. & Matos A. (2006) Depres-sion in women with endometriosis with andwithout chronic pelvic pain. Acta Obstetriciaet Gynecologica Scandinavica 85 (1), 88–92.

Moreira D. & Paula C. R. (2006) Vulvovaginalcandidiasis International Journal of Gynecol-ogy and Obstetrics 92 (3), 266–267.

Price N., Jackson S. R., Avery K., Brookes S. T.& Abrams P. (2006) Development and psy-chometric evaluation of the ICIQ VaginalSymptoms Questionnaire: the ICIQ-VS.

BJOG: An International Journal of Obstetricsand Gynaecology 113 (6), 700–712.

Price J., Farmer G., Harris J., et al. (2006)Attitudes of women with chronic pelvic painto the gynaecological consultation: a qualita-tive study. BJOG: An International Journal ofObstetrics and Gynaecology 113 (4), 446–452.

Seehusen D. A., Johnson D. R., Earwood J. S.,et al. (2006) Improving women’s experienceduring speculum examinations at routinegynaecological visits: randomised clinical trial.British Medical Journal 333 (7560), 171–173.

Seo J. T. & Kim J. M. (2006) Pelvic organsupport and prevalence by Pelvic OrganProlapse-Quantification (POP-Q) in KoreanWomen. Journal of Urology 175 (5), 1769–1772.

Simoes J. A., Discacciati M. G., Brolazo E. M.,et al. (2006) Clinical diagnosis of bacterialvaginosis. International Journal of Gynecologyand Obstetrics 94 (1), 28–32.

Siwe K., Wijma B. & Berterö C. (2006) ‘Astronger and clearer perception of self.’Women’s experience of being professionalpatients in teaching the pelvic examination: aqualitative study. BJOG: An InternationalJournal of Obstetrics and Gynaecology 113 (8),890–895.

Sogaard M., Kjaer S. K. & Gayther S. (2006)Ovarian cancer and genetic susceptibility inrelation to the BRCA1 and BRCA2 genes.Occurrence, clinical importance and interven-tion. Acta Obstetricia et Gynecologica Scandi-navica 85 (1), 93–105.

Spencer C. & Pakarian F. (2006) The role ofchildbirth in the aetiology of rectocele. BJOG:An International Journal of Obstetrics andGynaecology 113 (7), 849–849.

Summers A., Winkel L. A., Hussain H. K. &DeLancey J. O. L. (2006) The relationshipbetween anterior and apical compartmentsupport. American Journal of Obstetrics andGynecology 194 (5), 1438–1443.

Swift S. (2005) Pelvic organ prolapse: is it time todefine it? Severity of pelvic organ prolapseassociated with measurements of pelvic floorfunction. International Urogynecology Journal16 (6), 425–427.

Topcu S, Caliskan M., Gullu H., et al. (2006)Do women with polycystic ovary syndromereally have predisposition to atherosclerosis?Australian and New Zealand Journal of Obstet-rics and Gynaecology 46 (2), 164–167.

Taylor A. W., Maclennan A. H. & Avery J.C.(2006) Postmenopausal hormone therapy:who now takes it and do they differ fromnon-users? Australian and New ZealandJournal of Obstetrics and Gynaecology 46 (2),128–135.



Woad K. J., Watkins W. J., Prendergast D. &Shellin A. N. (2006) The genetic basis ofpremature ovarian failure. International Jour-nal of Gynecology and Obstetrics 93 (2), 242–244.

Woodman P. J., Swift S. E., O’Boyle A. L., et al.(2006) Prevalence of severe pelvic organ pro-lapse in relation to job description and socio-economic status: a multicenter cross-sectionalstudy. International Urogynecology Journal 17(4), 340–345.

Gynaecological surgeryAlessandri F., Mistrangelo E., Lijoi D., Ferrero

S. & Ragni N. (2006) A prospective, random-ized trial comparing immediate versus delayedcatheter removal following hysterectomy.Acta Obstetricia et Gynecologica Scandinavica85 (6), 716–720.

Ankardal M., Heiwall B., Lausten-Thomsen N.,Carnelid J. & Milsom I. (2006) Short- andlong-term results of the tension-free vaginaltape procedure in the treatment of femaleurinary incontinence. Acta Obstetricia etGynecologica Scandinavica 85 (8), 986–992.

Ayhan A., Esin S., Guven S., Salman C. &Ozyuncu O. (2006) The Manchester operationfor uterine prolapse. International Journal ofGynecology and Obstetrics 92 (3), 228–233.

Bakas P., Liapis A., Giner M. & Creatsas G.(2006) Quality of life in relation to TVTprocedure for the treatment of stress urinaryincontinence. Acta Obstetricia et GynecologicaScandinavica 85 (6), 748–752.

Barber M. D., Walters M. D., Cundiff G. W. &the PESSRI Trial Group (2006) Responsive-ness of the Pelvic Floor Distress Inventory(PFDI) and Pelvic Floor Impact Question-naire (PFIQ) in women undergoing vaginalsurgery and pessary treatment for pelvic organprolapse. American Journal of Obstetrics andGynecology 194 (5), 1492–1498.

Carey M. P., Goh J. T., Rosamilia A., et al.(2006) Laparoscopic versus open Burch colpo-suspension: a randomised controlled trial.BJOG: An International Journal of Obstetricsand Gynaecology 113 (9), 999–1006.

Collinet P., Belot F., Debodinance F., et al.(2006) Transvaginal mesh technique for pel-vic organ prolapse repair: mesh exposuremanagement and risk factors. InternationalUrogynecology Journal 17 (4), 315–320.

de Tayrac R., Deffieux X., Resten A., et al.(2006) A transvaginal ultrasound study com-paring transobturator tape and tension-freevaginal tape after surgical treatment of femalestress urinary incontinence. International Uro-gynecology Journal 17 (5), 466–471.

Dumville J. C., Manca A., Kitchener H. C., et al.(2006) Cost-effectiveness analysis of open col-posuspension versus laparoscopic colposus-pension in the treatment of urodynamic stressincontinence. BJOG: An International Journalof Obstetrics and Gynaecology 113 (9), 1014–1022.

Engelsen I. B., Woie K. & Hordnes K. (2006)Transcervical endometrial resection: long-term results of 390 procedures. Acta Obstetri-cia et Gynecologica Scandinavica 85 (1), 82–87.

Engh M. A. E., Otterlind L., Stjerndahl J. H. &Lofgren M. (2006) Hysterectomy and inconti-nence: a study from the Swedish nationalregister for gynecological surgery. Acta Obste-tricia et Gynecologica Scandinavica 85 (5),614–618.

Ghanbari Z., Baratali B. H. & Mireshghi M. S.(2006) Posterior intravaginal slingplasty(infracoccygeal sacropexy) in the treatment ofvaginal vault prolapse. International Journal ofGynecology and Obstetrics 94 (2), 147–148.

Ghezzi F., Serati M., Cromi A., et al. (2006)Tension-free vaginal tape for the treatment ofurodynamic stress incontinence with intrinsicsphincteric deficiency. International Urogyne-cology Journal 17 (4), 335–339.

Giri S. K., Hickey J. P., Sil D., et al. (2006) Thelong-term results of pubovaginal sling surgeryusing acellular cross-linked porcine dermisin the treatment of urodynamic stress in-continence. Journal of Urology 175 (5), 1788–1793.

Glavind K., Bjork J., Nohr M., Jaquet A. &Glavind L. (2006) A prospective study onwhether a tension-free urethropexy procedureaffects the residual urine and flow up to 4years after the operation. Acta Obstetricia etGynecologica Scandinavica 85 (8), 982–985.

Howden N. S., Zyczynski H. M., Moalli P. A.,et al. (2006) Comparison of autologous rectusfascia and cadaveric fascia in pubovaginalsling continence outcomes. American Journalof Obstetrics and Gynecology 194 (5), 1444–1449.

Huang K. H., Kung F.-T., Liang H.-M. &Chang S.-Y. (2005) Management of poly-propylene mesh erosion after intravaginalmidurethral sling operation for female stressurinary incontinence. International Urogyne-cology Journal 16 (6), 437–440.

Huebner M., Hsu Y. & Fenner D. E. (2006) Theuse of graft materials in vaginal pelvic floorsurgery. International Journal of Gynecologyand Obstetrics 92 (3), 279–288.

Jordaan D. J., Prollius A., Cronjé H. S. & NelM. (2006) Posterior intravaginal slingplastyfor vaginal prolapse. International Urogyne-cology Journal 17 (4), 326–329.



Kitchener H. C., Dunn G., Lawton V., ReidF., Nelson L. & Smith, A. R. B. (2006)Laparoscopic versus open colposuspension –results of a prospective randomised controlledtrial. BJOG: An International Journal ofObstetrics and Gynaecology 113 (9), 1007–1013.

Kleeman S., Vassallo B., Segal J., Hungler M. &Karram M. (2006) The ability of history and anegative cough stress test to detect occultstress incontinence in patients undergoing sur-gical repair of advanced pelvic organ prolapse.International Urogynecology Journal 17 (1),27–29.

Kueck A. S., Gossner G., Burke W. M. &Reynolds R. K. (2006) Laparoscopic tech-nology for the treatment of endometrial can-cer. International Journal of Gynecology andObstetrics 93 (2), 176–181.

Kuuva N. & Nilsson C. G. (2006) Long-termresults of the tension-free vaginal tape opera-tion in an unselected group of 129 stressincontinent women. Acta Obstetricia et Gyne-cologica Scandinavica 85 (4), 482–487.

Mattox T. F., Moore S., Stanford E. J. & MillsB. B. (2006) Posterior vaginal sling experiencein elderly patients yields poor results. Ameri-can Journal of Obstetrics and Gynecology 194(5), 1462–1466.

Persson P., Wijma K., Hammar M. & KjølhedeP. (2006) Psychological wellbeing after laparo-scopic and abdominal hysterectomy – a ran-domised controlled multicentre study. BJOG:An International Journal of Obstetrics andGynaecology 113 (9), 1023–1030.

Rutman M. P., Deng D. Y., Shah S. M., Raz S.& Rodríguez L. V. (2006) Spiral sling salvageanti-incontinence surgery in female patientswith a nonfunctional urethra: technique andinitial results. Journal of Urology 175 (5),1794–1799.

Schraffordt Koops S. E., Bisseling T. M., HeintzA. P. M. & Vervest H. A. M. (2006) Theeffectiveness of tension-free vaginal tape(TVT) and quality of life measured in womenwith previous urogynecologic surgery: analysisfrom The Netherlands TVT database. Ameri-can Journal of Obstetrics and Gynecology 195(2), 439–444.

Seow K. M., Tsou C. T., Lin Y. H., et al. (2006)Outcomes and complications of laparoscopi-cally assisted vaginal hysterectomy. Inter-national Journal of Gynecology and Obstetrics95 (1), 29–34.

Somigliana E., Ragni G., Infantino M., et al.(2006) Does laparoscopic removal of non-endometriotic benign ovarian cysts affectovarian reserve? Acta Obstetricia et Gyneco-logica Scandinavica 85 (1), 74–77.

Sung V. W., Weitzen S., Sokol E. R., Rardin C.R. & Myers D. L. (2006) Effect of patient ageon increasing morbidity and mortality follow-ing urogynecologic surgery. American Journalof Obstetrics and Gynecology 194 (5), 1411–1417.

Tincello D. G. (2006) Open or laparoscopiccolposuspension for stress incontinence: newevidence too late? BJOG: An InternationalJournal of Obstetrics and Gynaecology 113 (9),985–987.

Viereck V., Nebel M., Bader W., et al. (2006)Role of bladder neck mobility and urethralclosure pressure in predicting outcome of ten-sion free vaginal tape (TVT) procedure. Ultra-sound in Obstetrics and Gynecology 28 (2),214–221.

Vierhout M. E., Stoutjesdijk J. & Spruijt J.(2006) A comparison of preoperative andintraoperative evaluation of patients undergo-ing pelvic reconstructive surgery for pelvicorgan prolapse using the pelvic organ prolapsequantification system. International Urogyne-cology Journal 17 (1), 46–49.

Wu J. M., Wells E. C., Hundley A. F., et al.(2006) Mesh erosion in abdominal sacral col-popexy with and without concomitant hyster-ectomy. American Journal of Obstetrics andGynecology 194 (5), 1418–1422.

Male incontinenceAzzouzi A.-R., Fourmarier M., Desgrand-

champs F., et al. (2006) Other therapies forBPH patients: desmopressin, anti-cholinergic,anti-inflammatory drugs, and botulinumtoxin. World Journal of Urology 24 (4), 383–388.

Kaplan S. A. (2006) Benign prostatic hyper-plasia. Journal of Urology 176 (3), 1061–1063.

MiscellaneousChan 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 thepubic portion of the levator ani muscle inwomen with unilateral defects in 3-d modelsfrom MR images. International Journal ofGynecology and Obstetrics 92 (3), 234–241.

Gilling-Smith C., Nicopoullos J. D. M.,Semprini A. E. & Frodsham L. C. G. (2006)HIV and reproductive care – a review of cur-rent practice. BJOG: An International Journalof Obstetrics and Gynaecology 113 (8), 869–878.

Sambrook P. & Cooper C. (2006) Osteoporosis.Lancet 367 (9527), 2010–2018.



Swanton A., Iyer L. & Reginald P. W. (2006)Diagnosis, treatment and follow up of womenundergoing conscious pain mapping forchronic pelvic pain: a prospective cohortstudy. BJOG: An International Journal ofObstetrics and Gynaecology 113 (7), 792–796.

Trybulski J. (2006) Women and abortion: thepast reaches into the present. Journal ofAdvanced Nursing 54 (6) 683.

van Brummen H. J., Bruinse H. W., van de PolG., Heintz A. P. M. & van der Vaart C. H.(2006) Which factors determine the sexualfunction 1 year after childbirth? BJOG: AnInternational Journal of Obstetrics and Gynae-cology 113 (8), 914–918.

Voorham-van der Zalm P. J., Pelger R. C., vanHeeswijk-Faase I. C., et al. (2006) Placementof probes in electrostimulation and biofeed-back training in pelvic floor dysfunction. ActaObstetricia et Gynecologica Scandinavica 85(7), 850–855.

WHO Study Group on Female Genital Mutila-tion and Obstetric Outcome et al. (2006)Female genital mutilation and obstetric out-come: WHO collaborative prospective studyin six African countries. Lancet 367 (9525),1835–1841.

ObstetricsAlbert H. B., Godskesen M., Korsholm L. &

Westergaard J. G. (2006) Risk factors indeveloping pregnancy-related pelvic girdlepain. Acta Obstetricia et Gynecologica Scandi-navica 85 (5), 539–544.

Alehagen S., Wijma B. & Wijma K. (2006) Fearof childbirth before, during, and after child-birth. Acta Obstetricia et Gynecologica Scan-dinavica 85 (1), 56–62.

Althaus J., Petersen S., Driggers R., et al. (2006)Cephalopelvic disproportion is associatedwith an altered uterine contraction shape inthe active phase of labor. American Journal ofObstetrics and Gynecology 195 (3), 739–742.

Aukee P., Sundstrom H. & Kairaluoma M. V.(2006) The role of mediolateral episiotomyduring labour. Analysis of risk factors forobstetric anal sphincter tears. Acta Obstetriciaet Gynecologica Scandinavica 85 (7), 856–860.

Barau G., Robillard P.-Y., Hulsey T.C., et al.(2006) Linear association between maternalpre-pregnancy body mass index and risk ofcaesarean section in term deliveries. BJOG:An International Journal of Obstetrics andGynaecology 113 (10), 1173–1177.

Constantino S., Esposito F., Nadalini C., et al.(2006) Ultrasound imaging of the female peri-neum: the effect of vaginal delivery on pelvicfloor dynamics. Ultrasound in Obstetrics andGynecology 27 (2), 183–187.

de la Chapelle A., Cahrles M., Gleize V., et al.(2006) Impact of walking epidural analgesiaon obstetric outcome of nulliparous women inspontaneous labour. International Journal ofObstetric Anesthesia 15 (2), 104–108.

Dodd J. M., Crowther C. A. & Robinson J. S.(2006) Oral misoprostol for induction oflabour at term: randomised controlled trial.British Medical Journal 332 (7540), 509–513.

Domingo C., Latorre E., Mirapeix R. M. &Abad J. (2006) Snoring, obstructive sleepapnea syndrome, and pregnancy. InternationalJournal of Gynecology and Obstetrics 93 (1),57–59.

Drake E., Drake M., Bird J. & Russell R. (2006)Obstetric regional blocks for women with MS:a survey of UK experience. International Jour-nal of Obstetric Anesthesia 15 (2), 115–123.

Dresner M., Brocklesby J. & Bamber J. (2006)Audit of the influence of body mass index onthe performance of epidural analgesia inlabour and the subsequent mode of delivery.BJOG: An International Journal of Obstetricsand Gynaecology 113 (10), 1178–1181.

Duncombe D., Skouteris H., Wertheim E. H.,et al. (2006) Vigorous exercise and birth out-comes in a sample of recreational exercisers: aprospective study across pregnancy. Austral-ian and New Zealand Journal of Obstetrics andGynaecology 46 (4), 288–292.

Gherman R. B., Chauhan S., Ouzounian J. G.,et al. (2006) Shoulder dystocia: the unprevent-able obstetric emergency with empiric man-agement guidelines. American Journal ofObstetrics and Gynecology 195 (3), 657–672.

Habiba M., Kaminski M., Da Frè M., et al.(2006) Caesarean section on request: a com-parison of obstetricians’ attitudes in eightEuropean countries. BJOG: An InternationalJournal of Obstetrics and Gynaecology 113 (6),647–656.

Jerbi M., Hidar S., Ammar A. & Khairi H.(2006) Predictive factors of vaginal birth aftercesarean delivery. International Journal ofGynecology and Obstetrics 94 (1), 43–44.

Kudish B., Blackwell S., McNeeley S. G., et al.(2006) Operative vaginal delivery and midlineepisiotomy: a bad combination for the peri-neum. American Journal of Obstetrics andGynecology 195 (3), 749–754.

Kung J., Swan A. V. & Arulkumaran S. (2006)Delivery of the posterior arm reduces shoulderdimensions in shoulder dystocia. InternationalJournal of Gynecology and Obstetrics 93 (3),233–237.

Latthe P., Mignini L., Gray R., Hills R. & KhanK. (2006) Factors predisposing women tochronic pelvic pain: systematic review. BritishMedical Journal 322 (7544), 749–755.



Lund I., Lundeberg T., Lonnberg L. & SvenssonE. (2006) Decrease of pregnant women’s pel-vic pain after acupuncture: a randomized con-trolled single-blind study. Acta Obstetricia etGynecologica Scandinavica 85 (1), 12–19.

Martin S. R. & Foley M. R. (2006) Intensivecare in obstetrics: an evidence-based review.American Journal of Obstetrics and Gynecol-ogy 195 (3), 673–689.

Mazouni C., Porcu G., Bretelle F., et al. (2006)Risk factors for forceps delivery in nulliparouspatients. Acta Obstetricia et GynecologicaScandinavica 85 (3), 298–301.

Mogren I. (2006) Perceived health, sick leave,psychosocial situation, and sexual life inwomen with low-back pain and pelvic painduring pregnancy. Acta Obstetricia et Gyneco-logica Scandinavica 85 (6), 647–656.

Nikkola E., Laara A., Hinkka S., et al. (2006)Patient-controlled epidural analgesia in labordoes not always improve maternal satisfac-tion. Acta Obstetricia et Gynecologica Scandi-navica 85 (2), 188–194.

Poston L., Briley A., Seed P., et al. (2006)Vitamin C and vitamin E in pregnant womenat risk for pre-eclampsia (VIP trial): random-ised placebo-controlled trial. Lancet 367(9517), 1145–1154.

Robinson H. S., Eskild A., Heiberg E. &Eberhard-Gran M. (2006) Pelvic girdle pain inpregnancy: the impact on function. ActaObstetricia et Gynecologica Scandinavica 85(2), 160–164.

Rost C. C. M., Jacqueline J., Kaiser A., Ver-hagen A. P. & Koes B. W. (2006) Prognosis ofwomen with pelvic pain during pregnancy: along-term follow-up study. Acta Obstetricia etGynecologica Scandinavica 85 (7), 771–777.

Sanders J., Campbell R. & Peters T. J. (2006)Effectiveness and acceptability of lidocainespray in reducing perineal pain during spon-taneous vaginal delivery: randomised con-

trolled trial. British Medical Journal 333(7559), 117–119.

Saunders T. A., Stein D. J. & Dilger J. P. (2006)Informed consent for labour epidurals: asurvey of Society for Obstetrics Anaesthesiaand Perinatology anesthesiologists from theUnited States. International Journal of Obstet-ric Anesthesia 15 (2), 98–103.

Thorsen P., Vogel I., Molsted K., et al. (2006)Risk factors for bacterial vaginosis in preg-nancy: a population-based study on Danishwomen. Acta Obstetricia et GynecologicaScandinavica 85 (8), 906–911.

Vacca A. (2006) Vacuum-assisted delivery: ananalysis of traction force and maternal andneonatal outcomes. Australian and NewZealand Journal of Obstetrics and Gynaecology46 (2) 124–127.

Viereck V., Nebel M., Bader W., et al. (2006)Role of bladder neck mobility and urethralclosure pressure in predicting outcome of ten-sion free vaginal tape (TVT) procedure. Ultra-sound in Obstetrics and Gynecology 28 (2),214–221.

Williams M. K. & Chames M. C. (2006) Riskfactors for the breakdown of perineal lacera-tion repair after vaginal delivery. AmericanJournal of Obstetrics and Gynecology 195 (3),755–759.

Yu C. K. H., Teoh T. G. & Robinson S. (2006)Obesity in pregnancy. BJOG: An InternationalJournal of Obstetrics and Gynaecology 113(10), 1117–1125.

Sexual healthBrubaker L. (2006) Partner dyspareunia (his-

pareunia). [Editorial.] International Urogyne-cology Journal 17 (4), 311.

Møller L. A. & Lose G. (2006) Sexual activityand lower urinary tract symptoms. Inter-national Urogynecology Journal 17 (1), 18–21.




Reading list

The list printed below has been compiled at therequest of ACPWH members and is for yourbenefit. It is not comprehensive, but is correctto the best of our knowledge at the time ofgoing to press. The inclusion of any title in thislist does not necessarily imply endorsement bythe ACPWH. It will be amended in each newedition of the Journal and suggestions arewelcome. Please e-mail your recommendations,including full details, to Victoria Muir at<[email protected]>.

Bibliography

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Norton C. & Kamm M. A. (1999) Bowel Control –Information and Practical Advice. Beaconsfield Publish-ers, Beaconsfield. (ISBN 0906584493.)

Payne R. A. (2000) Relaxation Techniques – A PracticalHandbook for theHealthcare Professional. ChurchillLivingstone, Edinburgh. (ISBN 0443062633.)

Priest J. & Schott J. (2001) Leading Antenatal Classes: APractical Guide. Butterworth Heinemann, Oxford. (ISBN07506498.)

Richardson C., Jull G., Hodges P. & Hides J. (1999)Therapeutic Exercise for Spinal Segmental Stabilisation inLow Back Pain: Scientific Basis and Clinical Approach.Churchill Livingstone, Edinburgh. (ISBN 0-443-05802-4.)

Robinson L. (2002) The Official Body Control PilatesManual. 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)Women’s 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) Maye’s Midwifery: A Textbook forMidwives, 12th edn. Baillière Tindall, London. (ISBN0 7020 1757.)

Yerby M. (2000) Pain Management in Childbearing – KeyIssues in Management. Baillière Tindall, London. (ISBN0702022993.)



Writing for the ACPWH Journal: guidelines for authors

+ Please always refer to a recent issue of theJournal, and follow the style and layout ofan article or item that is similar to yourcontribution. Manuscripts may be returnedto authors if they have not adhered to theguidelines. If necessary, the editor should beconsulted in the initial stages for clarification.

+ If a paper is submitted for publication, then itis assumed that it has not been submittedsimultaneously to another journal. All sub-missions should be original and previouslyunpublished.

+ Academic papers are subject to review andmay need to be revised before being accepted.The editor reserves the right to edit, amend orrevise any submission.

+ Offprints are available free of charge if noticeis given to the editor when the article issubmitted.

+ All published material becomes the copyrightof the ACPWH.

Preparation of manuscriptsAll articles must be typed double-spaced, withwide (3-cm) margins all round, on one side ofA4-size paper, using Courier New, font size 12.The pages should be numbered consecutively,and two hard copies of the article and a diskversion (text saved in Rich Text Format) shouldbe submitted. Articles should be a maximumof 7500 words (excluding the abstract andreferences).

Papers should be arranged as follows:

AbstractA summary of not more than 200 words shouldbe submitted on a separate sheet outlining thepurpose, scope and conclusions of the paper.This should be followed by a minimum of three,maximum of five, keywords which best representthe contents.

TitleThe title of the article should be in lower case,bold and ranged left, as in the title above: notethat there is no full stop and no underlining. Theauthor’s name(s) (initials and surname only)should be given below the article’s title in lower

case, bold and ranged left. Again, there is no fullstop. Below the author’s name(s), place(s) ofwork should be listed in italics, ranged left, nofull stop.

TextThe layout of the Journal is that the heading ofeach section is in bold lower case. Notice that,again, there is no full stop and no underlining.

The first paragraph is left-justified; subsequentparagraphs in the same section are indented, asis this part of the guidelines.

When including tables, diagrams and figures,these should be numbered in the order in whichthey appear in the text, and must be submitted,in duplicate, on separate sheets, i.e. not em-bedded in the text. Please indicate their placingin the text (e.g. ‘Fig. 1’). Any caption should beleft-justified above the table or below the dia-gram. All figures and tables must be referred toin the text.

When using numbers in the text, these shouldbe written out in words up to and including nine,unless they are measurements, numbers in tablesor years.

Clinical papers: referencingAll clinical papers must be fully referenced andthe references verified by the author. No excep-tions will be made. The reference list must bedouble-spaced on separate sheets, and arrangedalphabetically by the name of the first author oreditor. In the text, give the author(s) and date ofpublication in brackets [e.g. ‘(Smith 1998)’], or ifthe main author’s name is part of a sentence,then only the year is in brackets [e.g. ‘asdescribed by Smith (1998)’]. Note the absence ofcommas and full stops. For more than twoauthors, reference can be made in the text to‘Smith et al. (1998)’; note the italics and full stop.However, when writing the reference list, theconvention is as follows: for up to five authors,write all the authors’ names; for six or moreauthors, write the first three authors’ names,followed by ‘et al.’

For journals, give the author’s surname withinitials, the year of publication in brackets, thetitle of the paper, the full name of the journal,


the volume number, the issue number in brack-ets, and the first and last page numbers ofthe article (note the correct use of italic, bold,commas and full stops):

Laycock J., Knight S. & Naylor D. (1995) Pro-spective, randomised, controlled clinical trialto compare chronic electrical stimulation incombination therapy for GSI. Neurourologyand Urodynamics 14 (5), 425–426.

For books, give the author’s/editor’s surnameand initials, the year of publication in brackets,the book title in italics, and the publisher andcity of publication:

Williams P. L. & Warwick R. (eds) (1986) Gray’sAnatomy, 36th edn. Churchill Livingstone,Edinburgh.

For a chapter or section in a book by a namedauthor (who may be one of several contributors),both chapter and book title should be givenalong with the editor’s name(s), and the first andlast page numbers of the chapter:

Robinson K. L. (1996) Bioelectric fields andphysical principles. In: Physics in Medicineand Related Fields (eds P. Smith & P. S.Hascombe), pp. 335–349. Dekker Publishing,New York, NY.

Please adhere strictly to this style of referenc-ing in any contribution to the Journal.

AcknowledgementsPlease state any funding sources, or companiesproviding technical or equipment support.

PhotographsThese can be colour or monochrome, but mustbe in sharp focus. Please write any caption onthe back in soft pencil since ball-point and felt-tipped pens smudge. The photographs shouldbe numbered and their placing indicated in thetext. All photos will be returned. If digital pho-tographs are submitted, they should be of highresolution (minimum 300 dots per inch), savedto floppy disk or CD, and accompanied by ahard copy.

Case reportsThe Journal welcomes case reports of up to 2500words. These should be structured as follows:title, abstract and keywords, a brief introduc-tion, a concise description of the patient andcondition, and an explanation of the assessment,treatment and progress, followed finally by adiscussion and evaluation of implications forpractice. The study must be referenced through-out. Further guidance is available on request.

Book reviewsAt the beginning of the review, give all details ofthe book including title in bold, the author’s/editor’s full name(s), publisher, city and year ofpublication, price, whether hardback or paper-back, number of pages, ISBN number anddetails of how/where to purchase (if appropri-ate). The reviewer’s name should appear atthe end of the review in bold, right-justified,followed by their title and place of work initalics.

General points to notePlease enclose your home, work and e-mailaddresses, and telephone and fax numbers.

It is the author’s responsibility to obtain andacknowledge permission to reproduce anymaterial that has appeared in another journal ortextbook.

A brief biographical note on the authorshould be included at the end of a clinical paperin italics and should include an address forcorrespondence, if required.

All notes and news should have clinical rel-evance to our Association.

Please refer at all times to the style and layoutof previous ACPWH journals for whatever youare writing. Using these guidelines will save timefor the Journal team.

The copy deadline for the next issue of theJournal is printed in the current one and can befound below the Editorial at the beginning of theJournal. It must be strictly adhered to by allcontributors. Any further enquiries should beaddressed to the editor, whose name and addressappear on the inside front cover of the Journal.

Guidelines for authors


InteractiveCSPThe new iCSP website is now up andrunning. It is an easy-to-use interactivewebsite 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 CSPmembership number and an e-mailaddress. From the homepage, you canaccess the networks that are of interest toyou (e.g. women’s health), and directaccess to relevant websites, such as theACPWH, is also possible.

iCSP is mainly about sharing knowledge,networking irrespective of location, andtapping into the know-how of your peers.

Go on, register today – it is there foryour benefit!

IMPORTANT NOTICE

Communication by e-mail

At the Conference 2005discussion groups, membersresoundingly agreed that a moveto communication via e-mailwould be in the best interest ofthe Association.

If you have an e-mail addressthat you regularly use,please send it to membershipsecretary Alex Welman([email protected]),along with your postal address.Please remember to let her knowif you change it.

FOR SALE(limited availability)

Pilates for Mums with Lindsey Jackson£20 per DVD including postage andpacking within the UK

Chartex Antenatal and Postnatal Exerciseand Advice charts£15 per pair of charts (one antenatal andone postnatal) including postage andpacking within the UK

All profits 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 discusspostage costs outside the UK, pleasee-mail: [email protected].

Advertising ratesCharges apply for advertising courses,study days or workshops, and are asfollows:

(1) ACPWH-approved courses, studydays or workshops, or any othernon-profit making ACPWHeducational event:Free of charge

(2) Other courses or workshops (15%discount for ACPWH members):Full page £90Half page £60Quarter page £30

(3) Manufacturers’ rates:Full page £500Half page £300Quarter page £200

Please contact the advertising manager,Sue Brook, in the first instance

Journal of the ACP in Womens Health

Documents

Transcript of Journal of the ACP in Womens Health