0:04

Welcome to the Physio Discuss podcast.

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In today's episode, we're discussing pelvic floor health in sports medicine, and we discuss the following plus a lot more.

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We look at the new research and initiatives on pelvic health, how to incorporate pelvic floor screening and assessment in your practice, managing return to sport after pregnancy, management of symptomatic athletes and those not responding to our interventions.

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And finally, we talk through how and when to refer on to pelvic floor specialists and how you can stay up to date on the fast changing field that this is.

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We're joined by Gronny A. Donnelly and Sylvia Giesho, who are both specialists in female athlete pelvic health.

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Groningen is an advanced physiotherapist in pelvic health and a doctoral researcher at Cardiff Metropolitan University in the UK.

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She sits on the Pelvic Obstetric and Gynecological Physiotherapy Board and she is the current editor of the Journal of Pelvic Obstetric and Gynecological Physiotherapy.

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Sylvia is a PhD physiotherapist and researcher at the University of Bologna.

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Her research primarily focuses on pelvic floor health within the field of sports medicine and she currently collaborates with World Athletic I'm James Armstrong and this is Physio Discussed.

1:39

Grainne and Sylvia, welcome to the Physio Discussed podcast.

1:43

It is brilliant to have you on. I'm really excited.

1:46

The conversation we're going to have today, a really important topic.

1:48

So thank you so much for both of you coming on.

1:51

Thanks for having us, James. Thank you.

1:53

Thank you so much. It's a pleasure.

1:54

Wonderful. And I think it's great as well because Sylvia, you're joining us from Italy.

1:59

And Gronja, you're joining us from Northern Ireland, is that right?

2:03

Yeah, that's correct.

2:04

Yeah. So we're all over and I'm down in the wet and damp southwest of England.

2:08

So we're covering the globe a little bit today, which is great.

2:12

So we're going to dive straight into this because we haven't got a huge amount of time to cover a big topic.

2:17

So we're looking straight into specifically around the pelvic floor and new research and initiatives on female health.

2:26

So shall we start with an overview of the latest research initiatives around pelvic floor health in female athletes.

2:34

We're going to go straight to Groini on this one to start with.

2:37

Thank you. Yes, pelvic floor health is something that myself and Sylvia are really passionate about.

2:43

And for so long within sports and sports medicine, it has been completely overlooked and ignored.

2:48

So it's great to see this, I suppose, rising tide of new research.

2:53

And with everything from the International Olympic committee's series on female athlete well-being and the subsequent research that is built from that including some of the key sporting organizations such as World Rugby and have gotten bored with creating things like player educational toolkits including pelvic floor information and the World Rugby have also gotten bored with doing guidance for return to sport post-pregnancy so all these things are really exciting and I know Sylvia is involved in some aspects of this as well.

3:26

Yes, thank you, Goye. I'm involved into several research projects from World Athletics, promoting, of course, pelvic floor health into elite athletics.

3:37

That could be amazing to merge women's health into sports medicine as we are seeing a growing participation of female athletes in every competition all around the world.

3:52

And it's now time to make the right attention for women's health.

3:58

Absolutely. And as you said there, it's that attention, isn't it?

4:02

And it's the focus that's now finally and rightly being put into the sporting and high level athletics world.

4:10

And I think that's really important. And it then hopefully will cascade down to amateur sports across the board.

4:16

So what are we looking in terms of the key findings, sort of recent studies on pelvic floor health in athletes and how are these impacting now and the future of sports medicine?

4:27

So I come to you, Silvia, first of all.

4:29

Yes, first of all, there is a growing, increasing awareness about the topic among athletes, coaches and all the medical staff that have a contact with athletes.

4:43

And it's so important for opening the discussion about this topic that is considered still considered a kind of taboo in sports medicine so first of all is awareness and then again organizations are developing policies for athletes to supporting during the entire career for example during and after pregnancy that is so important so growing again could be one of the major experts into the field so there is another point of this discussion.

5:19

Yeah.

5:20

And to add to that, we've got really increased awareness of the impact of pelvic floor dysfunction and the symptoms involved.

5:27

And for anyone listening to this who maybe isn't familiar with what pelvic floor dysfunction actually means, it's symptoms like leaking from the bladder or bowel or having a really strong urge that you can't resist to empty or difficulty emptying either bladder and bowel.

5:42

Things like heaviness or pressure in the vaginal region and even pelvic pain or sexual dysfunction.

5:47

And these are not things that are just limited to women when they have babies.

5:52

Actually, these can start really early off in an athlete's lifespan.

5:56

And with particular emphasis on some sports like, it usually tends to be sports that have quite an aesthetic.

6:02

Thank you so much for joining us.

6:21

or negatively influences women exercising and we consider women and athletes across the range from recreational to elite because again we've got women in their day-to-day participating in sport and we want to I suppose we're so passionate about keeping everyone active

6:36

yes yes and at this point we just wrote an interesting commentary about that that It is under review at this moment.

6:47

So finger crossed to have the possibility to share with you and all the Physio Network community soon.

6:54

Wonderful. That'd be really interesting. Can you put any kind of perspective on this?

6:58

How many people is this and how many women is this affecting, do you think, in sports at the moment?

7:02

Do we have any kind of numbers and figures around how many people might actually be affected by this pelvic floor dysfunction?

7:09

Yes, there is various heterogeneous data about this, but literature has found that up to 80% of female athletes practicing high-impact sports may experience some form of pelvic floor dysfunction, primarily, mainly stress urinary incontinence.

7:29

But we really think that for others, dysfunction such as pelvic pain or an incontinence, the prevalence data are very underestimated for lots of reasons.

7:41

And why not this? It's that, unfortunately, this topic is still a taboo and there is not higher knowledge about this topic around the sports medicine field.

7:53

So the discussion is quite limited at the moment, but maybe with these initiatives, projects, there is room for improvement about that and some discover the real prevalence data.

8:09

It's really interesting because one of the things we've found is that if we think of sports medicine, it's really big into, and different sports organizations, they're really big into surveillance and surveillance of injuries.

8:21

And they don't ask or surveil any of these related issues.

8:25

issues until recent call to action so we are seeing some changes within bigger sporting bodies which is fantastic and again as Sylvia said a lot of things are underestimated so who knows what sort of figures we're going to have and find out it could really uncover.

8:40

Quite distressing data, actually.

8:42

I was involved in a recent study in female rugby players and stress urinary incontinence, and that was led by Dr.

8:48

Molly McCarthy-Ryan from Cardiff Metropolitan University and Dr.

8:52

Izzy Moore. And it was so interesting because we actually discovered in that study that prevalence and risk of stress urinary incontinence actually varied according to player position.

9:03

within rugby and according to different tasks.

9:06

So forwards tended to have a higher risk of stress urinary incontinence than backs and that makes more sense.

9:12

Forwards tend to be higher in terms of stature and BMI and they also undertake a lot of tackling tasks which are the kind of higher prevalence and more provoking activities.

9:23

So I do think we need to start looking at specific as well and really surveilling and getting insights into the different nuances within sports and that can help inform us better on this topic.

9:35

Brilliant segue into the next section we want to talk about in terms of looking at the ideal scenario because I think when we look forward to how we want practice and things to change we've got in our minds it'd be great if we were doing this, it'd be wonderful if we were doing that so I think it'd be really nice to look at this now in terms of two areas, in terms of pelvic floor screening and assessments, and also our return to sport after pregnancy.

10:00

So two key areas. I think we'll start with the pelvic floor screening and assessment, which we've sort of started to talk about.

10:06

And Sylvia, I'm going to come over to you in terms of that ideal scenario, and then also some of the work that you've been involved in and leading on.

10:14

So do you want to talk us through that a little bit?

10:16

Oh, thank you, James, because it's my passion, my favorite topic.

10:21

First of all, we have to say that surveillance and screening is just a fundamental, it's not just a fundamental part for any athletes, not only for pelvic floor, but for all athletes' health domains.

10:34

And currently, pelvic floor is not included in the standard PHE, so the periodic health evaluation made by the IOC, the International Olympic And we are working into including these domains for a better surveillance and screening.

10:54

And during my PhD journey, we developed the first screening tool that could be easily implemented into clinical part and practice.

11:04

Because as we know, there may be lots of risk factors, characteristics that could be associated with this.

11:12

and could influence the pelvic floor loads, activity, function, and may lead to possible dysfunction.

11:20

So we developed a very simple questionnaire composed by two parts.

11:24

The first one is about a very simple screen, five symptoms screening, the most common pelvic floor dysfunction, and then the clinician may screen for factors about sports characteristics or clinical characteristics that could be part of these associated disorders.

11:47

But I think that there are some prerequisites before in Italy implementing this screening tool, because we really need that there is a multidisciplinary team that could support athletes opening discussion with empathy, with a sensitive, I can say, manner to make comfortable athletes that could share this problem with them.

12:15

So yes, Italy, there is this tool, but Italy, the context, the setting, and the team could be really informed about this medical issue.

12:28

Absolutely. As you say, there's no point in asking questions if you don't create an environment where the answers can be real and comfortably given.

12:35

Yeah, definitely. Groni, do you have anything to add to that?

12:38

I just want to say that I have used the PFD Sentinel, including in some recent research, and I found this screening tool her symptoms aspect of it, so easy to use.

12:49

And I think it's important that for anyone who doesn't specialize in pelvic health or pelvic floor well-being, that you don't shy away from this or think that this is someone else's remit or it's not for me to ask because I don't really know that area.

13:03

You could be the person who's the really important link And you could be someone who's exposed to that athlete or player more often.

13:10

And the way their phrase within the PFD Sentinel is so user-friendly for both the clinician and the athlete.

13:17

But even at that, if you're really awkward about it, you could give the PFD Sentinel to the athlete and they could take any inbox which is relevant to them.

13:25

And at least it's highlighting something in a really non-confrontational way.

13:29

But The idea of screening, I want to highlight that when you work with athletes, if you're working within the field of sports medicine, whether as a coach, whether as a sports medicine physician, whether as a dietician, I'm sure you screen for other signs and symptoms of disease.

13:46

conditions or pathology or red flags that you don't have to manage, but you screen for them and signpost onwards.

13:53

And this is similar. You're just asking the questions to highlight, is there an issue and reassure that athlete, you know, there's actually something we can do about that.

14:01

You don't have to put up with those symptoms. Let's get a specialist involved.

14:04

So I just wanted to highlight that this is something that everyone in the multidisciplinary team should be aware of and should be actively utilising.

14:11

Yes, each professional would have an important role of opening discussion, refer athletes, managing athletes during their reassessment, during the career or during the season.

14:25

So this screening tool could be implementing pre-season, during the season, after a long break or after pregnancy.

14:34

So it could be a very practical check for monitoring pelvic floor health.

14:39

And as you say there, that part of that multidisciplinary team, and I know within the NHS in the UK, we talk about every contact counts, whereby it might be you, the next person, the next person, the next person.

14:52

But if every one of those people is aware of that screening, that questionnaire, you might be the one person that they feel able to open up to, or you might be in a situation like one of you say there that you can give that to for them to feel comfortable in their own time to tick and to highlight it.

15:06

So it's captured. And then the conversation that actually something can be done and let's signpost you to the right people, which is great.

15:13

Silvia, how do you feel that this PFD Sentinel tool might affect the landscape going forward of pelvic health management in sport?

15:23

Well, when we thought about this tool, my first goal, my main goal was to let sports medicine clinicians know that there is a problem.

15:34

Even if we don't consider the specific symptoms, because we have lots of pelvic floor symptoms that, of course, PFD centers could not cover, because it has to be a very long questionnaire, sports medicine, sports physical therapies have to be aware that pelvic floor is an important part of the musculoskeletal system that could be assessed, could be managed if there is any problems and there are lots of treatment and options that could not mean that the athlete has to stop competing or training because of this issue.

16:18

So I think that the PFT Sentinel could be the first step toward more awareness, more knowledge as a starting point for opening the discussion and I think opening the Pandora box of this problem, yes.

16:34

And I suppose you can't do anything about a problem that you're not aware of.

16:38

So from a coaching point of view, from training staff, medical staff, having that tool to open that dialogue is so, so important.

16:46

Because as you say, and I think if we're being honest, it's not an area that many people feel comfortable opening that dialogue.

16:52

So this might just be that.

16:53

Exactly, James. We basically respond to one question that sports medicine physicians and coaches told me that is, how can I introduce the topic.

17:06

How can I? So there is the PFD Sentinel, a very practical and friendly use tool for clinicians that are not experts in pelvic floor health because there is no need of specialized assessment.

17:20

There are just five questions and some risk factors.

17:24

So this is quite simple and could be essential and fundamental for athletes to be referred to a specialized clinician.

17:34

And that's the key. It's being able to, you're not taking this on yourself.

17:37

It's just, you're highlighting and gathering information to be able to do something with it.

17:42

Yeah. The first step. Totally. Yeah.

17:44

So we talked about that pelvic floor screening and we're going to go on to return to sport.

17:49

We're going to come back to pelvic floor management a little bit later on.

17:53

But pelvic sort of return to sport after pregnancy.

17:56

So Grona, can you talk us through some of these important considerations that we might be looking at in the female athlete when they're returning after pregnancy and specifically around pelvic floor health?

18:06

Yes, absolutely. And just after the recent Paris Olympic Games, we've seen the rise of the mother athlete and more and more women are not ending their career and are coming back.

18:18

So we really, really need to play catch up and put the screening and management and access to services in place.

18:27

Because I mentioned earlier that pelvic floor symptoms can occur at any time across the female lifespan, but there's certain periods in our life that increase our risk.

18:37

And one of those is that transition into and beyond pregnancy, because there's just such significant physical, physiological, psychological changes.

18:44

And particularly if we consider vaginal childbirth, there's exponential stretch on that region, like no other area in the body.

18:53

If you think of any other muscle group, they would absolutely tear well before that.

18:58

And of course, women do experience muscle tear during pregnancy and quite significant amounts of trauma.

19:03

So we need to be aware of that one.

19:05

And we need to put management in place afterwards.

19:09

And that was really the catalyst behind myself Ros Cook, Emma Brockwell and Dr.

19:15

Izzy Moorer and Dr. Alan Rankin creating the first return to sports framework applied to the pregnant postpartum population.

19:24

It was really because when I was looking for guidance on return to sport, the injury frameworks were great.

19:30

They represented a phased approach and some within a biopsychosocial context, which is exactly what we want, but they lacked female specific considerations.

19:39

So things like pelvic floor screening, things like energy levels in women and what the risk is for relative energy deficiency in sport days like breast support and of course another transitional time in our life when breasts are going to change even for the athlete who didn't have to think of breast support too often they're going to have fluctuations at this time period and those need to be addressed so it's all about creating a tool that captured that at each and every step and the six hours framework we published in BJSM in 2022.

20:11

And what we actually, one of my favorite steps of the framework is the first hour, which is ready because unlike an injury, the transition into motherhood is an opportunity that we can prepare for because we can either recognize that someone is either planning or pregnant.

20:28

And we can anticipate the upcoming changes and put plans in place.

20:32

We can never fully understand the way things are going to go.

20:35

But if we, you know, a best laid out plan is one that has been considered and there's been measures put in place.

20:41

even if that's just to make sure that that athlete is aware of what pelvic floor muscles are and how to train them, even if they are aware of what signs of pelvic floor dysfunction are so that they can tell their support team, even if it's just to keep them as active as possible during pregnancy, because we know that athletes who continue to train in whatever way they can, they maintain levels of conditioning and it makes the return to sport after easier.

21:07

So, yeah, that was really what the thinking behind the six hours framework was.

21:11

So Gornju, it's probably a good idea for us to actually just recap on, for those who haven't read the paper, what are the six R's?

21:19

Yes, and I often have to scratch my head a little bit to make sure I don't leave any out.

21:23

But the six R's are ready, which I talked about, really important preparatory phase.

21:27

Review, which is early postpartum, getting a review of how the delivery went, what the current rehabilitation and even just recovery needs are.

21:36

Restore, which is starting to build up that strength and conditioning and easing back into physical activity and training.

21:43

Recondition, which is really building and really starting to prepare for sport specific conditioning that's needed.

21:50

And then the return to play. And the last phase is refine because we don't want it just to stop at return and that's it and job done.

21:59

Really, we need to see what happens with exposure to return to sport over time.

22:04

And to really monitor that player to make sure that they don't then become symptomatic because someone could be okay and not provoking any symptoms while they're not back to full performance yet.

22:14

But sometimes they go to that level of higher performance and suddenly fatigue or any sort of reconditioning needs are provoked then because they're at that higher level.

22:24

So it's really ensuring that... the postpartum woman has regained the low tolerance necessary for the sport and activity she's going to be doing.

22:33

Definitely. It's interesting, actually, that the refine you put at the end there.

22:37

Is there any element of that? Do you feel that when a woman's gone back into sport, they might be two to three months playing and become symptomatic.

22:47

If there isn't someone else checking in, there's that reluctancy to put the hand up and say, actually, I've still got a problem.

22:54

And do you think that refine then helps highlight it without the owners being put on the female athletes?

23:00

100% because particularly in competitive sports, when re-establishing your position on a team or your position within that sport is actually really important.

23:10

And we know that athletes have training cycles.

23:13

They also have sponsorship commitments.

23:18

And so they want to make that return and show that they are back to the level they were at So I do think it's really important that someone is checking and checking in a way of, don't worry, this is just so that we can signpost you to where you need to get the strength and conditioning or rehabilitation that you need or adjuncts that you need.

23:36

Because like other areas of sports medicine, you know, people have sore shoulders, sore knees, ankles.

23:41

They might have taping or strapping or some sort of things that are adjunctive measures that help them maintain or achieve that level of performance that they need.

23:51

And like that within health at floor rehabilitation there's lots of different adjuncts and again keep your eyes peeled because Sylvia and I go into this in a clinical commentary that we really try to apply to this population but I think it's important to realise that if someone has quite significant birth related trauma or changes and they exhaust conservative rehabilitation, that that's not the end for them.

24:14

There are other things that you can add in similar to someone who's coming back from ACL recovery and always feels a bit of maybe vulnerability at that knee or etc.

24:24

Yes,

24:25

we can compare after pregnancy to muscle injury and apply similar framework to return to sport because I think that there is this misconception that the pelvic floor is another part so different from the entire musculoskeletal system but no it's part of this system works at the same modalities same manner as other muscle group and has to be looked at the same the same way and treated at the same way so We can talk about strength and conditioning for the pelvic floor.

25:07

We can talk about, in this case, return to sport.

25:12

It's quite the same. We have to change our minds and change our thoughts about the pelvic floor.

25:20

Definitely. I think it's really interesting. Silvia, when you put it like that, it does seem crazy.

25:24

This has become this separate entity that we just think it's the pelvic floor, so that's something else.

25:31

And when you put it like that, it just doesn't make sense that we've got to this stage, does it, at all?

25:37

Yeah, we have to apply the biopsychosocial model, not working silos.

25:43

There is such an amount of paper talking about that.

25:48

The BAJSM published a very relevant one a few years ago.

25:54

So we really have to integrate pelvic floor health into sports medicine.

25:59

I think it's It's quite a great movement in these years.

26:03

About this, of course, it may take years, but I think we did the main steps.

26:10

I always think when I look at the pelvic floor as a muscle group, again, really unique in the sense that it's almost like a muscle group that's only suspended around the perimeter so I always think of it almost like a trampoline in ways because unlike your quads muscle group your hamstring or your biceps which have mightn't be attached the whole way along but they have a muscle shaft underneath them so there's an element of structural support there and for them to be based on where we have a suspended group of muscles that have extra you know intersections in them and that really compromises the support and clinically one of the things I really see is that like Sylvia's highlighted, it's that different thinking or approach or assumptions that other health professionals might make because even if they do advise women to do pelvic floor muscle training, I often find that it's not significant enough training in the sense that people just do wee flicks of pelvic floor exercises.

27:07

And that would be like me trying to regain biceps muscle mass by just waving my arm about, you know, you have to add a weight resistance, you have to work that muscle to fatigue.

27:15

So it's all the same principles. And so we need to be training the pelvic floor in that way.

27:19

And the good news is that Athletes like to train in that way.

27:22

So if you can tell them that they need to actually train their pelvic floor to a higher degree, the competitive element of them will tap into that.

27:30

There's really nice ways that you can, you know, make rehabilitation functional.

27:35

It's not all about just lying down doing pelvic floor squeezes.

27:38

It's about getting up and doing functional pelvic floor exercises, maybe adding pushups.

27:43

weights you can get weights that you have to maintain in so again strength and condition and it's all the same principles and logic and and there can be a nice competitive element where athletes can see their progressions which they really like

27:55

definitely definitely and i think sort of going into this application now in terms of looking how feasible some of this is and how we engage and everything and we've got sort of our main topics here We've covered a lot about education and some of the misconceptions, I think, and the knowledge gaps that have been in there.

28:12

Is there anything you want to add into that before we talk about athlete engagement?

28:16

Yes, I think that one of the main misconceptions is, of course, there is a lack of basic knowledge from the pelvic floor anatomy treatment option.

28:28

But maybe there is this misconception that only female satellites could suffer from these symptoms.

28:37

That is not true because male satellites also female and younger athletes.

28:47

under 20s for example may experience some type of pelvic floor dysfunction that is this misconception that we have to address in sports medicine field and also to there is a gap between research and clinical practice because we have lots of prevalent studies about this issue now from 1990s till now there are quite 120 studies I conducted a scoping review about this topic.

29:20

But for treatment option, we have only a couple of RCTs.

29:25

So basically three and some protocols that are undergoing.

29:31

So there is kind of a gap in how we can manage athletes with these issues.

29:39

And it is basically addressed by expert clinician expertise.

29:44

But again, clinicians ask us, how can I manage elite athlete with this dysfunction?

29:53

Or if the rehabilitation didn't work for my athletes, how can I support athletes during competition, during training?

30:03

It's a relevant problem. And I think that more research studies are needed to close this gap so it's one misconception that we have on this field and another one could be that we have not assumed that athletes have a better understanding or have more strength in the pelvic floor than the general population because several studies told that this is not true again at the end athletes are human as humans of the general population, with different characteristics, of course, with different load tolerance and specific strengths and so on.

30:50

But for the pelvic floor, it's not quite the same.

30:53

So we have to think about it when we talk about pelvic floor function, dysfunction with athletes.

31:00

And to add to that, because everything Sylvia said is so important there, and what we do know from the research too is that we most likely need to be making pelvic floor approaches and health more proactive because at the minute, at best, if even, we're screening and being reactive.

31:21

But actually, if we can get those young teens, those adolescents, and we can inform them about pelvic health at that time during a developmental phase in their life and can get them adequately engaged in pelvic floor training, we build up their pelvic floor muscle baseline.

31:36

And John Delancey has done some really nice work in this field, studying pelvic floors, and he proposes a lifespan model whereby the higher your baseline, the more functional reserve you have in the pelvic floor, which means that should you expose it to high loads during sport or subsequently enter pregnancy and then childbirth, you've more chance of absorbing some of those changes and still functioning well than someone who had a lower baseline.

32:03

So I think that proactive approach really needs to be embedded.

32:07

Yeah, it's the point we are working on it with World Athletics.

32:12

I'm collaborating with World Athletics and the first study was regarding the younger elite athletes.

32:20

I went to Lima to speak with younger athletes, coaches and promoting awareness, knowledge and opening the discussion at It was amazing because athletes were really interested in to learn more about the pelvic floor and some of them opened the discussion about their problems.

32:43

So they asked us which was the best professional to speak this issue or treatment options.

32:51

So it was really amazing to speak with younger athletes.

32:57

I'm right in thinking of that kind of creating that standard exercise or standard training programs for female athletes.

33:04

Yeah, they really need to be embedded. Because again, everything we're talking about today is how nearly how bizarre it is that this large muscle group has been overlooked.

33:12

And as athletes, they participate in generalized body strength and condition as well as sports specific.

33:18

So this should really be part of that.

33:21

And Again, if we're embedding things like that early and they're used to the idea of pelvic floor rehabilitation being a component of their programming and training, it's not a shock then when they maybe highlight an issue and maybe have to increase focus on that region.

33:37

It's not the first time they're hearing about it. It seems less taboo because it's always been something that's been factored in.

33:44

And again, we start to normalize this issue, but also understand open up the opportunity for younger athletes to advocate for themselves because if they start to notice symptoms even if they haven't really received any topic education on this ship but they start to realise gosh my pelvic floor is a bit weak maybe I should say to someone because it's obviously important if they're including it in programming so we're breaking down a lot of the hurdles with each step.

34:08

Definitely, definitely. In terms of with athletes who find themselves symptomatic and particularly those who seem to have sort of persistent symptoms.

34:18

How might we manage and deal with those situations?

34:21

This is exactly one of the focuses of the commentary that we have under review.

34:25

And it's something we really enjoyed delving into because that's the clinical reality.

34:30

I think everyone listening to this, no matter what area you work in, we all have those patients where we've tried, you know, they're recommended standard care, best practice, and we still may have niggling or ongoing symptoms.

34:43

And that's very frustrating. So in the context of pelvic floor function, does that mean the end of the road for that athlete?

34:50

Absolutely not. Again, to contextualize it, we wouldn't tell someone with a knee injury, you know, we would find a solution.

34:58

We wouldn't say, oh, well, that's just it.

35:00

So we need to give the same context. focus and attention to females in pelvic floor function.

35:05

But I think it first comes down to nearly reviewing what has taken place until now, not just within your own practice as a physiotherapist or as a strength and condition coach or whatever background you come from, but linking in with that interdisciplinary team and ensuring that we're all doing consistent approaches that are lending towards this rehabilitation goal.

35:27

Looking at the athlete engagement, has the athlete adhered to the plan in place or what were the barriers or struggles or difficulties and how can we overcome them?

35:35

But I'll let Sylvia jump in and then continue some.

35:39

Yes, great. As you said, the close coordination among all professionals is really the key for these cases.

35:47

So engaging, as we wrote in the commentary, engaging in threshold training while addressing pelvic floor capacity through physiotherapy or other intervention is really crucial.

36:02

Also to have strategies across all the team to balance symptoms relief and with optimal athletic performance.

36:11

This is a key for, for example, other injuries, muscle tendinopathy and problems and so on.

36:19

And I think that the goal for sports medicine field in general when dealing with athletes is to maintain and optimize the athlete's health while they train and compete.

36:31

So it's our key also discussing this pelvic floor issue that is so specific.

36:37

But at the end, again, we could compare with other fields of rehabilitation.

36:43

For example, we suggested some practical intervention in the commentary for example the use of adjuncts or devices during sport that could allow athletes to perform well with minimizing symptoms during the athletic activity for example using pessaries for females that is an intravaginal devices and we have quite a lot options to support athletes.

37:13

One of the options that I'm hoping to discuss in the coming months more is I'm actually investigating compression shorts as a component of pelvic floor support for postpartum women so I'm specifically focusing on postpartum runners but there's you know we think about compression garments and lower limb compression garments as sports recovery in certain sports and there's some evidence that they do impact say muscle oscillation and they can help speed up athlete recovery.

37:40

I think the mechanisms might be slightly different in terms of pelvic floor support and I think it lends more towards that trampoline of support.

37:47

But I got into investigating compression garments because I had patients clinically tell me they reduced symptoms.

37:54

And I thought perhaps that was just placebo.

37:57

You know, it might be just their perception of it.

37:59

And I wanted to investigate a little bit more. And I have to say that I've started challenging my own biases through this research process, which is also always a healthy process.

38:08

But hopefully soon I'll be putting out some of the work that we've done to date.

38:13

And so that could be something that's a consideration.

38:16

And again, no one adjunct is for every athlete.

38:19

Everything's so individual. And even we've mentioned biopsychosocial a couple of times already within this podcast.

38:26

But what's an athlete's sleep like? What's their nutrition like?

38:29

And are they entering an energy deficit? Because it was actually the most recent update of the IOC relative energy deficiency in sport update that highlighted and acknowledge urinary incontinence as one of the telltale signs and symptoms potentially of relative energy deficiency.

38:46

So it highlights that there's greater physiological things happening body wide when one system's not off.

38:54

And so we really have to look at that entire individual and not just body sections?

38:58

Yes, totally. I 100% agree with you, Gwen.

39:03

And I think that as researchers, one of the best things that is happening, that are happening in these years is that we as a community, we have fresh eyes on it because we are, as a community again, exploring different factors from the past that could influence pelvic floor health in general.

39:26

So this new area of research exploring main different domains could be so beneficial to advance research and then inspire clinicians to support athletes.

39:42

And we're talking a lot about the work that both of you are doing and it leads quite nicely into talking about the funding or the lack thereof of funding and how that's affecting kind of going forward.

39:54

What were your thoughts around that and how do you see that play out at the moment?

39:58

We can talk about several layers of that funding because we've got the fact that despite equal representation in sport and that idea, women are still accessing less funding opportunities and less kidded out facilities and less opportunities than male counterparts.

40:15

So there's a lot of work to access equal opportunity there.

40:19

But even funding from a research perspective, because, you know, studies and investigations require funding.

40:25

And, you know, if I look, I'm self-funding my PhD as a pure passion project, you know, and so there's elements of that there that could become the barriers to people either undertaking research or doing the type of study or trial that they want to do, if you know what I mean, because time is money, access to investigative equipment is money.

40:44

And so we are seeing a lot more research grants that are starting to really try and promote research into female health, which is so exciting, but it's just that delay in it.

40:53

Would you add anything to that, Sylvia, in terms of funding?

40:56

No, I just think that there is lots of room of improvement on this area.

41:01

just to be very diplomatic. But I think also that, as you said, there are lots of organizations that are really getting into this area and promoting really great initiatives worldwide.

41:19

So let's see what could emerge in the following years.

41:24

But again, I'm quite positive. That's

41:27

how we should be. And that's nice to hear, Silvia.

41:30

In the time that we've got left, we've got future goals, which is kind of looking at where we're going to go with this.

41:35

And we kind of look in the three areas here we've highlighted, which is still building that awareness in local clubs, You talked already about referral to pelvic floor specialists, and then we're going to finally talk about the staying up to date, which one of the things is going to be most likely for most of our listeners is kind of following you both on the areas that you think would be best and so we can keep up to date.

41:56

But how do we get that awareness down through local clubs into grassroot level sports?

42:03

How do we manage that, Garnier, to start us off?

42:06

Well, there has been examples of really good attempts at doing exactly what you say, getting into grassroots, because we've a lot more, I suppose.

42:15

educational workshops being offered for both young athletes and their parents.

42:20

So when I think of in Ireland, one of our biggest sports is GAA, so it's the Gaelic Athletics Association.

42:26

And we've seen a lot of the clubs around the island of Ireland bringing in parents and their young athletes to talk about things like menstrual health, like pelvic floor.

42:36

And that's really exciting. So early on, they're hearing it.

42:39

And then if we think of soccer, you know, even people like Emma Brockwell has done really good work at getting into some of the clubs in the UK again to talk to younger athletes and even some of the higher level clubs to make sure that they are providing for their players so it'll be interesting to see what changes they're seeing again is there an impact with that proactivity but we need to make sure that it's consistent and People don't need to reinvent the wheel.

43:03

We've got Sylvia's done a lot of resources and work with World Athletics.

43:07

I've done some with World Rugby and England Rugby.

43:10

And again, a lot of these things are pulling from the same evidence base.

43:13

So they should be consistent and it should be similar.

43:16

So if anyone is having issues, access and health, look at some of the examples already out there.

43:21

And even in Australia, the.

43:24

Australian Institute of Sport has some fantastic free to access resources for athletes and the multidisciplinary team, including fact sheets and including videos to educate.

43:35

So really nice. Just we're making things more readily available, which is always beneficial to everyone.

43:41

Totally agree. And also as researchers, I think that could be relevant that we can spread and disseminate research findings through community, through social media, also today with this podcast.

43:55

So it's amazing to share this information that could be viewed by all the community, not only sports, medicine community, but for all people around the world.

44:06

So physio or other professionals, it could be an important part of this process.

44:13

Also, again, promoting discussion, but also creating, maybe it could be an hour goal, I don't know, maybe creating a sort of group or network of professionals with this specific expertise, because sometimes coaches or researchers, clinicians in general, have difficulties to reach out to professional clinicians with this particular expertise.

44:39

So crossing a emerging sports medicine and pelvic floor health.

44:44

So it could be a great thing that we could create one day a sort of network of professionals with this particular knowledge for referring athletes, for starting promoting discussion, create a sort of safe environment and an evidence-based environment.

45:03

With that importance to have, I suppose, for clinicians and for specialists to have access to pelvic floor specialists and sort of create their own network, I suppose.

45:12

And as we said early on in the podcast, identifying, gathering information, but then knowing where to go with it.

45:19

You want to have that in advance, don't you? You almost want a plan.

45:22

Who are you going to call, basically?

45:24

Yes, yes, totally.

45:26

And that's really important. And it takes also, I think that takes a responsibility or a feeling of responsibility from the clinician who may, it's not their specialist area, to feel more confident asking those questions, knowing they're not going to have to necessarily deal with it all, but they've got someone they know who they can use, who's got that specialist knowledge by creating those networks, which I think you've highlighted really, really well there.

45:48

So that's great. Anything more to add on that?

45:50

I just want to say that I often think that when we don't specialise in health, we do overthink it a little bit because like a lot of MSK and sports physiotherapists are potentially already asking some of these questions in the red flag screen in any way.

46:02

So if we're ruling out cauda equina or different things, we're asking about bladder and bowel symptoms, saddle region, anaesthesia and things.

46:10

And, you know, I have had colleagues who do report, well, I asked someone about whether they were having bladder or bowel symptoms.

46:17

They're like, oh, well, I don't know. I just leak when I cough.

46:19

And it's kind of like, all right. And they skip on. But that's the ideal opportunity to go, all right, good.

46:24

Actually, do you know that that's really common and you don't have to put up with that?

46:27

Do you mind if I refer you to a colleague? You don't have to discuss any more with me, but it's just not...

46:32

bumbling over it and getting that question over as soon as possible it's doing something with that information and being a stepping stone because it takes on average I think women oh it's at least maybe seven years for the general population to access services and that's usually because women tend to suffer in silence until it becomes absolutely bothersome enough that they can't put up with it anymore and that's a lot like they wait until it's quite significant and instead if someone kind of could hear or if a coach is on the field and can see that someone's maybe running differently or calling themselves back a little bit and you know they ask them they know they don't have an injury or pain starting to think of what other dimension have you not explored yet because if it's a case that someone's holding themselves back because they're afraid of leaking or feeling a heaviness it's really important that we signpost them then because if we don't that person suffers or maybe withdraws from sport maybe creates up another excuse we're very good at creating excuses that are not the real reason and so let's break down barriers is basically the whole idea of this and let's make sure that women feel comfortable enough to say I have this symptom and that they understand that they're not the only one by design as female we're already at risk when women get symptoms particularly young athletes they're like this shouldn't happen and nobody else leaks and it is very taboo whereas if they can understand and be educated that this is actually quite common it shouldn't be but it is there's an element of relief to the athlete of not feeling that there's something wrong with them And then understanding that it's just another rehabilitation goal.

48:01

Yes, as we said in, I think, every paper we wrote and the community wrote is maybe common, but it's not normal.

48:10

So it has to be a very clear message for athletes and for all the medical staff and technical staff.

48:17

Even if it's common, okay, but it's not normal.

48:20

So please refer athletes, manage the issue for their performance, but also for their quality of life.

48:29

Because maybe these younger female athletes may have a pregnancy in their life, will have menopause period.

48:38

So... Lots of risk factors that is the same of general population, but with other factors that are specific from the athletic career.

48:50

So let's think about the all-athletes lives.

48:55

Definitely. And I think, again, it leads back to what we were saying before, embedding this in normal training, in kind of not just be reactive, that enables then or empowers women in sports at any level to then know that actually, well, hang on a minute, this has started to change.

49:12

It's regular and normal for me to bring it up rather than to have to be asked.

49:16

And that'd be a great place to be.

49:18

Any gender, any performance level, in any sports, it's important for all athletes.

49:25

That reoccurring surveillance, because not just doing it as a checkbox on entry and taking it and never asking again, revisiting either...

49:34

bi-annually or annually or however often they're doing surveillance for other things and having it as an integrated part of that surveillance because that's an important factor to revisit.

49:43

And again, changing that psychology of the athlete to even going, gosh, they ask this every time, it must be important.

49:49

So from a sort of sports medicine and healthcare professional point of view, with everything else, we know it's important to stay up to date with the latest research, initiatives.

49:58

What tips have you got For listeners who are thinking, yeah, I do need to keep up to date or I need to get more up to date in the first place.

50:06

What do we do? How can clinicians go about this within amongst a lot of them doing lots of other things as well?

50:12

Well, I think, first of all, as Sylvia said, even podcasts like this, I know when I go on a long commute, podcasts are my way of getting information in really easily because one, they're easy listening and they take you along on the journey of the discussion.

50:27

But if they... mentioned something within the podcast that really sticks with you, you're likely to go and maybe look a little further.

50:34

What was that resource they mentioned? What was that paper they mentioned?

50:37

And so it kind of directs you and it keeps you current with where the discussion is at if you're not actively involved in the research and keeping track of that.

50:46

But Again, that interdisciplinary collaboration, another reason, because if you're constantly talking with your peers, you're going to be bringing it up or you're going to be hearing someone else mention this new paper or what we now understand about pelvic floor rehabilitation or some new development or change.

51:01

And so that's how we keep up to date. And I just think even reflective practice and the fact that if you're doing surveillance, don't just have the data sitting there and not doing anything.

51:10

You're looking at it, you're reviewing it, and then you're seeing what you need to do with that.

51:14

And that keeps the conversations going as well.

51:17

Yes, totally. And follow researchers and clinicians' social media pages, organizations.

51:24

But my invitation is to critically apprise the continent.

51:30

Because as we know, there are lots of misinformation in social media.

51:36

There is great information from a great continent, but also maybe some biased continent.

51:43

So have your own thoughts.

51:46

Be critical. when you read the continent on social media.

51:51

And except this, follow Physionetwork account.

51:59

That's a really, really good place to, I think, almost finish there.

52:02

Before we finish, because we've covered so much and time has flown by, is there anything either you want to add before we close off today?

52:10

No,

52:10

just really thank you for the opportunity because even having platforms like PhysioNetwork that do reach wide backgrounds of clinicians, I think it's really, really useful that topics like this are appearing and appearing within that generalised physiotherapy approach and they're not just siloed off for some other organisation to cover.

52:27

So thank you for giving a voice and platform to this.

52:31

Yes, totally. I really, really Thank you for having us to share this information with your community.

52:38

Again, it's one of the main steps for increasing awareness, knowledge for best supporting athletes.

52:45

So thank you.

52:46

So social media wise, if people wanted to follow you, do you use a particular platform that you think would be most useful for people?

52:53

Instagram I probably use the most and you can find me under at absolute.physio.

52:58

Yes, for me the same, sylviagiajo.physio.

53:02

or LinkedIn, but I mainly use Instagram.

53:06

Brilliant. So I think it's a really good starting point because by the sounds of it, you've got some interesting things coming up and listeners can use that as a starting point.

53:13

And as you say, get interested, pick up some of the things and then go searching, but remain critical to what you're looking at and no matter where it's coming from.

53:22

Gronia and Sylvia, thank you so much for your time.

53:25

You've been ever so generous with your time in the preparation for this and your time recording this.

53:29

So I thank you very, very much on behalf of the listeners and Physio Network.