Journal of the Association of Chartered Physiotherapists in Women's ...

Contents
Journal of the
Association of
Chartered
Physiotherapists in
Women’s
Health
Editor: Ros Thomas (ros.thomas@virgin.net)
Production editor: Andrew J. Wilson (ajwpublishing@gmail.com)
News editor: Helen Forth (helsandjohn@theforths.net)
Websites editor: Jenny Kinahan (Jkin64@aol.com)
Papers in other journals editor: Becky Aston (becks@wjsa.freeserve.co.uk)
Committee member: Gill Brook (gill.brook@lineone.net)
Committee member: Kathleen Vits (kmppvits@aol.com)
Editorial ........................................................................................... 2
Postnatal maternal mental health: an update on depression and post-traumatic stress disorder following birth by D. Bick & C. Rowan 4
Motivational interviewing and health behaviour change: an overview and their relevance to women’s health by C. A. Lane ... 14
‘Quote me happy’: can acupuncture make those hormones happy? by J. Longbottom ................................. 21
The perils of the perimenopause: contraceptive and hormonal needs in the perimenopause by A. E. Evans ................. 27
Multi-convergent therapy in the treatment of medically unexplained symptoms: a brief journey in time by M. Sadlier ........ 33
Bladders behaving badly: a randomized controlled trial of group versus individual interventions in the management of female
urinary incontinence by L. A. Hill ....................................................................... 37
Mammographic breast screening (Dr Kate Gower Thomas) ..................................................... 38
Presentation reflections:
Margie Polden Memorial Lecture: A midwife’s perspective (Rachel Kerr) ........................................ 39
GUM clinic: what to look for (Gill Brook) ............................................................... 39
Hormonal treatment of severe premenstrual syndrome (Clair Jones) ............................................ 40
Management of inherited bleeding disorders in pregnancy (Peter Collins) ........................................ 40
Assessing outcomes of urinary incontinence treatment using the International Consultation on Incontinence Questionnaire –
Urinary Incontinence Short Form by C. Jouanny ............................................................ 42
Executive committee response to Conference discussion groups ................................................. 49
Conference and course reports:
Research Officers’ Study Day (Yvonne Coldron) ............................................................ 52
The WellBeing of Women (WoW) Show – The Women’s Health Show That’s Serious Fun (Paula Igualada-Martinez) ...... 53
Pushy Mothers (Helen Forth) .......................................................................... 54
Cognitive Behavioural Therapy in the Physical Health Setting (Geraldine Buckley) ................................. 54
ACPWH Conference (Carole Broad, Michelle Gormley & Hannah Gray) ......................................... 54
Master Class in Advanced Urogynaecology (Riette Vosloo) ................................................... 60
An Introduction to Pilates in Women’s Health Physiotherapy (Ann Dennis) ...................................... 61
The Unique Role of the Women’s Health Physiotherapist in Antenatal Classes (Jane S. Brazendale) ................... 61
A Functional Approach to Assessment and Treatment of the Pelvic Girdle in Pregnancy and Postpartum (Paula Riseborough). 62
Physiotherapy for Pregnancy Related Pelvic Girdle Pain (Alison Crocker) ........................................ 63
From your executive .................................................................................. 64
Round the regions .................................................................................... 72
Area representatives 2006–2007 .......................................................................... 75
PhD thesis reports:
Multiple sclerosis and lower urinary tract dysfunction (Doreen McLurg) ......................................... 77
Characteristics of abdominal and paraspinal muscles in postpartum women (Yvonne Coldron) ........................ 78
Visit to the UK (Elisabeth Pulker) ........................................................................ 81
Book and DVD reviews ............................................................................... 83
Website watch (Jenny Kinahan) .......................................................................... 91
Notes and news ...................................................................................... 95
Letter ............................................................................................. 97
Papers in other journals ............................................................................... 98
Reading list ......................................................................................... 105
Writing for ACPWH Journal: guidelines for authors ......................................................... 106
Price list of publications .......................................................................... back cover
The opinions expressed in these papers are those of the authors and not necessarily those of the editors and publishers.
2007 Association of Chartered Physiotherapists in 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 past
3 years in developing our Journal into the very
professional and expansive tome that it has
become. She has, of course, been well supported
by the expert advice and experience of Andrew
Wilson, our production editor, and the Journal
subcommittee. I wish her every success in her
‘retirement’, but I’m delighted that she’s not
disappearing completely and remaining on the
Journal subcommittee to help me into my new
role. I’m very grateful for this because I’m
negotiating a very steep learning curve, but I
hope I can rise to the challenges that are bound
to confront me.
The first one was thrust upon me immediately
since this is our hundredth edition. The Journal
subcommittee decided to mark the anniversary
by reproducing some of the earliest newsletters.
Both Andrew Wilson and I had fun looking
at the early newsletters now stored for us in
Edinburgh by Fitwise Management Ltd. Sadly,
reproduction was not possible, so I have instead
extracted some very early references to the
‘birth’ of the idea of an Association newsletter
from the minutes taken from executive committee
meetings from 1949 onwards. These form
our cover montage.
2
Table 1. Former Journal editors
Editor Numbers Dates
To further commemorate the hundredth edition,
we present a list (Table 1) of all past editors
of the Journal of the Association of Chartered
Physiotherapists in Women’s Helath (formerly
the Newsletter of the Obstetric Association of
Chartered Physiotherapists and then the Association
of Chartered Physiotherapists in Obstetrics
and Gynaecology, and the Journal of the Association
of Chartered Physiotherapists in Obstetrics
and Gynaecology).
When sitting down to write this, my first editorial
since taking over in October, I decided to
look back to Gill’s first editorial (Spring 2004),
only to find that she had asked Jill Mantle to
contribute instead. Jill used the opportunity as a
timely reminder to us of the importance of research
in women’s health, and of our important
and continuing role in obstetrics – points that are
just as relevant today. The main reason that Jill
Mantle was asked to contribute was that Gill had
just retried as chairman, and therefore, considered
that the issue already featured her quite
heavily. I seem to be following in Gill’s footsteps,
but I didn’t have the foresight to ask someone
else to contribute, so I’m afraid you will have to
put up with me both in the editorial and in some
of the inside pages as well – but at least I shall
have the authority in future to monitor which
photographs are used and which are not!
Anonymous* 1–7 1948–1958
Mrs Margaret Williams 8–14 March 1958–January 1962
Miss J. Common 15–19 January 1962–December 1964
Mrs D. Mandelstam 20–26 December 1964–March 1969
Mrs P. Boughton 27–28 March 1969–October 1970
Mrs Margaret Williams 29–39 October 1970–July 1976
Mrs J. W. Cox 40–48 July 1976–Winter 1981
Mrs Anne Bird 49–59 Winter 1981–July 1986
Mrs Ruth Davidge 60–61 July 1986–July 1987
Mrs Christine Campbell & Anne Kite 62–67 July 1987–Summer 1990
Mrs Christine Campbell & Mrs Georgina Evans 68–69 Summer 1990–Summer 1991
Georgina Evans & Deborah Fry 70–74 Summer 1991–February 1994
Deborah Fry 75–78 February 1994–February 1996
Pauline Walsh 79–85 February 1996–February 2000
Daphne Sidney 86–87 February 2000–Spring 2001
Mary Bray 88–93 Spring 2001–Autumn 2003
Gill Brook 94–99 Autumn 2003–Autumn 2006
*Probably a team effort.
2007 Association of Chartered Physiotherapists in Women’s Health

At Conference in Cardiff, which was the last
opportunity for me to wear the ‘chains of office’
before handing them over, Jill told me she never
had a photo of herself wearing them when she
was chairman, so one of my first actions as
Journal editor is to rectify that (see p. 58).
The Journal subcommittee met at the end of
November 2006. The more observant amongst
you will notice a number of minor changes in the
Journal, some of them reflecting the increasing
involvement which Fitwise Management Ltd
has with ACPWH. Our new chairman, Pauline
Walsh, will be bringing you up to date more fully
in the Autumn 2007 issue, when the handover to
Fitwise is complete. In the meantime, I would lke
to draw your attention to the contact details (see
the inside front and back covers) for the team
in the key areas of finance (expenses and subscriptions),
the membership database, and the
distribution of small quantities of the books and
leaflets.
Editorial
One of the next challenges facing us will be
producing a commemorative edition for the sixtieth
anniversay of our Association in Autumn
2008. We already have a number of interesting
ideas. In the meantime, I’m planning two new,
regular pages in the Journal dedicated to ‘Education
and research’, and an ‘Honours’ section
highlighting member’s achievements such as
fellowships, distinguished sevice awards and
recipients of the Anne Bird Prize.
Gill never missed an opportunity to ask you to
consider writing for the Journal, or to encourage
someone you know or work with to stop ‘hiding
their light under a bushel’ and share their hard
work with us all, so neither should I. Or you can
just tell me about a course, write me a letter or
contribute in any other suitable way
Please e-mail me with any comments on the
current edition or ideas for the future.
Ros Thomas
Cover photograph: Montage of very early references to the idea of an Association newsletter from the
minutes taken from executive committee meetings from 1949 onwards.
Copy deadline
Copy (including disks) for the Autumn issue of the Journal (no. 101) must be submitted to the editor by
12 April 2007. Please note that academic and clinical articles must be received well before the deadline
since time must be allowed so that they can be informally reviewed. Manuscripts should be printed on one
side of A4 paper, double-spaced with a wide margin, and adhere to the author’s guidelines found on
p. 105. Articles for consideration should be sent to Mrs Ros Thomas, Byway, Chapel Lane, Box, Corsham,
Wiltshire SN13 8NU.
2007 Association of Chartered Physiotherapists in Women’s Health 3

Journal of the Association of Chartered Physiotherapists in Women’s Health, Spring 2007, 100, 4–13
ACPWH CONFERENCE 2006
Postnatal maternal mental health: an update on
depression and post-traumatic stress disorder
following birth
D. Bick & C. Rowan
Centre for Research in Midwifery and Childbirth, Faculty of Health and Human Sciences, Thames Valley
University, London, UK
Abstract
Maternal morbidity after birth can be widespread and persistent. A number of
physical and mental health problems may be experienced, including backache,
stress urinary and faecal incontinence, perineal pain, and depression. Up to half
of all women who have given birth will experience the ‘postnatal blues’, the
symptoms of which should be self-limited and transitory. A more severe health
problem, depression, is experienced by around 13% of women, and 1–2% may
experience a traumatic response to their birth. There are concerns that the current
organization and content of postnatal care fails to identify much of this morbidity.
Service evaluations and women’s views of care suggest that mental health services
for postnatal women are fragmented and uncoordinated, particularly across the
care sectors. Current evidence does not support the implementation of a national
screening programme for depression or the use of single-session debriefing
interventions to prevent psychological trauma. To enhance the care of women
with mental health needs, relevant healthcare professionals should be aware of the
signs and symptoms of problems after birth, and all women should be offered a
chance 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 stress
disorder.
Introduction
Recent research has shown widespread and
persistent maternal physical and psychological
morbidity after childbirth (Brown & Lumley
2000; MacArthur et al. 2002). In addition to a
number of chronic physical health problems,
such as backache or perineal pain, postnatal
women are also more vulnerable to mental
health problems. A variety of physical, psychological
and psychiatric problems may be experienced,
ranging in severity from transient
psychological symptoms (more often termed the
‘postnatal blues’) to depression, anxiety, psychosis
and post-traumatic stress disorder (PTSD).
Correspondence: Professor Debra Bick, Centre for Research
in Midwifery and Childbirth, Faculty of Health and Human
Sciences, Thames Valley University, 32–38 Uxbridge Road,
Ealing, London W5 2BS, UK (e-mail: debra.bick@
tvu.ac.uk).
4
Although giving birth is viewed as a positive,
life-changing event for a woman, for those who
experience mental illness after birth, it is an event
that can trigger a period of isolation and despair
that may impact negatively on their infant’s
emotional and cognitive development, and their
relationships with their partner and family
(Lovestone & Kumar 1993; Murray & Cooper
1997; Boath et al. 1998). Maternal mental health
has been described as a public health priority
(Bick 2003), with suicide now accounting for the
highest number of maternal deaths in the first
year after birth (Lewis & CEMACH 2004). The
present paper describes current research in relation
to postnatal mental health illness, with a
particular emphasis on depression and PTSD,
issues in relation to the prevention of mental
health illness after birth and the need to consider
revision of maternity service provision.
2007 Association of Chartered Physiotherapists in Women’s Health

Health after birth
It was previously assumed that most women
fully recovered from giving birth within the
6–8-week postnatal period (Bick & MacArthur
1995). Evidence from large observational studies
undertaken in a number of countries has found
that this is not the case (MacArthur et al. 1991;
Brown & Lumley 1998; Saurel-Cubizolles et al.
2000). For some women, health problems can be
severe, persisting for months or even years after
they have given birth (MacArthur et al. 1991;
Glazener et al. 1995). Commonly experienced
physical symptoms include backache, faecal and
urinary incontinence, perineal pain, sexual
health problems, and fatigue (MacArthur et al.
1991; Glazener et al. 1995). Symptoms may be
associated with interventions or events during
labour and birth, such as the use of forceps or
emergency Caesarean section (Glazener et al.
1995), or personal factors, such as the level of
postnatal social support available to a woman
(MacArthur et al. 1991). What is clear from the
research to date is that few women voluntarily
report problems to their healthcare provider, but
will give information on their health if they
are asked (Bick & MacArthur 1995; Brown &
Lumley 1998). However, many will have unmet
health needs because the current provision of
care focuses on routine observations and examinations,
and increasingly early discharge from
postnatal services does not allow sufficient time
to identify and appropriately manage maternal
health problems (Bick et al. 2002).
Postnatal mental health
Women may encounter a number of psychological
and mental health problems following childbirth.
The symptoms may be experienced for
the first time after giving birth, or represent a
recurrence of a previous mental health problem
or an ongoing disorder. Observational studies
have reported that around half of all women
who have undergone childbirth will experience
the postnatal blues, symptoms of which should
be transitory and self-limiting (Kendall et al.
1981; Stein et al. 1991). Maternal depression,
which is a more severe illness, has a reported
prevalence of between 4.5% and 28% (SIGN
2002). At the most severe end of the range of
mental health problems is psychosis, which
affects one or two women in every thousand
(SIGN 2002), and may be triggered by the
recurrence of previous mental health disorders
such as bipolar disorder or schizophrenia
Postnatal maternal mental health
(Chaudron & Pies 2003). Post-traumatic stress
disorder is an acute anxiety symptom associated
with exposure to an extreme event, such as being
involved in combat, a major disaster or road
traffic accident. Prior to the inclusion of childbirth
as a possible stressor in the fourth edition
of the American Psychiatric Association Diagnostic
and Statistical Manual of Mental Disorders
(DSM-IV; APA 1994), PTSD was considered to
be a reaction to an event ‘outside’ the range of
normal experience (Slade 2006).
Depression
Depression is one of the few postnatal maternal
health problems to have been extensively studied
(Gaynes et al. 2005). The wide prevalence of
depression referred to above (SIGN 2002) is a
result of the range of inclusion criteria used to
describe the study population, the timing of
assessments in relation to the birth, the length of
follow-up and the diagnostic criteria used. Some
studies have reported point prevalence, while
others have described period prevalence. O’Hara
& Swain (1996) conducted a meta-analysis that
showed an average prevalence of depression
after birth of 13%, based on data on over 12 000
women from 59 studies, mostly undertaken in
developed countries.
There has been some debate as to whether
depression is more likely to occur following
birth, or whether rates are similar to those found
in the general population. Depression is reported
twice as frequently in women as in men (Ebmeier
et al. 2006), although this gender difference may
not persist in later life (NCCMH 2004). A study
by Cox et al. (1993) found that the odds of
depression in the first 5 weeks after the birth
were three times that of a comparison group of
women who had not recently given birth.
Gaynes et al. (2005) reported that symptoms of
depression after the birth appear to be greatest
at 3 months postpartum, although the data
included in this Agency for Healthcare Research
and Quality review had wide confidence intervals
and did not allow conclusions to be reached
as to whether depression was higher in any
month following the birth, or indeed, during any
trimester of pregnancy.
Women may experience a spectrum of symptoms,
and timely referral and appropriate diagnosis
are essential to ensure that they receive
effective management tailored to their individual
needs. Two classification systems to guide the
diagnosis of mental health problems are available
to clinicians and academics working within
2007 Association of Chartered Physiotherapists in Women’s Health 5

D. Bick & C. Rowan
the field of perinatal mental health: the DSM-IV
(APA 1994) and the tenth edition of the World
Health Organization International Classification
of Diseases (ICD-10; WHO 1992). The DSM-IV
criteria for major depression are that the individual
will have experienced one or more episodes
of depression lasting for at least 2 weeks,
and will report four or more of the following
symptoms (APA 1994):
+ too much or too little sleep;
+ appetite or weight disturbance;
+ psychomotor agitation or retardation;
+ loss of energy;
+ feelings of worthlessness or excessive guilt;
+ problems with concentration or indecisiveness;
+ loss of interest in sex; and
+ recurrent suicidal thoughts.
Minor depression includes one or more episodes
of depression lasting for at least 2 weeks
with fewer than four of the above symptoms.
The ICD-10 (WHO 1992) distinguishes between
none, minor, moderate and severe depression,
and whilst there is some overlap between the
symptoms included within the criteria, there is a
lack of consensus as to which is the most appropriate
diagnostic criteria to use. Many studies
have used DSM-IV criteria, but anecdotal evidence
from the UK suggests that clinicians are
more likely to use the ICD-10 in practice. The
recently published guideline on the management
of anxiety from the National Institute for Health
and Clinical Excellence (NICE) used the ICD-10
classification (NICE 2004), while the NICE
guideline on the management of depression used
DSM-IV criteria (NCCMH 2004). The SIGN
guideline on depression and puerperal psychosis
(SIGN 2002) did not refer to either classification
in a section on diagnosis.
Around two women in every thousand will
be admitted to hospital with a diagnosis of a
non-psychotic condition, usually very severe
postnatal depression (Oates 2003). Healthcare
professionals should also be aware of the fact
that a woman may also experience depression in
pregnancy (Evans et al. 2001). The systematic
review of studies by Gaynes et al. (2005) found
that approximately 14% of pregnant women will
have a new episode of major or minor depression
during pregnancy, a statistic identified using a
variety of screening instruments. Considering
only major depression, 7.5% of women have a
new episode during pregnancy (Gaynes et al.
2005). These estimates are not significantly
6
different from the prevalence of depression
reported among women of a similar age in the
general population (Cooper et al. 1988; O’Hara
& Swain 1996).
Risk factors for the development of depression
after birth have been examined in a large
number of studies that have investigated
potential associations with maternal, obstetric
and sociodemographic characteristics, obstetric
interventions, parity, marital status, hormonal
disorders, previous psychiatric history, and personal
relationships (Bick et al. 2002). Because of
the range of outcome measures assessed, the
timings of the investigations and the instruments
used to assess the outcomes, these findings are
not conclusive. Nevertheless, some potential risk
factors have been commonly identified. It is
apparent that some social factors increase a
woman’s risk of becoming depressed. These
include life stresses such as bereavement, unemployment,
illness, migration and lack of social
support networks (O’Hara & Swain 1996; Austin
& Lumley 2003). Women who have a history of
abuse, and those with drug and alcohol problems
also have higher rates of mental health
problems after giving birth (Brockington 1996;
Buist 1996; O’Hara & Swain 1996). Between
20% and 40% of women with a previous history
of postnatal depression are likely to suffer a
relapse after a subsequent birth (Cooper &
Murray 1995).
Post-traumatic stress disorder
Research on postnatal psychological and psychiatric
morbidity has mainly focused on the effects
of depression, but there has been increasing
recognition that, for a small proportion of
women, symptoms of trauma may present after
giving birth. Post-traumatic stress disorder is
estimated to occur in 1–6% of women (Creedy
et al. 2000; Czarnocka & Slade 2000; Soet et al.
2003; Ayers 2004; White et al. 2006). Traumatic
birth is more often associated with specific physical
intervention, such as sustaining an episiotomy
or severe perineal tear related to an
instrumental vaginal delivery, but childbirth can
be psychologically traumatic for some women.
Beck (2004) described a traumatic event in relation
to birth as one that occurred during the
labour or birth in which there was actual or
threatened serious injury or death to the mother
or her infant, or in which the woman giving birth
experienced intense fear, helplessness, loss of
control and horror. It is important to note that,
whilst women may report psychological trauma
2007 Association of Chartered Physiotherapists in Women’s Health

or have symptoms of a stress response after
birth, not all will go on to experience symptoms
that meet the DSM-IV criteria for acute PTSD.
According to the DSM-IV, PTSD is classified
as an anxiety disorder that encompasses three
clusters of symptoms: reliving the event (e.g.
suffering flashbacks), persistent avoidance of
reminders and hyperarousal. Several characteristics
have been considered as predictors of PTSD.
Robust studies have consistently demonstrated
that a high level of obstetric intervention during
labour and delivery is associated with a risk of
developing psychological trauma symptoms in
the postnatal period, particularly if an intervention
(administered either routinely or under
emergency situations) happens in the context of
intense pain (Ryding et al. 1998; Creedy et al.
2000; Soet et al. 2003). Women who have an
emergency Caesarean section or instrumental
vaginal delivery are more likely to report symptoms
of PTSD than those who have a planned
Caesarean section or a normal vaginal delivery
(Ryding et al. 1998). However, since an apparently
normal birth could be traumatic for some
women, it is difficult to define what constitutes
traumatic birth based on mode of delivery or
the extent of obstetric intervention to which a
woman is exposed. Some women may be more
vulnerable because of previous trauma or personality
factors, and there may be mitigating
factors such as lack of social support.
Can mental health problems after birth be
prevented?
Screening
There is limited research evidence that primary
prevention of symptoms is clinically or cost
effective. Based on the findings of the studies
reported above, it is increasingly important that
women and healthcare professionals are aware
of the signs and symptoms of mental health
problems after birth, which may be amenable
to treatment (Dennis 2005). One of the most
commonly used tools to identify women at risk
of depression is the Edinburgh Postnatal
Depression Scale (EPDS; Cox et al. 1987), a
10-item self-report scale on which women who
have recently given birth are asked to rate how
they have felt in the previous 7 days. It has been
used internationally as an outcome measure in
research studies as well as an intervention in
routine clinical practice. A number of translated
versions are available that have been tested for
validity and reliability (Affonso et al. 2000). A
Postnatal maternal mental health
maximum score of 30 can be achieved, with a
score of 12–13 considered to identify those
women more likely to have depression (Cox
et al. 1987). Using this cut-off, the EPDS has
been found to have a sensitivity of 68–95% and a
specificity ranging from 78% to 96% at 6 weeks
postpartum when compared to a diagnosis of
major depression following a psychiatric interview
(Cox et al. 1987; Murray & Carothers
1990).
The EPDS has usually been offered to women
by their health visitors to complete at approximately
6–8 weeks after the birth. There are
concerns that a single administration of the
EPDS after birth will not accurately identify
those who are depressed to the extent of requiring
treatment (Oates 2003). Guidance on optimal
number of times that the scale should be
administered is not available. Qualitative data
suggests that women who complete the scale on
more than one occasion ‘learn’ how to respond
accordingly (Shakespeare et al. 2003; Thurtle
2003), although this was not found to be the
case in a large randomized controlled trial
(RCT) of a new model of midwifery-led postnatal
care (MacArthur et al. 2003). In addition,
other factors that may affect the screening outcome
should also be considered, including the
relationship between the woman and the healthcare
professional, the environment in which the
woman was asked to complete the tool, and the
way in which the healthcare professional administers
the tool (Raynor et al. 2003; Shakespeare
et al. 2003). Cultural differences may make
it inappropriate for use with women from
ethnic minority groups, since ‘depression’ may
be construed as a Western concept of illness
(SIGN 2002), and there is a dearth of evidence
as to its acceptability amongst different ethnic
groups.
Concern has also been expressed that the scale
may actually be measuring two separate entities,
i.e. depressive feelings and anxiety (Brouwers
et al. 2001), and it has recently been suggested
that a revised, eight-item version of the EPDS
would provide a more psychometrically robust
scale (Pallant et al. 2006). The NICE postnatal
care guideline (NICE 2006) has adopted the
National Screening Committee (NSC) recommendation,
based on a review by Shakespeare
(2001), that suggested that the EPDS should
not be used as a routine screening tool, but it
may serve as a checklist for postnatal mothers
when used alongside professional judgment and
clinical interview.
2007 Association of Chartered Physiotherapists in Women’s Health 7

D. Bick & C. Rowan
Antenatal and postnatal interventions
A number of antenatal or postnatal interventions
for women deemed to be at risk of depression
have been evaluated. In paper based on a
full Cochrane Library systematic review, Dennis
(2005) assessed the effects of psychosocial and
psychological interventions compared with usual
antepartum and postpartum care on a woman’s
risk of developing postnatal depression. Fifteen
studies were included in the review, providing
data on 7967 women. The outcome of the review
was that diverse psychosocial or psychological
interventions did not significantly reduce the risk
of postnatal depression. The one intervention
that did show promise was the new model of
midwifery-led extended postnatal care (referred
to above), which focused on the identification
and management of postnatal physical and
psychological health problems. This was associated
with a reduction in depression at 4 and 12
months (MacArthur et al. 2003); however, further
evaluation of this intervention as part of
routine National Health Service (NHS) care is
required. A Cochrane Library systematic review
was unable to draw clear conclusions about the
effectiveness of antidepressants given prophylactically
to prevent postnatal depression in those
with a previous history of depression or postnatal
depression (Howard et al. 2005).
Debriefing
A number of studies have evaluated the effectiveness
of debriefing to prevent mental health
problems after birth, including depression and
PTSD. The term debriefing describes a structured
process that is intended for the primary
prevention of acute psychological morbidity as
a result of experiencing a traumatic event
(Dyregov 1989). Psychological debriefing
evolved in the late 1980s as a way of assisting the
first responders to traumatic incidents, notably
firemen, to talk in a structured way about what
had happened. It was proposed that a one-off
session of debriefing would help to reduce
psychological trauma and prevent PTSD
(Mitchell 1983). In the 1990s, debriefing, also
known as critical incident stress debriefing, was
adopted as a therapeutic response for people
who experienced a wide variety of traumatic
events. Despite the upsurge of interest in implementing
debriefing after trauma, a Cochrane
Library systematic review (Rose et al. 2002)
found no evidence of the effectiveness of singlesession
debriefing for the prevention of PTSD in
the general population and some potential for
8
harm. Recent recommendations for the management
of PTSD in primary and secondary care
are that ‘watchful waiting’ should be instigated
after traumatic events, since most people will
recover from trauma experiences with good
social support (NCCMH 2005).
To date, eight RCTs have compared postnatal
psychological outcomes following debriefing or
counselling interventions after birth. Two trials
found a positive association: in one, a midwifeled
counselling intervention was compared with
current care (Gamble et al. 2005), while the other
described a midwife-led debriefing intervention
(Lavender & Walkinshaw 1998). A third RCT
reported evidence that the intervention (midwifeled
debriefing on the postnatal ward following
operative birth) resulted in harm in the shorter
term (Small et al. 2000), with no long-term
differences 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; Kershaw
et al. 2005; Selkirk et al. 2006), there were no
differences in outcomes. Methodological issues,
in addition to the timing of the intervention
assessed and study inclusion criteria, may have
accounted for differences in the effectiveness of
the outcomes.
In UK maternity services, the term ‘postnatal
debriefing’ has been used to describe a variety of
post-birth discussions, which are mainly offered
by midwives with the intention of providing
women with an opportunity to talk about their
birth experiences. This sometimes less structured
approach to debriefing in the childbirth arena
has led to some confusion about the purpose
and the effectiveness of such interventions
(Alexander 1998). A number of evaluations have
been published of this service provision that do
show that women who use the service value the
opportunity to talk about their birth and the
events surrounding to it (Charles & Curtis 1994;
Baxter et al. 2003; Dennett 2003). However, none
of the studies published to date has included
data on clinical outcomes, and further work is
required on the training needs of midwives to
enable them to deliver these interventions, the
timing of offering an intervention, the aims of this
service provision and whether it meets the needs
of women from a range of ethnic backgrounds.
Maternity service care for women who
have mental health needs
There is clearly a need to ensure that the identification
of mental health needs becomes part of
2007 Association of Chartered Physiotherapists in Women’s Health

the routine provision of postnatal care offered to
all women, which includes appropriate referral
and management for women with mental health
needs, including signs and symptoms of trauma
and depression. A recently published survey by
MIND (2006) found that most of the 148 women
questioned attributed the problems that they
experienced to a lack of understanding by health
professionals, and inadequate advice and information.
Women also felt that more support
should be offered to women’s partners and their
families. Two-thirds of the women surveyed had
to wait over a month or more for treatment, with
one in 10 having to wait over a year. Over
two-thirds of women were admitted to a general
psychiatric ward rather than a specialized
mother and baby unit, and most of these women
were admitted without their babies. Women also
reported a lack of communication and coordination
between services, an issue highlighted in the
most recent Confidential Enquiry into Maternal
and Child Health (CEMACH) report (Lewis &
CEMACH 2004).
If healthcare professionals are to address
women’s mental health needs, they will require
guidance and support, since a number of issues
would have to be addressed. These include being
able to discuss mental health symptoms with
women, increasing awareness of the signs and
symptoms of mental health problems, and provision
of effective care, including timely referral
to the most appropriate healthcare professionals.
There is a dearth of evidence about the extent to
which guidance is in use in current practice.
Tully et al. (2002) undertook a survey to identify
the use of policies and guidelines in relation to
the identification and management of antenatal
and postnatal depression; 182 units, 86% of the
then total units in England and Wales, provided
information. Over one-third of units had policies
or guidelines on maternal mental health needs,
although only one-fifth indicated that these
covered postnatal depression and psychosis.
Although most respondents indicated that
women were routinely asked about their mental
health history during their booking visit, few
units had audited the services offered to women
with mental health problems. A survey of 78
mental health trusts in England (Oluwato &
Friedman 2005) found that, although protocols
on mental health needs were available in 58%
of the trusts, 16 (48%) considered these to be
outdated or inadequate.
A suite of guidelines intended to inform the
management of mental health needs within the
Postnatal maternal mental health
NHS in England and Wales have been published
or are in development (www.nice.org.uk). There
is also a NICE guideline programme for the
maternity services, which include recommendations
for the care of pregnant and postnatal
women with mental health needs. The NICE
guideline on antenatal care (NCCWCH 2003)
recommends that women are asked early in
pregnancy if they have had any previous psychiatric
illnesses, and that women who have a
history of psychiatric disorder should be referred
for a psychiatric assessment. Guidelines for postnatal
care (NICE 2006) recommend that all
women should have an opportunity to discuss
and ask questions about the birth, and in line
with the Cochrane Library review by Rose et al.
(2002), single-session debriefing should not be
offered. A guideline on antenatal and postnatal
depression is scheduled for publication in 2007
(www.nice.org.uk). The impact of these guideline
programmes, which aim to reduce variation
in practice and ensure that the most clinically
and cost effective care is provided, is as yet
unclear, with local services expected to audit the
outcome of service provision.
Discussion
Women can experience a range of psychological
and psychiatric health problems after giving
birth that may have a long-term impact on their
health and well-being, as well as implications for
the health of their infants and families. For
some, these will be experienced in addition to
physical morbidity after birth. The present paper
has described some of the mental health symptoms
which may be experienced, focusing on
depression and psychological trauma, as well as
issues surrounding prevention and the need to
address the content and delivery of maternity
services.
Because much maternal physical, psychological
and psychiatric morbidity remains
unidentified by healthcare professionals and
unreported by women, it is important to increase
awareness of the signs and symptoms of mental
health problems after birth, including depression
and PTSD. This should be targeted at users and
providers of the maternity services, given the
concerns raised by the women in the survey
conducted by MIND (2006), i.e. that healthcare
professionals did not appear to understand mental
health needs, and as a consequence, were
unable to offer adequate advice and support.
Since there is evidence to support the contention
2007 Association of Chartered Physiotherapists in Women’s Health 9

D. Bick & C. Rowan
that a personal or family history of depression
or postnatal depression increases the risk of
these mental health problems (re)occurring after
giving birth, it is imperative that a woman’s
mental health history is documented in order
that appropriate postnatal care can be instigated.
All women should now be asked about
their personal and family mental health history
at their antenatal booking visit (NCCWCH
2003), and any current symptoms should be
explored, although there is little information
about the extent to which this takes place, or if it
is making a difference to women’s experiences of
mental health problems. The evidence to date
indicates that, although women with mental
health problems may be identified during pregnancy,
appropriate management plans may not
have been put in place (Lewis & CEMACH
2004) and communication between the members
of the multidisciplinary team may not have been
optimum. Therefore, referral pathways need to
be clear.
Universal screening of women who may be at
risk of depression using a tool such as the EPDS
is not currently recommended by the NSC,
although it is still commonly used in postnatal
care. Some of the issues in relation to the shortcomings
of the EPDS have been described,
including the environment in which it is administered,
but much of the data to date has come
from research studies rather than outcomes of
routine clinical practice. From the qualitative
data that are available, women may not find
completing the EPDS acceptable (Shakespeare
et al. 2003), suggesting that time to talk about
feelings and emotional well-being may be a
preferred alternative. If this is to be an option,
then there are clearly training needs to be
addressed, including communications skills,
for all relevant healthcare professionals
(Shakespeare et al. 2003).
The evidence to date does not support the use
of interventions during or after birth to prevent
mental health problems, with the exception that
planned and tailored midwifery-led care may
reduce the risk of depression (MacArthur et al.
2002, 2003; Dennis 2005). Formal debriefing
should not be instigated, and clarity relating to
the content and benefit of debriefing interventions
currently offered by the maternity services
is required so as to ensure that outcomes are
beneficial and services directed at the women
most in need of their support. Healthcare professionals
may continue to focus on physical
symptoms rather than addressing any mental
10
health needs a woman may be exhibiting,
although there is clearly a complex relationship
between physical and psychological symptoms
(Brown & Lumley 2000), and women have
reported a lack of focus on their emotional needs
after birth (Singh & Newburn 2002). The evidence
does suggest that women value the opportunity
to talk about their birth, which should
now be offered as part of routine care within
England and Wales (NICE 2006).
There is general agreement that the postnatal
services, particularly those provided by midwives,
need to be revised to enable women to
receive tailored, individual care based on their
needs (MacArthur et al. 2002). There are concerns
that, because of limited resource capacity,
postnatal services in the community are being
cut back, with the potential that health needs
will remain unmet. Clearly, not all women will
require intensive postnatal visiting, and it is
an important requirement that those who do
require care are identified and supported effectively.
Managers, policy-makers and healthcare
professionals should ensure that postnatal services
receive equal priority with antenatal and
intrapartum care.
Concerns about the care of women in the UK
have come to the fore following the report of the
2004 CEMACH, where suicide was identified as
the leading direct cause of maternal death. This
is a devastating outcome for all concerned, and
is an extreme consequence of an illness that
affects thousands of women each year. The needs
of women with mental health problems are not
consistently identified or addressed, and much
further work is required to ensure that comprehensive
service provision is implemented,
given its potential to affect the longer-term
health of the woman, her infant and her
family.
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2007 Association of Chartered Physiotherapists in Women’s Health

Debra Bick BA(Hons) MMedSci PhD RM is a
professor of Midwifery and Women’s Health at
the Centre for Research in Midwifery and Childbirth,
Faculty of Health and Human Sciences,
Thames Valley University, London, UK. She has
worked on a number of large studies examining
the impact of interventions during and after birth
on women’s physical and mental health. Debra
was the clinical advisor to the recently published
NICE guideline on postnatal care for healthy
women and babies, and has written extensively on
Postnatal maternal mental health
issues relating to the organization and content of
services for women after birth. She is the editorin-chief
of Midwifery: An International Journal.
Her current projects include a national clinical
quality improvement programme to enhance the
assessment and management of perineal care,
revising the content and planning of postnatal care
in hospital and on transfer home, and identifying
training needs in order to improve care for women
with mental health needs.
2007 Association of Chartered Physiotherapists in Women’s Health 13

Journal of the Association of Chartered Physiotherapists in Women’s Health, Spring 2007, 100, 14–20
ACPWH CONFERENCE 2006
Motivational interviewing and health behaviour change:
an overview and their relevance to women’s health
C. A. Lane
School of Nursing and Midwifery Studies, Cardiff University, Cardiff, UK
Introduction
Abstract
Encouraging patients to make changes to their health behaviour is challenging
for practitioners in most clinical disciplines. In relation to women’s health issues,
the challenges facing physiotherapists include encouraging women to adopt
treatment/exercise regimes to improve recovery and well-being, as well as maintaining
these practices over time. One method that has shown promise in
facilitating health behaviour change in a number of clinical settings is motivational
interviewing, ‘a directive, client-centred counselling style for eliciting behaviour
change by helping clients to explore and resolve ambivalence’. This paper aims to
provide an overview of the method, to present the evidence to date for its efficacy
and to discuss its relevance to women’s health.
Keywords: debriefing, depression, maternal health, postnatal care, post-traumatic stress
disorder.
‘Bizarrely, after a couch potato lifestyle, I
have discovered exercise with a vengeance . . .
but while the spirit is willing, the body isn’t
always and the old muscles down below aren’t
what they were. If I sneeze unexpectedly,
laugh or try a particularly energetic move
whilst playing tennis, then I’m likely to suffer
a ‘‘stress incontinence moment’’. Not great.
Do I do the exercises regularly? Do I heck!’
‘I’ve made a good recovery following my
ankle surgery, but keeping up with the balancing
exercises is hard. There’s always something
more pressing to do – be that writing papers,
preparing for conferences, or simply trying to
keep my home (that my husband continually
messes up) tidy. I know how important it is
to do my ankle exercises – after all I waited
5 years for the surgery to put it right – but
building them into my everyday life is hard.
Ironically, it’s even harder now that I am
feeling a lot better.’
Correspondence: Dr Claire Lane, Nursing, Health and Social
Care Research Centre, School of Nursing and Midwifery
Studies, Cardiff University, Fourth Floor, EastGate House,
35–43 Newport Road, Cardiff CF24 0AB, UK (e-mail:
LaneCA1@cf.ac.uk).
14
‘As I rumble towards my menopause, I’m
having to be much more careful about my
weight and it’s a huge effort because I really
like my food! My knees aren’t as good as they
were and I’m waiting for an operation to
scrape out the torn cartilage. I’ve had to have
physio and I can’t afford to gain extra weight.
If I want to be in good nick, I’ve got to look
after myself. Hmm, easier said than done.’
Do these stories ring a bell with you? No doubt
you can think of times when you have told a
patient what they need to do, yet when the
follow-up comes around, they do not seem to
have taken your advice. How many times has a
women complained that she could not do her
exercises because her husband was not
supportive/the kids needed her/there was so much
to do at home/she had people to stay/her job was
so demanding/she was so tired with everything
else that she had to do over the past fortnight?
In her training sessions, the present author
sometimes asks health professionals, ‘How
would you feel if you had to see three patients
like this in a row?’ Responses tend to range
from ‘exhausted’ and ‘frustrated’ through to
‘demoralized’ and ‘disillusioned’. It is perfectly
normal to feel this way. After all, the reason you
and your colleagues give advice like this is
2007 Association of Chartered Physiotherapists in Women’s Health

ecause you care, and you want the patient to
make as good a recovery as possible.
On the other hand, the patient is probably
feeling as frustrated with herself as you are. She
may feel as though she has failed because she has
not managed to do something that should be ‘so
easy’, and she may also be worried that she is
doing herself some damage because she has not
done what she was ‘meant to do’. The present
author should know – she is the author of the
second quotation.
Health behaviour change is a challenging
area – for both the patient and the practitioner.
The way in which this is addressed by a health
professional can make all the difference, and
therefore, it is important to take a flexible
approach to communication. All patients are
different, and some women will already be motivated
to make the changes or adhere to the
treatment plans that have been suggested for
them. Other patients may be a little more difficult,
and there are times when simple instruction
and advice does not do the trick. So, what can
you do instead?
What’s your style?
There are a number of different styles that we use
when communicating with others in our daily
lives. This was something the present author and
a colleague discussed in some detail with a group
of health visitors whom they trained in 2003
(Rollnick et al. 2004). For example, on a daily
basis, it might be appropriate at different points
to either direct, guide or follow (S. Rollnick,
personal communication). Directing involves the
provision of information or advice. Guiding usually
involves building on somebody’s strengths to
help them get better at something they already
know a little about. Following involves listening
to and understanding somebody. Imagine the
following scenarios that could occur in everyday
family life, and think about what style would be
appropriate in each situation:
+ A child runs out into a busy road. (Direct)
+ A child is learning to read. (Guide)
+ A child is crying and you do not know why.
(Follow)
It seems obvious where directing, guiding and
following seem most appropriate. Now imagine
restricting yourself to using just one style of
communication for every scenario, or using the
wrong style in the wrong situation – imagine the
consequences of directing the child who is
crying/learning to read, or guiding/following the
Motivational interviewing and health behaviour change
child who has run into the road. The same
principle applies when dealing with patients in
clinical practice. When it comes to behaviourchange
issues, some patients may require
‘direction’ – others may have more pressing
issues and need to be ‘followed’. However,
many will be most receptive to a ‘guiding’ style
(Rollnick et al. 2005). Looking at the psychological
processes behind behaviour change can
help us to understand why this may be the case.
The psychology of behaviour change
There are many factors that may affect how and
why patients make changes.
Patients often need to feel a degree of personal
choice with regard to changing their behaviour.
Brehm (1966) suggested that, if a person perceives
that their individual freedom is being
taken away, this may, in turn, motivate them to
actually perform the behaviour they are being
told not to do (or of course, fail to perform
the behaviour they are being told to do!). Put
simply, this describes the patient who reacts to
information/advice by thinking, No one tells me
what to do.
Many patients expect to be persuaded to make
lifestyle changes, which can, in turn, result in
resistance to making changes. Using ‘empathy’ –
listening carefully and demonstrating to patient
that they have been understood – can help to
lower resistance. For example, Carl Rogers
(1959) developed the ‘client-centred counselling
framework’, which draws closely on the use of
empathy, because he found that his psychotherapy
clients often had improved results if he
listened more and allowed them to determine the
rate of treatment. This led him to believe that a
flexible attitude to treatment was important,
since encouraging the client to be self-aware and
to make independent choices appeared to help
them to understand the problem at hand.
Self-perception can also have an effect on a
patient’s motivation to change (Bem 1972). If
patients see themselves as smokers, for example,
they think they like it and want to continue
doing it. If they hear themselves saying that they
do not want to be smokers and they are going to
quit, they may, in some cases, believe it and stop
smoking.
Similarly, Festinger (1957) discussed ‘cognitive
dissonance’ – people generally feel uncomfortable
when they hold two conflicting
beliefs – for example, ‘I want to be healthy, but I
eat a lot of fatty food, which is bad for me.’ This,
2007 Association of Chartered Physiotherapists in Women’s Health 15

C. A. Lane
in turn, may create an urge to resolve the
conflict – which could potentially mean that the
patient in the example decides to gradually
reduce the amount of saturated fat in their diet.
However, if patients do not believe that they can
reduce the amount of fat in their diets very
easily, it may be easier to despise what they feel
they cannot achieve: ‘Who wants to look like a
fake supermodel anyway? Let’s forget that idea.’
Another factor that may affect patient
motivation to change is their ‘readiness’ to make
changes. One model commonly used to try to
understand readiness is the transtheoretical
(or ‘stages of change’) model (Prochaska &
DiClemente 1983), which describes five possible
stages that individuals may be at in terms of
making a change:
+ the precontemplation stage – the person has
not even considered that she or he might need
to make changes at this point;
+ the contemplation stage – the person has considered
that there is something that she or he
probably needs to change;
+ the preparation stage – the person makes
plans as to how she or he might change;
+ the action stage – the person is actively undertaking
behavioural changes; and
+ the maintenance stage – the person maintains
the changes she or he made in the action stage
over a period of time.
The stages are not linear – an individual can
relapse and fall back into former stages at any
point in time. For example, perhaps the changes
made in the action stage were difficult to implement,
causing a patient to fall back into the
contemplation or preparation stage, or a stressful
life event such as a relationship breakup
forced the patient back into the precontemplation
stage.
Two factors that can influence patients’ readiness
to make changes are the degree of importance
that they attach to making the behaviour
change, and their confidence in their ability to
achieve it (Keller & White 1997; Rollnick et al.
1997). In general, if importance and confidence
are both high, patients are more likely to feel
ready to make changes. If importance and confidence
are both low, patients are not likely to feel
at all ready to make changes. If importance and
confidence are somewhere in the middle of the
range, or either importance or confidence is high,
but the other is low, patients are likely to be
ambivalent about making changes. Having the
confidence to achieve change is recognized as a
16
great factor in making lifestyle changes. If individuals
believe that they can change, this is often
half the battle. If they do not believe they can
change, they may not even try (Bandura 1995).
To summarize the information above, it is
clear that behaviour change is a phenomenon
that is personal and individual to the patient.
Motivation to change can be influenced by how
much freedom of choice patients feel they have,
how they view themselves in relation to how they
would like to be, how ready they feel they are to
change, how important they think it is to change,
and how confident they feel about their ability
to achieve it. The fact is that we cannot make
patients change or adhere to treatment regimes.
That decision is, and always will be, theirs to
make. However, what we can do is have constructive
discussions with patients about making
changes, help them to explore how they think
and feel about change, and guide them in thinking
about how and why they might change. One
method that can help with this is motivational
interviewing (MI; Miller & Rollnick 2002). The
following explanation of MI is based closely on a
previous description of the method (Lane 2006).
Motivational interviewing
Motivational interviewing originated in the
addictions/psychotherapy field, and has evolved
from the work by Rogers (1959) on the ‘clientcentred
counselling framework’ mentioned
above. The technique is similar to the clientcentred
counselling framework, in that:
‘[It] does not focus on teaching new coping
skills, reshaping cognitions or excavating the
past. It is quite focussed on the person’s
present interests and concerns. Whatever discrepancies
are explored and developed have to
do with incongruities among aspects of the
person’s own experiences and values.’ (Miller
& Rollnick 2002)
Motivation for change is drawn from the
client, rather than imposed. However, MI differs
from the client-centred counselling framework in
that it is purposely directive:
‘Motivational interviewing involves selective
responding to speech in a way that resolves
ambivalence and moves the person toward
change.’ (Miller & Rollnick 2002)
One misconception about MI is that it is often
viewed as a set of techniques that can be inflicted
on a patient without genuine empathy and
understanding. Motivational interviewing is a
2007 Association of Chartered Physiotherapists in Women’s Health

clinical skill, rather than a tool. To further define
the nature of MI, Miller & Rollnick (2002)
described the spirit of MI (or a ‘way of being’
with a patient), and presented four principles (or
‘conventions guiding practice’) behind the
method.
The spirit of MI is divided into three components:
collaboration, evocation and autonomy:
+ Collaboration refers to the patient and practitioner
working together in partnership, not
against each other (e.g. with the practitioner
advocating change and the patient arguing
why change is not a good idea).
+ Evocation describes the process of the practitioner
eliciting the patient’s goals, thoughts
and feelings about behaviour change, rather
than providing information as to how and
what they should feel about change.
+ Autonomy signifies practitioner respect for
the patient’s rights as an individual. Patients
know their own mind, and should be allowed
to choose what to do about their behaviour –
there is recognition that any changes that
patients do decide to make are entirely their
choice, and that the practitioner is not there
to force them to do anything. Should patients
decide that they do not want to make any
changes to their behaviour, the practitioner,
in turn, has to respect this decision.
The four principles to be followed while conducting
MI are to express empathy, develop
discrepancy, roll with resistance and support
self-efficacy (Miller & Rollnick 2002):
+ Expressing empathy describes how the practitioner
should demonstrate an understanding
of the patient’s perspective. This is mainly
achieved through the use of active, reflective
listening techniques, which demonstrate that
the practitioner understands what the patient
has told them.
+ Rolling with resistance is the approach taken
to avoid confrontation with a patient. It could
be described as ‘going along with what the
patient says for a bit’ while demonstrating
understanding for resistance as a means of
reducing it.
+ As well as eliciting the patient’s motivation to
change, the practitioner should support the
patient’s self-efficacy (a person’s belief that
they have the ability to do something) and
build on the patient’s confidence in achieving
change without telling her or him what to do.
+ Developing discrepancy is the most complex
of the principles underlying motivational
Motivational interviewing and health behaviour change
interviewing. It involves the practitioner listening
carefully to what the patient says about
her or his personal values, and illustrating
how this is at odds with the patient’s current
behaviour. This is often achieved by highlighting
how the behaviour in question does
not fit in with the patients’ perception of how
she or he would like to be.
With the spirit and guiding principles of the
method in mind, the practitioner uses a number
of skills to encourage the production of patient
‘change talk’ (patient talk about how and why
they might change their behaviour). This is
accomplished through a variety of means, such
as asking permission to talk about the behaviour
in question, encouraging the patient to set the
agenda for the consultation, assessing a patient’s
readiness to change, asking open-ended questions,
making summaries, and the skilful use of
reflective listening to both express empathy and
to direct the patient in producing change talk.
Following its success in the psychotherapy
field, MI has generated much interest within
healthcare settings where behaviour change is
often an issue. For this reason, the method has
been adapted for use in these contexts (Rollnick
et al. 1999), adhering to the spirit and principles
outlined above. There are a number of strategies
that clinicians can use to help implement MI into
their practice with patients. Although a comprehensive
guide to ‘doing MI’ is not possible
within the scope of a conference paper, four
strategies (i.e. agenda-setting, exploring the pros
and cons of change, exploring readiness to
change, and exchanging information) will be
outlined below to give readers an idea of how MI
works in clinical practice.
Agenda-setting
In MI, the patient is encouraged to set the
agenda for talking about behaviour change. This
is particularly important if there are a number of
different lifestyle issues to be addressed. For
example, a female cardiac rehabilitation patient
may have been identified as having a number of
risk factors that may have contributed to her
heart attack. She may need to make changes to
her diet, increase the amount of physical activity
that she does and cut down the amount of
alcohol she consumes. It is often easier to make
changes by trying to do a bit at a time, rather
than trying to make a number of substantial
changes all in one go. We are all at different
stages of readiness to change over different
2007 Association of Chartered Physiotherapists in Women’s Health 17

C. A. Lane
issues – and may even be at different stages of
readiness to change different aspects of one
health behaviour (Rollnick et al. 1999). Illustrating
the point with the example above, this
cardiac rehabilitation patient may be ready to
start going for a half-hour walk a couple of times
a week, but may not feel ready to start going
swimming too. Achieving small changes can
increase self-efficacy (Bandura 1995), making a
patient feel more able to make other small
changes. Therefore, it is important to start where
the patient feels most comfortable, and encourage
her or him to suggest what area she would
like to talk about, rather than selecting what the
healthcare practitioner feels is the most important
issue to talk about first. It is also important
to ask permission to talk about lifestyle changes,
so that the patient feels that she has a choice in
the matter.
Encouraging the patient to set the agenda can
be initiated through the use of open questions,
such as, ‘There are a number of different things
we can talk about today. I’m just wondering
what aspect of your lifestyle you would like to
talk about?’ One tool that can help with this task
is an ‘agenda-setting chart’ (a copy of which,
along with instructions for its use in clinical
practice, can be found in Rollnick et al. 1999),
which contains a number of circles containing
picture representations of various different lifestyle
factors, and some blank circles for other
factors to be inserted by the patient. Be prepared
for the patient to raise issues that you might not
have anticipated – drawing again on our cardiac
rehabilitation patient, worries about looking
after her family may be more pressing at that
particular point.
Exploring importance and confidence
Given the role that readiness plays in motivation
to change behaviour, it can be useful to gain an
understanding of this. One way this can be
achieved within clinical practice is by exploring
how important the patient feels it is to change
her behaviour, and how confident she feels about
achieving it.
Many practitioners find it useful to ask patients
to rate, on a scale of 0–10, ‘How important is it
for you, right now, to change X?’ and then ask
them to rate, on the same scale, ‘How confident
do you feel of success in changing X?’ Following
on from this, there is the opportunity to ask a
patient why she has given herself this score and
not a higher or lower number, or indeed what she
18
thinks would help her to move up the scale in
terms of importance and/or confidence.
This strategy can help the practitioner to
understand the patient’s barriers to change, and
therefore, can start the process of helping the
patient to overcome them.
Exploring pros and cons
Closely related to the importance/confidence
strategy, exploring the pros and cons of the
current behaviour and changing behaviour can
help the practitioner to understand the patient’s
barriers to change. This strategy simply involves
asking the patient what she likes/doesn’t like
about her current behaviour, and what she feels
she would gain/lose from making changes.
Exchanging information
Within healthcare consultations, there often
comes a point when we need to stop listening to
patients and give them information. Perhaps the
patient needs to know something for her safety/
well-being, she has asked you for information
about what she should do, or she has misunderstood
something with regard to her care or
recovery.
Information-giving within healthcare is usually
a process in which the patient is a passive
recipient. A typical example might be: ‘You are
eating too much of X. This means that you are at
a much higher risk of developing Y. What I
suggest you do is Z.’ This has the advantage of
being short, sweet and to the point. However,
it has the disadvantage of possibly telling the
patient something she knows already, or that she
may misunderstand in terms of its relevance for
her. It also makes the assumption that the
patient will just take the advice and do as she is
told (if only it was that easy!).
Within MI, information is exchanged with
patients, rather than given. This involves the use
of the ‘elicit–provide–elicit’ method, or first finding
out what the patient knows already, providing
information (after asking if the patient is
happy for you to do this), and then finding out
what the patient has made of that information.
This means that information is given in a neutral
manner, building on what the patient already
knows, and the interpretation of the facts is left
to the patient.
Exchanging information in this way can
encourage the patient to actively think of how
the information given applies to her as an individual,
and can even save the practitioner time,
2007 Association of Chartered Physiotherapists in Women’s Health

since it prevents the provision of redundant
information, or ‘telling the patient what she
knows already’.
Evidence for the effectiveness of
motivational interviewing
A number of recent systematic reviews have
presented growing evidence for the effectiveness
of MI as an intervention. The strongest evidence
is in the treatment of drug and alcohol misuse
(Dunn et al. 2001; Burke et al. 2002, 2003;
Hettema et al. 2005). Because MI is still a
relatively new method, and it entered the general
healthcare arena much later than the addictions
field, the evidence for the effectiveness of MI
within healthcare settings is still somewhat
limited, although it has shown much promise.
Rubak et al. (2005) conducted a systematic
review of 72 randomized controlled trials in
healthcare settings, and found that MI interventions
had a significant effect on reducing Body
Mass Index, cholesterol, systolic blood pressure,
blood alcohol content and standard ethanol content,
although not on the number of cigarettes
per day in smokers or glycosylated haemoglobin
(HbA1c) in people with diabetes. Vasliaki et al.
(2006) systematically reviewed studies that used
brief alcohol interventions based on MI, and
concluded that the technique was effective in
reducing alcohol consumption in the short
term with mainly risky (rather than alcoholdependent)
drinkers. A recent systematic review
by Knight et al. (2006) into the effects of MI
interventions on physical activity concluded that
these interventions do appear to increase exercise
uptake among patients, although the poor quality
of the trials made this hard to determine, with
just eight studies being included in the review as
a result, mirroring the findings of previous
reviews that have attempted to look at MI in
relation to specific health behaviours (Dunn
et al. 2001; Burke et al. 2002, 2003; Hettema
et al. 2005). To enhance the quality of such trials
of MI, more attention is being focused on the
quality of the intervention actually delivered by
practitioners in a number of different contexts,
resulting in the development of instruments to
measure practitioner skill in delivering MI (Lane
et al. 2005; Moyers et al. 2005; Lane 2006).
One of the advantages of MI is that it appears
to be beneficial in helping people of both sexes to
change behaviours that they are ambivalent
about changing. However, a number of studies
have taken an MI approach specifically with
Motivational interviewing and health behaviour change
women in various contexts – such as pregnant
drinkers (Handmaker et al. 1999), pregnant
smokers (Stotts et al. 2004), female sex workers
(Yahne et al. 2002) and women experiencing
marital dissatisfaction (Kelly et al. 2000;
Cordova et al. 2001) – and have found it to be
helpful in facilitating behaviour change among
these women. A fellow MI trainer has commented
on how using the technique in her
clinical practice with women has been useful:
‘I work on a research study in which I run
weight-loss groups for women who are overweight
and have urinary incontinence, and they
are very receptive to the lessons on exploring
values . . . and making themselves a priority. It
is quite gratifying to see the transformation
among these women, who begin to carve out
time to take better care of themselves and lose
weight.’ (J. Hecht, personal communication)
Conclusion
Motivational interviewing is a method for which
there is growing evidence that it may be an
effective way to facilitate behaviour change in
patients who are ambivalent about change, or
who are finding it difficult to put changes into
practice. No method of consulting can offer a
‘one size fits all’ approach, but given the importance
of being flexible, and trying to use the best
style of communication for each individual
patient, MI is one skill that practitioners may
find useful to include in their ‘toolbox’ of existing
skills when employing a guiding style with
their patients.
Want to find out more about motivational
interviewing?
More information about MI can be found on the
World Wide Web at .
Health Behaviour Change: A Guide
for Practitioners by Rollnick et al. (1999) and
Motivational Interviewing: Preparing People for
Change by Miller & Rollnick (2002) are recommended
further reading.
Acknowledgements
Many thanks to the Motivational Interviewing
Network of Trainers (MINT) and their colleagues
for their ideas and support, especially:
Majella Greene, Bob Mash, Marlyn Allicock,
Marci Campbell, Grant Corbett, Viv Mumby,
Donna Spruijtz-Metz, Cheryl Martin, Jacki
Hecht, Gary Latchford, Dee-Dee Stout and
Ineke Buskens.
2007 Association of Chartered Physiotherapists in Women’s Health 19

C. A. Lane
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Claire Lane is a research fellow at the Nursing,
Health and Social Care Research Centre, Cardiff
University.
Originally from a linguistics background, she
undertook her PhD in healthcare communication
at the Department of General Practice, Cardiff
University. Claire’s academic work to date has
focused on health behaviour change, and more
specifically, motivational interviewing. To this
end, her doctoral studies examined the effects of
training on practitioner skill in motivational interviewing,
and involved the development of an
instrument to measure this, the Behaviour Change
Counselling Index (BECCI).
Claire is currently working on the Transition
from Children to Adolescent Diabetic Services
(TCADS) project, which aims to investigate what
methods of progression seem to work well for
particular groups of teenagers. She is a member of
the trial management group on the Pre-Empt
Study at the Department of General Practice,
Cardiff University.
2007 Association of Chartered Physiotherapists in Women’s Health

Journal of the Association of Chartered Physiotherapists in Women’s Health, Spring 2007, 100, 21–26
ACPWH CONFERENCE 2006
‘Quote me happy’: can acupuncture make those
hormones happy?
J. Longbottom
Private Practice, St Neots, Cambridgeshire, UK
Abstract
The present paper outlines the neurophysiological and neurohumeral effects of
acupuncture with reference to pain modification, and systemic enhancement of
mood, 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 with
the richness of the underlying philosophy of traditional Chinese medicine in order
to enhance patient care and clinical management of the more complicated case
presentations within physiotherapy. The paper attempts to reinforce suggested
protocols, both within myofascial pain management and systemic dysfunction,
with appropriate research, in order to support clinical reasoning and ‘best
practice’ encompassing a variety of conditions ranging from the more peripheral,
superficial gynaecological infections to systemic dysfunction, whilst retaining the
scope of physiotherapeutic practice. The paper encompasses musculoskeletal
dysfunction, menopausal symptoms, infertility and mild depression as a means of
enhancing the physiotherapist’s clinical toolbox and offering a greater choice of
patient care to the acupuncture practitioner.
Keywords: acupuncture, hormones, pain, sleep, well-being.
Introduction
The word ‘hormone’ is derived from the Greek
hormon, meaning ‘to excite or to arouse’.
The present paper seeks to excite and arouse
further interest in acupuncture, within the scope
of physiotherapy practice, in order to ‘go
beyond’ (but not ignore) analgesic evidence for
acupuncture effectiveness. The paper emphasizes
the integration of acupuncture, within an
evidence-based paradigm, with the philosophy of
traditional Chinese medicine (TCM), while
offering an explanation of neurophysiological
and neurohumeral effects that may facilitate
systemic and emotional improvement. The effect
of acupuncture, from periphery to brain, is presented;
we take a journey to outline some conditions
encountered, some protocols suggested
and the supporting evidence to enhance clinical
reasoning.
Correspondence: Jennie Longbottom, 13 Park Avenue, Little
Paxton, St Neots PE19 6PB, UK (e-mail: jennie.longbo@
ntlworld.com).
Rehabilitation
Acupuncture is increasingly finding a place in
rehabilitation, and although the evidence base is
growing quickly, prejudice still surrounds its use
within conventional Western medical systems.
This resistance stems in part from acupuncture’s
roots in TCM, dating from 200 BC. The prevailing
belief at that time was of a system of organs
and channels (meridians) through which vital
energy, ‘qi’, flows. Qi is influenced by needling
specific locations on the body (acupuncture
points) in order to enhance or reduce qi flow,
achieve balance, restore homeostasis, and promote
health and healing. These early attempts at
understanding disease and disharmony persisted
until fairly recently. There is some stigma that
still attaches itself to acupuncture, with detractors
claiming that it has a placebo effect at best,
and is shamanism at worst. This prejudice,
coupled with initially unpromising reports
(Mendelson et al. 1983), hindered acupuncture’s
wider acceptance as an effective treatment
for pain, although recent studies (Carlsson &
Sjolund 2001) have been more encouraging.
2007 Association of Chartered Physiotherapists in Women’s Health 21

J. Longbottom
At the periphery
Acupuncture for pain control is more widely
accepted. Needling is a stimulus that releases
histamine and calcitonin-gene related peptide
(CGRP), and causes a local inflammatory reaction
(Sandberg et al. 2003).
The resulting therapeutic effect of acupuncture
is enhanced blood flow (Cao 2002), increased
phagocytic response and enhanced inflammatory
response to trauma with consequent tissue healing
(Hsieh 1998).
Interpreting the chemical responses at the
periphery into clinical practice leads to acupuncture
evidence in the field of treatment of interstitial
cystitis (Tucker 2004), leucorrhoea and
vaginitis (Flaws 1986), and Candida albicans
(Erconlani 1997).
Illiev et al. (1990) found significant changes
in immunoglobulin and lymphocyte proliferation
following electro-acupuncture (EA) at
large intestine (LI) 4 and stomach (ST) 36.
Rosted (1994) recommended a standard protocol
for skin diseases, demonstrating significant
effects using lung and large intestine points.
In short, there are optimistic studies for the
use of acupuncture in a variety of superficial
skin conditions, providing evidence of a strong
phagocytic reaction and antihistaminic effect
in healthy volunteers, but there is much
room for further well-controlled studies in this
area.
At the spinal cord
Small afferent A-fibres are stimulated by the
acupuncture needle, causing the release of
-endorphin and leu-enkephalin in the dorsal
horn of the affected spinal cord segment (Han
2004). These substances block the transmission
of small C-fibre-mediated nociceptive input to
the ascending sensory columns through the
mechanism of ‘pain gating’ (Han & Terenius
1982), thus reducing the experience of pain.
Segmental mechanisms of pain control are most
likely to act locally, and are probably responsible
for the analgesic effects of needling close to
the site of pain.
Clinical research suggests that pain modulation
for musculoskeletal management is enhanced
by the use of acupuncture and manual
therapy, compared with manual therapy alone
(Furlan et al. 2001), for lumbar pain and pelvic
pain as an adjunct to stabilization exercises
(Cummings 2003), and for sacroiliac dysfunction
(Betts 2005).
22
Myofascial pain
Recent evidence from the USA on endometriosis
pain and dysfunction (Lyttleton 1998; Whyte
Ferguson & Gerwin 2005) has suggested that
there is an 80% correlation in pain patterns
between active abdominal muscle trigger points
and the diagnosis of ‘endometriosis’. This
further supports previous work by Simons
et al. (1999), who suggested that the external
abdominal oblique muscle may cause abdominal
pain and reflux; the lateral abdominal muscles
causing pain and diarrhoea, and pyramidalis,
mirroring endometrial pain.
These active trigger points are capable of
reproducing strong somatovisceral and viscerosomatic
interactions, suggesting that the trigger
points are activated by the visceral component,
but persist after this component has resolved
(Simons et al. 1999). This may result in misleading
diagnoses and treatment regimes. Simons
et al. (1999) proposed the ‘energy crisis’ hypothesis,
according to which the crisis energy leads to
increased production of acetylcholine at a dysfunctional
motor end plate, which increases actin
and myosin filament contraction, resulting in
tight bands within the muscle fibre. The consequence
of this is increased pressure on surrounding
blood vessels, with resulting ischaemic
symptoms of pain and paraesthesia, which are
made worse by muscle loading and enhanced
sympathetic responses, such as anxiety or stress.
Research has demonstrated that symptoms
such as projectile vomiting, anorexia, intestinal
colic, diarrhoea, bladder and bowel sphincter
dysfunction, and dysmenorrhoea (Simons et al.
1999) can result from active abdominal trigger
points.
Assessment and palpation of all abdominal
muscles should be a mandatory component
of physiotherapy management when treating
patients who demonstrate these symptoms.
Appropriate trigger-point needling (Whyte
Ferguson & Gerwin 2005) should be undertaken,
followed by myofascial release techniques
(Chaitow 2001) and accompanying muscle
imbalance re-education (Wedenberg et al. 2000).
Brain and limbic system
The action of de qi, and the classic description of
a ‘heavy’, ‘numb’ or ‘sore’ sensation mediated
by the activation of the small C-fibres are essential
components of acupuncture effectiveness
(Abad-Alegria & Giaz 2004). It is essential for
producing analgesia (Lundeberg 1995) via the
2007 Association of Chartered Physiotherapists in Women’s Health

endogenous opiate system. Ascending C-fibre
mediates nociceptive input and stimulates the
periaquaductal grey, hypothalamus and pituitary
(Wang et al. 1990), which in turn stimulate
the release of serotonin, norepinephrine, histamine,
bradykinin, endorphin, dopamine and
adrenocorticotrophic hormone (ACTH) (Chen
& Han 1992). These chemicals modulate pain
by both pre- and post-synaptic inhibition.
Endorphin-like substances also appear in the
cerebrospinal fluid after needling (Shen 2001);
ACTH passes to the kidneys and stimulates the
release of cortisol (Han et al. 1992), a powerful
systemic anti-inflammatory.
At the hypothalamus–pituitary axis, we see
enhanced levels of oxytocin release following
acupuncture, leading to improved mood state,
relaxation and general quality of life, whilst
reducing anxiety and sympathetic hyperalgesia
(Alison et al. 2003).
The stimulation of -endorphin is known to
deactivate norepinephrine, which is known to be
responsible for increased climacteric responses in
menopausal flashes, improving stamina and personal
drive (Sandberg 2002; Cohen 2003). This is
well presented in TCM gynaecology texts, where
calming of liver and heart qi and enhancement
of spleen and kidney qi (Maciocia 1998) are
suggested protocols for the treatment of menopausal
syndrome (Jang et al. 2003).
Beyond pain
The practitioner should look beyond pain in
order to encompass the TCM philosophy of
homeostasis and balance, especially in the area
of hormonal response.
Acupuncture does not stop at the hypothalamus.
The hippocampus, which is thought to be
involved in memory, cognitive problem-solving
skills, and the storing and processing of physical
and spatial information, is believed to become
highly susceptible to fluctuations in oestrogen
and progesterone levels. This is often reported
by patients during periods of fluctuation, such as
the menopause, and the premenstrual and postnatal
periods. In a study by Dong et al. (2001),
acupuncture significantly improved vasomotor
symptoms at the end of treatment (P=0.0001)
and at 3-month follow-up (P=0.003). It did
not change psychosocial or sexual symptoms.
Sandberg et al. (2002) found significant changes
in mood scale in the EA group over superficial
acupuncture needling. Quah-Smith et al. (2005)
conducted a study of mild to moderate depres-
Acupuncture and hormones
sion in postnatal patients in a primary care
setting. A low-level laser was used and patients
were randomized to active or inactive laser
acupuncture. Beck Depression Inventory (BDI)
scores revealed significant falls (P=0.007) 12
weeks after treatment, although this study
involved a small sample size and a short posttrial
follow-up period. The improvement in BDI
scores was not significant at 4 weeks, but became
so at 12 weeks, which may be a result of natural
resolution of the disorder.
Betts (2005) suggested that acupuncture may
be valuable as an emotional support for postnatal
patients experiencing depression that persists
for more than 2 weeks. Postnatal depression
is often accompanied by poor appetite, insomnia,
and feelings of hopelessness and violence.
Deficiencies of qi, blood and yin, accompanied
by stasis of blood, are important concepts in
TCM diagnosis. Acupuncture is aimed at lifting
qi, resolving stasis, and aiding recovery and
return to homeostasis, thereby enabling the
patient to manage this interim period. Flaws
(2006) indicated its use in mild to moderate
premenstrual tension (PMT) as a means of
restoring homeostasis and preventing large doses
of antidepressant therapy. Bosco Guerreiro da
Silva et al. (2005) compared the effects of acupuncture
on a group of pregnant women with
those undergoing conventional treatment for
insomnia. Statistical difference was demonstrated
in the acupuncture group (P=0.0028),
with a 50% decrease in insomnia scores for the
acupuncture group in comparison to the controls.
Increased levels of the serum concentration
of melatonin in the blood were demonstrated
after acupuncture, levels that are often lowered
in pregnant women.
Blitzer et al. (2004) looked at the effects of
acupuncture on treatment of ‘major depressive
disorder’ using the Structured Clinical Interview
for the Diagnostic and Statistical Manual of
Mental Disorders criteria, as well as the BDI
I and II, and Reynolds Depression Survey
Inventory (RDSI), which indicated significant
improvements following acupuncture treatment
(BDI, P=0.01; RDSI, P=0.03). More significantly,
none of the participants in the group
treated with acupuncture met the criteria for a
major depressive disorder at the conclusion of
the study.
Magnetic resonance imaging evidence suggests
enhanced activity in the hippocampus following
acupuncture (Wu et al. 1999), while acupuncture
appears to modulate the limbic system (Hui et al.
2007 Association of Chartered Physiotherapists in Women’s Health 23

J. Longbottom
2002). The latter study by Hui et al. (2002)
reinforces the need to attain de qi stimulation in
order to moderate activity in the limbic system,
with particular attention needing to be paid to
the area of the anterior cingulate nucleus, which
is thought to be responsible for expectations and
attention (Abad-Algeria & Pomaron 2004).
Does this mean that acupuncture may just
help us find those things we keep losing,
especially during the premenstrual and menopausal
periods . . . or even at normal times of the
day?
Reproduction
In terms of fertility and the development of a
healthy foetus, it is known that healthy levels
of progesterone are required for maintenance
of pregnancy and stimulation of leutinizing
hormone (LH) for the continued development
of the corpora lutea. Recent research using
acupuncture before embryo transplant and after
in vitro fertilization (Paulus 2002; Lyttleton
2004; Stener-Victorin 2004) has demonstrated
improved clinical pregnancy rates (42.5% in the
acupuncture group compared with 26.3% in the
controls; P=0.03).
The use of acupuncture in the treatment of
blood flow impedance in uterine arteries resulting
in infertility (Stener-Victorin et al. 2003) has
always been referred to as a ‘cold uterus’ in
TCM (Betts 2005). In a group of infertile women
diagnosed with polycystic ovary syndrome,
acupuncture resulted in the induction of normal
ovulatory cycles in one-third of the group receiving
acupuncture, compared with no ovulation in
the group with hormonal implants.
We must not forget the males . . .
In a group of healthy, non-fertile men, acupuncture
was seen to increase the viability of live
sperm after acupuncture (P=0.05), as well as
increasing the percentage of live, viable sperm
(P=0.5) (Siterman et al. 1997).
And so to sleep . . .
Stimulation of melatonin from the pineal gland
(Sok et al. 2003) following acupuncture enhances
rapid eye movement during deep sleep while
stimulating normal circadian rhythms, releasing
increased levels of growth hormone and stimulation
of follicle stimulating hormone (FSH).
This is thought to induce deeper, dream sleep,
which enhances cartilage growth via chondro-
24
cytes, osteoclasts for bone repair and myoblasts
for muscle repair. It is thought to have a modifying
effect on joint and muscle pain associated
with sleep deprivation in patients with fibromyalgia
and chronic fatigue (Bosco Guerreiro da
Silva et al. 2005).
Urinary dysfunction
Acupuncture has been used extensively in the
treatment of incontinence and pelvic floor rehabilitation,
increasing levels of arginine vasopressin
as a means of controlling urine volume in
order to facilitate the rehabilitation and retraining
of urinary urge incontinence (Liu et al. 2002).
Vasopressin causes the kidneys to conserve
water and concentrates urine, reducing the urine
volume (Yang et al. 2003; Kelleher et al. 1994).
Kelleher et al. (1994) suggested a given protocol
to lift kidney and bladder qi, in an attempt to
hold fluid within the bladder and help in pelvic
floor retraining.
And finally, the menopause . . .
This is a subject that is currently very dear to the
heart of the present author, and one that often
causes angst and embarrassment for patients.
According to TCM (Maciocia 1998), the menopause
is a time when blood and qi, which have
been previously required within the pelvic basin
for reproduction, are taken away from the uterus
and converge on the brain. Menstruation ceases
and subsequent body changes take place. In
TCM philosophy, wisdom and insight come with
this change, and the ‘wise woman of the village’
emerges. Within a Western paradigm, this is not
an easy concept to embrace, but we do see vast
changes in body mass index, shape, hair and
skin. We also see huge fluctuations in emotional
responses, raging from a state of euphoria to
depression, memory loss and anxiety. The menopause
offers a period of mourning for some
women, with children leaving home, loss of
attractiveness and emotional lability. For others,
it may offer a period of enhanced liberation . . .
The essential problem encountered at this time
is the onset of climacteric symptoms (hot flushes)
owing to a fall in oestradiol, progesterone, FSH
and LH, combined with an increase in prolactin
(Dong et al. 2001). In the study by Dong et al.
(2001), climacteric conditions were eased by 50%
(P=0.00001) and physical discomfort by 50%
(P=0.014), which was maintained for up to
3 months following the trial. There was no
improvement in psychosexual symptoms or
2007 Association of Chartered Physiotherapists in Women’s Health

measured reproductive hormones. Again, in
TCM philosophy, the aim is to boost kidney and
spleen qi as a means of relieving exhaustion,
calming liver and heart fire so as to relieve
heightened sympathetic hyperaemia and hot
flushes.
Conclusion
The present paper seeks to offer the practitioner
a variety of clinical tools that go beyond pain,
but that may contribute to improved quality of
life and well-being in some patients. It is by no
means a definitive model, and there are many
areas that have not been covered. The author
hopes that it has offered the reader a greater
insight into this powerful modality, which we as
physiotherapists are privileged to have within
our clinical toolbox.
In the UK, physiotherapists are able to use
this skill to enhance their practice, while in
various other countries, acupuncture it is not
available to these clinicians, remaining in the
domain of physicians and consultants.
Acupuncture is a powerful modality when
used with knowledge, clinical reasoning skills,
and against a background of evidence to support
the choice of points and treatment diagnosis. Its
power should not be abused and should never be
used as a mere adjunct when other modalities
fail to produce results.
It is hoped that the present paper may change
practice, and stimulate a desire to know more
and seek further training in acupuncture in the
exciting challenge of women’s health.
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26
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Jennie Longbottom is chair of the Acupuncture
Association of Chartered Physiotherapists
(AACP), a member of the British Acupuncture
Council and runs a private practice. She lectures
at undergraduate, postgraduate and MSc level.
Her special interest is chronic pain, with a particular
focus on chronic pelvic pain and complex pain
syndromes.
2007 Association of Chartered Physiotherapists in Women’s Health

Journal of the Association of Chartered Physiotherapists in Women’s Health, Spring 2007, 100, 27–32
ACPWH CONFERENCE 2006
The perils of the perimenopause: contraceptive and
hormonal needs in the perimenopause
A. E. Evans
Bristol Royal Infirmary and Bristol Nuffield Hospital, Bristol, UK
Abstract
The perimenopause is poorly understood by women and healthcare professionals
alike. It is a time of hormonal instability, resulting in altered menstrual patterns,
worsening premenstrual syndrome, and for many women, multiple symptomatology,
which is often misdiagnosed and treated as depression. The contraceptive
needs of older women have never been more important than they are today in our
changing society, nor have their choices ever been so great. Sadly, many women
over 35 years of age are not having these needs met, and unplanned pregnancy and
termination rates are rising. Many women in their late thirties, and even more
in their mid-forties, are experiencing the effects of their fluctuating hormonal
environment. Many of the hormonal contraceptive options available would help
to stabilize this and ameliorate early symptoms. For those not seeking or needing
contraception, there are various techniques for stabilizing a woman’s underlying
hormonal environment: principally, transdermal or percutaneous luteal phase
oestradiol, and intrauterine levonorgestrel. These techniques are little-used, and
merit further exploration and validation. The present paper seeks to address some
of the problems of the perimenopause and their possible solutions.
Keywords: hormonal instability, levonorgestrel intrauterine system, non-contraceptive
benefits, percutaneous oestradiol, perimenopause.
Introduction
The contraceptive needs of older women have
never been more important than they are today
in our changing society, nor have their choices
ever been so great. Sadly, many women over
35 years of age are not having these needs met,
and unplanned pregnancy and termination rates
are rising (ONS 2002).
Many women in their late thirties, and even
more in their mid-forties, are experiencing the
effects of their fluctuating hormonal environment.
Many of the available hormonal contraceptive
options would help to stabilize this and
ameliorate early symptoms. However, most
women – and their general practitioners – are
unaware of this, or indeed, believe that they are
‘too old to use hormones’ or that it would be
risky in some way. For a few, there might be
Correspondence: Dr Annie Evans, Senior Clinical Medical
Officer in Sexual Health, Women’s Health Specialist, Bristol
Royal Infirmary and Bristol Nuffield Hospital, 3 Clifton Hill,
Bristol BS8 1BP, UK (e-mail: annie.dr@virgin.net).
genuine medical risk, but most could benefit
substantially from efficient contraception and
hormonal stabilization. It should be the role of
the doctor or practice nurse to proactively initiate
discussion at various stages in a woman’s
life – after childbirth, and during her late thirties
and forties – when many women or couples may
be considering sterilization.
Changes in society
With divorce rates in the UK running at around
41% of all marriages (ONS 2002), many women
in their ‘middle youth’ find themselves ‘back out
in the sexual market-place’. Not only must they
cope with the demands of their growing children,
they often form new relationships, and therefore,
must start dealing once more with the issues of
contraception and sexual health. If, as so often is
the case, their ex-husband has had a vasectomy,
they have not had to face these considerations
for many years, and are often unaware of
modern choices.
2007 Association of Chartered Physiotherapists in Women’s Health 27

A. E. Evans
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
The perimenopause
It is becoming increasingly apparent that the
transition into the menopause, specifically the
perimenopausal period, is a gradual process that
happens over many years. The age of onset and
the duration of this perimenopausal phase can
vary greatly (Li et al. 1996). Most women do not
move from regular menstruation to sudden
amenorrhoea, but rather, experience a time of
menstrual irregularity, often with shortened
or irregular cycles. Many women report
increased premenstrual symptomatology, including
headaches and migraine (MacGregor 1997),
increased menstrual flow, and more painful
periods.
This is a time of huge hormonal variability,
with hormone levels fluctuating more intensely
than at any other stage of a woman’s life. For
some, this leads to a variety of problems, including
insomnia, emotional lability, forgetfulness,
poor concentration, joint aches and tiredness.
This is a time, above all others, when a woman
may turn for advice to the medical profession.
To the unwary, this constellation of symptoms
could be misinterpreted as depression and it is
certain that significant numbers of women are
inappropriately labelled in this way. Many will
be offered antidepressant medication unnecessarily.
Unfortunately, at the present time, clinical
trial data are insufficient to establish
evidence-based treatment standards and clinicians
may need to rely on experience when
considering management options (Rebar et al.
2000). The need to include the woman herself in
the decision-making process is self-evident. The
problem is to balance her need for contraception
with that for hormonal support and to allow her
to make an informed choice.
The perimenopause as an entity has only been
recognized recently and little reference is
made to it in standard gynaecological texts,
making its management challenging (see Boxes
1 & 2).
28
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 womenyears)
by age (adapted from Evans 2000)
Variable
Age (years)

Figure 1. Patterns of UK contraceptive use by age
and method in 2002 (information on file at Schering
Health Care Ltd, Burgess Hill, UK): (IUD) intrauterine
device.
should be fully counselled about all such
alternatives, before proceeding to sterilisation’.
More than just contraception: positive
health benefits
Many women would more than welcome the
chance to eliminate some of their perimenopausal
symptoms, and these possibilities should be
discussed with them. The ability to stabilize a
woman’s hormonal environment, perhaps by use
of the combined Pill, in a non-smoker with no
other risk factors, may well enhance the quality
of her life.
Combined oral contraceptive use in the
perimenopause
Many women who stop the combined Pill to be
sterilized experience unwelcome hormonal and
menstrual changes, and conversely, those who
do continue the combined oral contraceptive
(COC) into their forties report that they continue
to feel well. There are many fears and
misconceptions about using the Pill, and the
duration of its use in this older age group, that
need to be addressed.
Modern, 20-g COCs offer first-rate contraception,
along with the benefits of regular, predictable
light withdrawal bleeds and masking
of early menopausal symptoms. This can be of
particular advantage to those women developing
menorrhagia and dysmenorrhoea at this stage in
their lives, where previously hysterectomy might
have been considered the best option. It can also
help to control worsening perimenopausal presmenstrual
syndrome (PMS) and mood change,
and give back a sense of control to many women
Contraceptive and hormonal needs in the perimenopause
Box 3. Risk factors for arterial disease contraindicating
combined oral contraceptive use in women over 35 years of
age: (BMI) Body Mass Index
+ Cigarette smoking
+ Family history of cardiovascular disease in a parent or
sibling 140/90
+ Obesity (BMI>35)
+ Migraine (including ‘without aura’ in this age group)
Box 4. Risk factors for venous thromboembolism (VTE).
N.B. Smoking

A. E. Evans
cycle-control, symptom relief and protection
from osteoporosis.
The combined oral contraceptive/hormone
replacement therapy overlap
After the menopause (or leading up to it, if
contraception is not an issue), ‘natural’ oestrogen
(17-oestradiol) is sufficient for symptom
relief; however, it is not contraceptive. If women
stay on the COC ‘until the menopause’, how
can this event be diagnosed and infertility be
assured?
One method is to try measuring the follicle
stimulating hormone (FSH) at the end of the
Pill-free week in a woman of 50 years of age. If it
is still normal, she cannot be advised to stop
using contraception, but nor would it seem wise
to continue the COC indefinitely, and therefore,
a switch to an oestrogen-free method might be
advisable. If the FSH is at menopausal levels on
two to three occasions, she might be advised to
switch, if she chooses, straight to hormone
replacement therapy (HRT).
Hormonal stabilization without use of
combined oral contraceptive
The most effective method of ameliorating the
premenstrual symptoms encountered in the perimenopause
(whether these are predominantly
physical, such as migraine, or mood-related) is
to attempt to stabilize the hormonal milieu in
the luteal phase. In a woman whose menstrual
pattern is still regular, this is achieved by delivering
a stable dose of oestradiol via a transdermal
patch or percutaneous gel for the second
half of each cycle. Oral dosage of oestrogen
produces fluctuating levels and may exacerbate
the symptoms. This treatment has been shown
to be effective in preventing both premenstrual/
menstrual migraine (MacGregor et al. 2003)
and perimenopause-related depression (Schmidt
et al. 2000).
However, a prediction of the timing of the
luteal phase cannot be made in women with
irregular cycles, and oestrogen must be delivered
continuously. This necessitates opposition with
progestogen, since there may be a risk of endometrial
thickening otherwise. Adding a cyclical
progesterone, as in ‘conventional’ HRT, may
reproduce many of the premenstrual symptoms
already exacerbated by the perimenopause itself.
The better option is to use a locally delivered
progestogen to protect the endometrium, using a
progestogen-loaded intrauterine system (IUS).
30
Contraceptive choices with add-on
benefits in older women
The levonorgestrel IUS (LNG-IUS) has been
hailed as one of the major advances in the field
of contraception since the introduction of the
Pill. It is not only a highly effective and reversible
method, but it also has other noncontraceptive
benefits.
Local release of LNG produces an inactive
and atrophic endometrium, and therefore,
normal menstrual flow is reduced. In turn, this
leads to less endometrial prostaglandin production,
and therefore, less dysmenorrhoea. Studies
have shown an objective reduction in menstrual
loss (86% and 97% after 3 and 12 months,
respectively; Andersson & Rybo 1990). Seventeen
per cent of users are amenorrhoeic after one
year of use (Ronnerdag & Odlind 1999), 27%
by the end of the first 5 years and up to 60%
after another 5 years. The number of bleeding
days per cycle also gradually diminishes. Within
30 days of removal, the endometrium has
returned to normal and menstruation occurs
(Silverberg et al. 1986). Thus, the LNG-IUS is
easily and completely reversible.
Lack of systemic side-effects with
intrauterine system use
The systemic absorption of LNG is extremely
low (two progestogen-only Pills per week;
Guillebaud 1997), thus minimizing side-effects
such as breast tenderness, greasy skin and hair,
headaches, and abdominal bloating. The plasma
oestradiol of users remains within the normal
range (Luukkainen et al. 1990), which is important
for perimenopausal women.
Other benefits of intrauterine system use
The ectopic pregnancy rate in users is exceptionally
low, being ten times less than the ectopic
rate for Nova-T users (0.02 versus 0.25 per 100
women-years; Andersson et al. 1994). The incidence
of pelvic inflammatory disease is also
much lower than for copper intrauterine devices,
because of a combination of factors including
thickening of the cervical mucus, endometrial
suppression and reduced bleeding (Toivonen
et al. 1991).
Efficient reversible contraception
The pregnancy rate in LNG-IUS users has
been shown to be exceptionally low (Pearl
index=0.16). The gross cumulative pregnancy
2007 Association of Chartered Physiotherapists in Women’s Health

ate at 3 years is 0.3 per 100 users. Given that the
‘real use’ failure rate of many contraceptive
methods reliant on committed use and user
memory are considerably higher than their
quoted method failure rates (or even the rates
achieved in trial circumstances), it is important
to recognize that real use and method failure
rates are almost equivalent in the case of the IUS
(Trussell 1998).
User acceptability
The extremely low side-effect profile, combined
with the obvious benefits of reduced or absent
menstrual flow, less dysmenorrhoea and an
improvement in PMS, are all reflected in
extremely high continuation rates, with one
study showing 81% at 3 years and 65% at 5 years
(Backman et al. 2000).
Long-term use of the intrauterine system
An important study of long-term IUS use was
reported by Ronnerdag & Odlind (1999). The
above authors followed 82 women in Uppsala,
Sweden, who were offered a second IUS after
prolonged, 7-year use of a first device. The
women were seen annually over the subsequent
5 years. There were no reported pregnancies
and 77% of these women reported no health
problems at all during the study period.
At the start of the study, 26% of women had
no bleeding, 70% had regular, scanty bleeds, and
4% had irregular, scanty bleeds.
At the end of the second, 5-year period, 60%
reported amenorrhoea, 28% regular, scanty
bleeds, and 12% irregular, scanty bleeds.
Overall, haemoglobin levels rose. Mean body
weight rose by 0.5 kg per year (which is equal to
non-hormonal users).
Seven women became postmenopausal during
the follow-up period, but there was no change in
bleeding pattern following the introduction of
HRT.
Long-term benefits of the intrauterine
system in the perimenopause
The LNG-IUS also provides an effective method
of delivering progestogenic opposition to
oestrogen in hormone replacement therapy
(Wolter-Svensson et al. 1997), especially in the
perimenopausal age group, in whom the incidence
of dysfunctional uterine bleeding is high
and there is still a need for contraception
(Suvanto-Luukkonen et al. 1997).
Contraceptive and hormonal needs in the perimenopause
Conclusion
Our aim as health professionals should be to
guide each woman towards informed choices,
while dispelling myths along the way. We should
not miss this golden opportunity to control the
hormonal milieu and help improve quality of life
in the perimenopause.
References
Andersson K. & Rybo G. (1990) Levonorgestrel-releasing
intrauterine device in the treatment of menorrhagia.
British Journal of Obstetrics and Gynaecology 97, 690–
694.
Andersson K., Odlind V. & Rybo G. (1994)
Levonorgestrel-releasing and copper-releasing (Nova T)
IUDs during 5 years of use: a randomised comparative
trial. Contraception 49, 56–72.
Backman T., Huhtala S., Tuominen J., et al. (2000) Length
of use and symptoms associated with premature removal
of levonorgestrel-releasing intrauterine system: a nationwide
study of 17,360 users. British Journal of Obstetrics
and Gynaecology 107, 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 University
Press, Oxford.
Li S., Lanuza D., Gulanick M., et al. (1996) Perimenopause:
the transition into menopause. Health Care for
Women International 17, 293–306.
Lidegaard O. & Kreiner S. (2002) Oral contraceptives and
cerebral thrombosis: a five-year national case-control
study. Contraception 65, 197–205.
Luukkainen T., Lahteenmaki P. & Toivonen J. (1990)
Levonorgestrel-releasing intrauterine system. Annals of
Medicine 22, 85–90.
MacGregor E. A. (1997) Menstruation, sex hormones and
migraine. Headache 15, 125–141.
MacGregor E. A., Frith A., Ellis J. & Aspinall L. (2003)
Estrogen ‘withdrawal’: a trigger for migraine? A doubleblind
placebo-controlled study of estrogen supplements
in the late luteal phase in women with menstruallyrelated
migraine. Cephalgia 23, 684.
Marchbanks P., McDonald J. A., Wilson H. G., et al.
(2002) Oral contraceptives and the risk of breast cancer.
New England Journal of Medicine 346, 2025–2032.
Office for National Statistics (ONS) (2002) Social Trends
Document, 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-dose
oestrogen oral contraceptives. Lancet 354, 301–302.
Rebar R. W., Natchigall L. E., Avis N. E., et al. (2000)
Clinical challenges in the perimenopause: consensus
opinion of the North American Menopause Society.
Menopause 7, 5–13.
Ronnerdag M. & Odlind V. (1999) Health effects of longterm
use of intrauterine levonorgestrel releasing system.
Acta Obstetricia et Gynecologica Scandinavica 78, 716–
721.
Royal College of Obstetricians and Gynaecologists
(RGOG) (1999) Evidence-Based Guidelines, No. 4: Male
2007 Association of Chartered Physiotherapists in Women’s Health 31

A. E. Evans
and Female Sterilisation. Royal College of Obstetricians
and Gynaecologists, London.
Schmidt P. J., Lynette N., Danaceau M. A., et al. (2000)
Estrogen replacement in perimenopause-related depression:
a preliminary report. American Journal of Obstetrics
and Gynecology 183, 414–420.
Silverberg S. G., Haukkkamaa M., Arko H., Nilsson C. G.
& Luukkainen T. (1986) Endometrial morphology during
long-term use of levonorgestrel-releasing devices.
International Journal of Gynecological Pathology 5 (3),
235–241.
Suvanto-Luukkonen E., Sundstrom H., Penittinen J., et al.
(1997) Percutaneous estradiol gel with an intrauterine
levonorgestrel releasing device or natural progesterone in
hormone replacement therapy. Maturitas 26, 211–217.
Toivonen J., Luukkainen T. & Allonen H. (1991) Protective
effect of intrauterine release of levonorgestrel on pelvic
infection: three year’s comparative experience of
32
levonorgestrel- and copper-releasing devices. Obstetrics
and Gynecology 77, 261–264.
Trussell J. (1998) Contraceptive efficacy. In: Contraceptive
Technology, 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 in
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Obstetricia et Gynecologica Scandinavica 76, 449–454.
Dr Annie Evans is a women’s health specialist at
the Bristol Royal Infirmary and Bristol Nuffield
Hospital. This article is based on lectures given
nationally and internationally, some of which have
been supported by educational grants by Schering,
Organon and Janssen Cilag.
2007 Association of Chartered Physiotherapists in Women’s Health

Journal of the Association of Chartered Physiotherapists in Women’s Health, Spring 2007, 100, 33–36
ACPWH CONFERENCE 2006
Multi-convergent therapy in the treatment of medically
unexplained symptoms: a brief journey in time
M. Sadlier
Department of Physiotherapy, University Hospital of Wales, Cardiff, UK
Abstract
Medically unexplained symptoms (MUS), which mostly occur in women, are
generally chronic and disabling conditions that present with extensive subjective
symptoms, although objective findings or causal explanations are lacking. Not
only are MUS very disabling, but these incur a high cost to both patients and
health providers. Multi-convergent therapy (MCT), which blends aspects of
cognitive behavioural and physical therapy in a seamless way, is one approach to
dealing with conditions that defy certainty. Its emphasis is on how our perceptions,
behaviours and life influences shape or evolve us into who and what we are
by way of neuroplastic adaptation. Multi-convergent therapy can not only be
adapted to different conditions, but is also adaptable between patients within the
same group. It seeks initially, from the onset of an intense therapeutic relationship,
to coach and facilitate patients towards a stronger internal locus of control.
Clinical decision-making becomes a shared process, with the patient involved in
the development of the strategy from the beginning. Flexibility of repertoire and
the dynamic of the interpersonal relationship rather than the application of a
given procedure or technique is probably more predictive of positive outcome and
is the hallmark of MCT. Triangulated evaluation has shown this approach to be
acceptable and cost-effective.
Keywords: gender differences, medically unexplained symptoms, multi-convergent therapy.
Introduction
Patients with medically unexplained symptoms
(MUS) tend to be characterized more by symptoms,
disability and handicap than by any
consistently demonstrable tissue abnormality
(Table 1). They are often refractory to reassurance,
explanation or conventional medical treatment
(Barsky & Borus 1999). The same patients
are frequent attendees at general practitioner
surgeries (Hamilton et al. 2001) and outpatient
clinics, and are responsible for a high proportion
of healthcare costs (Zook & Moore 1980;
Garfinkel et al. 1988). Patients with MUS make
up 15–30% of all consultations at the primary
care level (Kirmayer et al. 2004). These conditions
are noted for their overlap, often sharing
demographic, clinical and psychosocial features.
Correspondence: Michael Sadlier, Department of Physiotherapy,
University Hospital of Wales, Heath Park, Cardiff
CF14 4XW, UK (e-mail: mike.sadlier@cardiffandvale.wales.
nhs.uk).
Indeed, it has been said that, given the overlap
between these disorders, the label that is
assigned is more to do with the chief complaint
and clinical speciality than with the actual illness
settings (Buchwald & Garrity 1994; Wessely et al.
1999; Aaron & Buchwald 2001). Comparative
Table 1. Functional somatic syndromes by speciality
Specialty Functional somatic syndrome
Gastroenterology Irritable bowel syndrome
Gynaecology Premenstrual syndrome, chronic
pelvic pain
Rheumatology Fibromyalgia
Cardiology Atypical or non-cardiac chest pain
Respiratory medicine Hyperventilation syndrome
Infectious diseases (Chronic postviral) fatigue
syndrome
Neurology Tension headache
Dentistry Temporomandibular joint
dysfunction, atypical facial pain
Ear, nose and throat Globus syndrome
Allergy Multiple chemical sensitivity
2007 Association of Chartered Physiotherapists in Women’s Health 33

M. Sadlier
investigations in populations from referral clinics
have reported that 70% of patients with fibromyalgia
(FM) meet the case definition for chronic
fatigue syndrome (CFS), as do 18% of those with
temporomandibular disorders. Furthermore,
80% of patients with FM, 92% of those with
CFS and 64% of patients with temporomandibular
disorders meet the criteria for irritable bowel
syndrome (IBS) (Aaron & Buchwald 2001).
Aronowitz (2001) and Sharpe & Carson (2001)
have argued that a price has been paid for this
emphasis on measurable, objective pathology, to
the detriment of a sizeable minority.
Gender
The rates for MUS are much higher in women
than in men. With a prevalence rate of between
10% and 15%, IBS is four times more common in
women, with a threefold increase in cholecystectomy,
and a twofold increase in appendectomy
and hysterectomy. Chronic fatigue syndrome is
twice as common in women and headaches are
three times more frequent. Chronic pelvic pain
affects 12–25% of women at any given time.
Approximately one-third of women with chronic
pelvic pain have IBS (Williams et al. 2005).
Women with MUS form a substantial part of
the workload of gynaecologists, gastroenterologists
and surgeons. Each specialist investigates
with their own diagnostic bias, but the source of
dysfunction or pain often remains obscure, with
a lack of abnormal findings or failure of symptom
resolution despite treatment of the identified
pathology. The patient’s physical and social disability
may become compounded by diagnostic
confusion, and by prolonged and ineffective
treatments, including surgery. The end result is
often a sense of helplessness in both the patient
and the physician.
Adding to the complexity is the presence of
depression. As a co-morbid presentation, depression
may worsen the prognosis of other medical
illnesses, including heart disease (Frasure-Smith
et al. 1993).
The prevalence of major depression is double
the rate in women in comparison to men. This
can have a dramatic long-term effect in that
women who develop major depression in the
postpartum period are more likely to have recurrent
episodes over the following 5 years and
beyond, and their babies are more likely to
develop cognitive, social and mood problems
(McKinlay et al. 1987). This situation is made all
the worse for women by the failure at times to
34
recognize that the peaks of depression occur at
times of hormonal fluctuation in the premenstrual,
postpartum and perimenopausal phases.
For example, a woman in the perimenopausal
phase who has depression but is still having her
periods, albeit with fairly low oestrogen levels,
may end up been treated with antidepressants
rather than oestrogens (Studd & Panay 2004).
The predominance of female-to-male ratios is
also influenced by genetic differences, vulnerability
to psychosocial factors related to the stress
response, gender roles, and the experience of
physical, mental and sexual abuse (Payne 2004).
Paradigm shift
The deductive approach to patient presentation
has made great strides in the field of medicine,
while bringing great benefit to patient suffering.
However, it runs into difficulties when the problem
presentation is not so clear or when the
objective findings do not match the symptom
presentation. This is the realm of MUS or disorders
of function. These sizable minorities of
presentations involve complex brain–body interfaces.
It crosses over the traditional divide
between medicine and psychology into the area
of neuropsychology, where a network of interacting
systems demonstrates bi-directional communication
with the central nervous system,
which mediates the effects of psychosocial
factors, perceptions and behaviours on the
production of physical symptoms (Weiner 1992).
These processes are all the more important
when it comes to understanding symptom presentation
and narrative in women, given the
greater depth of the limbic system (which influences
the formation of memory by integrating
emotional states with stored memories of physical
sensations), the high integration with the left
and right sides of brain, the profound influences
of the oestrogen cycle, and the more sensitive
hypothalamic pituitary adrenal axis. Therapy for
women has to acknowledge these differences,
exploring the predisposing, precipitating and
perpetuating variables to case presentation. The
setting on which this exploration takes place is
fundamental to outcome.
Therapeutic alliance
Communication is essential to maintain trust
and credibility. However, the window of opportunity
within therapy is limited, especially for
patients who are already distressed. Such is its
importance that patients can be lost or gained
2007 Association of Chartered Physiotherapists in Women’s Health

within the first meeting. The establishment of an
equal partnership with the patient on a brief
journey together facilitates this trust and credibility,
which lies at the heart of the therapeutic
relationship.
Therefore, the therapeutic alliance is the setting
in which an exploration of problems, beliefs,
fears and emotions, and the facilitation of positive
change, can take place between the therapist
and the patient. Its prerequisites are empathic
understanding, trust in the therapist and the
therapeutic process, freedom of expression, and
a multiplicity of perspective empirically supported
treatments, such as cognitive, behavioural
and cognitive behaviour therapy.
It is of note that different forms of psychotherapy
have been shown to provide effective
relief for similar conditions, despite the fact that
these therapies are treatment-specific (Chambless
& Ollendick 2001). There is nothing new in all of
this. In the mid-eighteenth century, Dr Samuel
Tissot highlighted the importance of the therapeutic
relationship. Paul Mobius proposed that
the therapist’s personality was an essential tool
to effect a change in the patient in 1888, while in
1891, P. Dubois pinpointed the importance of
patient and therapist as partners. More recently,
Horvath & Symonds (1991) stated that a solid
therapeutic alliance was more predictive of outcome
than either the type or length of therapy.
This is consolidated by Luborsky et al. (2002)
and Wampold (2001) in their empirical study
of 225 depressed patients. The above authors
found that the therapeutic bond formed between
therapist and patient was a leading influence on
a patient’s recovery, regardless of the type of
treatment modality used.
Multi-convergent therapy
Multi-convergent therapy (MCT), which incorporates
cognitive behaviour therapy, graded
exercise, mindfulness meditation, hypnotherapy,
connective tissue massage and appropriate
advice on antidepressants, is a biopsychosocial
approach that is intended to reduce uncertainty
in areas of MUS, thereby facilitating success.
Deale et al. (1997) echoed this philosophy of
approach with their comment that, given the
heterogeneous nature of some of these syndromes,
what is called for is a pragmatic and
flexible use of a range of behavioural and cognitive
techniques, closely tailored to the individual
patient, rather than adherence to a rigid protocol
(Deale et al. 1997) (Table 2).
Multi-convergent therapy in the treatment of medically unexplained symptoms
Table 2. Ordinary versus extraordinary management
Ordinary management Extraordinary management
Clear stages Reflection in action
Producer-pushed Consumer-led
Authority drives
Therapeutic alliance drives
interactions
interactions
Outcomes by prior
Outcomes emerge in time
intention
and are articulated later
Joint action emerges from Policy and strategy emerge
policy and strategy
from joint action
Therapy actively interacts with the patient,
changing course whenever the need arises.
Flexibility of repertoire and the dynamic of the
interpersonal relationship rather than the application
of a given procedure or technique are
probably more predictive of positive outcome
(Krupnick et al. 1996), and are the hallmark of
MCT.
The heterogeneous nature of patient presentation,
as seen in disorders such as CFS/
myalgic encephalomyelitis, FM, IBS and noninflammatory
pelvic pain, necessitates that the
therapist has the flexibility of repertoire to
suit each individual patient on their journey, a
journey interspersed with many crossroads and
alternative pathways. It is for this reason that
MCT embraces the underlying tenets of such
evidence-based practice as cognitive behaviour
therapy, mindfulness meditation and graded
exercise therapy, adopting a synthesized generic
approach that is disease-specific.
Triangulated evaluation over 18 years, including
randomized controlled trials has shown this
approach to be cost-effective and acceptable to
all the major stakeholders (Shaw et al. 1991;
Sadlier & Stephens 1995; Sadlier et al. 2000;
Thomas et al. 2006).
Conclusion
Multi-convergent therapy can be seen as a mind–
body approach in which the physical and
psychological aspects are seamless. Its inherent
flexibility in dealing with the physical and psychosocial
aspects of female presentation is its
unique selling point. There is nothing new about
the different aspects of MCT. What is different is
how it is used and integrated by the individual
therapist.
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2007 Association of Chartered Physiotherapists in Women’s Health 35

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trial. Digestion 50 (1), 36–42.
Studd J. & Panay N. (2004) Hormones and depression in
women. Climacteric 7 (4), 338–346.
Thomas M., Sadlier M. & Smith A. (2006) The effect of
Multi Convergent Therapy on the psychopathology,
mood and performance of Chronic Fatigue Syndrome
patients: a preliminary study. Counselling and Psychotherapy
Research 6 (2), 91–99.
Wampold B. (2001) The Great Psychotherapy Debate: Models,
Methods, and Findings. Lawrence Erlbaum Associates,
Hillsdale, NJ.
Weiner H. (1992) Perturbing the Organism: The Biology of
Stressful Experience. University of Chicago Press, Chicago,
IL.
Wessely S., Nimnuan C. & Sharpe M. (1999) Functional
somatic syndromes: one or many? Lancet 354, 936–939.
Williams R., Hartmann K., Sandler R., et al. (2005) Recognition
and treatment of irritable bowel syndrome
among women with chronic pelvic pain. American
Journal of Obstetrics and Gynecology 192, 761–767.
Zook C. J. & Moore F. (1980) High-cost users of medical
care. New England Journal of Medicine 302, 996–1002.
Michael Sadlier works as a physiotherapist at the
University Hospital of Wales, Cardiff, and is the
director of the multi-convergent therapy clinic.
His primary research interests are in chronic
fatigue syndrome, irritable bowel syndrome and
tinnitus. He works clinically in both the National
Health Service and the private sector. His main
focus is on medically unexplained symptoms,
particularly among women.
2007 Association of Chartered Physiotherapists in Women’s Health

Journal of the Association of Chartered Physiotherapists in Women’s Health, Spring 2007, 100, 37
ACPWH CONFERENCE 2006
Bladders behaving badly: a randomized controlled trial
of group versus individual interventions in the
management of female urinary incontinence
L. A. Hill
George Eliot Hospital NHS Trust, Nuneaton, UK
Abstract
Incontinence is a sensitive healthcare issue. Its prevalence is estimated to be 8.5%
and 57% of women aged between 15 and 64, and 45 and 65 years, respectively, and
it is one of the most common chronic diseases. A multi-centre randomized
controlled trial of group versus individual management of urinary incontinence in
180 women was undertaken over a 2-year period. The views of women with female
urinary incontinence (FUI) were sought on the acceptability and efficacy of
physiotherapy as a treatment method for FUI when delivered in groups. The trial
aimed to test the effectiveness of a group approach to treatment using outcome
measures of symptom severity and quality of life pragmatically applied in the UK
National Health Service, and to investigate whether group treatments are more
cost-effective than individual management. Outcome data for 174 women provided
evidence that a group educational approach to treatment is as clinically
effective as an individual educational approach, and that group treatment is more
cost-effective than individual treatment. Pelvic floor exercises and bladder retraining
are simple, low-cost treatments, and have been shown to be effective. Women
should be encouraged to take these up.
Keywords: female urinary incontinence, group intervention, individual intervention,
outcome, physiotherapy.
Lesley Hill, a clinical member of a multi-centre
team, gave a presentation at the 2006 ACPWH
Conference to share the clinically significant and
cost-effective results of this multi-centre randomized
controlled trial of group versus individual
Correspondence: Lesley Hill, George Eliot Hospital NHS
Trust, Lewes House, College Street, Nuneaton CV10 7DJ,
UK (e-mail: lesley.hill@geh.nhs.uk).
intervention in the management of female urinary
incontinence.
The above is an abstract, and it is hoped to
include a more detailed account of her research in
the next issue of the Journal.
2007 Association of Chartered Physiotherapists in Women’s Health 37

Journal of the Association of Chartered Physiotherapists in Women’s Health, Spring 2007, 100, 38
ACPWH CONFERENCE 2006
Mammographic breast screening
Breast cancer is the commonest female malignancy,
accounting for around 41 000 cases per
annum in the UK in 2004, with up to half of
these women dying from the disease. There is a
gradual upwards trend in its incidence, with
registrations of 50–64-year-old women increasing
by 50% since 1988.
The National Health Service Breast Screening
Programme (NHSBSP) commenced in 1988.
This followed convincing evidence from
Scandinavia that showed a reduction in mortality
from breast cancer in asymptomatic
women who had been given mammographic
screening.
Initially, women between the ages of 50 and 64
years were offered single-view mammography
every 3 years. More recently, this has been
extended to women up to the age of 70 years,
with older women having screening only on
request. Two views of each breast are now
obtained, i.e. mediolateral-oblique and craniocaudal
images, which increases the detection
rate.
The majority of women who accept the invitation
for screening have their films taken on
mobile trailers staffed by experienced mammographers
(radiographers with expertise in mammography).
The films are processed back at the
screening centre and loaded onto high-capacity
roller viewers for reading. Most breast cancers
detected by screening are impalpable, and breast
cancer has a variety of appearances on mammography:
dominant nodule, spiculate density,
area of glandular distortion or glandular asymmetry,
or microcalcification. Benign lesions may
look malignant and vice versa.
Women who are thought to have a significant
abnormality are recalled for assessment of the
lesion to the screening centre within a few weeks
of their initial mammogram. They have further
specialized mammograms performed that may
38
compress or magnify an area of concern. Many
women will undergo an ultrasound examination
of the area as well. If a biopsy is required, then
this is performed using image guidance to accurately
sample the focus of concern. A wide-bore
needle (14 or 16 French) and mammotomy may
be used (11 or 8 French).
A breast surgeon will examine the women and
assess the lesion for its palpability and possible
surgical options, if required.
The samples are analysed by specialist breast
pathologists, and the clinical teams meet to
discuss the results and conclusions. Great importance
is attached to the decision-making process
in order that the correct diagnosis is reached.
Should a biopsied lesion be malignant, the
treatment options are decided before discussing
the results with the patient.
The number of women screened by the programme
continues to increase year on year, as do
the number of cancers found. In 2002–2003, 1.3
million women were screened in England, yielding
a total of 9849 cancers. Not all of these
tumours are invasive, i.e. will spread within the
breast and be capable of spreading elsewhere.
Around 25% of abnormalities are pre-invasive,
but these are still treated by surgery with, or
without, radiotherapy.
Screened women are a little more likely to be
diagnosed with breast cancer than those who are
not screened, implying that some screen-detected
cancers may be overdiagnosed and might never
have become manifest to the women during her
lifetime. For every 400 women who are regularly
screened over a 10-year term, one fewer woman
will die of the disease. The NHSBSP saves
around 1400 lives per annum in England.
Dr Kate Gower Thomas
Consultant radiologist
Breast Test Wales
Cardiff
2007 Association of Chartered Physiotherapists in Women’s Health

Journal of the Association of Chartered Physiotherapists in Women’s Health, Spring 2007, 100, 39–41
ACPWH CONFERENCE 2006
Presentation reflections
The following speakers did not submit a paper
based on their Conference presentations, but were
happy for us to publish details from their abstracts
and to reflect on their talks.
Margie Polden Memorial Lecture: A
midwife’s perspective
Mary Cronk MBE, midwife in independent
practice, Chichester, UK
Mary Cronk was introduced to Conference by
Jeanette Haslam, which was to give us a flavour
of the presentation to follow. In addition to
background information on Mary’s long career,
Jeanette has first-hand experience of her expertise,
having had her in attendance at her own
home births.
Mary’s presentation was full of interesting and
thought-provoking ideas, demonstrating her
commitment to women’s health in the most
holistic of senses. She recalled how, since her
training, practices have changed massively; in
particular, the mandatory use of episiotomy (a
process she described as a form of female genital
mutilation) has, thankfully, become a thing of
the past. She remembered her own contact with
physiotherapists as a patient and the help that
she received from the profession after the birth
of her own children.
The main theme was that of breech birth, and
her belief that Caesarean deliveries are performed
far too frequently when safe vaginal
delivery is possible. The slides that followed were
an amazing insight into how breech presentation
babies can be born at home uneventfully. Case
histories were presented with this rare opportunity
to view the initial presentation and
stage-by-stage snapshots of normal breech
deliveries.
Another theory presented was a proposed
explanation of why symphysis pubis dysfunction
(SPD) has apparently become a more prevalent
condition in recent years. It was suggested that
panty girdles might have had a role in preventing
the symptoms of pelvic instability in the past.
Now that these are no longer commonly
worn, the incidence of SPD has consequently
increased. Mary’s suggestion for clinical practice
was the selective use of such undergarments in
women who are recognized to have hypermobility
syndrome or are otherwise susceptible to
developing SPD.
The presentation was very well received with a
terrific round of applause, having kept our interest
throughout. Chairman Ros Thomas presented
Mary with her Margie Polden certificate
and a bouquet.
Rachel Kerr
GUM clinic: what to look for
Linda Furness, health advisor, Genito-Urinary
Medicine Clinic, Cardiff and Vale NHS Trust,
Cardiff, UK
A presentation on genito-urinary medicine
(GUM) was, perhaps, a challenging start to
Sunday morning following the Conference
dinner on Saturday night, but Linda Furness
gave a comprehensive and interesting talk on the
subject.
She explained how the Venereal Disease (VD)
Act means that the information that patients
give staff at GUM clinics cannot be shared with
anyone outside the unit. This, perhaps, contributes
to its isolation from mainstream medicine.
She went on to say that we should not be
judgemental: anyone can be at risk of contracting
a sexually transmitted infection (STI).
Linda listed viral and bacterial STIs, and
reported a recent increase in cases of gonorrhoea
and, currently, syphilis.
A run-down on signs and symptoms – things
you see, smell or are told about – followed,
accompanied by some graphic photographs. She
also pointed out that some infections cause no
evident symptoms. Chlamydia falls into this
category, with 80% of females and 40% of males
showing no signs and symptoms, but sufferers at
risk of major problems such as pelvic inflammatory
disease or infertility. Linda also discussed
HIV, which might present itself in many ways,
including myalgia, arthralgia, fever, pharyngitis,
lymphadenopathy, skin rash, and mucosal
ulceration of the mouth, genitals or oesophagus.
2007 Association of Chartered Physiotherapists in Women’s Health 39

Presentation reflections
This was an interesting and understandable
presentation that was, I felt, useful to women’s
health physiotherapists, especially those working
with women experiencing incontinence and other
pelvic floor dysfunctions. As Linda said, we are
just the type of people – empathic practitioners,
with more time for women than some healthcare
professionals – to whom they might divulge a
problem. I would not presume to make a diagnosis
of a STI, but I will be more vigilant and
would have no hesitation in suggesting that a
woman should visit a GUM clinic.
Linda directed us to the website of the Society
of Sexual Health Advisors (www.ssha.info). I
have checked this out and it is, indeed, a good
source of information on STIs that is accessible
to the general public.
Gill Brook
Hormonal treatment of severe
premenstrual syndrome
Professor John Studd, consultant gynaecologist,
London, UK
We were indeed fortunate to hear the thoughts
of Professor John Studd, esteemed gynaecologist
and founder of the first menopausal clinic in the
UK in 1969. His descriptions of ‘reproductive
depression’ were enlightening, including a redefinition
of premenstrual syndrome (PMS) as an
ovarian cycle dysfunction, rather than one
related to the menstrual cycle. As such, PMS
cannot be surgically cured by hysterectomy, only
by bilateral salpingo-oophorectomy (BSO).
Women with severe PMS can often fit their
symptoms into a pattern of hormone-related
depression. Severe PMS symptoms may be completely
relieved in pregnancy, but may return as
postnatal depression, followed by a return to
cyclical depression that worsens with age. Unfortunately,
this aggravation of PMS often becomes
less regular with the approaching menopause. A
good question to gauge symptom severity in a
patient may be, ‘How many good days do
you have in a month?’ Some women with postnatal
depression respond well to transdermal
oestrogen.
Current treatments for PMS consist of
hormonal therapy alongside psychiatric support,
lifestyle changes and alternative therapies.
According to Professor Studd, antidepressants
do not have a role here. This is a stark contrast
to the historical treatments described during his
lecture. In days gone by, women with conditions
such as ‘menstrual madness, nymphomania,
40
ovarian mania or hysteroepilepsy’ (PMS) were
often sent to the nearest asylum. Here, early
gynaecologists pioneered BSO as an effective
treatment of PMS. It was so effective for these
women that the risky surgery was soon rolled
out to many women in asylums, who were
particularly popular as subjects for doctors
who needed to gain experience in surgery.
Fortunately, these practices were eventually
stopped.
Overall, Professor Studd advocates the use of
the best treatment for the individual, which may
or may not include surgery. He has found that
hormonal manipulation is certainly effective,
and often cheaper than the antidepressants promoted
by the heavily research-biased literature
base. Further information can be found on his
website .
Clair Jones
Management of inherited bleeding
disorders in pregnancy
Dr Peter Collins, consultant haematologist,
University Hospital of Wales, Cardiff, UK
Inherited bleeding disorders include haemophilia,
von Willebrand disease and disorders of
platelet function. The management of these
disorders during pregnancy requires a multidisciplinary
team approach between haemophilia
centres, obstetric services and anaesthetists
(Lee et al. 2006).
Antenatal diagnosis can be offered to most
carriers of severe haemophilia from about 10
weeks. Future options will include the use of
in vitro fertilization with re-implantation of
female or unaffected male embryos.
Affected women may bleed secondary to
trauma associated with vaginal delivery, or
invasive procedures such as Caesarean section or
epidural anaesthesia. Correction of haemostasis
may be required.
It is usually not known whether a baby born
to a woman who is a carrier of a bleeding
disorder is affected until she is tested postnatally.
Children with bleeding disorders are at risk of
cephalohaematoma and intracranial bleeding at
the time of delivery. Therefore, these children
should be delivered on the assumption that they
have a bleeding disorder. This means avoiding
invasive procedures such as ventouse extraction,
foetal scalp monitoring and high forceps. Children
should be tested for the family disorder at
birth. At present, there is no consensus as to
whether children born with a severe bleeding
2007 Association of Chartered Physiotherapists in Women’s Health

disorder should be treated at birth, and individual
centres should have a policy on this.
Peter Collins
Reference
Lee C. A., Chi C., Pavord S. R., et al. (2006) The obstetric
and gynaecological management of women with inher-
Presentation reflections
ited bleeding disorders – review with guidelines produced
by a taskforce of UK Haemophilia Centre Doctors’
Organization. Haemophilia 12 (4), 301–336.
2007 Association of Chartered Physiotherapists in Women’s Health 41

Journal of the Association of Chartered Physiotherapists in Women’s Health, Spring 2007, 100, 42–48
CLINICAL AUDIT
Assessing outcomes of urinary incontinence treatment
using the International Consultation on Incontinence
Questionnaire – Urinary Incontinence Short Form
C. Jouanny
Urotherapy Clinic, Westmount Assessment and Rehabilitation Centre, Overdale Hospital, St Helier, Jersey,
Channel Islands
Abstract
Outcome measures should prove to be useful tools in the development of the
provision of optimal physiotherapy treatment for women with urinary incontinence
(UI). The International Consultation on Incontinence Questionnaire –
Urinary Incontinence (ICIQ-UI) Short Form was used to assess treatment
outcomes, and scores were compared with subjective treatment outcomes. This
paper details the outcomes of treatment for the first 51 women with UI who
underwent therapy after the introduction of the ICIQ-UI Short Form in a
urotherapy clinic. The audit showed that over 75% of women referred to the clinic
had improved after attendance and that the ICIQ-UI Short Form reflected the
subjective outcomes. It is recommended that use of the questionnaire should be
continued as an outcome measure for physiotherapy for UI in clinical practice.
Keywords: audit, outcomes, urinary incontinence.
Introduction
Following attendance at a Chartered Physiotherapists
Promoting Continence (CPPC) study
day in October 2003, the means of assessing
treatment outcomes at a urotherapy clinic were
reviewed by the present author. The King’s
Health Questionnaire (Kelleher et al. 1997) had
previously been used in the assessment of women
with stress urinary incontinence (SUI), but this
had proved to be too unwieldy and timeconsuming
for effective use in the clinical
setting.
The fully validated International Consultation
on Incontinence Questionnaire – Urinary Incontinence
(ICIQ-UI) Short Form (Avery et al.
2004) was presented by its author at the CPPC
study day. Women’s health physiotherapists
were encouraged to consider using it both as an
outcome measure for research as well as in
routine clinical practice. The higher the score
on the questionnaire, the greater the ‘symptom
bother’.
Correspondence: Mrs Clare Jouanny, Urotherapy Clinic,
WARC, Overdale Hospital, Westmount Road, St Helier,
Jersey JE1 3UN, Channel Islands (e-mail: c.jouanny@
health.gov.je).
42
Since 2004, the ICIQ-UI Short Form has been
used at the Urotherapy Clinic of the Westmount
Assessment and Rehabilitation Centre, Overdale
Hospital, St Helier, Jersey, Channel Islands, for
any woman referred to the service whose referral
suggests that she is incontinent of urine. Patients
may have other diagnoses, of course, and incontinence
may not always be the primary clinical
sign.
Subjects and methods
Questionnaires were sent with the first appointment
letter to all women who, according to their
referral, were suffering from urinary incontinence
(UI). The questionnaire was collected the
first time that the patient was seen and the
information was entered into a computer database.
After treatment was completed, women were
sent another ICIQ-UI Short Form, along with a
return envelope.
The present paper describes an audit of the
first 51 ICIQ-UI Short Forms to be completed
both before and after treatment at the urotherapy
clinic.
2007 Association of Chartered Physiotherapists in Women’s Health

Figure 1. Subjective outcomes of treatment for urinary
incontinence (total n=51).
Results
The number of questionnaires that were not
returned, either before or after treatment at the
urotherapy clinic, was not documented because
of time constraints.
The average ICIQ-UI Short Form scores
before and after treatment at the urotherapy
clinic were 9.2 and 6.4, respectively. The subjective
outcomes of treatment are shown in Fig. 1.
The information was then analysed further:
+ Twenty-one (41%) women attended an individual
(one-to-one) appointment first. For
these women, the average ICIQ-UI Short
Form scores before and after treatment were
8.9 and 5.7, respectively. The subjective outcomes
of their treatment are shown in Fig. 2.
+ Twenty-nine (57%) women attended a group
information session first. Twenty-five of these
subjects were referred with SUI, urge UI
(UUI) or mixed UI (MUI), which showed
that, in general, the criteria (local criteria
based on referral information) for attending
a group information session first were being
followed. For these women, the average
ICIQ-UI Short Form scores before and after
treatment were 9.3 and 7.2, respectively. The
Figure 2. Individual first appointment: subjective outcomes
of treatment for urinary incontinence (total
n=21).
Urinary incontinence treatment
Figure 3. Group first appointment: subjective outcomes
of treatment for urinary incontinence (total
n=29).
subjective outcomes of treatment are shown
in Fig. 3.
The outcomes were then analysed according
to the secondary diagnosis recorded on the database.
Some women may have had more than one
diagnosis (e.g. SUI and genital prolapse), in
which case the most problematic diagnosis was
recorded.
Urge urinary incontinence (n=6)
The average ICIQ-UI Short Form scores before
and after treatment were 10.5 and 6.3, respectively.
Half the women were cured.
Mixed urinary incontinence (n=17)
The average ICIQ-UI Short Form scores before
and after treatment were 10.8 and 7.6, respectively.
Eleven (64.7%) of these women attended a
group information session 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 before
and after treatment were 8.8 and 7.2, respectively.
Nine (64.3%) of these women felt better
after treatment (i.e. cured or greatly improved).
Other diagnoses
Other diagnoses included pelvic pain, anal
incontinence, genital prolapse, urinary frequency,
post-micturition dribble, pelvic floor
muscle (PFM) weakness and urinary urgency.
The final analysis was a comparison of the
women’s subjective outcome of treatment with
the ICIQ-UI Short Form score:
+ Eleven (21.6%) of the women considered
themselves cured. The average ICIQ-UI Short
2007 Association of Chartered Physiotherapists in Women’s Health 43

C. Jouanny
Figure 4. Difference in pre- and post-treatment International Consultation on Incontinence Questionnaire – Urinary
Incontinence (ICIQ-UI) Short Form scores compared to subjective urinary incontinence treatment outcomes.
Form scores before and after treatment were
8.8 and 4.2, respectively.
+ Sixteen (31.4%) of the subjects considered
themselves greatly improved. The average
ICIQ-UI Short Form scores before and after
treatment were 8.6 and 6, respectively.
+ Five (9.8%) of the women considered themselves
improved. The average ICIQ-UI Short
Form scores before and after treatment were
9.4 and 7.2, respectively.
+ Seven (13.7%) of the subjects received a oneoff
advice session. The average ICIQ-UI
Short Form scores before and after treatment
were 6.4 and 3.1, respectively,
+ Nine (17.6%) of the women were referred on.
The average ICIQ-UI Short Form scores
before and after treatment were 11.8 and 10.5,
respectively.
These results are displayed in Fig. 4.
Discussion
The women who attended an individual (one-toone)
appointment first had a greater difference in
ICIQ-UI Short Form pre- and post-treatment
scores (3.2) than those who attended a group
information session first (2.1).
The 21 women who attended an individual
(one-to-one) appointment first were 11.4% more
likely to be cured. Fifteen (71.4%) of these
subjects felt better (i.e. cured, greatly improved
44
or improved) compared to 17 (58.6%) of the
29 women who attended a group information
session first.
The reason for this difference is not clear.
Grimshaw (2005) audited physiotherapy classes
for women with pelvic floor dysfunction, but felt
that it would be too difficult to do an audit on
medical improvement since there were so many
variables in diagnosis, and in extent and type of
symptom; therefore, the outcome of the patient’s
symptoms was not audited. Using the findings of
a limited literature review and information
gained from women’s health physiotherapists,
Smith (2004) assessed the advantages and disadvantages
of groups. Again, there was no information
on the outcomes of symptoms for those
attending such a group.
Cook (2001) reviewed the evidence relating to
the group treatment of female UI, including the
effect of group treatment on the strength of the
PFMs, bladder training and improvement of
patient knowledge. Eight studies were identified,
but it was concluded that there is a lack of
available evidence and that further research is
required.
In contrast to the present audit, papers by
Demain et al. (2001) and Janssen et al. (2001)
found that individual and group treatments were
equally effective in improving female UI at 3 and
9 months after treatment. However, it should be
noted that subjects in the present audit who
2007 Association of Chartered Physiotherapists in Women’s Health

attended a group session first, then went on to
have individual follow-up and did not remain
in a group for the duration of their treatment,
which could account for the difference.
Vestergaard (1997) aimed to compile guidelines
for group sessions rather than assess the outcome
of treatment for those attending a group
session first versus an individual session first,
and therefore, did not add to this discussion.
It is possible that those women who attended a
one-to-one session first had more individualized
treatment from the outset, which motivated
them more and led to an improved outcome.
However, since the women who attended the
group information session were more likely to be
referred on, it is possible that the problems that
they were referred with were more complex and
less likely to respond to physiotherapy intervention
in the first place.
In this group of women, although the numbers
were small, a main complaint of UUI was the
diagnosis with the most successful outcome.
Fifty per cent were cured and this corresponded
with a considerable difference in pre- and posttreatment
ICIQ-UI Short Form scores. It should
be noted that there were only six women with
UUI, compared to 14 and 17 for SUI and MUI,
respectively; success rates may have been different
with a larger sample.
A systematic review by Hay-Smith & Dumoulin
(2006) found that trials in women with SUI that
suggested a greater benefit recruited a younger
population and recommended a longer training
period than the one trial in women with detrusor
overactivity (urge) incontinence. It would be useful
to conduct a further audit to investigate the
number of treatment sessions that women with
SUI received compared to those with UUI, in
order see if this relates to the different outcomes.
Borello-France et al. (2006) reported a 67.9%
reduction in the frequency of episodes of SUI
following PFM exercises (PFMEs), regardless
of the position adopted. In a review of an
earlier cohort of women, Bø et al. (2005) found
that 60% were almost or completely continent
6 months after intensive PFM training,
although this was not maintained 15 years later.
Dannecker et al. (2005) found that self-reported
improvement of incontinence symptoms was
95% for women after an intensive and
electromyography-biofeedback-assisted PFM
training programme. These more recent papers
add to the considerable body of evidence
suggesting that physiotherapy is a successful
therapy for SUI.
Urinary incontinence treatment
However, in a limited literature review, no
studies were found that directly compared the
outcomes for SUI versus UUI. This suggests
that little has changed since Hay-Smith et al.’s
(2001) systematic review, which concluded that
the role of PFM training for women with UUI
alone remains unclear.
Women with MUI had a considerable difference
in pre- and post-treatment ICIQ-UI Short
Form scores of 3.2, with 11 (64.7%) feeling
better. However, there was a high onward referral
rate (n=4, 23.5%) for these women, which
implies that physiotherapy treatment alone did
not make them sufficiently better. On further
investigation of their records, more of these
subjects had overactive bladders diagnosed
on cystometrogram (after appropriate onward
referral), and some also had prolapse as a secondary
diagnosis. From the difference between
their pre- and post-treatment scores, physiotherapy
would seem to have made these women
less bothered about their urinary symptoms.
In women whose main complaint was SUI,
nine (64.3%) felt better after treatment, but the
difference in pre- and post-treatment ICIQ-UI
Short Form scores was only 1.6. This could be
because they felt better about their symptoms,
even though the symptoms themselves were not
much improved. In Hay-Smith et al.’s (2001)
review of PFMEs versus no treatment, exercises
were found to significantly improve self-reported
cure rates, and self-reported cure or improvement
rates over 3–6 months, compared with no
treatment. Cure or improvement rates in two
randomized controlled trials showed 62/78 (79%)
with PFMEs versus 3/86 (3%) with no treatment.
Other recent research, already cited above (Bø
et al. 2005; Dannecker et al. 2005; Borello-France
et al. 2006), has also suggested a higher cure/
improvement rate than seen in the present audit.
Hay-Smith & Dumoulin (2006) undertook a
systematic review and found 13 trials involving
714 women (375 doing PFM training; 339 controls)
that met the inclusion criteria, but only six
trials (403 women) contributed data to the
analysis. Overall, the review provided some support
for PFM training as first-line conservative
management, but indicated that the treatment
effect may be greater in younger women with
SUI alone. The subjects in the current audit were
of varying ages and reported SUI as their main
symptom, but it may be that other symptoms
such as urgency and frequency were still bothersome,
and this was reflected by the ICIQ-UI
Short Form score.
2007 Association of Chartered Physiotherapists in Women’s Health 45

C. Jouanny
A usable measure to capture how patients feel
about their problem after treatment at the urotherapy
clinic would be useful. In the past, as
mentioned above, the King’s Health Questionnaire
was used, and the present author also has
experience of the Short Form 36 questionnaire,
both of which provide greater detail about quality
of life. However, these tools are considered
too time-consuming for routine clinical practice,
and despite various searches, a more suitable
measure has not yet been found.
Other diagnoses were too infrequent to allow
comment on their treatment outcomes, or did
not involve incontinence.
The comparison of subjective outcomes with
ICIQ-UI Short Form scores did show a correlation:
those women who felt that they had been
cured had a greater difference (4.6) in pre- and
post-treatment scores on the questionnaire in
comparison to those who only felt that they had
improved (2.2).
The ICIQ-UI Short Form scores of those
women who received a one-off advice session
(with or without a group information session as
well) demonstrated a difference in pre- and posttreatment
ICIQ-UI Short Form scores of 3.3,
implying that their symptoms were at least
greatly improved.
In a literature review, Cook (2001) examined
the theoretical framework of group treatment,
and commented that the capacity for comparison
and support within a group reduces both
feelings of isolation and the need for secrecy.
This should make women feel better about their
symptoms. Cook (2001) also noted that pretraining
influences the effectiveness of group
intervention. All women attending the information
group session first do receive a leaflet
detailing why they have been invited and what
the session entails. These factors could have
enhanced the outcomes of these women.
Keller (1999) examined the occurrence, attitudes
and knowledge of UI among older women
in a rural setting, and concluded that ‘misconceptions
concerning the causes of and the availability
of treatment for incontinence [. . .] may
have an impact on their decision to seek care for
this typically remediable condition’. Newman
(2004) used a simple mail-in questionnaire to
survey 1500 women with bladder control disorders;
422 responded. The survey concluded
that these women wanted more information
regarding incontinence. This should remind us
that the importance of giving women relevant
advice should not be underestimated.
46
Conclusions
Over 75% of women referred to the present
author’s urotherapy clinic improved after
attendance.
The ICIQ-UI Short Form reflects the subjective
outcomes of cured, greatly improved,
improved and referred on, and it is recommended
that its use should be continued as an
outcome measure for physiotherapy for UI.
It is also recommended that new versions of
this questionnaire that are being developed as
outcome measures for vaginal symptoms and
faecal (anal) incontinence are used at the urotherapy
clinic, when available, and subsequently
audited.
The present author considers that many
women with UI feel better about their problem
after being able to discuss it and understand it
during assessment and treatment at the urotherapy
clinic, but this is not well captured as an
outcome of therapy. Therefore, it is recommended
that usable measures to record this
important outcome are explored and employed if
possible.
The following subjective outcomes used need
to be reconsidered:
+ ‘one-off advice session’ and ‘cancelled or did
not attend last session’ – those who attended
a one-off advice session did not attend the
clinic again, meaning that their subjective
outcome could not be recorded, but this could
be added to the letter accompanying the
ICIQ-UI Short Form sent out after discharge;
+ more consideration needs to be given to the
subjective outcomes of patients who are
referred on, many of whom feel better as a
result of the treatment they receive, but not
better enough; and
+ there needs to be greater clarity as to whether
the subjective outcome is recording the outcome
for the treatment as a whole, or only the
outcome for the main complaint – this may
be where an outcome measure of perceived
benefit would be useful.
Therefore, it is recommended that the subjective
outcomes recorded should be brought into
line with those now used at the Physiotherapy
Department, Jersey General Hospital, St Helier,
Jersey, Channel Islands, as follows:
+ resolved;
+ much better;
+ improved;
+ unchanged;
+ worse;
2007 Association of Chartered Physiotherapists in Women’s Health

+ physiotherapy not required (e.g. patient does
not perceive any problem, incorrect referral
or going privately); and
+ DNA – the patient did not attend (i.e. it cannot
be judged whether they benefited or not).
If the patient does not attend after their third
session, an outcome should be chosen from
the first five listed above, based on subjective
changes recorded in the Subjective, Objective,
Analysis, Plan (SOAP) notes.
A more accurate record should be kept of the
number of ICIQ-UI Short Forms sent out and
the number of those returned. Although it would
be difficult to follow up women who did not
return their ICIQ-UI Short Form posttreatment,
it would be interesting to know if they
failed to return it because they were no better
and, therefore, demoralized, or if they were in
fact better and were too busy enjoying a better
quality of life to return the questionnaire.
Finally, it is recommended that, in future
treatment outcome audits, the number of
appointments is recorded and analysed in relation
to outcome, in order to see whether women
who attend more appointments have a better
outcome or not.
These recommendations should be implemented
by June 2006, after discussion with relevant
parties, and there will be a follow-up audit
in June 2007.
Addendum
Changes have been implemented since the
present audit was completed.
The ICIQ – Vaginal Symptoms questionnaire
has been used with appropriate patients,
although it is in long form, and therefore, more
time-consuming.
The subjective outcomes have been changed to
come into line with Jersey General Hospital
policy, and this certainly helps to reflect a more
accurate outcome when a patient cancels or does
not attend their last session.
A record is now kept of the number of ICIQ-
UI Short Forms sent out and returned. Currently,
only approximately 50% of those sent out
at discharge are returned, despite an addressed
(though not stamped) envelope being included.
A usable measure to capture the ways in which
women feel better after gaining a greater understanding
of their problem is actively being
sought. There are many measures available, but
none have appeared more suitable so far.
Re-audit is due in June 2007.
Acknowledgments
Grateful thanks go to Kerry Avery for her
permission to use the ICIQ-UI Short Form and
her continued interest in its use in this setting,
and to Nikki Gardener for her advice on the
presentation of this audit, as well as her continued
enthusiasm and support. My thanks also
go to Yvette Dobin for sending out the initial
questionnaires, Gerard Dubras for his technical
assistance and Gill Brook for editing the
paper.
References
Urinary incontinence treatment
Avery K., Donovan J., Peters T. J., et al. (2004) ICIQ: a
brief and robust measure for evaluating the symptoms
and impact of urinary incontinence. Neurology and
Urodynamics 23 (4), 322–330.
Bø K., Kyarstein B. & Nygaard I. (2005) Lower urinary
tract symptoms and pelvic floor muscle exercise adherence
after 15 years. Obstetrics and Gynecology 105 (5, Pt
1), 999–1005.
Borello-France D. F., Zyczynski H. M., Downey P. A.,
Rause C. R. & Wister J. A. (2006) Effect of pelvic-floor
muscle exercise position on continence and quality-of-life
outcomes in women with stress urinary incontinence.
Physical Therapy 86 (7), 974–986.
Cook T. (2001) Group treatment of female urinary incontinence:
literature review. Physiotherapy 87 (5), 226–
235.
Dannecker C., Wolf V., Raab R., Hepp H. & Anthuber C.
(2005) EMG-biofeedback assisted pelvic floor muscle
training is an effective therapy of stress urinary or mixed
incontinence: 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 physiotherapy
for female urinary incontinence in primary care:
pilot study. Physiotherapy 87 (5), 235–242.
Grimshaw R. (2005) An audit of physiotherapy classes for
women with pelvic floor dysfunction. Journal of the
Association of Chartered Physiotherapists in Women’s
Health 96, 62–64.
Hay-Smith E. J. C., Bø K., Berghmans L. C. M., Hendriks
H. J. M., de Bie R. A. & van Waalwijk van Doorn E. S.
C. (2001) Pelvic floor muscle training for urinary incontinence
in women (Cochrane Review). In: The Cochrane
Database of Systematic Reviews, Issue 1. Art. No.:
CD001407. DOI: 10.1002/14651858.CD001407.
Hay-Smith E. J. C. & Dumoulin C. (2006) Pelvic floor
muscle training versus no treatment, or inactive control
treatments, for urinary incontinence in women
(Cochrane Review). In: Cochrane Database of Systematic
Reviews, Issue 1. Art. No.: CD005654. DOI: 10.1002/
14651858.CD005654.
Janssen C. C. M., Lagro-Janssen A. K. M. & Felling A. J.
A. (2001) The effects of physiotherapy for female urinary
incontinence: 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
2007 Association of Chartered Physiotherapists in Women’s Health 47

C. Jouanny
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 of
urinary incontinent women. British Journal of Obstetrics
and Gynaecology 104 (12), 1374–1379.
Newman D. K. (2004) Report of a mail survey of women
with bladder control disorders. Urology Nurse 24 (6),
499–507.
Smith R. (2004) Advice groups for female patients with
pelvic floor dysfunction. Journal of the Association of
Chartered Physiotherapists in Women’s Health 95, 53–57.
48
Vestergaard A. (1997) Promoting continence in group
sessions. Journal of the Association of Chartered Physiotherapists
in Women’s Health 80, 27–30.
Clare Jouanny is a senior physiotherapist specializing
in pelvic floor muscle dysfunction in Jersey,
Channel Islands. She works both for the States of
Jersey Health Service and in private practice.
Clare is an ACPWH area representative and is
also a moderator for the ACPWH network on
iCSP.
2007 Association of Chartered Physiotherapists in Women’s Health

Journal of the Association of Chartered Physiotherapists in Women’s Health, Spring 2007, 100, 49–51
ACPWH CONFERENCE 2006
Executive committee response to Conference
discussion groups
As is practice at each Conference, discussion
groups were held. Delegates were invited to
join a small group facilitated by an executive
committee member. The questions posed, the
comments made by members and a response
from the executive committee are given below.
Business planning working party
Should the Association set up a working group
to discuss business planning to help members
secure funds for service development?
There was a unanimous ‘yes’ in response to this
question, and a gratifying number of volunteers
said that they would like to be involved.
Comments included the feasibility of using
Interactive Chartered Society of Physiotherapy
(iCSP) and/or area representatives as a contact
query medium, and that there should be a realistic
approach to setting up and maintaining the
service. There was agreement that there should
be a risk-management approach.
Executive response
Members’ comments will be taken to the next
executive committee meeting in January 2006
for discussion about the best way to approach
setting up the working party.
What are the pros and cons of a move to a
biennial conference?
1. Because of current financial restraints, lack
of funding and time-off issues within the
National Health Service, the executive committee
wonders whether there is any benefit to
holding our Conference every 2 years instead
of annually. This might maximize support and
make it better value for money
There was a majority in favour of retaining an
annual Conference. This topic generated a great
deal of discussion, and many general points
surrounding conference were raised.
Comments ‘for’ a biennial conference:
+ funding issues; and
+ implications for an annual general meeting
(AGM) (could this be held at Congress?).
Comments ‘against’:
+ other training is available, but Conference is
good for ‘extras’/added value;
+ some teams take turns attending Conference;
+ yearly funding may be lost if it is not used;
+ the support network is essential;
+ there are fears that the ACPWH could lose
profile if there is no annual Conference and
that there could be a loss of members’ interest
in their Association;
+ it is good to have the option of going every
year, even if members are unable always to
attend;
+ there would be a long time between Conferences
if one is missed;
+ new members would have a long time to wait
before getting involved;
+ the AGM could be held annually – only a
small body is needed to look at the constitution
between Conferences;
+ discussion groups are valuable annually; and
+ for many, Conference is their only update for
portfolio/reflection.
General comments (most were not related
to 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, and
delegates could choose which to attend;
+ many members have trouble getting time off
work;
+ a full Conference could be alternated with a
one-day conference;
+ accommodation not included may be a
problem;
+ some members could cope with less-salubrious
surroundings;
+ the possibility of concentrating the Conference
so that members only have to stay for
one night was raised;
2007 Association of Chartered Physiotherapists in Women’s Health 49

Executive committee response
+ the possibility that the cost of gala dinner
could be reduced was mentioned;
+ sponsorship could be obtained;
+ some members find it difficult to get funding
for a ‘conference’ (could it be called something
else, e.g. a ‘study weekend?);
+ an application form to investigate funding
was suggested;
+ the Chartered Physiotherapists Promoting
Continence have single study days with a
9.00 a.m. start, but these still require an overnight
stay;
+ the iCSP and/or the ACPWH website forum
could be used to canvass opinions and find
out the reasons for decreased attendance;
and
+ a retrospective audit of those attending could
be conducted.
2. Plans are already under way for 2007, so
2008 could be the first year with no
Conference. However, 2008 coincides with
our sixtieth anniversary, which the Association
would presumably like to celebrate. What do
members feel? Should we have a Conference
in 2008 or celebrate our sixtieth in some other
way?
Suggestions for 2008:
+ a 2-day Conference;
+ do not hold it over a weekend;
+ holding the Conference on 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 (is
the number applying in 2006 a ‘blip’?);
+ members will have to stay anyway, so the
Association should have a 2-day conference;
and
+ it would be a shame to miss our sixtieth
anniversary in 2008, so Conference should go
ahead.
Executive response
Many differing issues have been raised. The
executive committee will consider all of them
and decide how best to please the majority.
50
Acronym
There has been a suggestion that we should
change the name of our Association to reflect
the fact that some of our members treat men
and children as well as women. The executive
committee has discussed this at length and
invited comment from the membership prior to
Conference
There was a virtually unanimous ‘no’ to a
change of name for our association, but some
comments were made:
+ there could be a subgroup for those who treat
men;
+ patient awareness of ACPWH is low anyway;
+ we have a good website, so men will be
directed to the ACPWH;
+ many men contact us because of mentions
women’s magazines (!); and
+ it’s a local issue.
Executive response
The executive committee is not in favour of a
name change, and this view was reinforced by
both the vast majority at Conference and a
number of e-mails from members received prior
to Conference. Therefore, the acronym will
remain as ACPWH.
Annual Representatives Conference
motion on dyslexia
If our motion is put forward in 2007 at the
Annual Representatives Conference (ARC), it
should read as follows: ‘Conference urges
Council to survey the membership, to identify
how many are affected by dyslexia and to
ascertain from them how the Society can best
meet their needs.’ Do members have further
comments?
Suggestions:
+ the British Dyslexia Association and Dyslexia
Institute should be contacted;
+ we need awareness of Equality and Diversity
legislation; and
+ CSP information packs for students.
General comments:
+ ask for CSP guidance (e.g. more time for
writing notes);
+ there are huge issues surrounding lack of
support in the workplace;
+ it is up to the local manager to address this;
+ this must be considered for ACPWH courses;
2007 Association of Chartered Physiotherapists in Women’s Health

+ other issues that are ‘more clinical’ should be
addressed;
+ three out of five people in one group had a
child with dyslexia, and for two out of three,
this had adversely affected their education;
and
+ one staff member who is known to be dyslexic
does not want any special treatment or allowances
made.
Executive response
The executive will ask our diversity officer to
take the suggestions forward for action on behalf
of the ACPWH, after further discussion at the
next executive committee meeting. This will
happen whether or not our motion is accepted at
ARC.
Papers in other journals
The Journal editor would like feedback on
whether the ‘Papers in other journals’ section,
which is in each edition, is well received, or
not? If so, are there any other journals you
would like to see papers from listed in addition
to, or instead of, those currently used?
This section of the Journal is appreciated by
most members. The majority are very happy
with Journal at present, especially the most
recent edition.
Executive response
The executive will pass on all the comments
received, plus the names of individuals wishing
to help with ‘Papers in other journals’, to the
Journal editor
Any other business
Many topics were raised, including the following:
+ Should we, as a women’s health association,
be encompassing all aspects of women’s
Executive committee response
health; for example, Ca breast and osteoporosis
(future workshops?)?
+ The (previously unconfirmed) pelvic girdle
pain lecture was removed from Conference,
leaving little for obstetric-only physiotherapists.
+ The ARC motion on the CSP guidelines for
domestic violence: if the CSP is not interested,
then what about the ACPWH?
+ There has been either slow or no feedback on
points that have been previously raised (e.g.
electrotherapy and symphysis pubis dysfunction
guidelines).
+ It is a shame that courses are run without
ACPWH approval; for example, ACPWH
approval is needed for the 2-day musculoskeletal
course, and obstetric courses are
needed.
+ The iCSP very useful and very easy to access.
The ACPWH website is also useful, but the
iCSP forum is probably used more frequently.
Executive response
The executive committee thanks members for
raising so many valid points. One or two were
addressed during the course of the Conference
weekend. The remainder will be discussed by
the executive and there will be full response/
explanation/update on the website as soon as
possible after the next executive meeting.
+ The most recent issue of the Journal was
excellent.
+ The postgraduate courses are good.
+ Thanks were given to the committee for their
time and the Journal.
Executive response
The executive committee thanks members for
their comments, which are much appreciated.
Ros Thomas
2007 Association of Chartered Physiotherapists in Women’s Health 51

Journal of the Association of Chartered Physiotherapists in Women’s Health, Spring 2007, 100, 52–63
Conference and course reports
Research Officers’ Study Day
Chartered Society of Physiotherapy,
London, 19 May 2006
The Chartered Society of Physiotherapy (CSP)
hosted a study day for research officers (ROs)
from each of the clinical interest/occupational
groups (CI/OGs) in May 2006 and about 12
groups were represented. The main aims of the
day were to discuss strategies for the development
of a research culture in the physiotherapy
profession, and also to help the CI/OGs to
identify the type of help needed to develop their
own research culture. It was an opportunity for
CI/OGs to share information on different
approaches/types of support for physiotherapy
research. It was emphasized that a research
culture must be clinically driven, and ultimately,
be for the patients’ benefit.
Much of the day was spent in discussing the
new National Physiotherapy Research Network
(NPRN) and outlining its purpose. The NPRN
was set up in 2005 to support and encourage
engagement in physiotherapy research. It is a
mutual support network involving a full range
of research experience and interests. It supports
physiotherapy research in different regions
throughout the country and aims to develop a
research culture in the workplace, particularly in
clinical settings rather than the traditional university
setting. There are 20 regional research
hubs, each one led by a senior researcher based
in a university, but with links to clinicians. This
enables CSP members to tap into mentorship and
research expertise in the region. You can access
information via the CSP website at: , or contact Dr Philippa Lyon, the
NPRN research officer, at .
We had to complete a strengths, weaknesses,
opportunities and threats (SWOT) analysis of
our CI/OG’s research culture, and there were
many common themes across the groups. The
points most pertinent to ACPWH are summarized
below.
Strengths:
+ the ACPWH is associated with postgraduate
courses that have a research culture; these are
now offered at Bradford and allow the oppor-
52
tunity for a full MSc, and thus, new members
of ACPWH should have more background in
research;
+ the Association is a member of the international
women’s health group of the World
Confederation for Physical Therapy and has
links to international researchers;
+ it publishes a partially peer-reviewed journal;
+ the ACPWH runs an annual conference that
presents some scientific papers; and
+ it runs evidence-based approved workshops.
Weaknesses:
+ the isolation of workers in women’s health
makes the generation of ideas and implementation
of research ideas difficult;
+ research among ACPWH members is limited
to a few people, although numbers are rising
slowly;
+ the Association has only had a RO at executive
level for a short time (this was previously
a subcommittee post);
+ a research culture is not ‘built in’ to clinical
practice in the way that it is in higher education;
and
+ there can be some resistance to challenging
custom and practice within physiotherapy as
a whole.
Opportunities:
+ we could make our Annual Conference more
scientific by having some shorter sciencebased
presentations and using the Conference
to ask for poster presentations;
+ the RO should have strong links with the
Journal committee;
+ we could increase bursaries to include those
supporting research done by members;
+ we should produce a database of researchers
in women’s health;
+ we should foster links with higher education
institutes to promote teaching of women’s
health to undergraduates; and
+ we should have a page dedicated to research
on our website.
Threats:
+ the current lack of resources in the National
Health Service (NHS);
2007 Association of Chartered Physiotherapists in Women’s Health

+ a shift in culture of the NHS to payment
by results, and no mention of research and
development;
+ many members of the Association qualified
before the degree was available and so do not
have research background; and
+ there is some opposition from members.
This list is not exhaustive, but it gives a loose
framework for the development of the role of the
research officer.
Other items covered during the day included
the development of CI/OGs’ newsletters and
journals to include evidence-based articles. This
session highlighted the difference between
CI/OGs, with some having a chatty, newsletterstyle
publication and others having a fully peerreviewed
journal. It was not suggested or agreed
that CI/OGs should move towards a totally
peer-reviewed journal, since CI/OG groups
are diverse. However, it was felt that CI/OGs
should be encouraging the publication of some
evidence-based and research articles within the
scope of their publication. As this already exists
to some extent with the ACPWH Journal, I felt
that we were contributing to developing a
research culture among our members, and that
we were one of the leading CI/OGs with an
emphasis on evidence-based practice.
There was a short presentation on accessing
and sharing research training and development
resources through the CSP and the NPRN, and
members were encouraged to access the websites
of these two groups. Overall, the day had a
strong emphasis on the idea that clinicians
(rather than academics) should generate clinical
research questions, and it was demonstrated that
there was support within the physiotherapy
profession for clinicians to develop a research
culture within their practice.
Yvonne Coldron
Research officer
The WellBeing of Women (WoW)
Show – The Women’s Health
Show That’s Serious Fun
Royal College of Obstetricians and
Gynaecologists, London, 8 July 2006
WellBeing of Women (WoW) is a UK charity
dedicated to the funding of research, and to
raising awareness of all aspects of women’s
health across three areas: pregnancy and birth;
quality-of-life problems (e.g. the menopause,
Conference and course reports
endometriosis, polycystic ovary syndrome and
incontinence); and gynaecological cancers. If you
require more information about the charity you
can log onto .
Last summer, the Royal College of Obstetricians
and Gynaecologists (RCOG) kindly hosted
The Big Squeeze, part of the WoW campaign to
raise awareness of urinary incontinence and
other bladder problems, the importance of preventative
action, and the availability of effective
treatments. The ACPWH was invited to take
part in this exciting event.
I have to admit that I expected hundreds of
women to attend, but unfortunately, that wasn’t
the case. This could be for two reasons. On
the one hand, it is possible that not enough
marketing/advertising was done to promote the
show; on the other, urinary incontinence is still
a taboo subject, and therefore, it is likely that
some women still feel too embarrassed to openly
discuss their complaint in an environment that
doesn’t ensure their privacy.
We had a marvellous day in which we gave
advice to a few women. All of them were very
grateful. We directed women towards their local
women’s health physiotherapist, advised them
on a variety of topics (e.g. constipation and
prolapse), taught them how to do pelvic floor
muscle exercises (PFMEs) correctly and we
showed them different gadgets. We had a nice
stand with lots of information on it.
A few issues were raised by the women. There
is a lot of information on stress urinary incontinence,
but not enough on urge urinary
incontinence. Only a few had been offered
physiotherapy as a first-line treatment. In fact,
the majority of women did not know that
physiotherapy could help them. Many were not
sure what our treatment involved. Very few
women were doing PFMEs correctly. Some of
the women had a concomitant prolapse and
wanted to know more about that. We gave
information about the different types and
degrees of prolapse, and how PFMEs should
help them.
Women were quite shy about coming to the
stand, and some were asking for information for
‘their friends’.
I think we did a fantastic job; it was a shame
that only a few women attended the show. I
appreciated the opportunity to be with two other
women’s health physiotherapists, Julia Muman
and Katie Jeitz – many of us tend to work on
our own, so it was nice to share information and
knowledge with Julia and Katie. The downside
2007 Association of Chartered Physiotherapists in Women’s Health 53

Conference and course reports
was that attendance was so low. I hope that the
show will be better advertised in the future.
Paula Igualada-Martinez
Senior women’s health physiotherapist
Royal London Hospital
London
Pushy Mothers
Gladstone Park, London, July 2006
It was with great interest and, dare I say it,
excitement that I attended my first Pushy
Mothers session in Gladstone Park, a 5-min
walk from home, back in July 2006. At the time,
I was about 8 weeks postnatal, following the
birth of my first baby, Chloe, and I was itching
to get going.
I found out about Pushy Mothers quite by
chance. Judy DiFiore, one of the founders, had
contacted me asking if I could ‘spread the word’
with my team at the Royal Free Hospital (RFH),
not realizing I was on maternity leave. She knew
that we run a postnatal class at RFH, and
thought that we might be willing to inform our
patients about the existence of Pushy Mothers.
It actually proved to be the ideal opportunity
for me to do a bit of exercise, meet some other
mums in the local area and do some professional
‘spying’.
Judy set up Pushy Mothers earlier in 2006,
along with her colleague Rachel Berg. Both are
members of the Guild of Pregnancy and Postnatal
Exercise Instructors, and are highly qualified
fitness and exercise professionals. The ethos
of Pushy Mothers is to provide a safe and unique
buggy workout, focusing on core stability training
and cardiovascular fitness for new mums. All
Pushy Mothers instructors hold a postnatal exercise
qualification and have undergone a 2-day
Pushy Mothers training course.
I have found Pushy Mothers to be good fun,
and good exercise. The exercises are safe, functional
and effective, and the classes are very
social. It is wonderful to exercise in the open air,
and to be able to take your baby along (they
tend to sleep in the buggies, which is great!). Our
instructor, Karen, is excellent, combining just the
right balance of professionalism, motivation and
humour. I will not hesitate to recommend these
classes to my patients when I return to work.
At the time of writing (September 2006),
Pushy Mothers has really taken off in the parks
of North London, and there are plans for it to
54
become nation-wide in time. I am still attending,
and have made some great friends.
For further details, visit the website, .
Helen Forth
Cognitive Behavioural Therapy in
the Physical Health Setting
Manchester, 9–10 September 2006
This course was organized by physiotherapist
Chris Irving, and was led by Sister Karen
Heslop, respiratory nurse specialist, and Dr
Chris Baker, consultant psychologist.
Twenty-three physiotherapists and two occupational
therapists attended. They worked in a
variety of settings, including pain management,
cardiac and pulmonary rehabilitation, mental
health, and urology.
Many therapists see their patients regularly
over a number of weeks, during which time they
will often discuss their non-physical problems.
The aim of cognitive behavioural therapy
(CBT) is to change unhelpful thought–feeling–
behaviour patterns by experimenting with alternative
patterns of thinking and behaviour.
By applying the principles of CBT with some
of my patients, I feel I can assist my patients to
cope better, and I would recommend this as a
most worthwhile course.
ACPWH Conference
Geraldine Buckley
Senior physiotherapist
Mercy University Hospital
Cork, Ireland
Copthorne Hotel, Cardiff, 22–24 September
2006
This year’s Annual Conference (Figs 1–15) was
held in the capital of Wales on a beautiful sunny
weekend. The theme, ‘Hormones to Happiness’,
was chosen by the committee, and the aim was
to look at the holistic approach of the physiotherapist
to women’s health. The age range of
delegates meant that there was something for
everyone!
The opening speaker was Dr Annie Evans,
who gave a fascinating presentation on the perils
of the perimenopause (see pp. 27–32). This gave
us the scientific reasons behind the changes
2007 Association of Chartered Physiotherapists in Women’s Health

Figure 1. Caron James of the Cardiff organizing
committee with Dr Charlotte Fleming.
Figure 2. Chairman Ros Thomas with Margie Polden
lecturer Mary Cronk.
undergone by women. The evening closed with
a presentation on domestic abuse and what
physiotherapists need to know.
Saturday began with the opening of the trade
stands exhibition and bookstall. Then Mary
Cronk (Fig. 2) delivered the Margie Polden
Memorial Lecture (see p. 39). She paid a warm
tribute to Margie, and gave us a valuable insight
into the expertise of the midwife. This was
followed by a succession of fascinating presentation
topics, including the management of
clotting disorders in pregnancy (see pp. 40–41),
acupuncture and its use in women’s health (see
pp. 21–26), the hormonal treatment of premenstrual
syndrome (see p. 40), postnatal depression
(see pp. 4–13), and breast screening (see p. 38).
A very pleasant evening was spent at the gala
dinner, where we sampled some Welsh cuisine,
accompanied by music from a Welsh harpist.
This was followed by presentations of certificates
for the long Bradford course, and finally, the
transfer of the ACPWH chains of office from
Conference and course reports
Figure 3. Michelle Gormley, winner of the Margie
Polden student award, with Ros Thomas.
Figure 4. Dr Peter Collins with Carole Board, Cardiff
organizing committee chairman.
2007 Association of Chartered Physiotherapists in Women’s Health 55

Conference and course reports
Figure 5. Mair Whittall thanks Professor John Studd
and Jennie Longbottom.
Figure 6. Retiring executive member Sue Brook with
Ros Thomas.
Ros Thomas, the outgoing chairman, to Pauline
Walsh.
Sunday began with a slideshow and a very
interesting talk on sexually transmitted infections
(see pp. 39–40), followed by one of our
own women’s health physiotherapists, who
described research on the effectiveness of classes
in the treatment of urinary stress incontinence
(see p. 37). The conference drew to a close with
two presentations considering motivation and
cognitive behavioural therapy (see pp. 14–20
and 33–36), which left us all with food for
thought.
56
Figure 7. Caron James with Debra Bick.
Figure 8. Jill Mantle, Ros Thomas and the Right
Honourable the Lord Mayor of Cardiff enjoy a chat
before the gala dinner.
Figure 9. Our friends from Slovenia, Lidija, Darija
and Gabrijela, enjoy a moment with the Lord Mayor
and Lady Mayoress.
Special thanks go to all the staff of Fitwise, the
conference organizers used to help us with this
year’s Conference. They gave constant support
2007 Association of Chartered Physiotherapists in Women’s Health

Figure 10. Ros Thomas with the Lord Mayor and
Lady Mayoress.
Figure 11. Mair Whittall and Dr Annie Evans.
to our event both running up to and over the
weekend. Very special thanks go to Blair King,
who came down from Edinburgh and spent the
whole weekend with us, facilitating and coordinating
the Conference.
Conference and course reports
Figure 12. Jeanette Haslam presents Romy Tudor
with her certificate for completing the Bradford continence
course.
Figure 13. The first words from the new chairman,
Pauline Walsh.
From the Cardiff organizing committee
Everyone felt that the whole Fitwise team, led by
Blair King, provided excellent support for our
event. He acted efficiently as the coordinator
between us and his staff. Each member of each
team had dedicated roles, which became more
apparent as we neared the Conference date and
was very useful in ensuring that all queries were
being answered. He pursued all enquiries quickly
2007 Association of Chartered Physiotherapists in Women’s Health 57

Conference and course reports
Figure 14. Ex-chairman Jill Mantle.
Figure 15. Linda Furness, health advisor.
and effectively, and was able to suggest realistic
options when posed with problems such as keeping
the overall cost below £300 and how to use
58
other accommodation to achieve this, giving
delegates an option to stay at cheaper hotels.
Analysis of the evaluation forms (only 54 of the
78 delegates attending filled in the form) showed
that 46% did stay at the Copthorne, and 44% of
these were self-funding.
Sponsorship through trade stands proved very
difficult to achieve. It may be that the cost to the
companies was too high in relation to the
number of delegates attending, and this issue
needs to be addressed by future Conference
organizing committees (92% of the delegates
appreciated the trade stands and bookshop).
Delegates may not realize the importance of
the trade stands, which provide a vital source of
income that enables us to balance the books. The
bookshop donated 10% of its takings.
Finally, 67% of delegates completed the evaluation
forms. Ninety-six per cent rated the
Conference above 4, with 81% giving it 6 out
of 6, so we can call Conference 2006 a success
overall.
Carole Broad
Chair of Conference organizing committee 2006
(retired!)
Report from the winner of the Margie Polden
Award 2006
Earlier this year, I applied to the Margie Polden
Memorial Fund for a place at the ACPWH
Annual Conference in Cardiff. In doing so, I
expressed both my passion for women’s health
physiotherapy, and my long-term goal to be part
of a team that raises awareness of the many
women’s health issues and decreases the chance
of women suffering in silence.
Thanks to Margie Polden’s family funding my
place and the ACPWH awarding it, I was able to
attend the Conference. It could not have come at
a better time. I graduated from Cardiff in July
2006 and have been applying for jobs since then,
with no luck to date.
The Conference was a tonic: inspirational,
enchanting, and full of fascinating topics that I
could not wait to share with friends, colleagues
and future patients.
Throughout the 3 days, I met so many wonderful,
like-minded women’s health physiotherapists
from a broad range of organizations.
They were full of positive advice and support
with regard to my current situation, and
all encouraged my love of women’s health
physiotherapy.
2007 Association of Chartered Physiotherapists in Women’s Health

I was never lucky enough to meet Margie
Polden, but after attending the Conference, I
now have seen the impact that she has had on
both individuals and the development women’s
health. Those I spoke to who knew Margie
showed me by their actions that she is a muchloved
legend and is greatly missed. They told me
that she educated numerous physiotherapists
and professionals, and was renowned for inspiring
student physiotherapists. How lucky I felt to
know that I am one of them.
There were 13 guest speakers over the 3 days,
all of whom had the audience captivated and
inspired. How refreshing it was to hear such
serious and worthwhile topics explained in such
simple and effective ways, often laced with
humour, touching every person in the room,
since we all know someone for whom this information
would be of great help.
The conference had over 100 attendees,
including junior physiotherapists, lecturers and
members of the ACPWH executive committee.
The gala dinner, breakfasts, lunches and breaks
were excellent opportunities to meet with, and
finally put faces to, well-known names in
women’s health.
In the present climate, when CPD is so
important, I was surprised to hear about the
financial implications that may affect the frequency
of future Conferences and the levels of
attendance. To me, this weekend was priceless
because it encouraged physiotherapists to think
outside the box, embrace new concepts and let
go of old myths. It gives us the opportunity to
meet the living legends in women’s health, and to
learn about their own heroines, from whom we
are still benefiting today.
Michelle Gormley
Vagina monologue from a ‘Conference virgin’
The Annual Conference was greatly anticipated
at Saint Mary’s Hospital, Manchester, with
much talk of gin and tonics, and gala dinners!
Fortunately, I was able to sit comfortably in my
chair this time round – in contrast to the other
ACPWH courses I’ve attended this year, where
I’ve had to ‘de-robe’ for the benefit of practical
learning!
The highlight of the Conference, not counting
the hotel breakfast, was the Margie Polden
Memorial Lecture by the absolutely amazing
Mary Cronk. She spoke from a midwife’s
perspective about issues of significance to
women’s health physiotherapists, including sym-
Conference and course reports
physis pubis dysfunction (SPD), and the unnecessarily
high incidence of Caesarean sections
for breech presentation. As I rushed onto the
maternity wards on the Monday morning after
Conference, there were ‘ahs’ amongst the midwives
as I spoke of the lecture – Mary’s a true
heroine.
The other lecture that particularly sticks in my
mind is ‘The perils of the perimenopause’ by
Dr Annie Evans (see pp. 27–32). She spoke so
confidently about hormones, dispelling many
common myths, and it was clear that most
knowledge had been gained as a direct result
of listening carefully to and caring for women
for many years. I remember dashing up to my
room before dinner and phoning my mother,
saying, ‘Mum, you really must get some of
these oestrogen patches!’ – clearly, the answer to
absolutely everything!
Conference, in a word, was fantastic. I learned
a tremendous amount and it was great being
among. like-minded people. As a Conference
virgin, I was made to feel so welcome – I made
lots of contacts with colleagues from across the
country and I’m looking forward to seeing you
all again next year!
Master Class in Advanced
Urogynaecology
Hannah Gray
Royal College of Surgeons, London,
2 October 2006
The Advanced Urogynaecology Master Class
was constructed as a joint national project with
the British Society of Urogynaecology, the
Association for Continence Advice, the International
Continence Society and the Continence
Foundation. Twelve patient case studies were
presented and discussed by a panel of six experts,
including Mr Julian Shah (urology), Mr Dudley
Robinson (urogynaecology), Mr Robert Freeman
(urogynaecology), Ms Pauline Walsh (physiotherapy),
Professor Mike Kirby (primary care
and general practice) and Mr Ray Addison
(specialist nurse). Professor Linda Cardozo
(urogynaecology) acted as chairman to facilitate
proceedings.
The whole day was a highly interactive exercise,
and a wide range of difficult, unusual and
problematic clinical cases were discussed in the
light of the latest research. Mr Julian Shah
played devil’s advocate, provoking great
2007 Association of Chartered Physiotherapists in Women’s Health 59

Conference and course reports
responses from a very spontaneous audience,
with excellent multidisciplinary input that challenged
delegates to think laterally and beyond
the scope of their own specialty. There were 60
delegates in all, and physiotherapy was well
represented by Pauline Walsh, Eva Johnston,
Victoria Muir, Ros Thomas, Riëtte Vosloo and
Shernaz Screwvala.
Case studies were presented with history and
characteristics, followed by a discussion of investigations
and treatment options by the expert
panel, with participation from the audience.
Consensus was sought on optimal clinical
strategy. It was very interesting to hear the
differences of opinion regarding appropriate
investigations, surgical options and catheterization
between members on the expert panel as
well as delegates. However, the patient’s best
interest was always the highest priority in all
considerations. The importance of making a
diagnosis instead of treating a symptomcomplex
was highlighted throughout the day, as
was careful consideration of surgery in the view
of complications.
Multiple sclerosis (MS) proved to be a very
interesting topic of discussion, since it is often
picked up in urodynamics clinics long before the
patient presents with other neurological symptoms.
The use of suprapubic catheters versus
clean intermittent self-catheterization (CISC), as
well as the high cost of single-use catheters for
CISC, and the need for it to be single use only,
were valid points of discussion. The National
Institute for Health and Clinical Excellence
guideline statement that cranberry juice should
never be recommended to patients who suffer
from MS also came into question. This recommendation
is based solely on the lack of evidence
to support the potential benefit of cranberry
juice in the prevention of urinary tract infections
in this specific patient group.
The pros and cons of tension-free vaginal tape
(TVT) versus colposuspension and TVT versus
transobturator tape were discussed in different
case scenarios. The preferred use of autologous
sling procedures in very young women (14–21
years) with stress urinary incontinence was
very interesting. There were also differences in
opinion about whether Caesarean section would
be more protective than vaginal delivery following
continence (or prolapse) surgery or not.
The use of botox for detrusor overactivity is
still very much experimental at this stage, and
should be explained as such to patients, together
with the relatively high risk of the need for
60
CISC after injections. The effect of botox is not
permanent, but wears off within 4–8 months
on average, and according to the literature,
botox should not repeated more than seven
times.
A case study that was of particular interest
was a male patient who presented with bladder
symptoms following spinal manipulation for
back and hip pain. This highlighted the
musculoskeletal aspect that is often neglected
in the assessment of incontinence, raising concerns
about the use of spinal manipulation,
and its potential effect on bladder and bowel
function.
Another area of concern was the policy for the
use of indwelling Foley catheters during vaginal
delivery. It is not uncommon for a catheter to
come out during delivery with the balloon still
inflated, as happened in one specific case study
presented. It would be very difficult to determine
whether urinary incontinence after delivery was
the result of urethral sphincter damage caused
by the balloon coming out inflated, or whether it
was related to the size of the baby, long second
stage of labour, pudendal nerve neuropathy
or pelvic floor damage. However, the question
remained: should nursing protocols regarding
this issue be reviewed? Can an inflated catheter
balloon cause real damage to the urethral
sphincter? Should midwives or nursing staff
be expected to do regular intermittent selfcatheterization
to prevent over-distension of the
bladder when they hardly have time to monitor
the mother and baby’s vital signs? Does the risk
of over-distension because of a lack of care
outweigh the potential risk of an inflated balloon
coming out during delivery? Should the balloon
be deflated when the woman enters the second
stage of delivery?
Finally, no consensus was reached regarding
the use of hormone replacement therapy (HRT)
to treat urogenital atrophy and its effect on
incontinence or irritative symptoms. Current evidence
indicates that HRT may have a negative
effect on urinary incontinence, and the Cochrane
Incontinence Group meta-analysis (Moehrer
et al. 2003) was the only study that showed
greater improvement of symptoms in the oestrogen
group than in the placebo group. The overall
impression was that the prescribing of topical
oestrogen (with or without systemic HRT)
should be maintained to treat urogenital atrophy,
specifically if patients have overactive bladder
symptoms, but that more research into topical
treatments is needed.
2007 Association of Chartered Physiotherapists in Women’s Health

As a physiotherapist, I found the master class
session most interesting and learned a great
deal from the different case studies discussed. It
gave me a much broader perspective on patient
management, and highlighted the importance
of multidisciplinary input and interdisciplinary
communication. It is about the whole package!
Physiotherapy, specifically pelvic floor muscle
training, was well supported, but also questioned,
by members of the expert panel as well as
the audience, but Pauline Walsh represented us
well. Provided that patients take responsibility
for their improvement, are compliant with treatment
and adhere to a regular exercise routine,
physiotherapy could help to improve their quality
of life, and may even help to avoid, or at least
postpone, surgery.
I would recommend such a master class to all
physiotherapists with an interest in women’s
health.
Reference
Riette Vosloo
Moehrer B., Hextall A. & Jackson S. (2003) Oestrogens for
urinary incontinence in women (Cochrane review). In:
Cochrane Database of Systematic Reviews, Issue 2. Art.
No.: CD001405. DOI: 10.1002/14651858.CD001405.
An Introduction to Pilates in
Women’s Health Physiotherapy
Bournemouth Hospital, Bournemouth,
11–12 November 2006
The pilot of this ACPWH workshop proved to
be an excellent course that all the participants
seemed to thoroughly enjoy. It was the perfect
mix of theory and practice, with updates on all
the latest research. We were made to use our
Figure 17. Pilates class at the ACPWH pilot workshop.
Conference and course reports
brains and do short presentations, but with
absolutely no pressure or fear of ‘getting it
wrong’. Here is a photo (Fig. 17) – weren’t we
having fun!
Gail Stephens and Amanda Savage are great
tutors, and we were lucky enough to have the
other two tutors present, along with assessors
Judith Lee and Diane Stark, and workshop
coordinator Ruth Hawkes.
I would thoroughly recommend this course,
not just as an introduction, but as an update for
those with previous experience of Pilates.
I hope that the ACPWH will grant approval
for the workshop and it will be running in
2007. Please contact Ruth Hawkes for
details.
Ann Dennis
Solent Group area representative
The Unique Role of the Women’s
Health Physiotherapist in
Antenatal Classes
Chorley and South Ribble District General
Hospital, Chorley, 2–3 December 2006
The first weekend in December was dedicated to
the long-awaited and eagerly anticipated pilot of
the ACPWH antenatal workshop, the overall
aim of which was to evaluate the unique role of
the women’s health physiotherapist in antenatal
classes. The 21 enthusiastic delegates who congregated
in the physiotherapy department of
Chorley and South Ribble District General
Hospital – an excellent venue for any course –
were met each morning by the wonderful aroma
of steaming hot coffee and delicious Danish
pastries! Our grateful thanks are extended to
the excellent organizational skills of Michelle
Horridge!
The friendly and helpful course tutors, Judith
Lee and Maggi Saunders, professionally delivered
a tightly packed 2-day programme that
provided a good mixture of evidence-based
theoretical and practical sessions. These included
the anatomical and physiological changes
associated with pregnancy, the complications
and discomforts of pregnancy, and safe core
stability exercises. Day 2 comprehensively covered
the stages of labour, along with coping
skills physiotherapists can teach women and
their birthing partners. These skills included
positions for labour, relaxation and massage
techniques – wonderful!
2007 Association of Chartered Physiotherapists in Women’s Health 61

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

Prior to attending the day, I was sent an
excellent information pack outlining the aims
and objectives of the course, the day’s timetable,
and a reference list of two essential books to
read. It looked a full and daunting day. How
much of the biomechanics was I supposed to
understand prior to attending? It would have
been easier for me to have a specific outline
about how much to read. In the end, this was not
something I needed to worry about!
The day consisted of an informal lecturebased
introduction, and teaching of form and
force closure, and the impact of muscles and
gait on the joints. It included pregnancy-related
musculoskeletal changes, terms, incidence and
classifications of the different types of SPD and
SIJ dysfunction, and management of these conditions.
It was nice to relearn and clarify some
basic knowledge about the joints and relate this
to new findings and evidence from Yvonne’s
research. The environment was relaxed and
open, and it was good to talk to people in the
group with varied skill mixes and experience.
The practical learning was very informative
and well structured, giving each individual a
Conference and course reports
chance to assess and practise treatment techniques
on each other in small groups. The time
seemed to fly by too quickly to allow me to
remember all the techniques, and I was tired by
the end of the session. There was a huge amount
of information to cover in one go – this would
definitely be a course I would like to complete
over 2 days if I had a choice.
The outcome of the day made me challenge
and question my practice with regard to the
emphasis put on the transversus abdominis when
treating divarication, at the expense of the
importance of the obliques and rectus abdominis
function. I also newly learned about the altered
influence of the gluteal and adductor muscles on
the pregnant pelvis in relation to SPD.
Thanks to this study day, I feel more confident
in my ability to assess and treat manually those
patients with pregnancy-related musculoskeletal
pain. I look forward to reading Yvonne’s
research to further consolidate my understanding
of her assessment and treatment choices.
Alison Crocker
2007 Association of Chartered Physiotherapists in Women’s Health 63

Journal of the Association of Chartered Physiotherapists in Women’s Health, Spring 2007, 100, 64–71
From your executive
Chairman’s report
Having just returned home from a great Conference
in Cardiff, I should like to begin by thanking
the Cardiff team, led by Carole Broad, for
organizing the event. They have had the unenviable
task of trying to attract delegates who
have little or no funding, but I hope those who
managed to attend both enjoyed it and learned a
lot.
Those of you who were at Conference in 2005
will remember that we periodically have to
undergo the reaccreditation process to be recognized
as a clinical interest group (CIG) by the
Chartered Society of Physiotherapy (CSP). This
process requires us to be seen to fulfil five criteria
over a 5-year period. At Cardiff, I explained
briefly how we have continued to fulfil those
criteria.
Category 1: Continuing professional
development
Demand is high for the urinary incontinence
and anorectal workshops, and we are now developing
a treatment workshop to include both
conditions.
The Pilates and antenatal workshops will be
piloted in November and December 2006,
respectively. If you are unable to access a course,
or wish to organize one, please contact Ruth
Hawkes, who is both the area representative
coordinator and the workshop coordinator (see
inside front cover).
Our postgraduate courses continue to be
popular. Achieving success in one of them continues
to be the main way of gaining membership
to the ACPWH, and three candidates received
their certificates at the gala dinner.
Category 2: Influencing and informing
Ruth Hawkes and I had a useful meeting with
most of the area representatives in June 2006,
and the task of disseminating information to all
members nationwide is becoming easier and
more efficient. I am delighted that 14 out of 16
areas of the UK are represented. With the retirement
of Ann Johnson, Yorkshire is looking for a
new area representative and Amanda Savage is
looking for replacement in Cambridge. Thank
you Ann and Amanda for all you have done.
64
Giving and receiving awards is always a good
way to gain attention for the ACPWH. At
Conference, the Margie Polden Student Award
was presented to Michelle Gormley, who, coincidentally,
has just graduated from Cardiff. I
hope this Conference has inspired her to continue
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 to
provide some familiarization for some delegates.
Our website continues, although it remains to
be seen how it will evolve alongside iCSP. The
executive committee will monitor its use. Please
continue to place your adverts on it for courses
and study days.
Many of us continue to work with other,
‘outside physiotherapy’ organizations. Recently,
we were approached by the Royal College of
Obstetricians and Gynaecologists to peer review
a new document on the assessment, surgery and
treatment of third- and fourth-degree anal tears
in childbirth.
Gill Brook continues to act as the treasurer
of the International Organization of Physical
Therapists in Women’s Health (IOPTWH),
and next year, we both hope to represent the
ACPWH at the World Confederation for Physical
Therapy conference in Vancouver, Canada.
Two representatives will be attending the
CIGs’ conference in November. Representatives
from each CIG are eligible to go, and it is usually
a rewarding weekend. The Annual Representative
Conference (ARC) was cancelled in 2006,
but our motion will be reconsidered for inclusion
in 2007 and I have a team of keen people ready
to attend on our behalf.
These two conferences are open to any of you,
so please contact the honorary secretary if you
are interested.
Category 3: Promoting physiotherapy
With more members than ever and, therefore,
more voices raising awareness about what we do,
women’s health issues are becoming generally
more talked about. You will read in public
relations officer Ann Mayne’s report below that
we are continually bombarded by requests for
comments on various aspects of women’s health
2007 Association of Chartered Physiotherapists in Women’s Health

for inclusion in newspapers, magazines and
radio programmes. We do our best to respond to
as many of these requests as possible, but the
report is often required almost immediately and
it is very difficult for many of us to find time in
the middle of a working day.
A group of us went for media training in
London, and the guidance we produced is
available from your area representatives or the
website.
Some of you will know that Fit for Motherhood
has been reviewed and replaces the original
version. The Pregnancy-Related Pelvic Girdle
Pain leaflets, one for health professionals and
one for patients, are scheduled to be printed by
the end of 2006. These replace the old symphysis
pubis dysfunction (SPD) leaflet, which has not
been available for some time. We are hoping to
get the production and printing of our patient
leaflet sponsored so that it will be free, but in
these cash-strapped times, we can only wait and
see. All our leaflets sell well, and again, raise the
public face of the ACPWH in what I hope is a
positive and professional manner. Once the new
publications are all in stock, we will begin the
review of our other leaflets. These have remained
at the same price since we started with Fit for
Motherhood in 2000. Since the postage and
packaging rates changed radically last month,
Ralph Allen Press are revising their entire costings
so please refer to the ACPWH website and
the back page of the Journal before making
an order. Tidy’s Physiotherapy has also been
reviewed this year, and many ACPWH members
have contributed to part of a chapter or written
a whole one.
Category 4: Quality assurance
The education subcommittee (ESC) handles so
many of the tasks that take time to achieve.
Currently, it is updating and reviewing many of
our documents. My thanks to the committee
members for all their hard work.
By monitoring articles in the press, and by
being selective about who we speak and give
interviews to, it is possible to maintain quality
assurance and high standards of reporting.
The Journal continues to go from strength to
strength and could probably be included in each
of the categories I’ve mentioned. The standard is
ever higher, so my thanks to Gill Brook for
coordinating her team so efficiently.
Diversity issues are few in number, but it is
good to know that we have a trained individual
on the executive to manage any that might arise.
From your executive
Category 5: Research and clinical
effectiveness
Work continues to evolve the role of the research
officer both in terms of facilitating research and
advising on clinical governance issues (see p. 68).
Believe it or not, we are still attempting to
produce guidance for electrotherapy during
pregnancy and labour. It is an ongoing project,
but rest assured, the executive and the ESC will
not be giving up until it is resolved.
We have been massively involved with the
National Institute for Health and Clinical Excellence
this year. Work continues with the urinary
incontinence and the faecal incontinence guidelines.
We have been consulted recently on the
antenatal guideline review and the antenatal
mental health guidelines. Our comments on the
intrapartum guidelines were not accepted.
If anyone is interested in being more involved
in key areas of the ACPWH, such as with the
Journal, archives, CIG conference, ARC, joining
the executive or belonging to non-committee
groups for small tasks that come up from time
to time, then please speak to me or one of the
executive committee – we really would love to
hear from you.
As always, I would like to acknowledge the
hard work done by many people. They are
the members of the executive, the members of
the ESC, the members of the Journal subcommittee
and the area representatives, who all give
a great deal of time and commitment to the
ACPWH. I cannot name you all, but you know
who you are.
So, as I come to the end of my 3 years as
chairman, I reflect on the achievements and
experiences we have had during my term of
office. I am sure it is every departing chairman’s
wish to pass on an Association that better meets
the needs of not only its members, but also its
wider stakeholders – patients, other health professionals
and, indeed, the general public. This
would be a wonderful legacy for me. One of my
personal aims was to involve more of the
younger members and I am delighted that four
have been nominated this year for election to the
committee. This is a tremendous start and I very
much I hope the trend will be continued. I have
recently worked hard to appoint an administrator
to provide help and support by tackling some
of the routine day-to-day activity, leaving the
executive to concentrate on what it was elected
to do. I hope this will make a tremendous
difference to us all and you will be updated
regularly during the probationary period.
2007 Association of Chartered Physiotherapists in Women’s Health 65

From your executive
We have five members leaving the executive
this year.
First, Sue Brook, who has, during her 6 years
of service, been willing, reliable and always
cheerful, even when tasked with being the minutes
secretary.
Secondly, Trish Evans, who has served for
4 years, most recently as book and leaflet
secretary.
Thirdly, Alex Welman, who also served on the
executive committee for 6 years, and latterly, has
taken on the enormous task of membership
secretary. During this time, she has also sat on
the ESC, and has been a reliable and helpful
member, contributing an enormous amount.
Fourthly, Rachel Grubb was appointed as
secretary soon after joining the executive and
then became treasurer 2 years ago. Although this
is not a popular job with anyone, she has tackled
it cheerfully and effectively. Rachel has been
level-headed and sensible throughout, and
always quick to respond to important issues.
Both Alex and Rachel will be leaving their posts
when the new administrator has got to grips with
them.
And last, but very much not least, Gill Brook,
who has been part of the ACPWH for 12 years.
She has held the honorary posts of secretary,
book and leaflet secretary and chairman, and is
now retiring as Journal editor. She continues as
treasurer to IOPTWH. We owe her an enormous
debt of gratitude for all she has done for the
Association. She has led us admirably and is the
most laid-back person I know, happily taking
the ‘p’ out of panic for me on many an occasion.
I thank all five of them for their massive
contributions and support; they will all be sorely
missed.
Your next chairman, Pauline Walsh, was
elected at Conference 2006 in Cardiff and I
formally handed over the chains of office at the
gala dinner. I know Pauline will make a splendid
chairman and I wish her every success leading
the ACPWH onwards for the next 3 years.
I have found my 3 years at the helm of the
Association challenging and enjoyable, both
frustrating and rewarding, but most of all, it has
simply been a pleasure to work with and for
so many lovely people, many of whom have
become firm friends. I am looking forward to the
next challenge of Journal editorship and hope I
can continue the good work which Gill has
implemented so well.
66
Ros Thomas
Treasurer’s report
This will, I hope, be my final report as treasurer.
As I outlined to those of you who were at
Conference 2006 in Cardiff, our association
continues to grow, and with it, the workload of
committee members. This is a concern not only
to the ACPWH, but also to other CIGs. For this
reason, the executive committee has decided to
pilot the use of paid administrative help; indeed,
by the time you read this, it may be under way.
The cost of this pilot will be met from existing
funds and will be reviewed at the end of one
year. The membership will be kept informed via
the website and mailings, and of course, will be
given notice if this is likely to have an impact on
annual subscriptions.
Association funds remain reasonably healthy.
Our income and expenditure are largely the same
from year to year, and I am confident that
ACPWH funds can sustain the cost of administrative
support in the short term. I am equally
sure that this will be a very positive change for
the association that will be of benefit to the
members.
Rachel Grubb
Membership secretary’s report
Total membership stands at 722 as of 1 October
2006 (Table 1).
As I write this, I am in the process of handing
over to Blair King at Fitwise Management Ltd.
I have thoroughly enjoyed my time as your
membership secretary and the time I have spent
working for the ACPWH. I have particularly
relished welcoming new members into the
Association, and in the 3 years that I have been
your membership secretary, this has amounted
to over 200 new members! I have also thoroughly
enjoyed helping members of the public
find a specialist women’s health physiotherapist
in their local area.
Table 1. Membership of the ACPWH as of 1 October 2005
Membership type Number
Full 316
Affiliate 298
Associate 55
Honorary 6
Retired 47
Total 722
2007 Association of Chartered Physiotherapists in Women’s Health

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

From your executive
There have been 15 successful candidates on
the University of Bradford continence course
this year. We offer them all our heartiest congratulations
and look forward to seeing more of
them in the future.
Jeanette Haslam
Research officer’s report
Earlier this year, I attended a research officers’
study day at the CSP, and information from that
day is reported separately (see pp. 52–53). However,
there was much publicity about the launch
of the National Physiotherapy Research Network
(NPRN). There are now 20 regional
research hubs in the UK and Ireland, and I
attended a meeting of the South East hub, partly
in my capacity as the research officer for the
ACPWH, but also as a clinical physiotherapist
with an interest in research. The meeting was
at the University of Brighton (Eastbourne),
and participants came from both the academic
and clinical sectors. The content of the evening
largely consisted of group discussion about the
way forward for the hub, as well as discussion
regarding the scope and problems of clinical
research. The CSP members at the meeting were
enthusiastic about the way that research could
be undertaken in a clinical setting. It was recognized
that academic support may be necessary,
and the Physiotherapy Department at the
University of Brighton is keen to be involved
with clinicians.
The South East hub is an active organization
and meetings are arranged every 3–4 months.
These regional meetings are open to all CSP
members who have an interest in research – you
do not have to be involved in active research to
attend. I found the meeting to be very supportive
of clinicians who had had very little experience
of research.
If you wish to know more about your local
research hub or the NPRN, you can access
information via the CSP website or contact Dr Philippa Lyon, NPRN
Research Officer at .
I have continued to lead the production
of two evidence-based, peer-reviewed, multiprofessional
leaflets on pregnancy-related pelvic
girdle pain (PGP) (encompassing both symphysis
pubis and sacroiliac dysfunction). One leaflet
is aimed at health professionals involved with
ante- and postnatal care (including physiothera-
68
pists, midwives, health visitors, general practitioners
and obstetricians), and the other is
aimed at women who have experienced PGP.
These leaflets are in their final review stages and
we hope to have them printed by the New Year.
I have continued to support the ESC and we
are meeting TENS experts in October to review
our current policy on TENS in pregnancy.
I have received many queries from members
and non-members about various issues relating
to research, and this makes for some interesting
discussion. However, for general discussion
about matters relating to women’s health, iCSP
is a good resource and I would encourage those
members who would like to explore wider issues
to sign up! The process is easy – just access the
CSP website and follow the instructions.
For 2007, I am concentrating on developing
the role of the research officer, and shall be
particularly exploring issues around research
bursaries, development of a research page on our
website and gaining information on current
research activity from members.
New executive committee
members
Yvonne Coldron
Becky Aston
After qualifying as a physiotherapist from the
University of East London (UEL) in 1997, I
embarked on a junior rotational programme at
the Royal Free Hospital in London. It was
during this period that I was lucky enough to be
given the opportunity to attend a 3-day course
entitled ‘An introduction to women’s health’,
and followed this with a 4-month women’s
health placement. Since then, I have specialized
in women’s health, moving to St George’s
Hospital in London, where I completed the
Bradford course and became a full member of
the ACPWH. I moved to the Homerton
Hospital in East London in 2002 as a senior I
physiotherapist, and then a clinical specialist. I
have recently returned to work after maternity
leave and embarked on a 2-year research fellow
post, investigating different aspects of pelvic
floor dysfunction and service design models.
I have been a member of the Association since
1999 and a full member since 2001. In 2001, I
joined the ACPWH Journal subcommittee and
have been an active member, responsible for the
‘Papers in other journals’ section (see pp. 97–
103). Furthermore, I have lectured on women’s
2007 Association of Chartered Physiotherapists in Women’s Health

health issues at an undergraduate level at UEL
since 2003. I feel that it is important to contribute
to an Association which supports us as
members in our clinical work. I hope to bring
enthusiasm and motivation to the ACPWH
executive.
Becky Aston
Katie Mann
Like many of us, pelvic floor physiotherapy fell
upon me by accident, having followed my basic
postgraduate experience in the usual way (Fig.
1). I qualified from Salford in 1989 and joined
Southport District General Hospital. A ‘return
to work’ course in Exeter after the birth of
my son reintroduced me to the pelvic floor. I
then went on to complete the first ACPWH
continence course in 1996.
After several years developing the Physiotherapy
Pelvic Floor Clinic, I am now clinical
specialist at Southport and Ormskirk Hospitals,
with some private work at the local Capio
hospital.
I currently treat men and women with pelvic
floor dysfunction, and work closely with the
urogynaecologists and nurse specialists of our
trust. I am a clinical supervisor and regional
group mentor for the ACPWH course, and have
been involved in research with Jo Laycock. I am
an active participant in the Mersey region, implementing
the government’s Integrated Continence
Figure 1. Katie Mann.
From your executive
Services White Paper. I teach postgraduate nurses
at Edge Hill College and undergraduate midwives
at Aintree Hospital, and I am often asked to give
talks at various courses and meetings.
I look forward to the challenge of being a
member of the executive committee of the
ACPWH. I can offer 13 years of experience
working in the field of pelvic floor dysfunction. I
wish to actively promote the role of physiotherapy
in this area and support the work of the
Association in continually developing national
quality standards.
Katie Mann
Lesley Southon
I have spent many years working in musculoskeletal
departments both in England, Scotland
and Norway. I started dealing with continence
patients about 6 or 7 years ago in a part-time
capacity as part of my musculoskeletal caseload,
and then about 4 years ago, I was fortunate
enough to transfer to work in the Kingfisher
Clinic in Norwich, which is a multidisciplinary
continence clinic, our core team comprising of
physiotherapists and nurses.
I completed the UEL’s graduate continence
course in 2004 and have acted as a mentor this
year for the new Bradford continence course. I
have just written a chapter for the second edition
of Therapeutic Management of Incontinence and
Pelvic Pain edited by J. Laycock & J. Haslam,
which is scheduled to be published this year,
entitled ‘The athletic woman/women and exercise’,
based on my group’s presentation during
the UEL course. I am presently involved in
a research project with a medical student from
the University of East Anglia’s medical school.
This will look at various aspects of the patient’s
journey and care whilst treated in our clinic.
I was keen to stand for the ACPWH executive
committee because I would like to become more
involved in the continuing development of the
Association. I foresee that it will be challenging,
but think that the role for the ACPWH is
ever-increasing and it is an exciting time to be
involved.
I believe that any membership group is only as
good as its members and that everyone has a
responsibility to input into that group in some
way. I hope that I will be able to be involved
particularly with the aspects of integrated continence
care that are constantly evolving in many
different ways throughout the country.
Lesley Southon
2007 Association of Chartered Physiotherapists in Women’s Health 69

From your executive
Figure 2. Gail Stephens.
Gail Stephens
I am a physiotherapist, working in both primary
care and the private sector, who specializes in
men and women with continence problems, and
also pelvic girdle pain (Fig. 2).
I qualified from Keele University in 1999,
and worked at Addenbrooke’s Hospital in
Cambridge, becoming more interested in
women’s health before relishing the opportunity
to work within primary care in the Continence
Service as the sole physiotherapist in 2003. I
work closely with continence advisors running
joint clinics across Cambridgeshire whilst constantly
striving to improve the service offered to
patients within primary care.
I am actively involved in audit and research,
and I am a tutor on the ‘Introduction to Pilates
in women’s health’ ACPWH workshop. I am
regularly asked to teach and lecture at local and
regional events, and have published articles in
national journals as well as local publications. I
completed the UEL continence course in 2004.
I firmly believe in a good work/life balance,
since this is fundamental to performing
efficiently and effectively at work and play. So,
when I am not a physiotherapist, I am a Brownie
and Guide Guider. Through Girlguiding UK, I
have been involved in promoting sexual health
through PFMEs, and bladder and bowel health.
I strongly believe that organizations such as
Girlguiding UK and the ACPWH should be
70
forward-thinking, and adapt to a progressive
National Health Service and changing society.
Gail Stephens
Fitwise Management Ltd
Since Conference 2006 in Cardiff, we have made
great progress in acquiring administrative assistance
for the executive committee. We have decided
to pilot using the services of Fitwise
Management Ltd, which is based near Edinburgh
(Fig. 3). Fitwise already manages our conference
for us, and its involvement with ACPWH has
now been extended to include management of
the membership database, our finance and
accounts, and distribution of our stock of books
and leaflets.
Some of you will be familiar with Blair King,
one of the directors, who attended the Cardiff
conference with Lynn Ward. Sandra Rees is our
new financial manager and Gillian Reid manages
the membership database. Details of how to
contact Fitwise are given on the inside front
cover.
We are doing our best to ensure a smooth
handover to Fitwise, and the benefits to the executive’s
workload are already becoming obvious.
We will continue to have nominal posts for the
specific roles of treasurer (Doreen McClurg),
and book and leaflet secretary (Clair Jones). If
you have any concerns during the handover
Figure 3. Ros Thomas on a flying visit before
Christmas to the Bathgate headquarters of the
Fitwise Management team. Back row, left to right:
Stacy Martin (ACPWH conference administrator),
Ros Thomas, John Matthews (director), Lynn Ward
(general administration) and Blair King (director).
Front row, left to right: Gillian Reid (ACPWH membership
database), Sandra Rees (ACPWH accounts
and finance), Anne Ross (sales of trade exhibition
space) and Lynne Martin (general administration).
2007 Association of Chartered Physiotherapists in Women’s Health

period, please contact Doreen or Clair, or for
general concerns, contact the secretary, Julia
Bray, so that we can deal with issues as they
arise.
There will be another update on the success of
the enterprise in the Autumn 2007 Journal and
From your executive
at Conference. ACPWH funds will cover the
administrative costs for the coming year and the
executive will look carefully at any impact on
subscription levels in the future.
Pauline Walsh & Ros Thomas
2007 Association of Chartered Physiotherapists in Women’s Health 71

Journal of the Association of Chartered Physiotherapists in Women’s Health, Spring 2007, 100, 72–74
Round the regions
Channel islands
The audit on ‘Assessing outcomes of urinary
incontinence treatment using the International
Consultation on Incontinence Questionnaire –
Urinary Incontinence Short Form’ is published
in this issue of the Journal (pp. 42–48)! The
recommendations have been implemented and
re-audit is scheduled for the middle of 2007.
The next audit on the agenda is the Chartered
Society of Physiotherapy Standards, and we are
planning to do this across women’s health.
Our obstetric service review is still on the
boil – these things always seem to take longer
than first thought – and we will soon be training
the first line of midwifery care assistants to
deliver one-to-one pelvic floor advice to new
mums who are at low to medium risk according
to the PromoCon Pelvic Floor Risk Assessment
Tool. This should free up some time to spend
with high-risk women and antenatal care.
Clare Jouanny
Area representative
E-mail: jouanny@localdial.com
London
In April 2006, Elizabeth Emerson and Linda
Boston delivered a talk on ‘Incontinence in the
athletic woman’ on behalf of the East England
group. This presentation was part of their
Graduate Certificate in Professional Development
in Health Continence at the University
of East London. It was a fascinating review of
the literature on incontinence in the elite athlete
that revealed a high level of urinary and faecal
incontinence. Urinary incontinence is prevalent
in gymnasts and athletes, a possible cause being
a predominance of type 3 collagen in the connective
tissue, resulting in a hypermobile urethra.
Low oestrogen levels, combined with increased
type 3 collagen fibres, and the repeated physical
forces generated by repetitive jumping, long
jump, running, gymnastics and trampolining, are
conducive to urinary incontinence, trampolining
producing the greatest incidence of urinary
incontinence in girls aged 15 years. Faecal incontinence
in long distance runners is not
uncommon (30–60%). With her reasoning skills
and knowledge of physiology, the women’s
72
health physiotherapist is well placed to assist
athletes to optimize the muscular aspect of the
continence mechanism, and take part in health
promotion activities with athletics coaches
and fitness instructors. This was an excellent
evening.
In June, we hosted a study day at Hammersmith
Hospital on ‘The perinatal pelvic girdle:
a functional approach to assessment and treatment’.
The course tutor was Dr Yvonne
Coldron. She ran an excellent day that gave us
an opportunity to practise our musculoskeletal
skills in order to enable us to examine, manage
and treat pelvic girdle problems in ante- and
postnatal women. We revised the physiological
changes in pregnancy, had the altered biomechanics
of the spine and pelvic girdle
explained to us very clearly, discussed the possible
aetiology of these pains, and were shown
manual techniques and exercises for the pelvic
girdle in pregnancy and following delivery. It
was a lot to absorb in one day, but a muchneeded
course for those of us who see and
treat many patients with symphysis pubis
dysfunction/pelvic girdle pain (SPD/PGP) in
pregnancy. Thank you, Yvonne.
I will be retiring in March 2007, and I am
looking forward to finding a successor who will
continue to provide the London group with
interesting and stimulating study days and workshops,
keeping the Margie Polden thirst for
knowledge in women’s health alive.
Avril Hillyard
Area representative
Email: avrilhillyard@hotmail.com
North East
Over the past year, the north-east group has had
two evening meetings. In November 2005, a
small group attended a very interesting talk by a
midwife on optimal foetal positioning, and the
programmes offered to mums and their families,
at the large regional hospital in Newcastle upon
Tyne. We did not meet again until June, when
the same small group brought journal articles
for discussion. We agreed to try a new format
and held a successful afternoon meeting in
September. Lunch was provided by the Lyrinel
XL representative. We used the session to report
2007 Association of Chartered Physiotherapists in Women’s Health

on Conference 2006 in Cardiff and the London
scientific updates in urogynaecology. We also
viewed the video on erectile dysfunction, postmicturition
dribble and urinary incontinence,
and decided that we would next meet in the New
Year, topics to be arranged. I asked for volunteers
for area representative.
In February 2006, we hosted the ACPWH
anorectal assessment and treatment workshop in
North Tyneside. The enthusiasm of lecturers
Janette Haslam and Julia Herbert was evident,
and the practical session was conducted in a very
sensitive yet helpful manner. The demonstration
of anorectal physiology tests by the consultant
was extremely helpful. The course evaluated very
well and ended with the participants feeling the
need for a further workshop on physiotherapy
treatments for continence problems. Is anyone in
the region interested in hosting this?
Emilie Nesbit
Area representative
E-mail:
Emilie.Nesbit@northumbria-healthcare.nhs.uk
Northern Ireland
We in Northern Ireland are presently undergoing
a period of change.
The consultation on the Review of Public
Administration has looked at reforming the
Health and Personal Social Services structure.
From April 2007, the new structure will be
made up of fewer (i.e. five) trusts, which we hope
will create new opportunities to integrate services
across the existing hospitals in the long
term.
Furthermore, many of us have been working
with our other professional colleagues on introducing
Integrated Clinical Assessment and
Treatment Services to Northern Ireland. Along
with the Agenda for Change, these seem to be
causing us a lot of headaches.
To keep our spirits up, we all met at the end of
September 2006 for a half day to hear a wellpresented,
very informative talk on hormone
replacement therapy and the menopause by Dr
Raymond White. We also planned for the year
ahead. Doreen McClurg was elected as chairperson,
with Caroline Hackney stepping down.
Gail Allen was elected as treasurer, with Paddy
Mullan stepping down. Lorraine Johnston has
agreed to stay on for another year as secretary.
We would like to thank the girls for their help
and to congratulate Doreen on the successful
completion of her doctorate.
Round the regions
Two introductory weekend courses on urinary
incontinence and faecal incontinence are being
run for less-experienced senior staff and juniors
interested in women’s health by the Continuing
Professional Development (CPD) Centre in early
2007.
We also plan to run a study day in March
2007 on overactive bladder. Speakers are currently
being sought.
Thamra Ayton
Area representative
E-mail: mayton@ukonline.co.uk
Scotland
The Scottish branch meeting took place on
26–27 October 2006. Eighteen physiotherapists
attended the weekend and there was a waiting
list to get on the course! All interested members
got places and then we opened it up to outpatients
colleagues. It was lovely to see so many
younger physiotherapists, and we had two new
graduates on their first rotations, which were in
women’s health (we hope they will be future
members). The course even persuaded two colleagues
to travel from the Western Isles to the
mainland, and one member made the 8.30 a.m.
start from Inverness.
The course was run by Helen Thomson, a
physiotherapist in private practice who is
involved in women’s health. She has a downto-earth
approach to outpatients, and with her
wealth of experience, guided us through the
sacroiliac joint, coccyx, lumbar spine, ribs and
diaphragm with her insights into the relationship
between musculoskeletal dysfunction and
continence. Helen gained everyone’s respect by
demonstrating on two pregnant ladies. One of
them said, ‘I think you’re a white witch. I feel
brilliant!’ At the end of the course, I asked
everyone if they would be interested in learning
more and all 18 put their hands up! I take it from
this that we had a successful meeting! I recommend
other members to think of inviting Helen
to talk at your meetings.
Our next meeting will be in the spring and
it will be a day course. The venue and time
have still to be arranged. You must be fed up
of coming to Wishaw, so come on, I need a
volunteer!
I also need someone to think about taking on
the area representative role next year.
Elaine Struthers
Area representative
E-mail: Elaine_struthers@hotmail.com
2007 Association of Chartered Physiotherapists in Women’s Health 73

Round the regions
South East
At the time of writing in October 2006, no
meetings have been held this year so far because
of a lack of response to requests for speakers and
venues (we have had only one reply), and staff
being very overstretched. The next meeting is
planned for November 2006, and will include a
talk from a consultant urologist from Brighton
on bulking injections, feedback from Conference
and arrangements of further meetings.
Five members from the region went to Conference
this year. Romy Tudor received her
membership of the ACPWH following completion
of the University of Bradford Postgraduate
Continence modules.
Our plan for the next 6 months is to get
together in November to find ways of maintaining
interest in regional meetings, and to try to
encourage more input from the whole of the
South East region. Offers of speakers and venues
are very welcome!
Susannah Staples, Debbie Joice, Romy Tudor &
Nadine Ranger
Area representatives
E-mail: Nadine.ranger@wash.nhs.uk
or Susannah.staples@wash.nhs.uk
South Midlands
At our Autumn 2005 meeting, Simon Jackson,
consultant urogynaecologist at the John
Radcliffe Hospital in Oxford, started the earlymorning
session by giving us an overview of
female continence problems and the treatments
available. Simon is very supportive of conservative
therapies and is always happy to help us
with our CPD. The talk was followed by a
demonstration by Mike Morter, representing
Diagnostic Sonar Ltd, in which he showed us
what a real-time ultrasound machine can do,
using himself as a model.
The session was rounded off by Nicole Tudor-
Williams, one of our senior physiotherapists
at the Women’s Centre, who has been very
involved in an SPD/PGP audit currently being
undertaken in Oxfordshire. The results of the
audit were presented, and this was followed by a
practical demonstration of manual techniques
that may be used on women with pelvic ring
pathology in the child-bearing year.
Twenty-one delegates attended and it was
pleasing to see how many physiotherapists are
74
new to the speciality. The only complaint was
that we ran out of time – we could have easily
filled the whole day.
At our next meeting, in May 2006, we listened
to an experienced urogynaecology nurse, Sue
Larner. She explained to us how urodynamic
investigations are carried out and then interpreted
graphs pertaining to various bladder
problems. A review of the anatomy of the
abdominal corset made us put our thinking caps
on, and then we broke up into smaller groups to
discuss the physiotherapeutic management of
weak abdominal musculature in different client
groups. Finally, we had an informal session
discussing when physiotherapy interventions
may not be appropriate.
Linda Boston
Area representative
E-mail: linda2004@btinternet.com
West London
There are various groups in the West London
area, meeting regularly in Wiltshire, Gloucestershire,
Bristol and Ascot. The Wiltshire Group
have recently completed work on a matrix of
priorities for women’s health and continence
work that we developed as a local tool to use
with managers questioning why we are (or are
not) doing certain jobs that might come within
our remit (this is particularly useful where there
is scant evidence). They are also completing a
survey of the benefits of splints for carpal tunnel
syndrome in pregnancy.
At the time of writing, our planned study days
are ‘A functional approach to assessment and
treatment of the pelvic girdle in pregnancy and
postpartum’ with Yvonne Coldron on Saturday
4 November 2006 at the Great Western Hospital,
Swindon (see pp. 62–63), and ‘Physiotherapy
for bone health’, an osteoporosis study day with
Meena Sran on Saturday 1 December 2006 in
Swindon.
We plan to run more local study days or half
days, so please contact me with your suggestions
or if you want to be e-mailed about upcoming
events.
Ruth Vidal
Area representative
E-mail: ruthmvidal@hotmail.com
2007 Association of Chartered Physiotherapists in Women’s Health

Journal of the Association of Chartered Physiotherapists in Women’s Health, Spring 2007, 100, 75–76
Area representatives 2006–2007
In response to requests from members, the following table details the area representatives and how to
contact them. N.B. Some postcodes are shared by more than one representative.
Ruth Hawkes is both the area representative and workshops coordinator. Queries about either should
be addressed to her at Dunston House, Dunston, Lincoln LN4 2ES, or sent by e-mail to
.
Name Contact details Area and postcodes Start date
Thamra Ayton Northern Ireland July 2005
E-mail: mayton@ukonline.co.uk
Linda Boston South Midlands: OX November 2004
Shared: HP, MK, RG
E-mail: linda2004@btinternet.com
Carole Broad Wales October 2004
E-mail: BroadAP@Cardiff.ac.uk
Lynne Coates South West: PL, EX, TA, April 2005
TR, TQ
E-mail: Lynnecoates2004@yahoo.co.uk/
Lynne.Coates@nepct.cornwall.nhs.uk
Ann Dennis Solent: PO, SO, BH, GU, June 2005
DT
E-mail: annpam@btinternet.com
Gillian Hawkins Midlands: B, CV, HR, June 2005
NN, TF, WR, WS, WV,
DY
E-mail: gillian.hawkins@heartofengland.nhs.uk
Avril Hillyard London: UB, WD, EN, August 2004
IG, RM, AL (retires March
Shared: HP, MK 2007)
E-mail: avrilhillyard@hotmail.com
Michelle Horridge Manchester: PR, BL, LA, September 2002
BB, WN, L, WA, SK, M, (looking for
CA replacement)
E-mail: michelle.horridge@cmmc.nhs.uk
2007 Association of Chartered Physiotherapists in Women’s Health 75

Area representatives 2006–2007
Name Contact details Area and postcodes Start date
Clare Jouanny Channel Islands: October 2003
JE, GY (to continue for
further year)
E-mail: jouanny@localdial.com/
c.jouanny@health.gov.je
Emilie Nesbit North East: NE, DH, August 2000
SR, TS, DL (looking for
replacement)
E-mail:
emilie.nesbit@northumbria-healthcare.nhs.uk
Nadine Ranger South East: BN, RH, TN, August 2004
(see Susannah
Staples below
CT, ME
E-mail: nadine.ranger@wash.nhs.uk
Maggie Saunders Trent: NG, S, LN, DN October 2004
Shared: LE, DE
E-mail: maggie.saunders@nhs.net
Susannah Staples South East: BN, RH, TN, Maternity cover
(covering for
Nadine Ranger’s
maternity leave
CT, ME
E-mail: Susannah.staples@wash.nhs.uk
Elaine Struthers Scotland June 2003
E-mail: Elaine_struthers@hotmail.com
Ruth Vidal South: SN, BA, BS, GL November 2004
Shared: RG
E-mail: ruthmvidal@hotmail.com/
Ruth.vidal@smnhst.sweást.nhs.uk
– – East Anglia: CB, NR, Vacant position
CO, SS, PE, CM, SG, IP
– – Leeds: LS, WF, YO, HD, Vacant position
HX, HG, HU, BD
76
2007 Association of Chartered Physiotherapists in Women’s Health

Journal of the Association of Chartered Physiotherapists in Women’s Health, Spring 2007, 100, 77–80
PhD thesis reports
Multiple sclerosis and lower
urinary tract dysfunction
Coincidence? Referrals of a specialist nature
with little evidence to point to effective treatment
and the opportunity to undertake research
within this population: a combination too good
to miss or a nightmare scenario? I will leave you,
the reader, to be the judge.
As a senior physiotherapist working in gynaecology
and urology, referrals had been received
concerning people with multiple sclerosis (MS)
and lower urinary tract dysfunction. However,
there was little evidence as to best practice.
Around the same time, the University of Ulster
had been awarded a substantial grant by the MS
Society of Great Britain and Northern Ireland to
undertake research into the relief of symptoms
within this population, and bladder and/or
bowel dysfunction was one of the proposed
studies. I applied, was accepted and took a
3-year career break.
The first few months were spent reviewing the
literature. This was a time of adjustment: instead
of thinking about patients and hospital life, the
computer seemed to devour my time. At the end
of the day (and many evenings), it was sometimes
difficult to say what you had done and
then it always seemed to be the articles that you
wanted most that had to be ordered. An outline
proposal had already been approved by the
University’s Ethical Committee, so that scenario
was negated; however, amendments were discussed,
discussed again and approved. A pragmatic
pilot study to establish the efficacy of
physiotherapy interventions within such a neurological
population was proposed. Honorary
contracts were established, outcome measures
reviewed and training in urodynamic procedures
undertaken.
Everything was in place, but what about some
patients? Consultant neurologists, MS specialist
nurses, continence advisors and colleagues all
helped with recruitment. Advertisements were
also placed in relevant charity magazines and I
was able to attend the meetings of these
charities – one of the most enjoyable aspects of
the 3 years was the appreciation shown that
someone was taking the time to come and talk
about what is still a taboo subject. Recruitment
went well. There were some disappointments,
but 9 months later, 30 participants had completed
the 9 weeks of treatment, and the 16- and
24-week follow-ups.
Then came the dreaded statistics – a new
language – and the many drafts of the first
paper, culminating in its acceptance for publication,
another milestone. The first and second
seminars were stressful times, but there were
some good laughs with fellow students, and
coffee became an addiction (it could have been
worse). A trip to Vienna, Austria, to present at
an International MS conference was a high – the
thought of the ice cream is making my mouth
water while writing this.
Based on the results of the pilot study, a
double-blind randomized controlled trial (RCT)
was undertaken to further establish the use of
physiotherapy modalities within this population
and to evaluate if the additional benefit that was
demonstrated in those who received electrical
stimulation was real or placebo. Seventy-four
participants were recruited and were seen at 12
centres throughout Northern Ireland. A full year
was devoted to this study, involving many long
hours of travelling and organization. During
this time, I had a car accident – a wooden pallet
fell off an oncoming skip and smashed my
windscreen – but thankfully, I had no serious
injuries. (I also got caught speeding on my way
to an assessment clinic, and the eldest of our four
daughters was married!) Again, one of the most
special things about this study was the opportunity
to meet many lovely people with such
diverse and sometimes severe disabilities. There
were ups and downs, but eventually, all were
recruited; and then, almost unbelievably, all the
assessments were completed. The statistics and
writing up was so much easier the second time
around, but the added pressure of the completion
date was also looming. Submission was a bit
of an anticlimax because it was still difficult to
relax. Then came the viva, an experience not to
be repeated.
Was it all worth it? Would I do it again?
Would I advise allied health professionals to
undertake a PhD? These are all questions that I
have been asked. The answer to all is probably a
2007 Association of Chartered Physiotherapists in Women’s Health 77

PhD thesis reports
yes. It may sound inane, but I did it to try to
improve the continence services for people with
MS, and I hope that the benefits will be tangible.
Locally, a direct referral system has been established
whereby MS nurses, consultant neurologists
and rehabilitation physiotherapists can all
send us patients, and we hope to establish multidisciplinary
classes for those who have been
newly diagnosed. Part of the content of these
classes will include information on good bladder
management, as well as on rehabilitation and
other aspects of treatment.
I would probably do it again. The learning
curve was steep, but I did things, such as presenting,
travelling and meeting people from
many different walks of life, that I would not
have done otherwise. If someone was contemplating
undertaking a PhD and asked my advice,
I would say that you should consider it carefully
and make sure that it is something you are really
interested in. At times, I felt that the worlds of
academics and of clinicians were very different,
and it is of paramount importance that you
have a good working relationship with your
supervisors. As someone once told me, a PhD
becomes your extra ‘baby’, and just like a baby,
there are good and bad times, and it can be
difficult to extricate yourself in order to have a
family life. Then, at the end, it can feel like
leaving the child at the school gate with a
mixture of sadness, relief, pride and exhaustion.
The results of the pilot study have been published
in McClurg et al. (2006). The results of the
RCT are about to be submitted for publication.
Doreen McClurg
Clinical specialist physiotherapist
Belfast City Hospital
Belfast
Reference
McClurg D., Ashe R. G., Marshall K. & Lowe-Strong A. S.
(2006) Comparison of pelvic floor muscle training, electromyography
biofeedback and neuromuscular electrical
stimulation for bladder dysfunction in people with multiple
sclerosis. Neurology and Urodynamics 25 (4), 337–
348.
Characteristics of abdominal and
paraspinal muscles in
postpartum women
I have often been asked why I decided to do a
PhD and how I decided what to investigate. My
appetite for research was whetted when I did
a Master’s degree in 1993 and I was lucky to
78
work with a renowned muscle physiologist Dr
Olga Rutherford in her laboratory at St Mary’s
Medical School, London. I considered going on
to study for a PhD after this, but an opportunity
did not present itself immediately.
However, in 1995, I was working as a lecturer/
practitioner at Brunel University and Kingston
Hospital in London with a specialist role as a
musculoskeletal physiotherapist when I met the
dynamic Sarah Murdoch, who, at the time, was
senior 1 in women’s health. I became interested
in her work with pregnant and postnatal women
with low back/pelvic girdle pain, and we discussed,
examined and treated many women
together. At the time, studies on motor control
of the abdominal muscles were a new and fastchanging
musculoskeletal physiotherapy practice.
I wondered whether this new approach
would be of benefit to Sarah’s clients, and we
tried different strategies with varying degrees of
success. I realized that very little was known
about the actual physiological changes to the
abdominal muscles during pregnancy and postpartum,
and therefore, if we were going to use
rehabilitation strategies for abdominal muscles
in the ante- and postnatal periods, it would be
preferable that we understood the changes that
occurred during pregnancy.
I changed jobs and was fortunate to be given
the opportunity to do a part-time PhD, funded
for 3 years, at St George’s Medical School,
London. Naïvely, I thought it would be done
and dusted in 3 years whilst working part-time:
lesson number one, part-time working extends
the total length of the project. I also got married
6 months into the project, which added to some
of the delay! I decided to study the characteristics
of abdominal and multifidus muscles in postnatal
women in order to inform future studies
for clinical practice. Therefore, the project was
registered in the field of ‘neuromuscular physiology’
at the University of London. I decided
that I would use real-time ultrasound imaging
to study abdominal and multifidus muscle size,
plus electromyography (EMG) to study (1) fatigability
and (2) recruitment of these muscles in
response to trunk perturbation.
I had to start from scratch: designing the
project, finding willing supervisors, getting ethical
approval (a mammoth task), applying for
funding for equipment (begging, borrowing and
stealing equipment, if necessary!), learning how
to use new equipment and doing a pilot study.
This took over 12 months to accomplish, and
there were many setbacks but also a few golden
2007 Association of Chartered Physiotherapists in Women’s Health

moments. A rheumatologist, Dr (now Professor)
John Axford, agreed to be my official internal
supervisor and offered me office space in his
department. Professor Maria Stokes very kindly
agreed to be my scientific supervisor. She has
always been 100% supportive, and I am so
grateful for all her advice and knowledge.
During my first few months, I put the proposal
together and it was approved by the ethics
committee. I had been promised use of an ultrasound
scanner, but it did not materialize, and I
realized that my project was in jeopardy. Enter
the second person who was to keep me sane
during the next 2.5 years: Katy Cook is a specialist
ultrasonographer in the foetal medicine
department at St George’s and she was allowed
to work with me for half a day a week. Katy
worked hard to ensure that I had access to an
ultrasound machine, and with her help, I gained
access to the postnatal wards. I applied for,
and was given, funding by the Medical School
and the ACPWH (the Dame Josephine Barnes
Bursary) to purchase an EMG machine and
accessories. I was given further financial help by
the ACPWH during my write-up time and I am
very grateful for the support given to me by the
Association.
During the next few months, I undertook a
pilot study using both ultrasound scanning and
EMG in order to establish the methodology for
the full study, and recruited a small sample of
nulliparous female controls and day 1 postpartum
women. Part of this pilot study determined
that the size of the multifidus did not differ
whether ultrasound imaging was performed in
prone or side-lying (Coldron et al. 2003). This
was important to determine because breastfeeding
women could not easily lie prone.
Measurements of ultrasound imaging of the four
abdominal muscles and lumbar multifidus were
shown to be reliable from intra- and inter-rater
reliability studies.
I had to learn to use the EMG apparatus and
programme the computer to analyse the results.
This was a steep learning curve! I was lucky that
Professor Di Newham agreed to be my second
scientific supervisor, and with her help and that
of the technical representative of the EMG
company, I learned to use the EMG equipment.
Di Newham helped me to develop the exercises
to measure fatigue and motor recruitment, and
at the end of the pilot study, we realized that we
needed more equipment to determine the force
output of a maximum voluntary contraction
(MVC) of the abdominal muscles and, thus,
PhD thesis reports
calculate the percentage force output necessary
to induce fatigue during a one-minute sustained
contraction. Professor Stokes worked at the
Royal Hospital for Neuro-disability, London,
and with the help of their mechanical workshop
engineers, we devised a testing chair. This chair
allowed two restraining straps to be attached to
strain gauges to record force output when
women performed an MVC of the abdominal
muscles. Sixty per cent of the MVC value was
used for the fatiguing one-minute contraction
and the EMG signal was recorded. Trunk perturbation
exercises in standing were adapted
from those of Hodges & Richardson (1996), and
again, the EMG signal was recorded.
All PhD students registered at St George’s,
University of London, are required to undertake
a transfer viva to go from MPhil registration
to PhD registration. This comprised writing a
summary of my pilot studies (10 000 words) and
undertaking a viva – all good preparation for
the real thing! I undertook this successfully 12
months after registering for the PhD, but 18
months into my funding.
From then on, it was all systems go to collect
my data before the funding ran out. At this
point, I was lucky to gain semi-permanent access
to a room in the School of Physiotherapy where
I could store my equipment (by that time, I had
access to an ultrasound machine) and test
women at later stages postpartum. (I continued
to test day 1 postpartum women on the postnatal
wards.) It was decided to make my design
mainly cross-sectional, and for the next 18
months, I recruited women at day 1, and at 2, 6
and 12 months postpartum. Some of these
women attended on more than one occasion and
formed the small longitudinal part of the study.
I also continued to recruit nulliparous female
controls of childbearing age. One of the joys of
this project was meeting so many women who
volunteered willingly to undergo the ultrasound
scanning and participate in exercise that fatigued
their abdominal muscles. I became an expert in
juggling a baby with one hand and operating the
computer mouse with the other!
I left St George’s after 3 years, and decided
that I would quickly analyse my results and write
up within the year whilst working part-time as
a clinician. Another lesson: data analysis and
writing up a doctoral thesis take much longer
than one thinks. Life traumas, including the
prolonged illness and subsequent death of my
father, problems with my own health, my husband’s
redundancy, returning to full-time work,
2007 Association of Chartered Physiotherapists in Women’s Health 79

PhD thesis reports
and moving house, meant that I submitted over
2 years later. However, this was still well inside
the submission time since part-time students
have 7 years in which to submit.
During these years, I relied on my husband,
Tim, who looked after and supported me (I have
totally forgotten how to cook!), and I would
advise anyone thinking of undertaking a PhD to
look for support outside of work and discuss
things fully with their family. One of the most
unsupportive things anybody can say during this
writing up time is, ‘Haven’t you finished yet?’
In order to do a doctoral thesis, one has to be
prepared to give up evenings, weekends and
holidays for many years, and this is something to
consider when embarking on such a project. The
viva was a trial, and fortunately, did not have to
be repeated. I passed with some revisions and
was finally awarded the doctorate in 2006.
I learnt that doing doctoral study is much
more than just answering the original research
question. It is a journey through the research
process, learning about writing a proposal, presenting
before an ethics committee, recruiting
subjects, gaining access to and learning how to
use complicated measuring tools, reviewing literature,
analysing spreadsheets full of data, and
writing scientifically. These aspects of research
all have value for future studies. The results of
my study were interesting, although not necessarily
those that might have been expected. I
hope that, once further papers are published
from the thesis, others may be encouraged to
undertake study into appropriate postnatal
abdominal exercise or other aspects of postnatal
physiotherapy.
Life after a PhD is mainly one lived with a
sense of relief that it is finished, but there are still
papers to be written and presented at conferences.
The results of one experimental chapter
are currently in press (Coldron et al. 2007).
80
Would I recommend others to do a PhD? I
think it was worth it because I learnt so much
not only about postpartum abdominal and
multifidus muscle characteristics, but also about
the research process. However, it can be a lonely
process, and it requires stamina and tenacity to
finish a thesis. Studying for a PhD fits more
easily into the academic way of life than into
that of an National Health Service department,
but maybe that is because we are still a young
profession in research terms and we have not yet
managed to find many ways in which research
can be incorporated into clinical practice. For
anyone considering undertaking doctoral study,
I would advise that you need to love the subject
since it will be with you for a very long time. I
also know that I could not have undertaken or
completed the PhD without the full support
of Professors Stokes and Newham, so I would
advise that your choice of supervisors is paramount.
I hope that I will have scope to use my
new research skills in the future in order to
inform evidence-based clinical practice. I would
hate all the effort to go to waste!
Yvonne Coldron
Research officer
References
Coldron Y., Stokes M. & Cook K. (2003) Lumbar multifidus
muscle size does not differ whether ultrasound
imaging is performed in prone or side lying. Manual
Therapy 8, 161–165.
Coldron Y., Stokes M. J., Newham D. J. & Cook K. (2007)
Postpartum characteristics of rectus abdominis on ultrasound
imaging. Manual Therapy 12, in press.
Hodges P. W. & Richardson C. A. (1996) Inefficient
muscular stabilization of the lumbar spine associated
with low back pain. A motor control evaluation of
transversus abdominis. Spine 21, 2640–2650.
2007 Association of Chartered Physiotherapists in Women’s Health

Journal of the Association of Chartered Physiotherapists in Women’s Health, Spring 2007, 100, 81–82
Visit to the UK
I am an Austrian physiotherapist specializing in
women’s health and pelvic floor re-education.
Having worked in this field for 12 years, I took
the opportunity to share and improve my
knowledge with colleagues by starting lecturing
courses for pelvic floor re-education in 1999.
While presenting my results at the World Confederation
for Physical Therapy Congress in
Barcelona, Spain, I got to know Gill Brook and
Teresa Cook from the UK, who helped me to
amend my lectures.
The European Union offers the opportunity to
undertake working experience in other countries,
and so I planned a 9-week trip to the UK, during
which I would spend each week in a different
hospital, shadowing physiotherapists specializing
in the field of women’s health and incontinence.
Gill helped me to find 10 different places
where I could shadow staff. This was a very
difficult job: in some places, some staff were on
holiday, and others wanted me to pay for my
observation. Gill was a great help and it is
thanks to her that I could put this project into
practice.
I started my visit in London, where I observed
the treatment of patients with constipation who
were taught defecation techniques with Julie
Duncan, Brigitte Collins, Lorraine O’Brien and
Trish Evans at St Mark’s Hospital. I received
lots of the assessment sheets and folders that are
used there. I also had the opportunity to see a
defecating proctogram, an examination of the
colon transit via X-ray, and a manometry and
ultrasound examination.
After St Mark’s, I spent 2 weeks in Hammersmith
Hospital with Avril Hillyard, Yasmine
Ransome, Janine Shaw, Rachel Keeling and Susi
Cook. This gave me an opportunity to see work
on the wards, pre- and postnatal classes, and
individual treatments of women with incontinence
problems or prolapse. I also attended
gynaecological surgery and a Caesarean section
of twins. Avril made it possible for me to participate
in a study day with Jeanette Haslam in
Ascot, where I got to know 20 other physiotherapists
working in the speciality.
My next stop was the world-famous Great
Ormond Street Hospital children’s hospital,
where I had the opportunity to follow the treat-
ment of children with bladder or bowel problems.
Brid Carr, Laureen, Caren and Kath
looked after me there. I saw two videourodynamics,
and attended clinics for outpatients
and the weekly meeting of all the doctors
specializing in that field, where they discuss
difficult cases.
After this, I went north to Manchester, where
I spent a week in St Mary’s Hospital with Ann
Mayne, Michelle Horridge, Courtney Gum,
Hanna Gray, Lisa Roberts and Nicole
Needham. It was interesting to see more ward
work and outpatient treatments. I also spent a
day shadowing Gordon Hosker, a worldrenowned
research fellow, who showed me manometry,
ultrasound and pudendal nerve latency
tests for patients with faecal incontinence.
I then visited Cumbria (Fig. 1), where I spent
4 days with Jeanette Haslam. It was fascinating
to look at her private library, as well as see how
she organizes her lecturing and finds relevant
Figure 1. Elizabeth Pulker with a couple of
friends.
2007 Association of Chartered Physiotherapists in Women’s Health 81

Visit to the UK
papers when needed. In the lovely countryside of
the Lake District, I had long and interesting
talks with Jeanette about her years of experience
in lecturing and about carrying out studies.
My next stop was Bradford Royal Infirmary,
where I spent 3 days shadowing colleagues, and
this gave me the opportunity to thank Gill
Brook personally for all she had done for me. In
Bradford, I met Stephanie Knight again (we had
previously met at an International Continence
Society conference), and I got to know Dianne
Naylor, Helen Bryer and Pauline Bibby, whom I
shadowed as they carried out pelvic floor reeducation
with outpatients. I observed Stephanie
performing urodynamics as a physiotherapist,
something that would not be possible in Austria
because it is only carried out by doctors.
After this, I went back to London and the
Willesden Centre of Health and Care, where I
spent a week with Lizelle Miller, a South African
physiotherapist who only works with outpatients.
She showed me how to carry out perineal
ultrasound for biofeedback. I saw it in use
on patients, and we had the opportunity to try it
on our own. It was fascinating for both myself
and for the patients.
I then went up to Scotland where I spent a
week in Glasgow with Julie Lang in the Victoria
Infirmary and Diane Stark in the Southern
82
General Hospital. Observing Julie, I saw many
treatments performed on patients with anorectal
dysfunction, and with Dianne, I found out about
the pelvic organ prolapse qualification – a study
in which Dianne is involved – which gave me a
broader understanding of the scope of our work
as physiotherapists.
I spent my last week with colleagues in two
different London hospitals: Charlotte Lion and
Wendy Harper, who work in the Chelsea and
Westminster Hospital showed me their work
on the wards and with outpatients; and Paula
Martinez and her colleague Emily Hoile showed
me their work in the Royal London Hospital.
In my 9 weeks in the UK, I got to know a total
of 46 physiotherapists working in many different
ways with pelvic floor re-education. I returned
home with new ideas and enthusiasm for my
work. I was very well looked after, and besides
learning better English, I got to see a lot of
the beauty of the UK and made many new
friends.
Elisabeth Pulker
Museumstraße 28
6020 Innsbruck
Austria
E-mail: pulkerliese@yahoo.de
2007 Association of Chartered Physiotherapists in Women’s Health

Journal of the Association of Chartered Physiotherapists in Women’s Health, Spring 2007, 100, 83–90
Book and DVD reviews
A Headache in the Pelvis: A New
Understanding and Treatment for
Prostatitis and Chronic Pelvic Pain
Syndromes, 3rd edn
By David Wise & Rodney Anderson
National Center for Pelvic Pain, Occidental, CA,
2003, 333 pages, paperback, $24.95
ISBN 0-9727755-2-8
This book is dedicated to helping both men and
women with a variety of chronic pelvic pain
syndromes gain a better understanding of the
problem of chronic pain, and its causes and
treatment. The focus is primarily on male
chronic pelvic pain syndrome (CPPS)/chronic
prostatitis, since this is the area of work on
which the authors’ research has concentrated. Dr
David Wise is a psychologist at Stanford University,
CA, USA, and has suffered from chronic
prostatitis himself. Rodney Anderson is an eminent
neurourologist. The regime described in the
book originally helped Dr Wise to overcome his
own chronic pain, which prompted him to devise
the ‘Stanford Protocol’, a multidisciplinary
treatment approach to CPPS/chronic prostatitis.
‘Headache in the pelvis’ is the name given to
all forms of pelvic pain and dysfunction when
no primary pathology is found. The analogy is
based on the premise that, when no other cause
can be found, CPPS may be the result of chronic
tension in the pelvic floor muscles (PFMs), in a
similar way to that in which chronic upper back
and neck muscle tension may cause headache.
The holistic treatment protocol is aimed at
teaching the patient to release this tension by
using both physical and psychological methods,
thus relieving the ‘headache’.
Because A Headache in the Pelvis is written for
the patient, it is written in appropriate layman’s
language, and contains no references or footnotes.
For those interested in reading a more
scientific basis for the theory, the authors have
published a reasonably robust research study
to add weight to the use of their protocol
(Anderson et al. 2005).
The opening chapter gives definitions and
categories of CPPS in both men and women, and
in addition to chronic prostatitis, includes conditions
such as vulvodynia, urethral syndrome,
proctalgia fugax and interstitial cystitis, all of
which may have an underlying element of
increased PFM tension. This leads the way into
the rest of the book, which explains the Stanford
model for explaining chronic pelvic pain.
A Headache in the Pelvis is interesting to read
because it tells a story, and uses parables and
allegory to help the reader gain a better understanding
of the reasons why pelvic floor dysfunction
may develop. The current model of the
multifaceted nature of chronic pain, and the
pain–anxiety–tension cycle is written in an interesting
style, although this sometimes becomes
repetitious rather than reinforcing the explanations.
Case histories are included amongst the
theoretical text to let the reader know that there
are many other sufferers out there.
The methodology of the Stanford Protocol is
then outlined. The authors do make it clear from
the outset that the treatment is not suitable for
everyone, and that thorough diagnostic evaluation
is necessary to rule out organic conditions
that require different treatment. Neither do they
make claims for how many, nor which type of
patient, will benefit from the protocol. Assessment
tools are included that may be useful for
clinicians, but are not, as yet, validated. Other
validated questionnaires are mentioned.
The basis of the treatment protocol is a
combination of paradoxical relaxation and
myofascial/trigger point release. The relaxation
techniques are based on Edmund Jacobson’s
method of ‘Progressive Relaxation’. The relaxation
techniques are described in detail. Dr Wise,
the psychologist, produces a series of relaxation
tapes. He emphasizes that the tapes cannot be
purchased on a stand-alone basis, but must be
bought in conjunction with one-on-one teaching
to gain the full benefit of achieving deep relaxation
of the PFMs.
The next part of the protocol is physical. It
aims to release trigger points in the pelvic floor,
and restore the muscles to their correct length
and tension. This part of the treatment is carried
out by a physical therapist, although the authors
do say that a ‘willing partner’ may be taught to
perform the techniques, since treatment may
take many weeks or months, and the patient
often lives a long distance from the clinic. Part of
2007 Association of Chartered Physiotherapists in Women’s Health 83

Book and DVD reviews
the protocol (except for the manual treatment!)
is available on the Internet. The chapter on
myofascial release is very useful, and contains
illustrations of all the possible affected muscles
and their trigger points. Stretching exercises are
another important part of the overall therapy,
and again, good illustrations are included.
The book concludes with patients’ questions
in ‘Frequent concerns’. These explore issues such
as sex and sexuality, faith, Eastern philosophy
and alternative therapies in a very colloquial
fashion, which is at an appropriate level for the
intended readership. There are also many selfreported
cases histories, but of course, these only
describe the patients who were improved or
cured. However, this book is not intended to be
a research paper, and it does an excellent job
of informing sufferers about the possibility of
exploring this treatment option.
The authors do not adopt a ‘hard sell’
approach, although many men from Europe do
travel to California for an intensive 6-week
course of treatment offered by the Stanford
team. Not all of these patients get better, and
the course is expensive. Many therapists in the
UK who specialize in pelvic floor dysfunction
are capable of treating these cases following a
similar approach; it is merely a question of
‘spreading the word’.
A Headache in the Pelvis is a ‘must read’ for
any physiotherapist treating men with CPPS/
chronic prostatitis since most well-informed
patients will come with the book in their hand
and ask for the Stanford Protocol. It is a useful
source of information for male CPPS patients,
but less useful for women. The Stanford team
are happy to share their protocol, and more
long-term research is indicated in order to establish
who is likely to benefit.
Reference
Stephanie Knight
Airedale General Hospital
Keighley, West Yorkshire
Anderson R. U., Wise D., Sawyer T. & Chan C. (2005)
Integration of myofascial trigger point release and paradoxical
relaxation training treatment of chronic pelvic
pain in men. Journal of Urology 174 (1), 155–160.
The Essential Guide to Acupuncture in
Pregnancy and Childbirth
By Debra Betts
Journal of Chinese Medicine Ltd, Hove, 2006,
328 pages, hardback, £35.00
ISBN 0951054694
84
This well-presented clinical textbook is written
by Debra Betts, an experienced New Zealand
midwife and acupuncturist. Although the book
is aimed primarily at midwives, it provides clinical
guidance for multi-professional acupuncture
practitioners who encounter pregnant and postpartum
women.
The Essential Guide to Acupuncture in Pregnancy
and Childbirth is divided into 26 chapters
and nine appendices. Individual sections
cover most of the common conditions found in
pregnancy, including nausea and vomiting,
musculoskeletal conditions, heartburn, fatigue,
insomnia, anxiety, depression, and oedema.
Several chapters are devoted to birth and the
postpartum period, highlighting the role of
acupuncture during these times. Each section
is clearly written and explains both the Western
and traditional Chinese medicine (TCM)
approaches to acupuncture for each condition.
The pathology of conditions in Western and
TCM terms, followed by a discussion on the
recommended acupuncture points, are detailed
in each chapter. Where possible, the selection of
acupuncture points is based on evidence from
the literature, but the Bett’s own wide clinical
experience also informs the text. Most clinical
chapters include case histories to illustrate the
relevance of acupuncture to the given condition/
pathology presented.
Importantly, the first chapter deals with safety
of acupuncture treatment for pregnant women,
and clearly outlines the acupuncture points that
may promote labour, and thus, are contraindicated
during pregnancy. Furthermore, there is
clear adaptation of needling technique for the
pregnant woman, and details of the number of
needles used and the method of acupuncture.
Several chapters contain information that would
be relevant for women’s health physiotherapists
who practise needling. In particular, Chapter 8
deals with musculoskeletal conditions. I think
that the information presented in this chapter
would enhance safe practice, as well as encouraging
physiotherapists to use acupuncture as a
modality to treat pregnant women with upper
and lower back pain, pelvic girdle pain, rib pain,
and carpal tunnel syndrome.
Chapter 26 reviews some of the research evidence
underpinning the use of acupuncture in
pregnancy. Betts cites only one recent study that
investigated acupuncture in low back/pelvic
girdle pain, although there have been several
papers published in recent years. Unfortunately,
the paper cited was physiotherapy generated and
2007 Association of Chartered Physiotherapists in Women’s Health

used contraindicated points (although there
were no adverse effects), and Betts makes the
point that questions should be raised about the
way point-prescription acupuncture is used by
physiotherapists. Many of the chapters deal with
wider issues around pregnancy, and Chapter 27
deals solely with dietary advice during and after
pregnancy. The appendices are extensive and
informative, and include Western and TCM
glossaries that would be useful for physiotherapists
practising acupuncture. Of particular value
is Appendix 7, which describes the location and
needling of points that have been used in the
text, and is accompanied by clear illustrations.
Overall, this book is clearly presented and the
arrangement of each chapter makes it easy to
read. There are clear sections on Western and
TCM viewpoints, clinical manifestations of conditions,
discussion of acupuncture points, case
histories, and references. Within each chapter,
coloured inset boxes are placed in the wide
margins, and used to emphasize key clinical
aspects, precautions and acupuncture points.
Debra Betts’ approach to the holistic management
of women pre-, ante- and postnatally
makes this much more than a textbook of acupuncture
points. Her concern for the well-being
of women at each stage of pregnancy, birth and
afterwards is paramount, and the reader could
not fail to improve her or his clinical practice. As
a physiotherapist practising acupuncture and
dealing with pregnant women, I have no hesitation
in recommending The Essential Guide to
Acupuncture in Pregnancy and Childbirth to
those women’s health physiotherapists who wish
to undertake further acupuncture training and
extend their knowledge into this field.
Yvonne Coldron
Mayday Healthcare NHS Trust
Croydon
I felt very privileged when asked to review this
long-awaited clinical approach to a subject I
have particular interest in and I was far from
disappointed. Even before opening The Essential
Guide to Acupuncture in Pregnancy and Childbirth,
the cover is so aesthetically pleasing that it
makes the book a must for those wanting to find
out more. As the title announces, this is an
essential clinical guide, crossing professional disciplines,
and encompassing proven solutions to
the management of the mother and the foetus,
whether you are a professional acupuncturist,
Book and DVD reviews
midwife, physiotherapist or doctor working with
acupuncture in the field of gynaecology and
obstetrics.
Within the realms of physiotherapy, I would
fully recommend this text as essential reading
matter if practitioners are about to embark
on further advanced acupuncture training in
women’s health, provided they have a fundamental
knowledge of TCM philosophy.
The Essential Guide to Acupuncture in Pregnancy
and Childbirth is divided into sections
covering a number of conditions, such as nausea
and vomiting, musculoskeletal conditions,
insomnia, and anxiety. These are presented at
prepartum, during labour and postpartum, with
a chapter dedicated to each. Within each chapter,
Debra Betts has integrated Western medical
diagnosis into a TCM framework. She uses
succinct, manageable language – something I
find lacking in several other texts on this subject,
and something I welcome within our clinical
practice.
The book has an added advantage in that
treatment protocols are provided within each section.
The anatomical positions of relevant points
are superbly illustrated by Peter Deadman,
Mazin Al-Khafaji and Kevin Baker, and indepth
clinical reasoning for their use is provided.
Chapter 26, citing a review of current research
with clinical application to acupuncture in pregnancy,
is an added bonus.
Each page provides the reader with the
author’s clinical experience and knowledge of
the subject matter. I am grateful for this knowledge
and for the easy style in which it has been
written, which has the dual benefits of enhancing
my clinical reasoning and aiding my patients’
recovery. I welcome texts that augment the clinician’s
patient care and problem-solving skills
within an evidence base that is effective, relevant
and pertinent to current healthcare. The
Essential Guide to Acupuncture in Pregnancy and
Childbirth provides all these qualities and more.
Jennie Longbottom
Acupuncture Association of Chartered
Physiotherapists
Peterborough
The Pelvic Floor
Edited by Beate Carrière & Cynthia Markel
Feldt
Georg Thieme Verlag, Stuttgart, 2006, 476
pages, paperback, V69.95
ISBN 1-58890-325-7
2007 Association of Chartered Physiotherapists in Women’s Health 85

Book and DVD reviews
This book is small in size, but huge in content,
boasting contributions from a team of internationally
renowned experts, including Kari
Bø, Pauline Chiarelli, Grace Dorey and Paul
Hodges, as well as the two main authors,
Americans Beate Carrière and Cynthia Markel
Feldt. The Pelvic Floor covers in great detail the
current state of our knowledge of the pelvic
floor, and its contribution to pelvic health and
illness.
My first impression on opening the book was
‘overwhelming’. The content is very comprehensive,
and although small, The Pelvic Floor contains
over 500 pages, all very busy with a small
typeface and minimal marginal space on each
page. However, I appreciate that this keeps the
production costs of the book down to an affordable
amount. One would expect a text with such
comprehensive content to be priced much higher
than it is. However, it could have be improved
if the different sections of the book were more
identifiable. As it stands, it is difficult to distinguish
between different parts, and therefore,
not so easy to find things without frequently
resorting to the contents for a page number.
In my opinion, a quote from the first section
describes the essence of this book:
‘The pelvic floor cannot be viewed in isolation
and has to be considered in connection with
the surrounding structures, as well as its individual
parts.’
It is a truly holistic account of the treatment of
pelvic floor dysfunction.
The book encompasses a wide range of conditions
that a women’s health physiotherapist
might be asked to treat. Although the title is The
Pelvic Floor, it also includes a section on the
management of lymphoedema.
Many of the treatment techniques are wellknown
amongst physiotherapists and supported
by a strong evidence base. However, the book
also includes many less-known techniques –some
that have been used for many years and others
much more recent – that do not currently have
a good evidence base. Indeed, some sections in
The Pelvic Floor have no real evidence to support
them, being based solely on expert opinion.
I think one of the strengths of this book is that
all these treatments are included. The authors
describe the strength of evidence supporting
their statements, and there is an extensive reference
list at the end of each section.
The Pelvic Floor is divided into six main
sections:
86
(1) Basics: anatomy and physiology, nervous
system, musculoskeletal chronic pelvic pain,
posture and the pelvic floor, low back pain and
the pelvic floor, reflex incontinence, psychosocial
influences, and evidence-based physiotherapy
for stress and urge incontinence.
(2) Treatment techniques: manual physiotherapy
techniques for pelvic floor disorders, strain
and counterstrain for pelvic pain, connective
tissue manipulations and other physical
therapies, visceral mobilization, PFM training,
reflex incontinence, and therapy for
lymphoedema.
(3) Paediatric therapy: enuresis and encopresis
(assessment and treatments).
(4) Therapy for women: back-to-nature labour,
storage and emptying disorders of the bladder,
prolapse, and sexual and pelvic floor
dysfunctions.
(5) Therapy for men: anatomy and physiology,
assessment and treatment of incontinence,
pelvic pain, and erectile dysfunction.
(6) Treatment of anorectal disorders: anal dysfunction
after delivery and physiotherapy for
anorectal disorders.
The diagrams and accompanying photographs
throughout the book are of a consistently high
quality. However, some parts are very detailed,
particularly the anatomy and physiology section
at the beginning of the book, and some segments
of the treatment sections. In these areas, I think
the text would have been more accessible if it
had been accompanied by more illustrations.
In conclusion, I would strongly recommend
The Pelvic Floor to any women’s health physiotherapist.
It is an up-to-date, affordable, comprehensive
guide for the treatment of all conditions
associated with pelvic floor dysfunction.
It enhances our understanding of the functional
significance of the pelvic floor, and will contribute
to better treatment for all our patients.
Dianne Naylor
Bradford Teaching Hospitals NHS Foundation
Trust
Bradford
Pelvic Dysfunction in Men
By Grace Dorey
John Wiley & Sons Ltd, Chichester, 2006,
187 pages, paperback, £26.99
ISBN 0-470-2836X
This is an updated edition of the author’s
first textbook, Conservative Treatment of Male
2007 Association of Chartered Physiotherapists in Women’s Health

Urinary Incontinence and Erectile Dysfunction,
published in 2001. It is primarily aimed at
specialist continence physiotherapists, and as a
guide for urology and continence nurses, urologists
and general practitioners.
This edition contains an abundance of information,
beginning with four chapters on the
history, symptoms, anatomy and physiology,
and nervous control of the urinary tract. An
overview of prostate conditions, urinary incontinence
and pelvic pain in men is provided, followed
by chapters on patient assessment and
conservative treatment.
Although one has to recognize that it is difficult
to provide information about such a large
and evolving field as products within such a
book, the relevant section is out of date and
lacks information on washable products and
urinals, and does not promote the use of information
services such as PromoCon.
Two chapters deal with the treatment of postprostatectomy
problems. The first is a review of
the literature, which is perhaps unnecessary in
such a textbook since the following chapter
describes the treatments available and references
the relevant literature. More information on the
risk of incontinence after surgery and the longterm
prognosis would have been useful.
A further chapter discusses pharmacotherapy
for a wide range of conditions from detrusor
overactivity to prostate cancer. Thereafter,
faecal incontinence is covered, with a further two
chapters pertaining to male sexual dysfunction:
first, a description of the condition, and then an
outline of the treatment with a review of the
relevant literature on physical therapy for erectile
dysfunction. Again, it would have been useful
if the actual percentage of men experiencing
retrograde ejaculation, urethral stricture and/or
erectile dysfunction following prostatectomy was
documented.
The final chapter is entitled ‘Setting up a
continence service’, which is perhaps misplaced
within such a textbook, although the importance
of interdisciplinary collaboration is discussed
with a plethora of information on relevant professional
and patient literature and specialist
groups. However, it is possible for a director
of continence services to be any member of the
multidisciplinary team, not just a continence
nurse specialist or specialist continence physiotherapist.
Pelvic Dysfunction in Men is an essential reference
book for physiotherapists working in the
field of male pelvic floor disorders. Although it is
Book and DVD reviews
not particularly cheap, one of the main things I
liked about the book was its simple layout, with
each chapter detailing key points at the beginning,
and those concerned with treatment ending
with a question-and-answer page/case study.
Most of the anatomical drawings and figures are
relatively simple and appropriate. There are also
many up-to-date references and recommendations
for further research, and I hope that some
of these will taken up. Pelvic Dysfunction in Men
is a handy size, and is both a useful addition to
the shelves of medical libraries and a helpful
guide to other disciplines treating this group of
patients.
Doreen McClurg
Belfast City Hospital
Belfast
Menstrual Disorders: A Practical Guide
By Deborah Ehrenthal, Paula Adams Hillard &
Matthew Hoffman
American College of Physicians, Philadelphia,
PA (distributed by the Royal Society of Medicine
Press, London), 2006, 262 pages, paperback,
£30.95
ISBN 1-930513-66-6
This book’s stated aim is to provide a blend of
all the latest information from the fields of
internal medicine, gynaecology, adolescent
medicine and other subspecialties in order to
give a comprehensive overview of menstrual
disorders.
Menstrual Disorders: A Practical Guide starts
with a review of the normal menstrual cycle,
followed by a chapter on common menstrual
complaints, including abnormal uterine bleeding,
amenorrhoea, perimenopausal bleeding,
dysmenorrhoea and premenstrual syndrome.
It then moves on to medical issues, including
polycystic ovary syndrome, menstrual disorders
in women with developmental disabilities, bleeding
disorders and menstrual disorders, and
reproductive issues in women with chronic medical
problems. This last is the most useful because
it covers, in one chapter, diabetic women,
obesity, eating disorders, substance abuse, the
female athlete, acute and chronic liver disease,
renal disease, lupus, heart disease, and seizure
disorders.
Menstrual Disorders: A Practical Guide concludes
with a chapter on surgical procedures.
The main drawback of this book is that it uses
jargon whenever possible, making it very difficult
2007 Association of Chartered Physiotherapists in Women’s Health 87

Book and DVD reviews
to read, especially since the authors can take
several pages before they explain the meaning of
the terminology. This meant looking up terms in
a medical dictionary only to find them explained
later. The authors use American spelling
throughout, which can be disconcerting to a
British reader.
Women’s health physiotherapists could find
some of Menstrual Disorders: A Practical Guide
quite patronizing. On the plus side, the chapter
on chronic medical influences on menstrual disorders
is comprehensive. You might normally
have to look through several texts to find this
information. It is also reasonably priced, and
available on Amazon. However, I can only see
this as a reference book for limited use, and as
long as the hospital library is good, I would not
particularly want to buy it for my department.
Kathleen Vits
Southampton University Hospitals NHS Trust
Southampton
The Menopause: What You Need to Know,
2nd edn
Edited by Margaret Rees, David W. Purdie &
Sally Hope
Royal Society of Medicine Press Ltd and British
Menopause Society Publications Ltd, London,
2006, 102 pages, paperback, £10.95
ISBN 1-85315-672-8
The stated aim of the second edition of this guide
to the menopause is ‘to provide unbiased and
non-promotional information about the menopause
and its management to doctors, nurses,
their patients and families’. The book achieves
this difficult task very well. The Menopause:
What You Need to Know combines good medical
knowledge with information that is easy for the
lay person to understand. This is particularly
evident in Chapter 8, which covers the controversies
over hormone replacement therapy
(HRT). It explains the different types of clinical
trial, how to understand the evidence, what risk
means, and in particular, discusses the more
recent clinical trials that have made the newspaper
headlines.
The chapters are well set out and easy to read,
and at the end of each, there are sources of
information, such as journal articles, books and
websites. The Menopause: What You Need to
Know explains what the menopause is, its symptoms
and long-term effects. It discusses HRT
and its alternatives in the treatment of particular
88
symptoms such as osteoporosis. There is an
informative chapter on complementary therapies,
information on managing the menopause
when you have other medical conditions, and a
useful glossary at the end of the book.
As a woman ‘of that certain age’ myself, I
jumped at the chance to review The Menopause:
What You Need to Know. I have read many
books recently on the menopause, but none
written so succinctly or with as much information.
As women’s health physiotherapists, we
are often asked about the menopause and our
opinions on HRT. This is an excellent source of
information and would be a welcome edition to
any physiotherapy department, both for staff
and for patient loan.
Clinics in Motion DVDs
Rachel Grubb
Warwick Hospital
Warwick
Clinics in Motion is an Irish healthcare learning
company providing the ‘world’s first DVD publication
and resource centre for physiotherapists
[. . .] featuring an internationally developed syllabus
[. . .] and online assessment programme’.
The company has produced six active learning
tools in its Neuromusculoskeletal Physiotherapy
Series 1. These cover: the lumbar spine; the
pelvis and hip; the cervical and thoracic spine;
the shoulder; the knee, ankle and foot; and the
elbow, wrist and hand.
The excellent website (www.clinicsinmotion.
com) allows you to sample the series and view
the contents of each DVD. You can also try the
test!
Practical Techniques of Physiotherapy
Examination and Treatment, Vol. 2: The
Pelvis and Hip
By Helen French, Karen McCreesh, Mark
Sexton, & Jeremy Walsh
Clinics in Motion, Dublin, 2005, interactive
DVD, £69.00
I was asked to review this DVD just as a new
restriction was placed on our study leave, which
highlighted to me what a very useful resource
this series should prove to be. For less than the
cost of a study day, you can watch techniques
on your own television. This is an e-learning
package, and a workbook and examination are
2007 Association of Chartered Physiotherapists in Women’s Health

available online from when you register your
purchase.
The contents of the DVD are described in a
small accompanying booklet that sets out the
aims of the series, i.e. ‘to explain and demonstrate
the practical aspects of physiotherapy
diagnosis and treatment that are universally and
internationally useful in physiotherapy education
and continuing professional development
(CPD)’.
Practical Techniques of Physiotherapy Examination
and Treatment, Vol. 2: The Pelvis and Hip
includes surface anatomy, observation tests and
techniques. Using the angle button on the DVD
remote control gives the viewer close-ups, wide
angles and a ‘skeleton shot’, which is particularly
useful for learning techniques. A case study,
some tips and information on applied radiology
complete the package.
This is a very useful learning and revision aid.
I will certainly be watching it again to check up
on my basic skills.
I would recommend this DVD to any
ACPWH members who want to revise this
subject.
Caroline de Chair Gill
Norfolk and Norwich University Trust Hospital
Norwich
For the inexperienced practitioner, or for those
returning to work, this is a comprehensive and
informative guide to the manual skills needed for
the physical examination of the pelvis and the
hip.
The logical progression and well-defined order
of the chapters makes the information easy to
follow and the techniques easily reproducible.
The practitioners clearly demonstrate common
techniques at a fundamental level, while reinforcing
the need for treatment to be clinically
reasoned and patient-orientated.
However, the graphics and overall presentation
of Practical Techniques of Physiotherapy
Examination and Treatment, Vol. 2: The Pelvis
and Hip could have been enhanced to improve
the learning experience. The visual learning tools
were a little dated and, although adequate, uninspiring.
Better use of computer graphics could
have been made to show the relationships of the
joints to one another, and to put the techniques
in context.
There is an opportunity to make use of the
workbooks on the Internet, which allows for
interactive learning, and this definitely enhances
Book and DVD reviews
the learning experience and will assist greatly
with CPD.
Although it is no substitute for ‘hands on’
practice, this production would support and
complement prior learning for students and
practitioners alike, and would be a useful tool to
review basic knowledge and skills.
Lucy Craig
Norfolk and Norwich University Trust Hospital
Norwich
Practical Techniques of Physiotherapy
Examination and Treatment, Vol. 3: The
Cervical and Thoracic Spine
By Helen French, Karen McCreesh, Mark
Sexton, & Jeremy Walsh
Clinics in Motion, Dublin, 2005, interactive
DVD, £69.00
This DVD consists of 16 chapters that can be
selected individually from the main menu,
including sections on joint screening, surface
anatomy, active movement (including passive
physiological intervertebral motions and passive
accessory intervertebral motions), neurological
examination, treatment techniques and exercise
prescription. Each chapter consists of a variable
number of sub-chapters that can also be selected
individually.
The style of Practical Techniques of Physiotherapy
Examination and Treatment, Vol. 3:
The Cervical and Thoracic Spine is that of an
informal lecture delivered in your living room.
Repeated references are made to possible
variations between individual patients and the
importance of relating findings to the subjective
examination. Care is taken to ensure safety in all
aspects of assessment and treatment (e.g. cervical
vascular insufficiency, overpressure indications
and contraindications, and ergonomic advice for
the physiotherapist).
The DVD provides only a general anatomical
description, but this is appropriate for the aims
of the production. It also assumes knowledge of
the principles of assessment, and concepts such
as irritability and quadrants of movement. All
sections are of an appropriate length; for
example, there is a brief discussion of clearing
other joints, but there are prudent caveats about
when a more detailed examination would be
indicated.
Careful explanation and demonstration of
techniques is enhanced by ‘Multi-Angle
Vision’. This function enables the viewer to
2007 Association of Chartered Physiotherapists in Women’s Health 89

Book and DVD reviews
access a split screen demonstrating the technique
from another angle and/or performed on a skeleton.
This would be invaluable if you were to
practice techniques at the same time as they are
being demonstrated. Useful tips for checking
bony palpation are included.
Overall, this is an excellent learning device
with clear explanations and demonstrations of
an entire cervical and/or thoracic assessment,
advice about treatments, and a relevant case
study. Although several different tutors demonstrate
the techniques, any inconsistencies
between models are easily overcome. It is a good
90
revision aid for an experienced physiotherapist,
and an effective way to study teaching methods
and fine-tune specific techniques. It is difficult to
take in the DVD in its entirety: I felt that it
would be better used as a modular learning aid,
with the viewer choosing particular areas and
techniques to review. The basics are covered for
each technique, ensuring correct application and
meaning that each chapter can stand alone.
Clair Jones
Norfolk and Norwich University Trust Hospital
Norwich
2007 Association of Chartered Physiotherapists in Women’s Health

Journal of the Association of Chartered Physiotherapists in Women’s Health, Spring 2007, 100, 91–94
Website watch
The first four websites described in this article
are ones that I have been asked to review by
members (the remaining two were mentioned at
Conference 2006). Please do keep sending me
links to sites that you think might be interesting
for others. There is so much information on the
World Wide Web that it is good to narrow down
the search by referring to a review. My e-mail
address is .
www.breastfeeding.nhs.uk
I liked this website very much and feel it would
be useful to all new mothers. It is simple, clear
and unfussy, containing good information in a
very easily understood format. A link from the
homepage takes you to a section entitled ‘About
breastfeeding’ that lists a few introductory facts
about breast-feeding and has a menu divided
into ‘How to breastfeed’, sections ‘For mums’
and ‘For health professionals’, and ‘Questions
and answers’. ‘How to breastfeed’ has an excellent
series of pictures showing how best to sit
and position the baby, with clear stages of how
to get a child to open her or his mouth and
correctly latch on, how it should feel when the
baby is correctly on the breast, and reassurance
that it may not work first time, but to take baby
off and repeat the process until you both succeed.
The pictures are backed up by captions,
but even if a user’s English was poor or nonexistent,
I still think it would be possible to
understand this section.
The ‘For mums’ section contains common
questions asked about breast-feeding, along with
good, comprehensive answers and a seven-page
directory of breast-feeding resources, with lists
of books and leaflets by such organizations as
the United Nations Children’s Fund (UNICEF),
the National Childbirth Trust (NCT) and the
Leleche League. The titles cover all areas of
breast-feeding and weaning, as well as the feeding
of infants. Some are specifically for health
professionals.
There is also a section on weaning on the site.
This has another series of pictures and captions,
and two downloadable booklets in a printable
format, one on weaning and one on bottle-feeding.
A very good area tells the stories of six
women’s experiences of breast-feeding. I particu-
larly liked the way that they had chosen a
selection of primigravidae and multigravidae,
single and multiple pregnancies, and different
ages and races, addressing the resistance that
may come from family or friends, or the social or
economic situation in which a woman may find
herself. I felt that reading about some women’s
experiences in this way would give others confidence
and reassurance that breast-feeding would
be worth a try.
I hate to admit that it is over 32 years now
since I began breast-feeding our first baby, but I
still remember how difficult I found it at first. It
was not the ‘fashion’ to feed at that time, but my
determination to do it, and my mother’s reassurance
and help – because she had successfully
fed – got me going. The health professionals told
me to bottle-feed because it was ‘easier’, which
seems unbelievable now! Had there been such a
thing then, I am sure I would have found this
website a boon and a reassurance to be returned
to regularly during the early years of feeding that
first child. Use this site yourself if you are
expecting your first baby, or recommend it to
patients, friends and family.
www.1in3women.co.uk
This website is designed by Eli Lilly and was
launched this year. It is intended for women
suffering from urinary incontinence (UI), giving
advice on the different types of UI, the treatments
available, and how to approach your
general practitioner (GP) or nurse for help. All
the information is downloadable in a printable
format. From the homepage, a menu leads you
to a description of the symptoms, prevalence and
causes of stress UI (SUI). There is a diagram of
the anatomy of the bladder, urethra and pelvic
floor, but the labelling could have been made
clearer. Later in the text, there is a reference to
‘the bladder muscle’, but I am not sure that a lay
person would understand that this refers to the
muscle of the bladder wall. However, I could not
get a printout of the information on SUI in
anything but a very small type, one probably
used so that the information fitted onto a single
page of A4, but very difficult for those who have
a visually impairment. Of even more concern
was the fact that the questionnaire to be filled in
2007 Association of Chartered Physiotherapists in Women’s Health 91

Website watch
and taken to your doctor or nurse to help with a
diagnosis, or to get over the embarrassment of
having to discuss your symptoms, was also in
very small print, whereas the information on
mixed UI and overactive bladder was in very
large type. This inconsistency is strange.
There is a section on the ‘real life’ experience
of a 47-year-old woman with SUI, and I was
delighted to read that she improved her symptoms
with pelvic floor muscle exercises, Pilates
and maintaining a healthy weight. Rather cynically,
I had expected drug treatments to have
been recommended first, given the owners of the
website. There is an area detailing the different
treatments that are available, conservative treatment
being given the largest share of the coverage.
Pelvic floor muscle exercises are mentioned,
but there are no detailed instructions on how to
do them. Also mentioned are vaginal cones and
electromagnetic (?) stimulation, but again, with
no accompanying details as to what they are,
how they work, or who would be able to advise
a woman or give treatment. Medications are
mentioned, but not explained, as are surgical
options. There follows a list of frequently asked
questions and answers that may be useful, but
best of all are the links to the websites and phone
numbers for Incontact and the Continence
Foundation.
On the whole, I felt that this was too superficial
to be a good resource for patients. The
Continence Foundation has such a good website
with excellent, detailed advice and explanations,
and extremely good downloadable and printable
leaflets, why would you bother with this one? I
suppose the questionnaire to be filled in and
taken to the GP is a good idea, but I hope all
concerned have good enough eyesight to read it!
www.motherhood.org.uk
This site belongs to the Forum for Maternity
and the Newborn, which is part of the Royal
Society of Medicine (RSM). It is designed to give
information to members and guests on future
meetings of the Forum, as well as information
on past meetings and topics discussed. The meetings
are held five times a year at the RSM
headquarters in Wimpole Street, and are generally
2.5-h-long evening meetings, although there
are some whole-day seminars. These meetings
are free to members and usually take the format
of a presentation with a discussion afterwards.
Members are typically midwives, GPs, obstetricians,
physiotherapists, psychologists, health
92
visitors, paediatricians and neonatal nurses, as
well as members of the NCT, the Association for
Improvements in the Maternity Services and
others, so this forum is a broad interest group.
The website is fairly basic, with the usual list
of who’s who, the address, phone and fax numbers
of the RSM, and an e-mail link. The coming
meetings are advertised and those in London, or
anyone else with easy access, should keep an eye
on what is coming up since I think the topics
look very interesting. I am afraid the website
does not explain how to become a member, but
no doubt, an e-mail or a phone call will produce
that information.
The links area, unfortunately, does not appear
to work, or did not while I was doing my
research or today as I wrote this.
The best bit of the site for me was the long
list of previous topics from the past few years,
and from most recent years, full reports and
abstracts of meetings. These make excellent
reading and I will now make a regular habit of
returning to the site to read these. There is a lot
of information and it will take me a while to
work my way through, but it is very informative
indeed.
www.pushymothers.com
Pushy Mothers (see also p. 54) is a new exercise
system designed for pregnant and postnatal
women by pregnancy and postnatal fitness professionals.
It offers a one-hour buggy workout,
although, sadly, it is only available in London
at present. What a great idea it is and I do hope
that more people will train and take it countrywide.
The exercise sessions are arranged in various
London parks and a 3-min demonstration
video is available on the site to give a taste
of what a session involves. The sessions are
designed to help mothers get back to fitness
under the supervision of a well-trained instructor,
with the added benefit of being out in the
fresh air, having baby with you, meeting other
mums, and one would hope, making new
friends. It looks much more fun than going to
the gym and putting baby in a crèche!
The class workout includes cardiovascular
activities to burn off the extra adipose tissue
after pregnancy, stretches and toning, and core
stability for a healthier back, firmer abdominal
and pelvic floor muscles. The joining fee is £15,
for which you get a Pushy Mothers tote bag,
exercise band, exercise booklet and discount
vouchers for Ocado (the Waitrose delivery
2007 Association of Chartered Physiotherapists in Women’s Health

service), Sweaty Betty sports clothing (15% on
purchases of £90 or more!) and Running Needs
(only in London). There are 16 people in a class
and you must commit to at least four classes,
which are booked in advance.
Pushy Mothers was the brainchild of
Rachel Berg, who was a professional dancer and
then became a fitness instructor and personal
trainer specializing in pregnancy and postnatal
fitness. She has a lot of impressive experience,
as does her business partner, Judy DiFiore, who
has written a book called The Complete Guide to
Postnatal Fitness, and is one of the founding
members of the Guild of Pregnancy and Postnatal
Exercise Instructors and a qualified Pilates
instructor. Both are mothers, and so have firsthand
knowledge and have practiced what they
preach.
Within the website, there is all the information
needed to join, as well as a ‘Pushy Bloggers’
section containing news of events and a very
good section of advice for safe postnatal exercise.
I particularly liked the advice to have your
feet measured and a new pair of trainers fitted
after pregnancy because of the changes that may
have occurred to your feet during pregnancy.
How many postnatal women would have given
that a thought? It is also possible to find out how
to become an instructor, and I was pleased to see
that anyone interested would need to have an
existing ante- or postnatal exercise qualification,
although they are happy to arrange this as extra
training if necessary.
Inevitably, Pushy Mothers is London-based at
present and primarily has a middle-class appeal,
but it is a very good idea, and I wish them well
and hope it catches on.
www.ssha.info
During her very interesting, if rather gruesome,
Conference talk and slideshow on sexually transmitted
infections (STIs) and what to look for,
Linda Furness, health advisor for the Cardiff
and Vale National Health Service (NHS) Trust,
gave us this website reference. The Society of
Sexual Health Advisors (SSHA) is the professional
organization for health advisors working
in departments of genito-urinary medicine
and sexual health. Sexual health advisors do not
need to have a core qualification, but generally
come from a variety of professional backgrounds,
including nursing, health visiting and
social work. Training courses are run by various
educational establishments and there are now
Website watch
350 sexual health advisors in the country. Clinics
vary in what they have to offer, but commonly
include treatment, partner notification/contact
tracing, sexual health promotion, teaching and
training, counselling, as well as research and
audit.
Although this website is primarily for members,
it does also include a very good public
education section. This is a rich source of information
on STIs. There are at least 25 of these
infections, and there is detailed information on
15 of the commoner varieties. The introduction
with general information on STIs and good
sexual health advice is followed by details of
specific infections with descriptions of symptoms,
how common they are, how they are
passed on, the treatment necessary and good
practice. Some of the conditions mentioned are
not actual STIs, but symptoms can be very
worrying and it is reassuring to know that many
can be treated easily if caught early. There are a
few pictures of symptoms of the conditions for
ease of identification.
This website is a very useful resource for both
patients and healthcare professionals.
www.homebirth.org.uk/marycronk
Mary Cronk MBE gave the Margie Polden
Memorial Lecture at Conference and I found her
talk very interesting (see p. 39). She emanated
such knowledge and enthusiasm for her subject,
and would instinctively inspire great confidence
in any woman who chose Mary as an independent
midwife for her pregnancy, birth and postnatal
care. I typed ‘Mary Cronk’ into Google
and found more than 20 references, although
only 10 were related to Mary the midwife. The
rest were for Mary Cronk Farrell, who would
seem to be a Catholic author of novels and texts,
and I don’t think this is the same person in
another guise! Mary describes herself on her
website as a mature midwife who has helped
birth 1600 babies! She worked in the NHS for 30
years, mainly as a domiciliary midwife specializing
in home births, but left in 1991 to become
an independent practitioner because it was increasingly
difficult to provide a woman-centred
service within the NHS. She will take on clients
within an hour’s drive of Chichester, West
Sussex, and offers antenatal care tailored to a
woman’s needs. She delivers the baby with the
woman at home, but can arrange honorary
contracts to deliver the baby in hospital within
her practice area if this is necessary or is what a
2007 Association of Chartered Physiotherapists in Women’s Health 93

Website watch
woman wants. She lists an e-mail contact and
telephone numbers on the site.
The links on the site are excellent, and cover
breech birth workshops for midwives (one of
Mary’s particular skills is the normal delivery of
breech babies, as she demonstrated with her talk
and PowerPoint presentation at Conference) and
her list of equipment for a home birth (what she
provides and what she requires the parents to
provide). This is such a sensible list and finishes
with ‘frequent cups of proper building site tea’ –
none of this Earl Grey or healthy herbal stuff for
Mary!
Her advice on what to expect if an unplanned
or emergency Caesarean section should be necessary
would be a good preparatory read for any
94
ACPWH polo shirts
Following their re-launch at Conference
2003, the ever-popular ACPWH polo
shirts are on sale:
+ Easy-care Pique polo
+ Twin-needle stitching to sleeves and
hems
+ 50% cotton, 50% polyester
+ Navy blue or white
+ ACPWH badge and initials
embroidered on left side of chest
+ Sizes (bust)=32$, 34$, 36$, 38$, 40$,
42$
+ Price £10.50 (including P&P per shirt).
Cheques payable to ‘ACPWH’.
For further information, e-mail:
robertsonco@btinternet.com
or send your orders to:
Sue Davies
34 Exeter Road
Mapesbury
London NW2 4SB
pregnant woman and her partner, and her notes
for women expecting twins are extremely helpful.
Do have a look at Mary’s website and at other
references to her on Google. There is some very
interesting and encouraging information. I will
certainly remember it for advice when/if I am an
expectant grandmother, although I don’t think
Mary will be able to attend my daughter who
lives in New Zealand! (I am reassured, though,
because I have it on good authority that maternity
care is very much more woman-centred
there.) What a shame that so many of our
midwives here have become ‘de-skilled’ because
of the prevailing system in the NHS.
Jenny Kinahan
2007 Association of Chartered Physiotherapists in Women’s Health

Journal of the Association of Chartered Physiotherapists in Women’s Health, Spring 2007, 100, 95–96
Notes and news
Distinguished Service Award
It is my pleasure to inform you that Jane
Goudge has been awarded the Distinguished
Service Award by the Chartered Society of
Physiotherapy for her services to women’s health
over 30 years.
Ros Thomas
Dame Josephine Barnes Bursary
Dame Josephine Barnes was a former president
of our association (1977–1995). The bursary was
started through her generosity and is now owned
by the ACPWH. It is used for educational and
research needs, and for promoting women’s
health and continence in this country and
abroad. The bursary is topped up each year by
any profit from the Annual Conference. Up to
£2000 will be made available per year for this
award and this amount will be reviewed every
2 years by the executive committee.
The following constitutes the policy and criteria
for the Dame Josephine Barnes Bursary.
Jeanette Haslam
Chairman
Education subcommittee
Use of the bursary
The bursary will be made available for use in the
following ways:
(1) Part-funding of courses:
(a) to help towards subsidizing up to four
places on the validated university courses
which are recognized by ACPWH as a
route to membership of the Association
[In order to qualify for this assistance,
the candidate must be a member or
affiliate member of the ACPWH and will
be required to pledge a further year’s
membership on completion of the
course. The maximum amount granted
will be £250.00 (12.5% of the annual
sum).];
(b) to part-fund places on other appropriate
courses/conferences in this country or
abroad; and
(c) to give financial help to those doing a
Master’s degree relevant to women’s
health and continence.
(2) The development of research in women’s
health and continence:
(a) to give funding towards research projects
relevant to women’s health and
continence;
(b) to fund/part-fund a course that would
enable a project or a piece of research to
be undertaken;
(c) to encourage evidence-based practice; for
example, an ACPWH annual workshop
on how to get started with a research
project (this would be at the members’
request); and
(d) to promote a project nationally for the
benefit of physiotherapists working in
women’s health or continence; for
example, standardized outcome measures
or research organized country-wide
(i.e. small groups bringing information
to a central point).
(3) Directive of the Association:
(a) fund an issue that emerges from the
discussion groups at the Annual Conference
that the members consider needs
addressing; and
(b) enable members to travel abroad where
they would be acting as an ambassador
for the ACPWH, and also promoting
women’s health and/or continence.
Criteria for selection
All 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 or
unsuccessful, including any employer’s contribution,
i.e. study leave;
+ give concise reasons for application, explaining
the benefits to women’s health, the
Association, the patient and/or physiotherapy
generally;
+ provide a curriculum vitae;
+ explain the relevance to the applicant’s career
development and future continuing professional
development;
+ provide a precise breakdown of expected
expenses, i.e. course fees, travel and subsistence;
2007 Association of Chartered Physiotherapists in Women’s Health 95

Notes and news
+ seek the cheapest travel and accommodation
(within reasonable limits, i.e. block travel
bookings by agreed carriers, block hotel
bookings, APEX and cheap return tickets);
+ provide evidence of adequate insurance cover
when travelling abroad;
+ provide a précis of the course content or
research project, or an abstract of the lecture
or poster presentation;
+ provide evidence of acceptance on the course
or an invitation to speak;
+ agree to write up their work for the ACPWH
Journal; and
+ submit the application before the agreed
deadline.
Application forms are available from the current
ACPWH secretary (see the address on the
inside front cover of the Journal). Applications
will be considered every 6 months and must be
submitted before the closing date, which will be
published in the Journal or by application to
the ACPWH secretary. Applications – whether
single or as a group – can be retrospective or
anticipatory, and should be returned to the
ACPWH secretary.
The implementation of the awards will be
overseen by a small group from the executive
and the education subcommittee that will
include the ACPWH chairperson and treasurer.
The next closing date is 1 July 2007.
Anne Bird Prize
The Anne Bird Prize commemorates the life
of Anne Bird, chairman of the Association of
Chartered Physiotherapists in Obstetrics and
Gynaecology from 1985 to 1988, by encouraging
those qualities which she herself valued. It will
normally be awarded annually to individuals
who show overall excellence, professionalism
and empathy in their educational development
within the ACPWH, and who also make a
special contribution to an ACPWH postregistration
course or to physiotherapy in
women’s health.
Nominations are invited for the Anne Bird
Prize for this year. Each nominee must be nominated
by three people, one of whom must be an
ACPWH member. Nominations must be confidential.
Forms are available from the ACPWH
secretary (see address on the inside front cover),
96
and completed nominations must be received by
1 July 2007.
Ann Johnson was the winner of the Anne Bird
Prize 2006. Ann has been an active member of
ACPWH for many years, her roles including
book and leaflet secretary, secretary, and most
recently, area representative for Yorkshire. She
is also a tutor for the University of Bradford
Postgraduate Certificate in Women’s Health.
Amongst her numerous attributes, Ann is
tremendously enthusiastic, hard-working and
cheerful. She more than fulfils the criteria for the
Prize, and exemplifies the excellence and professionalism
that the ACPWH encourages. The
award also recognizes ‘a special contribution to
an ACPWH post-registration course’, which – as
a student – Ann demonstrated as an excellent
tutor group leader, and continues to do – from
the other side of the fence – as a course tutor.
Ann is always willing to share her knowledge,
and her contribution to any project is given
enthusiastically and always thoroughly undertaken.
She is measured and fair in her responses
and opinions, and therefore, greatly respected by
her colleagues and peer group.
Ann never seeks personal reward and was the
last person to have expected this award, as was
evident by the shock she had when I announced
the winner. It gave me enormous pleasure to
present Ann with her well-deserved prize.
Ros Thomas
World Physical Therapy 2007
The 15 th International Congress of the World
Confederation of Physical Therapy (WCPT) will
be held in Vancouver, Canada, from 2 to 6 June
2007, hosted by the Canadian Physiotherapy
Association.
Many internationally known and respected
speakers will lecture during the Congress on
issues concerning practice, research, education
and management. Physiotherapists will have an
unparallelled opportunity to access a huge range
of international expertise under one roof.
The programme is both stimulating and
thought-provoking, and if you think you would
like to attend, further details can be found on
the WCPT website or
e-mail .
2007 Association of Chartered Physiotherapists in Women’s Health

Journal of the Association of Chartered Physiotherapists in Women’s Health, Spring 2007, 100, 97
Letter
Madam,
Re: The Urgent PC Neuromodulation System
I am writing to express my concern about the
Urgent PC Neuromodulation System distributed
by Uroplasty Ltd.
The technology of sacral afferent nerve stimulation
(SANS) or percutaneous tibial nerve
stimulation (PTNS) has been known for some
considerable time (Govier et al. 2001), and indeed,
there have been other units in circulation
(Klinger et al. 2000), although it would never
seem to have successfully ‘taken off’ as a routine
treatment for overactive bladder.
My concern is that, unless we are acupuncture
trained (and I am aware that many of our
members are), we will be working outside our
scope of practice in using this equipment. The
company does not provide training to a certified
level of competence, and I would urge (!) members
to be cautious if they are considering the use
of this modality.
That said, it is always exciting to see new
products appearing on the market, and despite
its considerable expense, Jersey General Hospital
will be setting up a nurse-led clinic to trial the
Urgent PC Neuromodulation System for those
patients who have intractable urinary urge
incontinence.
Clare Jouanny
Urotherapy Clinic
WARC
Overdale Hospital
Westmount Road
St Helier
Jersey JE1 3UN
Channel Islands
E-mail: c.jouanny@health.gov.je
References
Govier F. E., Litwiller S., Nitti V., Kreder K. J., Jr &
Rosenblatt P. (2001) Percutaneous afferent neuromodulation
for the refractory overactive bladder: results of a
multicenter study. Journal of Urology 165 (4), 1193–1198.
Klinger H. C., Pycha A., Schmidbauer J. & Marberger M.
(2000) Use of peripheral neuromodulation of the S3
region for treatment of detrusor overactivity: a
urodynamic-based study. Urology 56 (5), 766–771.
2007 Association of Chartered Physiotherapists in Women’s Health 97

Journal of the Association of Chartered Physiotherapists in Women’s Health, Spring 2007, 100, 98–104
Papers in other journals
Compiled by Becky Aston, Gill Brook, Roberta Eales, Helen Forth, Rachel Grubb,
Georgie Gulliford and Jo Whitehead
Bowel dysfunction
Faltin D. L., Otero M., Petignat P., et al. (2006)
Women’s health 18 years after rupture of the
anal sphincter during childbirth: I. Fecal
incontinence. American Journal of Obstetrics
and Gynecology 194 (5), 1255–1259.
Gregory W. T., Hamilton Boyles S., Simmons
K., Corcoran A. & Clark A. L. (2006) External
anal sphincter volume measurements using
3-dimensional endoanal ultrasound. American
Journal of Obstetrics and Gynecology 194 (5),
1243–1248.
Mahoney R. & O’Herlihy C. (2006) Recent
impact of anal sphincter injury on overall
Caesarean section incidence. Australian and
New Zealand Journal of Obstetrics and Gynaecology
46 (3) 202–204.
Nichols C. M., Nam M., Ramakrishnan V.,
Lamb E. H. & Currie N. (2006) Anal sphincter
defects and bowel symptoms in women with
and without recognized anal sphincter
trauma. American Journal of Obstetrics and
Gynecology 194 (5), 1450–1454.
Otero M., Boulvain M., Bianchi-Demicheli F.,
et al. (2006) Women’s health 18 years after
rupture of the anal sphincter during childbirth:
II. Urinary incontinence, sexual function,
and physical and mental health.
American Journal of Obstetrics and Gynecology
194 (5), 1260–1265.
Soligo M., Salvatore S., Emmanuel A. V., et al.
(2006) Patterns of constipation in urogynecology:
clinical importance and pathophysiologic
insights. American Journal of Obstetrics and
Gynecology 195 (1), 50–55.
Bladder dysfunction
Amaro J. L., Gameiro M. O., Kawano P. R. &
Padovani C. R. (2006) Intravaginal electrical
stimulation: a randomized, double-blind
study on the treatment of mixed urinary
incontinence. Acta Obstetricia et Gynecologica
Scandinavica 85 (5), 619–622.
Atala A., Bauer S. B., Soker S., Yoo J. J. &
Retik A. B. (2006) Tissue-engineered autologous
bladders for patients needing cystoplasty.
Lancet 367 (9518), 1241–1246.
Brubaker L., Chapple C., Coyne K. S. & Kopp
Z. (2006) Patient-reported outcomes in over-
98
active bladder: importance for determining
clinical effectiveness of treatment. Urology 68
(2, Suppl. 1), 1–48.
Burgio K., Locher J. L., Goode P. S., Locher
J. L. & Roth D. L. (2006) Global ratings
of patient satisfaction and perceptions of
improvement with treatment for urinary
incontinence: validation of three global
patient ratings. Neurourology and Urodynamics
25 (5), 411–417.
Cardozo L. (2006) Duloxetine in the context of
current needs and issues in treatment of
women with stress urinary incontinence.
BJOG: An International Journal of Obstetrics
and Gynaecology 113 (Suppl. 1), 1–4.
Coyne K. S., Matza L. S., Thompson C. L.,
Kopp Z. S. & Khullar V. (2006) Determining
the importance of change in the overactive
bladder questionnaire. Journal of Urology 176
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Dalpiaz O. & Curti P. (2006) Role of perineal
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25 (4), 301–306.
Daneshgari F., Moore C., Frinjari H. &
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Dietz H. P., Hyland G. & Hay-Smith J. (2006)
The assessment of levator trauma: a comparison
between palpation and 4D pelvic floor
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(5), 424–427.
Dong D., Xu Z., Shi B., et al. (2006) Urodynamic
study in the neurogenic bladder dysfunction
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Neurourology and Urodynamics 25 (5), 446–
450.
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surgery. BJOG: An International Journal of
Obstetrics and Gynaecology 113 (Suppl. 1),
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Durufle A., Petrilli S., Nicolas B., et al. (2006)
Effects of pregnancy and child birth on urinary
symptoms and urodynamics in women
with multiple sclerosis. International Urogynecology
Journal 17 (4), 352–355.
2007 Association of Chartered Physiotherapists in Women’s Health

Ellis-Jones J., Swithinbank L. & Abrams P.
(2006) The impact of formal education and
training on urodynamic practice in the United
Kingdom: a survey. Neurourology and Urodynamics
25 (5), 406–410.
FitzGerald M. P., Mulligan M. & Parthasarathy
S. (2006) Nocturic frequency is related to
severity of obstructive sleep apnea, improves
with continuous positive airways treatment.
American Journal of Obstetrics and Gynecology
194 (5), 1399–1403.
Freeman R. M. (2006) Initial management of
stress urinary incontinence: pelvic floor muscle
training and duloxetine. BJOG: An International
Journal of Obstetrics and Gynaecology
113 (Suppl. 1), 10–16.
Goldberg R. P., Sand P. K. & Beck H. (2005)
Early-stage ovarian carcinoma presenting
with irritative voiding symptoms and urge
incontinence. International Urogynecology
Journal 16 (5), 342–344.
Goldberg R. P. & Sand P. K. (2006) Electromagnetic
pelvic floor stimulation for urinary incontinence
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Urogynecology Journal 16 (5), 401–404.
Kenton K., Mahajan S., FitzGerald M. P. &
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function in the striated urethral
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Gynecology 194 (5), 1434–1437.
Kim J. C., Park E. Y., Seo S. I., Park Y. H. &
Hwang T.-K. (2006) Nerve growth factor and
prostaglandins in the urine of female patients
with overactive bladder. Journal of Urology
175 (5), 1773–1776.
McClurg D., Ashe R. G., Marshall K. & Lowe-
Strong A. S. (2006) Comparison of pelvic floor
muscle training, electromyography biofeedback,
and neuromuscular electrical stimulation
for bladder dysfunction in people with
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Neurourology and Urodynamics 25 (4), 337–
348.
Melville J. L., Katon W., Delaney K. & Newton
K. (2006) Urinary incontinence in US women.
A population-based study. Journal of Urology
175 (5), 1800.
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(2006) Construct validity of the Incontinence
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25 (5), 418–423.
Oelke M., Roovers J.-P. W. R. & Michel M. C.
(2006) Safety and tolerability of duloxetine in
women with stress urinary incontinence.
BJOG: An International Journal of Obstetrics
and Gynaecology 113 (Suppl. 1), 22–26.
Oh S. J. & Ku J. H. (2006) Does conditionspecific
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Papers in other journals
health-related quality of life and objective
incontinence severity in women with stress
urinary incontinence? Neurourology and Urodynamics
25 (4), 324–329.
Patel D. A., Xu X., Thomason A. D., et al.
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Journal of Obstetrics and Gynecology 195
(1), 23–28.
Patki P., Woodhouse J., Hamid R., Shah J. &
Craggs M. (2006) Lower urinary tract dysfunction
in ambulatory patients with incomplete
spinal cord injury. Journal of Urology
175 (5), 1784–1787.
Pauwels E., De Laet K., De Wachter S. &
Wyndaele J.-J. (2006) Healthy, middle-aged,
history-free, continent women – do they strain
to void? Journal of Urology 176 (4), 1403–1407.
Pfisterer M. H.-D., Griffiths D. J., Rosenberg L.,
Schaefer W. & Resnick N. M. (2006) The
impact of detrusor overactivity on bladder
function in younger and older women. Journal
of Urology 175 (5), 1777–1783.
Reid G. & Bruce A. W. (2006) Probiotics to
prevent urinary tract infections: the rationale
and evidence. World Journal of Urology 24 (1),
28–32.
Rortveit G. & Hunskaar S. (2006) Urinary
incontinence and age at the first and last
delivery: the Norwegian HUNT/EPINCONT
study. American Journal of Obstetrics and
Gynecology 195 (2), 433–438.
Savaris R. F., Teixeira L. M. & Torres T. G.
(2006) Bladder tenderness as a physical sign
for diagnosing cystitis in women. International
Journal of Gynecology and Obstetrics 93 (3),
256–257.
Schuessler B. (2006) What do we know about
duloxetine’s mode of action? Evidence from
animals to humans. BJOG: An International
Journal of Obstetrics and Gynaecology 113
(Suppl. 1), 5–9.
Sinha D., Nallaswamy V. & Arunkalaivanan A.
S. (2006) Value of leak point pressure study in
women with incontinence. Journal of Urology
176 (1), 186–188.
Wein A. J. (2006) Voiding function and dysfunction,
bladder physiology and pharmacology,
and female urology. Journal of Urology 176
(1), 210–214.
Wein A. J. (2006) Voiding function and dysfunction,
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 symptoms:
the next major therapeutic revolution.
World Journal of Urology 24 (4), 371–377.
2007 Association of Chartered Physiotherapists in Women’s Health 99

Papers in other journals
Gynaecology
Abrams P., Baranowski A., Berger R. E., et al.
(2006) A new classification is needed for pelvic
pain syndromes – are existing terminologies
of spurious diagnostic authority bad for
patients? Journal of Urology 175 (6), 1989–
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Bø K. (2006) Can pelvic floor muscle training
prevent and treat pelvic organ prolapse? Acta
Obstetricia et Gynecologica Scandinavica 85
(3), 263–268.
Constantino S. Esposito F., Nadalini C., et al.
(2006) Ultrasound imaging of the female perineum:
the effect of vaginal delivery on pelvic
floor dynamics. Ultrasound in Obstetrics and
Gynecology 27 (2), 183–187.
Donnay F. & Ramsey K. (2006) Eliminating
obstetric fistula: progress in partnerships.
International Journal of Gynecology and
Obstetrics 94 (3), 254–261.
Elmusharaf S., Elhadi N. & Almroth L. (2006)
Reliability of self reported form of female
genital mutilation and WHO classification:
cross sectional study. British Medical Journal
333 (7559), 124–128.
Hsu Y., Summers A., Hussain H. K., Guire K.
E. & Delancey J. O. L. (2006) Levator plate
angle in women with pelvic organ prolapse
compared to women with normal support
using dynamic MR imaging. American Journal
of Obstetrics and Gynecology 194 (5), 1427–
1433.
Hundley A. F., Yuan L. & Visco A. G. (2006)
Skeletal muscle heavy-chain polypeptide 3 and
myosin binding protein H in the pubococcygeus
muscle in patients with and without
pelvic organ prolapse. American Journal of
Obstetrics and Gynecology 194 (5), 1404–1410.
Jelovsek J. E. & Barber M. D. (2006) Women
seeking treatment for advanced pelvic organ
prolapse have decreased body image and quality
of life. American Journal of Obstetrics and
Gynecology 194 (5), 1455–1461.
Juang C. M., Yen M. S., Twu N. F., et al. (2006)
Impact of pregnancy on primary dysmenorrhea.
International Journal of Gynecology and
Obstetrics 92 (3), 221–227.
Lorentto C., Petta C. A., Navarro M. J.,
Bahamondes L. & Matos A. (2006) Depression
in women with endometriosis with and
without chronic pelvic pain. Acta Obstetricia
et Gynecologica Scandinavica 85 (1), 88–92.
Moreira D. & Paula C. R. (2006) Vulvovaginal
candidiasis International Journal of Gynecology
and Obstetrics 92 (3), 266–267.
Price N., Jackson S. R., Avery K., Brookes S. T.
& Abrams P. (2006) Development and psychometric
evaluation of the ICIQ Vaginal
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BJOG: An International Journal of Obstetrics
and Gynaecology 113 (6), 700–712.
Price J., Farmer G., Harris J., et al. (2006)
Attitudes of women with chronic pelvic pain
to the gynaecological consultation: a qualitative
study. BJOG: An International Journal of
Obstetrics and Gynaecology 113 (4), 446–452.
Seehusen D. A., Johnson D. R., Earwood J. S.,
et al. (2006) Improving women’s experience
during speculum examinations at routine
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British Medical Journal 333 (7560), 171–173.
Seo J. T. & Kim J. M. (2006) Pelvic organ
support and prevalence by Pelvic Organ
Prolapse-Quantification (POP-Q) in Korean
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1772.
Simoes J. A., Discacciati M. G., Brolazo E. M.,
et al. (2006) Clinical diagnosis of bacterial
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and Obstetrics 94 (1), 28–32.
Siwe K., Wijma B. & Berterö C. (2006) ‘A
stronger and clearer perception of self.’
Women’s experience of being professional
patients in teaching the pelvic examination: a
qualitative study. BJOG: An International
Journal of Obstetrics and Gynaecology 113 (8),
890–895.
Sogaard M., Kjaer S. K. & Gayther S. (2006)
Ovarian cancer and genetic susceptibility in
relation to the BRCA1 and BRCA2 genes.
Occurrence, clinical importance and intervention.
Acta Obstetricia et Gynecologica Scandinavica
85 (1), 93–105.
Spencer C. & Pakarian F. (2006) The role of
childbirth in the aetiology of rectocele. BJOG:
An International Journal of Obstetrics and
Gynaecology 113 (7), 849–849.
Summers A., Winkel L. A., Hussain H. K. &
DeLancey J. O. L. (2006) The relationship
between anterior and apical compartment
support. American Journal of Obstetrics and
Gynecology 194 (5), 1438–1443.
Swift S. (2005) Pelvic organ prolapse: is it time to
define it? Severity of pelvic organ prolapse
associated with measurements of pelvic floor
function. International Urogynecology Journal
16 (6), 425–427.
Topcu S, Caliskan M., Gullu H., et al. (2006)
Do women with polycystic ovary syndrome
really have predisposition to atherosclerosis?
Australian and New Zealand Journal of Obstetrics
and Gynaecology 46 (2), 164–167.
Taylor A. W., Maclennan A. H. & Avery J.C.
(2006) Postmenopausal hormone therapy:
who now takes it and do they differ from
non-users? Australian and New Zealand
Journal of Obstetrics and Gynaecology 46 (2),
128–135.
2007 Association of Chartered Physiotherapists in Women’s Health

Woad K. J., Watkins W. J., Prendergast D. &
Shellin A. N. (2006) The genetic basis of
premature ovarian failure. International Journal
of Gynecology and Obstetrics 93 (2), 242–
244.
Woodman P. J., Swift S. E., O’Boyle A. L., et al.
(2006) Prevalence of severe pelvic organ prolapse
in relation to job description and socioeconomic
status: a multicenter cross-sectional
study. International Urogynecology Journal 17
(4), 340–345.
Gynaecological surgery
Alessandri F., Mistrangelo E., Lijoi D., Ferrero
S. & Ragni N. (2006) A prospective, randomized
trial comparing immediate versus delayed
catheter removal following hysterectomy.
Acta Obstetricia et Gynecologica Scandinavica
85 (6), 716–720.
Ankardal M., Heiwall B., Lausten-Thomsen N.,
Carnelid J. & Milsom I. (2006) Short- and
long-term results of the tension-free vaginal
tape procedure in the treatment of female
urinary incontinence. Acta Obstetricia et
Gynecologica Scandinavica 85 (8), 986–992.
Ayhan A., Esin S., Guven S., Salman C. &
Ozyuncu O. (2006) The Manchester operation
for uterine prolapse. International Journal of
Gynecology and Obstetrics 92 (3), 228–233.
Bakas P., Liapis A., Giner M. & Creatsas G.
(2006) Quality of life in relation to TVT
procedure for the treatment of stress urinary
incontinence. Acta Obstetricia et Gynecologica
Scandinavica 85 (6), 748–752.
Barber M. D., Walters M. D., Cundiff G. W. &
the PESSRI Trial Group (2006) Responsiveness
of the Pelvic Floor Distress Inventory
(PFDI) and Pelvic Floor Impact Questionnaire
(PFIQ) in women undergoing vaginal
surgery and pessary treatment for pelvic organ
prolapse. American Journal of Obstetrics and
Gynecology 194 (5), 1492–1498.
Carey M. P., Goh J. T., Rosamilia A., et al.
(2006) Laparoscopic versus open Burch colposuspension:
a randomised controlled trial.
BJOG: An International Journal of Obstetrics
and Gynaecology 113 (9), 999–1006.
Collinet P., Belot F., Debodinance F., et al.
(2006) Transvaginal mesh technique for pelvic
organ prolapse repair: mesh exposure
management and risk factors. International
Urogynecology Journal 17 (4), 315–320.
de Tayrac R., Deffieux X., Resten A., et al.
(2006) A transvaginal ultrasound study comparing
transobturator tape and tension-free
vaginal tape after surgical treatment of female
stress urinary incontinence. International Urogynecology
Journal 17 (5), 466–471.
Papers in other journals
Dumville J. C., Manca A., Kitchener H. C., et al.
(2006) Cost-effectiveness analysis of open colposuspension
versus laparoscopic colposuspension
in the treatment of urodynamic stress
incontinence. BJOG: An International Journal
of Obstetrics and Gynaecology 113 (9), 1014–
1022.
Engelsen I. B., Woie K. & Hordnes K. (2006)
Transcervical endometrial resection: longterm
results of 390 procedures. Acta Obstetricia
et Gynecologica Scandinavica 85 (1), 82–87.
Engh M. A. E., Otterlind L., Stjerndahl J. H. &
Lofgren M. (2006) Hysterectomy and incontinence:
a study from the Swedish national
register for gynecological surgery. Acta Obstetricia
et Gynecologica Scandinavica 85 (5),
614–618.
Ghanbari Z., Baratali B. H. & Mireshghi M. S.
(2006) Posterior intravaginal slingplasty
(infracoccygeal sacropexy) in the treatment of
vaginal vault prolapse. International Journal of
Gynecology and Obstetrics 94 (2), 147–148.
Ghezzi F., Serati M., Cromi A., et al. (2006)
Tension-free vaginal tape for the treatment of
urodynamic stress incontinence with intrinsic
sphincteric deficiency. International Urogynecology
Journal 17 (4), 335–339.
Giri S. K., Hickey J. P., Sil D., et al. (2006) The
long-term results of pubovaginal sling surgery
using acellular cross-linked porcine dermis
in the treatment of urodynamic stress incontinence.
Journal of Urology 175 (5), 1788–
1793.
Glavind K., Bjork J., Nohr M., Jaquet A. &
Glavind L. (2006) A prospective study on
whether a tension-free urethropexy procedure
affects the residual urine and flow up to 4
years after the operation. Acta Obstetricia et
Gynecologica Scandinavica 85 (8), 982–985.
Howden N. S., Zyczynski H. M., Moalli P. A.,
et al. (2006) Comparison of autologous rectus
fascia and cadaveric fascia in pubovaginal
sling continence outcomes. American Journal
of Obstetrics and Gynecology 194 (5), 1444–
1449.
Huang K. H., Kung F.-T., Liang H.-M. &
Chang S.-Y. (2005) Management of polypropylene
mesh erosion after intravaginal
midurethral sling operation for female stress
urinary incontinence. International Urogynecology
Journal 16 (6), 437–440.
Huebner M., Hsu Y. & Fenner D. E. (2006) The
use of graft materials in vaginal pelvic floor
surgery. International Journal of Gynecology
and Obstetrics 92 (3), 279–288.
Jordaan D. J., Prollius A., Cronjé H. S. & Nel
M. (2006) Posterior intravaginal slingplasty
for vaginal prolapse. International Urogynecology
Journal 17 (4), 326–329.
2007 Association of Chartered Physiotherapists in Women’s Health 101

Papers in other journals
Kitchener H. C., Dunn G., Lawton V., Reid
F., Nelson L. & Smith, A. R. B. (2006)
Laparoscopic versus open colposuspension –
results of a prospective randomised controlled
trial. BJOG: An International Journal of
Obstetrics and Gynaecology 113 (9), 1007–
1013.
Kleeman S., Vassallo B., Segal J., Hungler M. &
Karram M. (2006) The ability of history and a
negative cough stress test to detect occult
stress incontinence in patients undergoing surgical
repair of advanced pelvic organ prolapse.
International Urogynecology Journal 17 (1),
27–29.
Kueck A. S., Gossner G., Burke W. M. &
Reynolds R. K. (2006) Laparoscopic technology
for the treatment of endometrial cancer.
International Journal of Gynecology and
Obstetrics 93 (2), 176–181.
Kuuva N. & Nilsson C. G. (2006) Long-term
results of the tension-free vaginal tape operation
in an unselected group of 129 stress
incontinent women. Acta Obstetricia et Gynecologica
Scandinavica 85 (4), 482–487.
Mattox T. F., Moore S., Stanford E. J. & Mills
B. B. (2006) Posterior vaginal sling experience
in elderly patients yields poor results. American
Journal of Obstetrics and Gynecology 194
(5), 1462–1466.
Persson P., Wijma K., Hammar M. & Kjølhede
P. (2006) Psychological wellbeing after laparoscopic
and abdominal hysterectomy – a randomised
controlled multicentre study. BJOG:
An International Journal of Obstetrics and
Gynaecology 113 (9), 1023–1030.
Rutman M. P., Deng D. Y., Shah S. M., Raz S.
& Rodríguez L. V. (2006) Spiral sling salvage
anti-incontinence surgery in female patients
with a nonfunctional urethra: technique and
initial results. Journal of Urology 175 (5),
1794–1799.
Schraffordt Koops S. E., Bisseling T. M., Heintz
A. P. M. & Vervest H. A. M. (2006) The
effectiveness of tension-free vaginal tape
(TVT) and quality of life measured in women
with previous urogynecologic surgery: analysis
from The Netherlands TVT database. American
Journal of Obstetrics and Gynecology 195
(2), 439–444.
Seow K. M., Tsou C. T., Lin Y. H., et al. (2006)
Outcomes and complications of laparoscopically
assisted vaginal hysterectomy. International
Journal of Gynecology and Obstetrics
95 (1), 29–34.
Somigliana E., Ragni G., Infantino M., et al.
(2006) Does laparoscopic removal of nonendometriotic
benign ovarian cysts affect
ovarian reserve? Acta Obstetricia et Gynecologica
Scandinavica 85 (1), 74–77.
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Sung V. W., Weitzen S., Sokol E. R., Rardin C.
R. & Myers D. L. (2006) Effect of patient age
on increasing morbidity and mortality following
urogynecologic surgery. American Journal
of Obstetrics and Gynecology 194 (5), 1411–
1417.
Tincello D. G. (2006) Open or laparoscopic
colposuspension for stress incontinence: new
evidence too late? BJOG: An International
Journal of Obstetrics and Gynaecology 113 (9),
985–987.
Viereck V., Nebel M., Bader W., et al. (2006)
Role of bladder neck mobility and urethral
closure pressure in predicting outcome of tension
free vaginal tape (TVT) procedure. Ultrasound
in Obstetrics and Gynecology 28 (2),
214–221.
Vierhout M. E., Stoutjesdijk J. & Spruijt J.
(2006) A comparison of preoperative and
intraoperative evaluation of patients undergoing
pelvic reconstructive surgery for pelvic
organ prolapse using the pelvic organ prolapse
quantification system. International Urogynecology
Journal 17 (1), 46–49.
Wu J. M., Wells E. C., Hundley A. F., et al.
(2006) Mesh erosion in abdominal sacral colpopexy
with and without concomitant hysterectomy.
American Journal of Obstetrics and
Gynecology 194 (5), 1418–1422.
Male incontinence
Azzouzi A.-R., Fourmarier M., Desgrandchamps
F., et al. (2006) Other therapies for
BPH patients: desmopressin, anti-cholinergic,
anti-inflammatory drugs, and botulinum
toxin. World Journal of Urology 24 (4), 383–
388.
Kaplan S. A. (2006) Benign prostatic hyperplasia.
Journal of Urology 176 (3), 1061–1063.
Miscellaneous
Chan M. F. & Ko C. Y. (2006) Osteoporosis
prevention education programme for women.
Journal of Advanced Nursing 54 (2), 159.
Chen L., Hsu Y., Ashton-Miller J. A. &
DeLancey J. O. (2006) Measurement of the
pubic portion of the levator ani muscle in
women with unilateral defects in 3-d models
from MR images. International Journal of
Gynecology and Obstetrics 92 (3), 234–241.
Gilling-Smith C., Nicopoullos J. D. M.,
Semprini A. E. & Frodsham L. C. G. (2006)
HIV and reproductive care – a review of current
practice. BJOG: An International Journal
of Obstetrics and Gynaecology 113 (8), 869–
878.
Sambrook P. & Cooper C. (2006) Osteoporosis.
Lancet 367 (9527), 2010–2018.
2007 Association of Chartered Physiotherapists in Women’s Health

Swanton A., Iyer L. & Reginald P. W. (2006)
Diagnosis, treatment and follow up of women
undergoing conscious pain mapping for
chronic pelvic pain: a prospective cohort
study. BJOG: An International Journal of
Obstetrics and Gynaecology 113 (7), 792–796.
Trybulski J. (2006) Women and abortion: the
past reaches into the present. Journal of
Advanced Nursing 54 (6) 683.
van Brummen H. J., Bruinse H. W., van de Pol
G., Heintz A. P. M. & van der Vaart C. H.
(2006) Which factors determine the sexual
function 1 year after childbirth? BJOG: An
International Journal of Obstetrics and Gynaecology
113 (8), 914–918.
Voorham-van der Zalm P. J., Pelger R. C., van
Heeswijk-Faase I. C., et al. (2006) Placement
of probes in electrostimulation and biofeedback
training in pelvic floor dysfunction. Acta
Obstetricia et Gynecologica Scandinavica 85
(7), 850–855.
WHO Study Group on Female Genital Mutilation
and Obstetric Outcome et al. (2006)
Female genital mutilation and obstetric outcome:
WHO collaborative prospective study
in six African countries. Lancet 367 (9525),
1835–1841.
Obstetrics
Albert H. B., Godskesen M., Korsholm L. &
Westergaard J. G. (2006) Risk factors in
developing pregnancy-related pelvic girdle
pain. Acta Obstetricia et Gynecologica Scandinavica
85 (5), 539–544.
Alehagen S., Wijma B. & Wijma K. (2006) Fear
of childbirth before, during, and after childbirth.
Acta Obstetricia et Gynecologica Scandinavica
85 (1), 56–62.
Althaus J., Petersen S., Driggers R., et al. (2006)
Cephalopelvic disproportion is associated
with an altered uterine contraction shape in
the active phase of labor. American Journal of
Obstetrics and Gynecology 195 (3), 739–742.
Aukee P., Sundstrom H. & Kairaluoma M. V.
(2006) The role of mediolateral episiotomy
during labour. Analysis of risk factors for
obstetric anal sphincter tears. Acta Obstetricia
et Gynecologica Scandinavica 85 (7), 856–860.
Barau G., Robillard P.-Y., Hulsey T.C., et al.
(2006) Linear association between maternal
pre-pregnancy body mass index and risk of
caesarean section in term deliveries. BJOG:
An International Journal of Obstetrics and
Gynaecology 113 (10), 1173–1177.
Constantino S., Esposito F., Nadalini C., et al.
(2006) Ultrasound imaging of the female perineum:
the effect of vaginal delivery on pelvic
floor dynamics. Ultrasound in Obstetrics and
Gynecology 27 (2), 183–187.
Papers in other journals
de la Chapelle A., Cahrles M., Gleize V., et al.
(2006) Impact of walking epidural analgesia
on obstetric outcome of nulliparous women in
spontaneous labour. International Journal of
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Dodd J. M., Crowther C. A. & Robinson J. S.
(2006) Oral misoprostol for induction of
labour at term: randomised controlled trial.
British Medical Journal 332 (7540), 509–513.
Domingo C., Latorre E., Mirapeix R. M. &
Abad J. (2006) Snoring, obstructive sleep
apnea syndrome, and pregnancy. International
Journal of Gynecology and Obstetrics 93 (1),
57–59.
Drake E., Drake M., Bird J. & Russell R. (2006)
Obstetric regional blocks for women with MS:
a survey of UK experience. International Journal
of Obstetric Anesthesia 15 (2), 115–123.
Dresner M., Brocklesby J. & Bamber J. (2006)
Audit of the influence of body mass index on
the performance of epidural analgesia in
labour and the subsequent mode of delivery.
BJOG: An International Journal of Obstetrics
and Gynaecology 113 (10), 1178–1181.
Duncombe D., Skouteris H., Wertheim E. H.,
et al. (2006) Vigorous exercise and birth outcomes
in a sample of recreational exercisers: a
prospective study across pregnancy. Australian
and New Zealand Journal of Obstetrics and
Gynaecology 46 (4), 288–292.
Gherman R. B., Chauhan S., Ouzounian J. G.,
et al. (2006) Shoulder dystocia: the unpreventable
obstetric emergency with empiric management
guidelines. American Journal of
Obstetrics and Gynecology 195 (3), 657–672.
Habiba M., Kaminski M., Da Frè M., et al.
(2006) Caesarean section on request: a comparison
of obstetricians’ attitudes in eight
European countries. BJOG: An International
Journal of Obstetrics and Gynaecology 113 (6),
647–656.
Jerbi M., Hidar S., Ammar A. & Khairi H.
(2006) Predictive factors of vaginal birth after
cesarean delivery. International Journal of
Gynecology and Obstetrics 94 (1), 43–44.
Kudish B., Blackwell S., McNeeley S. G., et al.
(2006) Operative vaginal delivery and midline
episiotomy: a bad combination for the perineum.
American Journal of Obstetrics and
Gynecology 195 (3), 749–754.
Kung J., Swan A. V. & Arulkumaran S. (2006)
Delivery of the posterior arm reduces shoulder
dimensions in shoulder dystocia. International
Journal of Gynecology and Obstetrics 93 (3),
233–237.
Latthe P., Mignini L., Gray R., Hills R. & Khan
K. (2006) Factors predisposing women to
chronic pelvic pain: systematic review. British
Medical Journal 322 (7544), 749–755.
2007 Association of Chartered Physiotherapists in Women’s Health 103

Papers in other journals
Lund I., Lundeberg T., Lonnberg L. & Svensson
E. (2006) Decrease of pregnant women’s pelvic
pain after acupuncture: a randomized controlled
single-blind study. Acta Obstetricia et
Gynecologica Scandinavica 85 (1), 12–19.
Martin S. R. & Foley M. R. (2006) Intensive
care in obstetrics: an evidence-based review.
American Journal of Obstetrics and Gynecology
195 (3), 673–689.
Mazouni C., Porcu G., Bretelle F., et al. (2006)
Risk factors for forceps delivery in nulliparous
patients. Acta Obstetricia et Gynecologica
Scandinavica 85 (3), 298–301.
Mogren I. (2006) Perceived health, sick leave,
psychosocial situation, and sexual life in
women with low-back pain and pelvic pain
during pregnancy. Acta Obstetricia et Gynecologica
Scandinavica 85 (6), 647–656.
Nikkola E., Laara A., Hinkka S., et al. (2006)
Patient-controlled epidural analgesia in labor
does not always improve maternal satisfaction.
Acta Obstetricia et Gynecologica Scandinavica
85 (2), 188–194.
Poston L., Briley A., Seed P., et al. (2006)
Vitamin C and vitamin E in pregnant women
at risk for pre-eclampsia (VIP trial): randomised
placebo-controlled trial. Lancet 367
(9517), 1145–1154.
Robinson H. S., Eskild A., Heiberg E. &
Eberhard-Gran M. (2006) Pelvic girdle pain in
pregnancy: the impact on function. Acta
Obstetricia et Gynecologica Scandinavica 85
(2), 160–164.
Rost C. C. M., Jacqueline J., Kaiser A., Verhagen
A. P. & Koes B. W. (2006) Prognosis of
women with pelvic pain during pregnancy: a
long-term follow-up study. Acta Obstetricia et
Gynecologica Scandinavica 85 (7), 771–777.
Sanders J., Campbell R. & Peters T. J. (2006)
Effectiveness and acceptability of lidocaine
spray in reducing perineal pain during spontaneous
vaginal delivery: randomised con-
104
trolled trial. British Medical Journal 333
(7559), 117–119.
Saunders T. A., Stein D. J. & Dilger J. P. (2006)
Informed consent for labour epidurals: a
survey of Society for Obstetrics Anaesthesia
and Perinatology anesthesiologists from the
United States. International Journal of Obstetric
Anesthesia 15 (2), 98–103.
Thorsen P., Vogel I., Molsted K., et al. (2006)
Risk factors for bacterial vaginosis in pregnancy:
a population-based study on Danish
women. Acta Obstetricia et Gynecologica
Scandinavica 85 (8), 906–911.
Vacca A. (2006) Vacuum-assisted delivery: an
analysis of traction force and maternal and
neonatal outcomes. Australian and New
Zealand Journal of Obstetrics and Gynaecology
46 (2) 124–127.
Viereck V., Nebel M., Bader W., et al. (2006)
Role of bladder neck mobility and urethral
closure pressure in predicting outcome of tension
free vaginal tape (TVT) procedure. Ultrasound
in Obstetrics and Gynecology 28 (2),
214–221.
Williams M. K. & Chames M. C. (2006) Risk
factors for the breakdown of perineal laceration
repair after vaginal delivery. American
Journal of Obstetrics and Gynecology 195 (3),
755–759.
Yu C. K. H., Teoh T. G. & Robinson S. (2006)
Obesity in pregnancy. BJOG: An International
Journal of Obstetrics and Gynaecology 113
(10), 1117–1125.
Sexual health
Brubaker L. (2006) Partner dyspareunia (hispareunia).
[Editorial.] International Urogynecology
Journal 17 (4), 311.
Møller L. A. & Lose G. (2006) Sexual activity
and lower urinary tract symptoms. International
Urogynecology Journal 17 (1), 18–21.
2007 Association of Chartered Physiotherapists in Women’s Health

Journal of the Association of Chartered Physiotherapists in Women’s Health, Spring 2007, 100, 105
Reading list
The list printed below has been compiled at the
request of ACPWH members and is for your
benefit. It is not comprehensive, but is correct
to the best of our knowledge at the time of
going to press. The inclusion of any title in this
list does not necessarily imply endorsement by
the ACPWH. It will be amended in each new
edition of the Journal and suggestions are
welcome. Please e-mail your recommendations,
including full details, to Victoria Muir at
.
Bibliography
Artal R., Wiswell R. A. & Drinkwater B. L. (1991) Exercise
in Pregnancy, 2nd edn. Williams & Wilkins, Baltimore,
MD. (ISBN 0683002570.)
Balaskas J. (1991) New Active Birth: A Concise Guide to
Natural Childbirth, 2nd edn. Thorsons, London. (ISBN
0722525664.)
Brayshaw E. (2003) Exercises for Pregnancy and Childbirth:
A Guide for Educators. Books for Midwives Press,
Oxford. (ISBN 075065600X.)
Butler D. S. & Moseley G. L. (2003) Explain Pain 2003.
Finsbury Green Printing, Adelaide. (ISBN 097509100X.)
Cardozo L. (1997) Urogynecology. Churchill Livingstone,
Edinburgh. (ISBN 0-443-05058-9.)
Cardozo L. (2000) Textbook of Female Urology and Urogynecology.
Isis Medical Media, San Francisco, CA.
(ISBN 1901865053.)
Cardozo L., Staskin D. & Kirby M. (2000) Urinary Incontinence
in Primary Care. Isis Medical Media, San
Francisco, CA. (ISBN 1901865681.)
Chiarelli P. E. (2002) Women’s Waterworks: Curing Incontinence.
Gore & Osment, Sydney. (ISBN 1-8755 31009.)
Dorey G. (ed.) (2006) Pelvic Dysfunction in Men: Diagnosis
and Treatment of Male Incontinence and Erectile Dysfunction.
John Wiley & Sons, Chichester. (ISBN 0-470-02836-
X.)
Edwards B. & Sanderson D. (2001) Swiss Ball Systems – A
Practical Guide. Swiss Ball Systems, Bangor. (ISBN
01248 372828.)
Elphinstone J. & Pook P. (2002) The Core Workout
Manual. Rugby Science, Fleet. (ISBN 0953985903.)
Getliffe K. & Dolman M. (2002) Promoting Continence: A
Clinical Research Resource, 2nd edn. Baillière Tindall,
London. (ISBN 0702026379.)
Heaner M. K. (1995) The 7 Minute Sex Secret. Hodder &
Stoughton, London. (ISBN 0-340-62860-X.)
Hobbs L. (2001) The Best Labour Possible? Books for
Midwives Press, Oxford. (ISBN 0750652004.)
King M. (2000) Pure Pilates. Mitchell Beazley, London.
(ISBN 1-84000-266-2.)
Laycock J. & Haslam J. (eds) (2002) Therapeutic Management
of Incontinence and Pelvic Pain: Pelvic Organ Disorders.
Springer-Verlag, Berlin. (ISBN 1852332247.)
McKenzie R. (1998) Treat Your Own Back. Spinal Publications,
Waikanae. (ISBN 0959804927.)
MacLean A. & Cardozo L. (eds) (2002) Incontinence in
Women. RCOG Press, London. (ISBN 1 900364 67.)
Mantle J., Haslam J. & Barton S. (2004) Physiotherapy
in Obstetrics and Gynaecology, 2nd edn. Butterworth
Heinemann, Oxford. (ISBN 1750622652.)
Melzack R. & Wall P. D. (1996) The Challenge of Pain.
Penguin Science, London. (ISBN 0140256709.)
Nolan M. (1998) Antenatal Education: A Dynamic Approach.
Baillière Tindall, London. (ISBN 0-7020-2279-9.)
Norton C. & Kamm M. A. (1999) Bowel Control –
Information and Practical Advice. Beaconsfield Publishers,
Beaconsfield. (ISBN 0906584493.)
Payne R. A. (2000) Relaxation Techniques – A Practical
Handbook for theHealthcare Professional. Churchill
Livingstone, Edinburgh. (ISBN 0443062633.)
Priest J. & Schott J. (2001) Leading Antenatal Classes: A
Practical Guide. Butterworth Heinemann, Oxford. (ISBN
07506498.)
Richardson C., Jull G., Hodges P. & Hides J. (1999)
Therapeutic Exercise for Spinal Segmental Stabilisation in
Low Back Pain: Scientific Basis and Clinical Approach.
Churchill Livingstone, Edinburgh. (ISBN 0-443-05802-4.)
Robinson L. (2002) The Official Body Control Pilates
Manual. Pan Books, London. (ISBN 0-333-78202-X.)
Royal College of Midwives (2001) Successful Breastfeeding.
ChurchillLivingstone, Edinburgh. (ISBN 0443059675.)
Sapsford R., Bullock-Saxton J. & Markwell S. (1997)
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 for
Midwives, 12th edn. Baillière Tindall, London. (ISBN
0 7020 1757.)
Yerby M. (2000) Pain Management in Childbearing – Key
Issues in Management. Baillière Tindall, London. (ISBN
0702022993.)
2007 Association of Chartered Physiotherapists in Women’s Health 105

Journal of the Association of Chartered Physiotherapists in Women’s Health, Spring 2007, 100, 106–107
Writing for the ACPWH Journal: guidelines for authors
+ Please always refer to a recent issue of the
Journal, and follow the style and layout of
an article or item that is similar to your
contribution. Manuscripts may be returned
to authors if they have not adhered to the
guidelines. If necessary, the editor should be
consulted in the initial stages for clarification.
+ If a paper is submitted for publication, then it
is assumed that it has not been submitted
simultaneously to another journal. All submissions
should be original and previously
unpublished.
+ Academic papers are subject to review and
may need to be revised before being accepted.
The editor reserves the right to edit, amend or
revise any submission.
+ Offprints are available free of charge if notice
is given to the editor when the article is
submitted.
+ All published material becomes the copyright
of the ACPWH.
Preparation of manuscripts
All articles must be typed double-spaced, with
wide (3-cm) margins all round, on one side of
A4-size paper, using Courier New, font size 12.
The pages should be numbered consecutively,
and two hard copies of the article and a disk
version (text saved in Rich Text Format) should
be submitted. Articles should be a maximum
of 7500 words (excluding the abstract and
references).
Papers should be arranged as follows:
Abstract
A summary of not more than 200 words should
be submitted on a separate sheet outlining the
purpose, scope and conclusions of the paper.
This should be followed by a minimum of three,
maximum of five, keywords which best represent
the contents.
Title
The title of the article should be in lower case,
bold and ranged left, as in the title above: note
that there is no full stop and no underlining. The
author’s name(s) (initials and surname only)
should be given below the article’s title in lower
106
case, bold and ranged left. Again, there is no full
stop. Below the author’s name(s), place(s) of
work should be listed in italics, ranged left, no
full stop.
Text
The layout of the Journal is that the heading of
each section is in bold lower case. Notice that,
again, there is no full stop and no underlining.
The first paragraph is left-justified; subsequent
paragraphs in the same section are indented, as
is this part of the guidelines.
When including tables, diagrams and figures,
these should be numbered in the order in which
they appear in the text, and must be submitted,
in duplicate, on separate sheets, i.e. not embedded
in the text. Please indicate their placing
in the text (e.g. ‘Fig. 1’). Any caption should be
left-justified above the table or below the diagram.
All figures and tables must be referred to
in the text.
When using numbers in the text, these should
be written out in words up to and including nine,
unless they are measurements, numbers in tables
or years.
Clinical papers: referencing
All clinical papers must be fully referenced and
the references verified by the author. No exceptions
will be made. The reference list must be
double-spaced on separate sheets, and arranged
alphabetically by the name of the first author or
editor. In the text, give the author(s) and date of
publication in brackets [e.g. ‘(Smith 1998)’], or if
the main author’s name is part of a sentence,
then only the year is in brackets [e.g. ‘as
described by Smith (1998)’]. Note the absence of
commas and full stops. For more than two
authors, reference can be made in the text to
‘Smith et al. (1998)’; note the italics and full stop.
However, when writing the reference list, the
convention is as follows: for up to five authors,
write all the authors’ names; for six or more
authors, write the first three authors’ names,
followed by ‘et al.’
For journals, give the author’s surname with
initials, the year of publication in brackets, the
title of the paper, the full name of the journal,
2007 Association of Chartered Physiotherapists in Women’s Health

the volume number, the issue number in brackets,
and the first and last page numbers of
the article (note the correct use of italic, bold,
commas and full stops):
Laycock J., Knight S. & Naylor D. (1995) Prospective,
randomised, controlled clinical trial
to compare chronic electrical stimulation in
combination therapy for GSI. Neurourology
and Urodynamics 14 (5), 425–426.
For books, give the author’s/editor’s surname
and initials, the year of publication in brackets,
the book title in italics, and the publisher and
city of publication:
Williams P. L. & Warwick R. (eds) (1986) Gray’s
Anatomy, 36th edn. Churchill Livingstone,
Edinburgh.
For a chapter or section in a book by a named
author (who may be one of several contributors),
both chapter and book title should be given
along with the editor’s name(s), and the first and
last page numbers of the chapter:
Robinson K. L. (1996) Bioelectric fields and
physical principles. In: Physics in Medicine
and Related Fields (eds P. Smith & P. S.
Hascombe), pp. 335–349. Dekker Publishing,
New York, NY.
Please adhere strictly to this style of referencing
in any contribution to the Journal.
Acknowledgements
Please state any funding sources, or companies
providing technical or equipment support.
Photographs
These can be colour or monochrome, but must
be in sharp focus. Please write any caption on
the back in soft pencil since ball-point and felttipped
pens smudge. The photographs should
be numbered and their placing indicated in the
text. All photos will be returned. If digital photographs
are submitted, they should be of high
resolution (minimum 300 dots per inch), saved
to floppy disk or CD, and accompanied by a
hard copy.
Guidelines for authors
Case reports
The Journal welcomes case reports of up to 2500
words. These should be structured as follows:
title, abstract and keywords, a brief introduction,
a concise description of the patient and
condition, and an explanation of the assessment,
treatment and progress, followed finally by a
discussion and evaluation of implications for
practice. The study must be referenced throughout.
Further guidance is available on request.
Book reviews
At the beginning of the review, give all details of
the book including title in bold, the author’s/
editor’s full name(s), publisher, city and year of
publication, price, whether hardback or paperback,
number of pages, ISBN number and
details of how/where to purchase (if appropriate).
The reviewer’s name should appear at
the end of the review in bold, right-justified,
followed by their title and place of work in
italics.
General points to note
Please enclose your home, work and e-mail
addresses, and telephone and fax numbers.
It is the author’s responsibility to obtain and
acknowledge permission to reproduce any
material that has appeared in another journal or
textbook.
A brief biographical note on the author
should be included at the end of a clinical paper
in italics and should include an address for
correspondence, if required.
All notes and news should have clinical relevance
to our Association.
Please refer at all times to the style and layout
of previous ACPWH journals for whatever you
are writing. Using these guidelines will save time
for the Journal team.
The copy deadline for the next issue of the
Journal is printed in the current one and can be
found below the Editorial at the beginning of the
Journal. It must be strictly adhered to by all
contributors. Any further enquiries should be
addressed to the editor, whose name and address
appear on the inside front cover of the Journal.
2007 Association of Chartered Physiotherapists in Women’s Health 107

InteractiveCSP
The new iCSP website is now up and
running. It is an easy-to-use interactive
website about physiotherapy and people,
not technology.
Register and log in at:
www.interactivecsp.org.uk
To register go to the website and click on
‘register’. You need your CSP
membership number and an e-mail
address. From the homepage, you can
access the networks that are of interest to
you (e.g. women’s health), and direct
access to relevant websites, such as the
ACPWH, is also possible.
iCSP is mainly about sharing knowledge,
networking irrespective of location, and
tapping into the know-how of your peers.
Go on, register today – it is there for
your benefit!
IMPORTANT NOTICE
Communication by e-mail
At the Conference 2005
discussion groups, members
resoundingly agreed that a move
to communication via e-mail
would be in the best interest of
the Association.
If you have an e-mail address
that you regularly use,
please send it to membership
secretary Alex Welman
(alexwelman@konekt.co.uk),
along with your postal address.
Please remember to let her know
if you change it.
FOR SALE
(limited availability)
Pilates for Mums with Lindsey Jackson
£20 per DVD including postage and
packing within the UK
Chartex Antenatal and Postnatal Exercise
and Advice charts
£15 per pair of charts (one antenatal and
one postnatal) including postage and
packing within the UK
All 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 discuss
postage costs outside the UK, please
e-mail: gill.brook@lineone.net.
Advertising rates
Charges apply for advertising courses,
study days or workshops, and are as
follows:
(1) ACPWH-approved courses, study
days or workshops, or any other
non-profit making ACPWH
educational event:
Free of charge
(2) Other courses or workshops (15%
discount for ACPWH members):
Full page £90
Half page £60
Quarter page £30
(3) Manufacturers’ rates:
Full page £500
Half page £300
Quarter page £200
Please contact the advertising manager,
Sue Brook, in the first instance