Women's Health Physiotherapy – Key Definitions & Clinical Points

1. Definition of (Urinary) Incontinence

2. Bladder Retraining Techniques

1. Timed/scheduled voiding – the patient voids at fixed, pre-set intervals regardless of urgency
2. Prompted voiding – caregivers prompt the patient to void at regular intervals (used in cognitively impaired patients)
3. Bladder drill (progressive voiding delay) – the patient deliberately postpones voiding, gradually increasing the interval between voids to expand bladder capacity
4. Urge suppression strategies – using distraction, relaxation, or pelvic floor contractions (quick flicks) to suppress the urge and defer voiding
5. Fluid modification – adjusting fluid intake timing and type (reducing caffeine/alcohol)
6. Bladder diary-guided training – using a voiding diary to set realistic baseline intervals and progressively extend them

3. Ergonomic Advice for Postnatal Mothers While Breastfeeding

1. Sit in a chair with good lumbar support; use a nursing pillow to bring the baby to breast level rather than leaning forward
2. Keep the back straight and shoulders relaxed — avoid hunching or protruding the neck
3. Support both feet flat on the floor; use a footstool if necessary
4. Bring the baby to the breast, not the breast to the baby
5. Use a breastfeeding/nursing pillow (e.g., C-shaped) to reduce arm and shoulder strain
6. Alternate feeding positions (cradle, football/clutch, side-lying) to vary postural stress
7. Take frequent breaks to stretch the neck, shoulders, and upper back
8. Avoid prolonged static postures; perform gentle shoulder rolls and neck stretches between feeds
9. Ensure adequate lighting to prevent further forward head posture

4. Importance of EMG (Electromyography) in Training the Pelvic Floor Muscles (PFM)

• Biofeedback via surface EMG provides real-time visual or auditory feedback of pelvic floor muscle activity, allowing patients to identify and correctly contract the PFMs rather than using accessory muscles (gluteals, hip adductors, abdominals)
• Helps confirm whether the patient is performing a correct contraction or erroneous co-contraction of unintended muscles
• Enables the physiotherapist to objectively assess baseline PFM activity, fatigue patterns, and progress over time
• Particularly valuable in patients who cannot perceive an internal contraction (poor proprioception)
• Facilitates down-training in hypertonic pelvic floors (e.g., vaginismus, chronic pelvic pain) by showing the patient how to relax the PFMs
• Improves patient motivation and compliance through visible progress monitoring
• Allows grading of exercise intensity — the therapist can set EMG thresholds the patient must meet during contractions

5. Three Goals of Physiotherapy in Breast Cancer Rehabilitation

1. Restore shoulder and upper limb function – recover range of motion, strength, and functional use of the arm and shoulder following surgery (mastectomy, axillary dissection) and radiotherapy
2. Prevent and manage lymphedema – through manual lymphatic drainage (MLD), compression therapy, exercise, and education to reduce post-surgical/post-radiation lymphedema of the arm
3. Improve quality of life and reduce pain – manage post-surgical pain, scar tissue adherence, postural dysfunction, fatigue, and functional limitations to enable return to daily activities and occupational roles

6. Definition of Bowel (Faecal) Incontinence

7. T-Score Cut-Off Value for Diagnosis of Osteoporosis

8. Ergonomic Advice for Postnatal Mothers While Lifting Heavy Weights

1. Never lift immediately postpartum – avoid heavy lifting for at least 6 weeks to protect healing pelvic floor and abdominal muscles
2. Pre-brace before lifting – engage the pelvic floor and deep abdominals (transversus abdominis) before and during the lift
3. Adopt a squat posture – bend at the hips and knees (not the waist); keep the back straight and the object close to the body
4. Use the "exhale on exertion" principle – breathe out while lifting to reduce intra-abdominal pressure
5. Avoid breath-holding (Valsalva manoeuvre) during lifting
6. Step or pivot to turn — do not twist the spine while holding a load
7. Do not lift loads heavier than the baby until cleared by a physiotherapist
8. Gradually progress load as pelvic floor strength improves

9. Pelvic Floor Muscles

• Pubococcygeus (including pubovaginalis / puboperinealis in females)
• Puborectalis
• Iliococcygeus

• Bulbospongiosus (bulbocavernosus)
• Ischiocavernosus
• Superficial transverse perineal muscle
• External anal sphincter
• External urethral sphincter
• Deep transverse perineal muscle

10. Warning Signs to Stop Exercise During Pregnancy

1. Vaginal bleeding or amniotic fluid leakage
2. Chest pain or palpitations
3. Dyspnoea (breathlessness) before exertion
4. Dizziness, faintness, or loss of consciousness
5. Headache (severe or unusual)
6. Calf pain, swelling, or redness (possible DVT)
7. Decreased or absent fetal movement
8. Preterm labour / regular uterine contractions
9. Muscle weakness affecting balance
10. Painful uterine contractions
11. Sudden severe abdominal pain

11. Stages of Lymphedema

12. Complications Following Mastectomy

1. Wound infection / dehiscence
2. Seroma formation (most common early complication)
3. Haematoma
4. Lymphedema of the ipsilateral arm
5. Shoulder stiffness and reduced range of motion
6. Axillary web syndrome (cording)
7. Nerve damage – intercostobrachial nerve injury (numbness/dysesthesia of inner arm)
8. Postmastectomy pain syndrome (PMPS) / chronic neuropathic pain
9. Scar adhesion / keloid formation
10. Postural changes (rounded shoulders, forward head posture)
11. Psychological complications – body image disturbance, anxiety, depression
12. Wound flap necrosis (in skin-sparing or flap reconstructions)

13. Advantages of Combining Biofeedback with Pelvic Floor Exercises

1. Improves correct muscle identification – confirms the patient is contracting the PFMs and not gluteals or abdominals
2. Provides real-time feedback – visual/auditory signals immediately reinforce correct technique
3. Enhances motor learning and proprioception – accelerates neuromuscular re-education of the PFMs
4. Quantifies progress objectively – enables measurement of contraction strength, endurance, and coordination over sessions
5. Increases patient motivation and adherence – visible improvement encourages compliance with the home exercise programme
6. Facilitates relaxation training – helps hypertonic patients learn to down-train and relax PFMs
7. Reduces compensatory strategies – prevents accessory muscle substitution that reduces exercise efficacy

14. Definition of Postnatal Depression

15. Risk Factors Associated with Low Back Pain in Postnatal Women

1. History of low back pain or pelvic girdle pain during pregnancy
2. Pre-existing lumbar pathology or prior LBP episodes
3. Hormonal laxity (relaxin effects persisting postpartum)
4. Weak core and pelvic floor muscles / diastasis recti abdominis
5. Poor posture during feeding, lifting, and infant care tasks
6. Repetitive bending, lifting, and carrying of the infant and equipment
7. Sleep deprivation and associated muscle fatigue
8. Psychological factors – stress, anxiety, depression
9. High BMI / excessive gestational weight gain
10. Multiparity
11. Mode of delivery (prolonged labour, instrumental delivery)
12. Rapid return to demanding physical activity without rehabilitation

17. Causes of Pelvic Floor Dysfunction

1. Obstetric trauma – vaginal delivery, prolonged second stage, instrumental delivery (forceps/ventouse), perineal tears/episiotomy
2. Pregnancy – increased mechanical load, hormonal changes (relaxin), postural changes
3. Aging and menopause – oestrogen deficiency, connective tissue atrophy
4. Chronic raised intra-abdominal pressure – chronic cough, constipation/straining, obesity, heavy lifting
5. Pelvic surgery – hysterectomy, prolapse repairs, prostatectomy
6. Neurological conditions – multiple sclerosis, Parkinson's disease, spinal cord injury, pudendal nerve damage
7. Connective tissue disorders – hypermobility syndromes (Ehlers-Danlos)
8. Congenital anomalies
9. Radiation therapy – pelvic radiotherapy causing fibrosis and nerve damage
10. Lifestyle factors – sedentary behaviour, poor posture, high-impact sports without pelvic floor conditioning
11. Psychological trauma – sexual abuse, vaginismus, chronic pelvic pain

18. Types of Osteoporosis

19. Use of the Bladder Diary

1. Establish baseline voiding patterns – frequency, timing, and volumes of urine passed
2. Identify triggers of urgency or leakage – fluid intake, activity, time of day
3. Quantify leakage episodes – frequency and severity of incontinence
4. Measure functional bladder capacity – largest single voided volume recorded
5. Guide bladder training programmes – set realistic voiding intervals based on documented patterns
6. Monitor treatment response – compare pre- and post-treatment entries to assess improvement
7. Aid differential diagnosis – distinguish stress, urgency, overflow, and mixed incontinence

20. Contraindications to Antenatal Exercise

1. Haemodynamically significant heart disease
2. Restrictive lung disease
3. Incompetent cervix / cervical cerclage
4. Multiple gestation at risk of premature labour
5. Persistent second- or third-trimester bleeding (placenta praevia)
6. Placenta praevia after 26 weeks
7. Premature labour (current pregnancy)
8. Ruptured membranes (PROM)
9. Pre-eclampsia or pregnancy-induced hypertension

1. Severe anaemia
2. Unevaluated maternal cardiac arrhythmia
3. Chronic bronchitis
4. Poorly controlled type 1 diabetes
5. Extreme morbid obesity or underweight (BMI <12)
6. History of extremely sedentary lifestyle
7. Intrauterine growth restriction (IUGR)
8. Poorly controlled hypertension
9. Poorly controlled seizure disorder
10. Poorly controlled hyperthyroidism
11. Heavy smoking

22. Use of the Perineometer

1. Objective assessment of PFM strength – measures squeeze pressure in cmH₂O or mmHg at baseline
2. Biofeedback during PFMT – provides real-time pressure readings to guide correct contraction
3. Monitoring treatment progress – serial measurements to document improvement over a rehabilitation programme
4. Motivation and compliance aid – patients see numerical evidence of progress
5. Research tool – standardised measurement of PFM function in clinical trials
6. Differentiating underactive vs. hypertonic PFMs – resting and active pressures both recorded

23. Complications Following Post-Gynaecological Surgery

1. Haemorrhage – primary or reactionary bleeding
2. Wound infection / pelvic infection / vault cellulitis
3. Deep vein thrombosis (DVT) and pulmonary embolism
4. Urinary tract infection (UTI)
5. Urinary retention / voiding dysfunction
6. Bladder or ureteric injury (especially in hysterectomy)
7. Bowel injury / ileus / adhesions
8. Pelvic organ prolapse (late complication post-hysterectomy)
9. Vault granulation or vault prolapse
10. Lymphocele / lymphoedema (after pelvic lymphadenectomy)
11. Nerve injury – femoral, obturator, or pudendal nerve damage
12. Fistula formation – vesicovaginal, rectovaginal
13. Psychological complications – altered body image, loss of fertility grief
14. Adhesion formation – causing chronic pelvic pain or bowel obstruction

24. Uses of a Pessary

1. Pelvic organ prolapse (POP) – first-line conservative management for cystocele, rectocele, uterovaginal prolapse, vault prolapse
2. Stress urinary incontinence – incontinence ring or dish pessaries provide urethral support and reduce leakage
3. Cervical incompetence in pregnancy – cervical pessaries (e.g., Arabin) reduce risk of preterm birth
4. Bridging therapy – for women awaiting surgery or who are medically unfit for surgery
5. Diagnostic use – to simulate surgical correction and predict surgical outcome
6. Postoperative support – after prolapse repair to support healing
7. Uterine retroversion – rarely, to reposition a retroverted uterus

25. Contraindications to Manual Lymphatic Drainage (MLD)

1. Active malignancy / untreated cancer in the drainage area (relative – requires oncologist approval in many protocols)
2. Acute infection / cellulitis in the region (risk of spreading infection)
3. Acute deep vein thrombosis (DVT) or phlebothrombosis
4. Acute cardiac failure / decompensated heart failure
5. Active pulmonary oedema