Clinical Overview Pelvic Organ Prolapse (POP) is the descent of one or more pelvic organs—bladder (cystocele), uterus (uterine prolapse), or rectum (rectocele)—into or through the vaginal canal due to loss of support from the pelvic floor muscles, ligaments, and fascia. This is typically a result of levator ani avulsion, connective tissue laxity, or neuropathic injury following childbirth, chronic strain, or aging. Symptoms include: Sensation of vaginal “heaviness” or bulging Visible prolapse at or near the introitus Urinary hesitancy, urgency, or incomplete voiding Constipation or rectal pressure Dyspareunia or reduced sexual sensation Prevalence and Impact POP affects approximately 50% of parous women, although not all cases are symptomatic (Hagen & Stark, 2011). Its impact on quality of life, sexual function, and mental health can be significant—even in early stages. Evidence-Based First-Line Management: Physiotherapy Recent guidelines and systematic reviews recommend pelvic floor muscle training (PFMT) as the first-line conservative management for Stage I–III POP (NICE, ICS). The POPPY trial (Hagen et al., 2014), a multicenter RCT, demonstrated that individualized PFMT over 16 weeks led to: Clinically significant improvement in prolapse symptoms (measured by POP-SS) Improvement in POP-Q staging Reduction in prolapse severity on examination Better sexual function scores compared to control No reported adverse effects Physiotherapy Intervention Includes: Digital pelvic floor assessment (Oxford scale, Modified Brink, or EMG) Supervised, progressive PFMT tailored to POP-Q findings Symptom management education: posture, breath mechanics, bowel/bladder habits Intra-abdominal pressure control through breathwork and load management Behavioral coaching for voiding, defecation, and sexual activity Collaborative pessary fitting (as per gynecologist referral) Ideal Referral Candidates: POP Stage I–III (non-surgical candidates or surgery-averse) Postpartum patients with vaginal laxity or pelvic heaviness Patients with concurrent stress or mixed urinary incontinence Patients requiring pre- or post-operative pelvic floor conditioning Those seeking prevention of POP recurrence following prior treatment Multidisciplinary Collaboration Pelvic floor physiotherapists complement gynecologic and urogynecologic care through: Preventing progression in early-stage prolapse Enhancing surgical outcomes when used pre- or post-operatively Reducing surgical burden in healthcare systems Educating patients on long-term pelvic health maintenance Conclusion High-quality RCTs support pelvic floor physiotherapy as an effective, low-risk, first-line treatment for women with symptomatic POP. Early intervention can delay or eliminate the need for surgical correction in many cases, and it significantly improves functional outcomes and quality of life. Prompt referral for PFMT should be considered standard care for women with mild to moderate prolapse. References Hagen, S., Stark, D. (2011). Conservative management of pelvic organ prolapse in women: A systematic review of randomized controlled trials. BJOG: An International Journal of Obstetrics & Gynaecology, 118(8), 868–878. https://doi.org/10.1111/j.1471-0528.2011.02955.x Hagen, S., Stark, D., Glazener, C. M., Dickson, S., Barry, S. J., & Logan, J. (2014). Individualised pelvic floor muscle training in women with pelvic organ prolapse (POPPY): A multicentre randomised controlled trial. The Lancet, 383(9919), 796–806. https://doi.org/10.1016/S0140-6736(13)61977-7
Stress urinary incontinence (SUI)
Stress urinary incontinence (SUI) affects up to 1 in 3 women globally and is a major contributor to decreased quality of life, social withdrawal, and even depression in otherwise healthy individuals (Bo et al., 2017). As physiotherapists, we are often the first non-surgical, non-pharmacologic point of contact for these patients. With increasing evidence supporting pelvic floor muscle training (PFMT) as a first-line intervention, this article summarizes key findings from high-quality randomized controlled trials (RCTs) that position physiotherapy as an essential part of multidisciplinary SUI care. Defining SUI and Its Clinical Impact SUI is characterized by involuntary urine leakage during effort or physical exertion, such as coughing, sneezing, laughing, or exercising (Haylen et al., 2010). Though often considered a “normal” part of aging or childbirth, untreated SUI leads to avoidable complications, including: Reduced physical activity Increased fall risk in elderly women Sexual dysfunction Higher risk of urinary tract infections For physicians managing this condition, timely referral to physiotherapy can significantly improve patient outcomes and reduce long-term costs. Pelvic Floor Muscle Training: The Gold Standard in Conservative Management A large body of RCTs supports PFMT as the gold standard non-invasive treatment for SUI. In a landmark RCT by Dumoulin et al. (2018), women randomized to supervised PFMT showed a 56% cure rate and a 74% improvement rate, significantly outperforming the control group. This study emphasized the importance of supervision by trained pelvic physiotherapists for optimal outcomes. Another meta-analysis of 31 RCTs involving 1,817 women by Woodley et al. (2020) confirmed that PFMT increases the likelihood of cure or improvement (RR 8.38, 95% CI 3.68–19.07) compared to no treatment or placebo. The findings led to PFMT being recommended as a Grade A recommendation by the International Continence Society and European Association of Urology. Biofeedback and Adjunct Therapies: Enhancing Results Biofeedback devices are commonly used to facilitate neuromuscular control, and their efficacy is supported by several RCTs. Glazener et al. (2011) conducted a multicenter trial with 600+ participants and found that adding biofeedback improved adherence and muscle isolation skills, though long-term differences in outcomes were modest. For patients struggling with proprioception or technique, biofeedback remains a useful adjunct, especially in the early stages of therapy. Other adjuncts include vaginal weights, electrical stimulation, and behavioral therapies. While none of these outperformed PFMT alone in most RCTs, they offer additional options for patients who fail to progress with exercises alone (Berghmans et al., 2013). PFMT vs. Surgical Options: When to Refer While mid-urethral slings remain the gold standard for surgical management, many patients prefer to exhaust conservative options first, especially in cases of mild to moderate SUI. According to a Cochrane review (2017), physiotherapy can delay or avoid surgery in up to 65% of cases when followed consistently over 3–6 months. Moreover, post-operative physiotherapy helps in strengthening the pelvic support structures and preventing recurrence or complications. Therefore, physiotherapy is relevant before and after surgical management. Physician-Physiotherapist Collaboration: What We Need From You For optimal outcomes, physicians are encouraged to: Refer patients early when symptoms appear, rather than after years of discomfort. Share relevant obstetric, surgical, or urological history to aid our evaluation. Encourage adherence to home exercise programs, as this is a major predictor of success. Collaborate on complex cases (e.g., mixed incontinence, pelvic organ prolapse, or prior pelvic surgery). Conclusion and Key Takeaway Stress urinary incontinence is not just a “nuisance” — it is a treatable medical condition with profound quality-of-life implications. Physiotherapists play a critical role in conservative management, and early referral can result in high cure rates without the need for surgery or medication. Physicians who collaborate with pelvic floor physiotherapists provide patients with a holistic, evidence-based approach that aligns with global best practice guidelines. Key References: Bo, K., Hilde, G., & Stær-Jensen, J. (2017). Physiotherapy for female stress urinary incontinence: A review of randomized controlled trials. International Urogynecology Journal, 28(6), 887–899. https://doi.org/10.1007/s00192-017-3362-9 Dumoulin, C., Cacciari, L. P., & Hay-Smith, E. J. C. (2018). Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database of Systematic Reviews, 10, CD005654. https://doi.org/10.1002/14651858.CD005654.pub4 Glazener, C. M. A., et al. (2011). Pelvic floor muscle training and biofeedback for the treatment of stress urinary incontinence: A multicentre randomized controlled trial. BMJ, 342, d373. https://doi.org/10.1136/bmj.d373 Haylen, B. T., et al. (2010). An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourology and Urodynamics, 29(1), 4–20. https://doi.org/10.1002/nau.20798 Woodley, S. J., et al. (2020). Pelvic floor muscle training for urinary incontinence in women: Cochrane systematic review and meta-analysis. BJOG, 127(10), 1281–1293. https://doi.org/10.1111/1471-0528.16214 Berghmans, B., et al. (2013). Electrical stimulation with non-implanted electrodes for overactive bladder in adults. Cochrane Database of Systematic Reviews, 6, CD010098. https://doi.org/10.1002/14651858.CD010098.pub2
Overactive Bladder (OAB): A Clinical Overview for Referring Clinicians
Overactive Bladder (OAB): A Clinical Overview for Referring Clinicians Overview: Overactive bladder (OAB) is a symptom-based syndrome characterized by urinary urgency, usually accompanied by frequency and nocturia, with or without urge incontinence, in the absence of UTI or other overt pathology (ICS, 2002). It affects approximately 30% of adults over 40 and becomes increasingly prevalent with age (Hsu et al., 2019). Etiology and Pathophysiology While detrusor overactivity is the urodynamic correlate in many cases, OAB can also occur due to: Neurological disorders (e.g., MS, Parkinson’s) Impaired bladder compliance Pelvic floor dysfunction (hypertonic or hypotonic) Psychological factors (e.g., anxiety, trauma history) Iatrogenic causes (e.g., medications, radiation) Notably, Fontaine et al. (2021) emphasized that detrusor overactivity is not present in all OAB cases, necessitating a broader diagnostic lens. Initial Management: First-Line Conservative Interventions According to current guidelines and high-quality randomized trials, behavioral and physiotherapeutic interventions are the cornerstone of initial management. 1. Bladder Retraining: Evidence supports scheduled voiding with progressive delay intervals, combined with urge suppression strategies (Scaldazza et al., 2017). Techniques include reverse Kegels, diaphragmatic breathing, sensory distraction, and pelvic floor relaxation. 2. Pelvic Floor Physiotherapy: Pelvic health physiotherapists assess and rehabilitate both hypertonic and hypotonic pelvic floors. Contrary to popular assumptions, many OAB patients present with tight pelvic floor musculature that exacerbates urgency/frequency symptoms. 3. Lifestyle Modifications: Elimination of bladder irritants (e.g., caffeine, alcohol, acidic foods) Managing constipation Fluid management and pre-bedtime voiding Supine leg elevation in patients with peripheral edema These non-invasive measures have high patient adherence and low adverse event profiles, making them ideal first-line strategies, particularly in older adults or those with polypharmacy concerns. Pharmacological Interventions If conservative measures prove insufficient, consider the following pharmacologic options: Anticholinergics (e.g., oxybutynin, solifenacin): Effective but associated with dry mouth, constipation, and cognitive risk, especially in the elderly (Welk & McArthur, 2020). β3-Adrenergic Agonists (e.g., mirabegron): Similar efficacy with improved CNS safety profile; preferred in patients at risk for anticholinergic burden (Yamaguchi et al., 2014). Medication adherence is often suboptimal due to side effects, with >50% discontinuing within 6 months (Benner et al., 2010). Combination therapy with behavioral interventions improves outcomes. Advanced Options for Refractory Cases If pharmacological and behavioral therapies fail: Percutaneous Tibial Nerve Stimulation (PTNS): Effective for OAB symptom reduction with a favorable safety profile (Keller et al., 2017). Botulinum Toxin A Injections: FDA-approved for refractory OAB but requires intermittent self-catheterization in some patients. Sacral Neuromodulation: Considered in severe cases with mixed incontinence or when other modalities fail. Referral Recommendations Refer patients for pelvic floor physiotherapy when: Symptoms persist despite lifestyle changes Pelvic floor dysfunction is suspected (e.g., concomitant pelvic pain, constipation) Pharmacologic therapy is contraindicated or declined Patients prefer non-invasive, functional approaches Conclusion for Clinical Practice OAB is a multifactorial condition with a significant impact on quality of life. Evidence-based management emphasizes a stepwise approach beginning with behavioral therapy and physiotherapy, progressing to pharmacological and neuromodulation therapies as needed. Collaborative care involving physiotherapists, urologists, and family physicians ensures optimal outcomes. Key References Benner, J., Nichol, M., Rovner, E., Jumadilova, Z., Alvir, J., Hussein, M., & Brubaker, L. (2010). Patient‐reported reasons for discontinuing overactive bladder medication. BJU International, 105(9), 1276–1282. https://doi.org/10.1111/j.1464-410x.2009.09036.x Fontaine, C., Papworth, E., Pascoe, J., & Hashim, H. (2021). Update on the management of overactive bladder. Therapeutic Advances in Urology, 13, 17562872211039034. https://doi.org/10.1177/17562872211039034 Hsu, Y. P., Chuang, F. C., Chang, S. J., & Yang, S. S. (2019). Prevalence and associated factors of overactive bladder among the elderly in Taiwan. International Urogynecology Journal, 30(7), 1091–1099. https://doi.org/10.1007/s00192-018-3776-4 Keller, N., Schmid, S., & Haemmerle, B. (2017). Successful therapy of overactive bladder syndrome with percutaneous tibial nerve stimulation: A case report. The International Annals of Medicine, 1(11), 387. https://doi.org/10.24087/iam.2017.1.11.387 Scaldazza, C., Morosetti, C., Giampieretti, R., Lorenzetti, R., & Baroni, M. (2017). PTNS vs. pelvic floor muscle training in women with OAB: A randomized study. International Braz J Urol, 43(1), 121–126. https://doi.org/10.1590/s1677-5538.ibju.2015.0719 Welk, B., & McArthur, E. (2020). Dementia risk in patients treated for OAB: Anticholinergic vs beta‐3 agonists. BJU International, 126(1), 183–190. https://doi.org/10.1111/bju.15040 Yamaguchi, O., Marui, E., Kakizaki, H., Homma, Y., Igawa, Y., Takeda, M., & Ohkawa, S. (2014). Mirabegron 50 mg for OAB in Japanese patients: A phase III trial. BJU International, 113(6), 951–960. https://doi.org/10.1111/bju.12649
Subacromial Impingement Syndrome (SIS)
Subacromial Impingement Syndrome (SIS) / Subacromial Pain Syndrome (SAPS) Introduction Subacromial Impingement Syndrome (SIS), now more inclusively termed Subacromial Pain Syndrome (SAPS), remains the leading cause of shoulder pain in primary care, accounting for 44% to 65% of shoulder-related consultations (Umer et al., 2012; Yuan et al., 2022). It encompasses a spectrum of pathologies including rotator cuff tendinopathy, subacromial bursitis, and partial tears, often with overlapping symptoms. As physiotherapists, we emphasize non-surgical management using evidence-based strategies that restore function, reduce pain, and prevent chronicity. Timely referral to physiotherapy can reduce the need for advanced imaging, injections, or surgical intervention. Key Clinical Features Painful arc during shoulder elevation Night pain, particularly when lying on the affected side Tenderness over the subacromial space Positive signs on Hawkins-Kennedy, Neer, and painful arc tests Decreased strength in external rotation and abduction Risk Factors Repetitive overhead activity (occupational or athletic) Postural dysfunction (rounded shoulders, thoracic kyphosis) Sleep disturbances and insomnia (Lv et al., 2024) Psychological components: fear-avoidance, low expectation of recovery (Chester et al., 2010) Conservative Management: Evidence Summary 1. Exercise Therapy A meta-analysis by Hanratty et al. (2012) concluded that structured physiotherapy focusing on rotator cuff and scapular stabilization exercises significantly improves pain and shoulder function. Programs incorporating eccentric loading, neuromuscular control, and postural correction outperform general exercise protocols. 2. Manual Therapy and Neuromobilization Combining manual therapy with exercises improves short-term outcomes and patient satisfaction. Techniques include soft tissue release, joint mobilization, and neural glides. 3. Lifestyle Modification and Sleep Education A 2024 Mendelian randomization study demonstrated that genetic predisposition to short sleep duration and insomnia is associated with a 53–66% increased risk of SIS (Lv et al., 2024). We educate patients on ergonomics, posture, and sleep hygiene as integral parts of care. 4. Shockwave Therapy Effective particularly for calcific tendinopathy, ESWT has shown positive results in pain reduction and calcium deposit resorption (Xie et al., 2023). Its benefit for non-calcific SIS remains limited. 5. Psychological Support Fear-avoidance behaviors and catastrophizing are barriers to recovery. Patient education and graded exposure are integrated into treatment plans. When to Refer to Physiotherapy Persistent shoulder pain > 2 weeks with overhead movements Night pain interfering with sleep Decline in function or work capacity Suspected SIS without red flags or full-thickness rotator cuff tear When to Consider Imaging or Injections Symptoms persist beyond 6 weeks with no improvement despite physiotherapy Suspicion of full-thickness tear or significant structural pathology Diagnostic uncertainty (ultrasound preferred over MRI in early phases) Outcomes and Prognosis With early physiotherapy, most patients demonstrate significant improvement within 6–12 weeks. Surgical intervention, including subacromial decompression, shows no superior long-term outcomes when compared to conservative care (Lähdeoja et al., 2020). Referral Pathway We offer evidence-informed rehabilitation programs tailored to the specific needs of each patient. Our assessments include: Detailed postural and functional analysis SPADI scoring to track progress Education on modifying aggravating activities and sleep habits Progressive exercise prescription, manual therapy, and, where indicated, shockwave therapy Physicians may refer patients directly to our clinic by fax or by having patients contact us directly. We are happy to collaborate and share outcome updates upon request. References Chester, R., Smith, T. O., Hooper, L., & Dixon, J. (2010). The impact of subacromial impingement syndrome on muscle activity patterns of the shoulder complex: A systematic review of EMG studies. BMC Musculoskeletal Disorders, 11, 45. https://doi.org/10.1186/1471-2474-11-45 Hanratty, C. E., McVeigh, J. G., Kerr, D. P., Basford, J. R., Finch, M. B., Pendleton, A., & Sim, J. (2012). The effectiveness of physiotherapy exercises in subacromial impingement syndrome: A systematic review and meta-analysis. Seminars in Arthritis and Rheumatism, 42(3), 297–316. https://doi.org/10.1016/j.semarthrit.2012.01.005 Lähdeoja, T., Karjalainen, T., Jokihaara, J., et al. (2020). Subacromial decompression surgery for adults with shoulder pain: A systematic review with meta-analysis. British Journal of Sports Medicine, 54(11), 665–673. https://doi.org/10.1136/bjsports-2019-101333 Lv, Z., Cui, J., Zhang, J., & He, L. (2024). Lifestyle factors and subacromial impingement syndrome of the shoulder: potential associations in Finnish participants. BMC Musculoskeletal Disorders, 25, 220. https://doi.org/10.1186/s12891-024-07345-w Xie, X., Ma, J., Feng, H., & Zhang, Y. (2023). Effectiveness of extracorporeal shockwave therapy for rotator cuff tendinopathy: A systematic review and meta-analysis. BMC Musculoskeletal Disorders, 24, 189. https://doi.org/10.1186/s12891-023-06345-3 Let’s Work Together If you’d like to refer a patient or request a case discussion, please contact Noshin’s Physiotherapy. Our goal is to provide high-quality, individualized care to support your patient’s recovery and long-term outcomes.
Pelvic Organ Prolapse: What It Is and How Physiotherapy Can Help You Feel Strong and Supported Again
Have you ever felt a heaviness or bulge in your vaginal area, especially after standing for a long time or lifting something heavy? You may be experiencing pelvic organ prolapse (POP) — a condition that happens when the organs in your pelvis (like the bladder, uterus, or rectum) drop or press against the vaginal wall. It can feel scary or uncomfortable, but the good news is: you are not alone, and you can get better without surgery. What Is Pelvic Organ Prolapse? Pelvic organ prolapse occurs when the muscles and connective tissues that support your pelvic organs become stretched or weakened — often due to childbirth, aging, heavy lifting, or hormonal changes during menopause. Organs such as the bladder, uterus, or rectum can slip down and bulge into the vaginal wall. You might feel: A feeling of “heaviness” or “falling out” A visible bulge near the vaginal opening Pressure or discomfort in the pelvic area Difficulty fully emptying your bladder or bowels Pain or decreased sensation during intimacy How Common Is It? POP is more common than people realize. According to large studies, up to 50% of women who have given birth vaginally will experience some form of prolapse, though not all feel symptoms (Hagen & Stark, 2011). Do I Need Surgery Right Away? Not at all. In fact, pelvic floor physiotherapy is now the first-line treatment for mild to moderate prolapse. A high-quality randomized controlled trial (Hagen et al., 2014) found that women who did 12 weeks of pelvic floor exercises had significantly improved symptoms and reduced prolapse severity. What Does Physiotherapy Involve? As a pelvic health physiotherapist, I guide women through a personalized, evidence-based plan that includes: Pelvic floor muscle training (PFMT) to strengthen internal support structures Education about safe lifting, posture, and breathing techniques Bladder and bowel management strategies Supportive devices like pessaries (if referred by a doctor) Guidance on returning to exercise safely How Long Before I See Results? Many women begin to notice improvement in symptoms like heaviness, pressure, and urinary leakage within 6–12 weeks, especially when exercises are done consistently. You Are Not Broken — You Just Need Support Pelvic organ prolapse is a physical condition — not a failure. With the right exercises, education, and support, your body has the power to heal and adapt. Takeaway Pelvic organ prolapse is common — but treatable. With guidance from a trained pelvic floor physiotherapist, you can feel stronger, more confident, and regain control of your daily life — naturally and without surgery. References Hagen, S., Stark, D. (2011). Conservative management of pelvic organ prolapse in women: A systematic review of randomized controlled trials. BJOG: An International Journal of Obstetrics & Gynaecology, 118(8), 868–878. https://doi.org/10.1111/j.1471-0528.2011.02955.x Hagen, S., Stark, D., Glazener, C. M., Dickson, S., Barry, S. J., & Logan, J. (2014). Individualised pelvic floor muscle training in women with pelvic organ prolapse (POPPY): A multicentre randomised controlled trial. The Lancet, 383(9919), 796–806. https://doi.org/10.1016/S0140-6736(13)61977-7
Urge Urinary Incontinence: Why It Happens and How Physiotherapy Can Help You Take Back Control
Do you feel a sudden, strong need to urinate that’s hard to hold back — and sometimes, you can’t make it to the bathroom in time? This condition is called urge urinary incontinence (UUI). It’s one of the most frustrating types of bladder leakage and often feels like your bladder has a mind of its own. But here’s the good news: you’re not alone, and you can regain control without relying on medications or surgery. What Is Urge Urinary Incontinence? Urge urinary incontinence is caused by involuntary contractions of the bladder muscle (called the detrusor muscle). This can happen even when the bladder isn’t full. You may feel a sudden, overwhelming need to pee — and often, leakage happens before you reach the toilet. Common Triggers: Running water Putting the key in your front door Cold weather Anxiety or stress Drinking caffeine or alcohol What Causes It? There’s usually no single cause, but contributing factors can include: Nerve dysfunction Aging Overactive bladder (OAB) Pelvic floor muscle weakness Bladder irritants (e.g., coffee, acidic foods) History of pelvic surgeries or trauma How Common Is It? According to high-quality randomized trials, UUI affects more than 20% of women over 40, and the numbers rise with age (Vaughan et al., 2019). It can also affect men, especially after prostate surgery. Can Physiotherapy Help? Absolutely! A physiotherapist trained in pelvic health can teach you to calm the bladder and strengthen the muscles that support your bladder and urethra. A 2018 Cochrane Review found that bladder training and pelvic floor exercises significantly reduced urgency, frequency, and leakage episodes in people with UUI (Wallace et al., 2018). Another RCT by Burgio et al. (2011) showed that behavioral training (including bladder retraining and urge suppression techniques) was as effective as medication — but without side effects like dry mouth or constipation. What Does Physiotherapy Involve? Bladder training: Learning how to gradually delay urination and retrain the bladder Pelvic floor muscle training (PFMT): Strengthening muscles that support bladder control Urge suppression techniques: Relaxation and breathing strategies to manage sudden urges Lifestyle coaching: Managing bladder irritants, fluids, and bathroom habits When Will You See Results? With weekly sessions and consistent home practice, many people improve within 6 to 8 weeks. You Don’t Have to Plan Your Life Around the Bathroom Many people silently suffer or restrict their fluid intake to avoid leakage. But the truth is: your bladder can be retrained. A pelvic floor physiotherapist can help you take back your confidence — naturally and safely. Takeaway Urge urinary incontinence is common but treatable. Physiotherapy offers effective, drug-free strategies to retrain your bladder, reduce leakage, and help you feel in control again. References Burgio, K. L., Goode, P. S., Locher, J. L., Umlauf, M. G., Roth, D. L., & Richter, H. E. (2011). Behavioral training with and without biofeedback in the treatment of urge incontinence in older women: A randomized controlled trial. JAMA, 291(9), 1163–1170. https://doi.org/10.1001/jama.291.9.1163 Wallace, S. A., Roe, B., Williams, K., & Palmer, M. (2018). Bladder training for urinary incontinence in adults. Cochrane Database of Systematic Reviews, (1). https://doi.org/10.1002/14651858.CD001308.pub3 Vaughan, C. P., Burgio, K. L., Goode, P. S., Markland, A. D., Redden, D. T., & Johnson, T. M. (2019). Behavioral therapy to improve urinary symptoms and voiding patterns in older adults: A randomized controlled trial. Annals of Internal Medicine, 170(8), 535–541. https://doi.org/10.7326/M18-2395
Stress Urinary Incontinence: What It Is, Why It Happens, and How Physiotherapy Can Help
Do you leak urine when you cough, laugh, sneeze, or lift something heavy? If so, you’re not alone. This is called stress urinary incontinence (SUI), and it affects 1 in 3 women at some point in their lives—especially after childbirth or menopause. But here’s the good news: you don’t have to live with it, and surgery isn’t your only option. Evidence shows that pelvic floor physiotherapy is a safe and highly effective first-line treatment. What Is Stress Urinary Incontinence? Stress urinary incontinence happens when the muscles and tissues that support your bladder and urethra become weak. This can happen due to: Pregnancy and childbirth Hormonal changes during menopause Aging Obesity Chronic coughing High-impact sports When these muscles are weakened, they can’t hold back urine during sudden pressure (or “stress”) on the bladder — like sneezing or lifting groceries. How Common Is It? According to a high-quality randomized controlled trial by Dumoulin et al. (2018), up to 35% of women worldwide experience SUI, and many suffer in silence due to embarrassment. Can It Be Treated Without Surgery? Yes! One of the most effective non-surgical treatments is pelvic floor muscle training (PFMT) — guided by a trained physiotherapist. A landmark 2014 Cochrane Review concluded that women who did PFMT were 8 times more likely to report being cured compared to those who did nothing (Dumoulin et al., 2014). Another randomized trial by Bø et al. (2017) found that a 3-month physiotherapy program reduced leakage episodes by 70%. What Does Pelvic Floor Physiotherapy Involve? Your physiotherapy treatment is private, gentle, and customized. It includes: Assessment of pelvic floor strength (externally or internally) Tailored exercises to improve muscle tone and coordination Education on bladder habits, posture, and breath control Biofeedback or electrical stimulation if needed How Long Until You See Results? With commitment to the home exercises and regular sessions, many people see improvements within 6–12 weeks. You Are Not Alone, and Help Is Available If you’re dealing with stress incontinence, talk to a pelvic floor physiotherapist. We are trained to support you with compassion, confidentiality, and evidence-based care. Takeaway Stress urinary incontinence is common, but it’s not something you have to accept as “normal.” Pelvic floor physiotherapy is a powerful, natural, and evidence-backed way to take control of your bladder again. References Bø, K., Berghmans, B., Mørkved, S., & Van Kampen, M. (2017). Evidence-based physical therapy for the pelvic floor: Bridging science and clinical practice (2nd ed.). Elsevier Health Sciences. Dumoulin, C., Cacciari, L. P., & Hay-Smith, E. J. C. (2018). Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database of Systematic Reviews, (10). https://doi.org/10.1002/14651858.CD005654.pub4
Understanding Overactive Bladder (OAB): A Guide to Regaining Control
As a pelvic health physiotherapist, I often meet patients who quietly suffer from sudden urges to urinate, frequent trips to the bathroom, or unexpected leakage. These symptoms may be signs of a condition called Overactive Bladder (OAB)—and the good news is, it’s treatable. What is Overactive Bladder? OAB is a condition where the bladder muscle (called the detrusor) contracts involuntarily, causing a sudden and powerful urge to urinate—even when the bladder isn’t full. People with OAB may: Feel urgent, frequent urges to urinate (8+ times per day) Leak urine before getting to the bathroom (urge incontinence) Wake up multiple times at night to urinate (nocturia) You are not alone—studies show that nearly 30% of adults over age 40 experience some form of OAB (Hsu et al., 2019). Why Does It Happen? There’s no single cause for OAB. Common contributors include: Age-related changes in bladder or nervous system Neurological conditions (e.g., stroke, multiple sclerosis) Tight or weak pelvic floor muscles Stress or anxiety Medications or bladder irritants (like caffeine or alcohol) Sometimes, the bladder muscle becomes overly sensitive or “trained” to signal urgency too often, even if it’s not truly full. Common Coping Strategies That Backfire Some people try to manage symptoms by: Toilet mapping (always knowing where the nearest washroom is) Fluid restriction “Just in case” urination These seem logical but can actually worsen symptoms by training the bladder to hold less and become more sensitive over time. What Actually Helps? 1. Bladder Retraining (with Physiotherapy Support) This is a proven method that helps you gradually increase the time between bathroom visits using: Scheduled voiding (e.g., every 90 minutes instead of every hour) Urge suppression techniques, like: Deep breathing Mental distraction Reverse Kegels (relaxing pelvic floor muscles) In a randomized controlled trial, behavioral therapies (like bladder training) improved urgency and leakage with minimal side effects, often matching or exceeding medication benefits (Scaldazza et al., 2017). 2. Pelvic Floor Physiotherapy As a physiotherapist, I assess whether your pelvic floor is: Too weak (needs strengthening) Too tight (needs relaxation) Both can contribute to OAB. A personalized program, often including biofeedback and exercises, can make a big difference. 3. Lifestyle Changes Hydrate smartly: Sip fluids throughout the day but reduce intake 2–3 hours before bedtime. Avoid bladder irritants: Caffeine, alcohol, spicy foods, and artificial sweeteners. Manage constipation and stress: Both can increase pressure on the bladder. 4. Medical Options (When Needed) When lifestyle changes aren’t enough, your doctor might recommend: Anticholinergic medications (e.g., oxybutynin) Beta-3 agonists like mirabegron—shown to have fewer cognitive side effects in older adults (Welk & McArthur, 2020). If medications don’t help, advanced options like tibial nerve stimulation or Botox injections into the bladder wall may be considered (Keller et al., 2017). Takeaway OAB is not a normal part of aging. It’s a treatable condition that responds well to physiotherapy, behavior change, and, if needed, medication. If you’re constantly searching for bathrooms, waking up at night, or feeling anxious about leaking—know that you can take control again. A pelvic health physiotherapist can be your first step toward regaining confidence and comfort. References Benner, J., Nichol, M., Rovner, E., Jumadilova, Z., Alvir, J., Hussein, M., & Brubaker, L. (2010). Patient‐reported reasons for discontinuing overactive bladder medication. BJU International, 105(9), 1276–1282. https://doi.org/10.1111/j.1464-410x.2009.09036.x Fontaine, C., Papworth, E., Pascoe, J., & Hashim, H. (2021). Update on the management of overactive bladder. Therapeutic Advances in Urology, 13, 17562872211039034. https://doi.org/10.1177/17562872211039034 Hsu, Y. P., Chuang, F. C., Chang, S. J., & Yang, S. S. (2019). Prevalence and associated factors of overactive bladder among the elderly in Taiwan. International Urogynecology Journal, 30(7), 1091–1099. https://doi.org/10.1007/s00192-018-3776-4 Keller, N., Schmid, S., & Haemmerle, B. (2017). Successful therapy of overactive bladder syndrome with percutaneous tibial nerve stimulation: A case report. The International Annals of Medicine, 1(11), 387. https://doi.org/10.24087/iam.2017.1.11.387 Scaldazza, C., Morosetti, C., Giampieretti, R., Lorenzetti, R., & Baroni, M. (2017). PTNS vs. pelvic floor muscle training in women with OAB: A randomized study. International Braz J Urol, 43(1), 121–126. https://doi.org/10.1590/s1677-5538.ibju.2015.0719 Welk, B., & McArthur, E. (2020). Dementia risk in patients treated for OAB: Anticholinergic vs beta‐3 agonists. BJU International, 126(1), 183–190. https://doi.org/10.1111/bju.15040
Understanding Subacromial Impingement Syndrome
As a physiotherapist with over a decade of experience treating shoulder pain, I often see patients struggling with a condition known as Subacromial Impingement Syndrome (SIS)—one of the most common causes of shoulder discomfort. It’s frustrating, painful, and can significantly affect your ability to work, sleep, or enjoy your daily activities. But the good news? In most cases, this condition can be managed effectively without surgery—and the earlier you address it, the better your outcome. What Is Subacromial Impingement Syndrome (SIS)? Your shoulder is a complex joint. SIS occurs when the tendons of your rotator cuff or the bursa (a fluid-filled sac that cushions the shoulder) get irritated or compressed in the narrow space beneath the top part of your shoulder blade called the acromion. This irritation can lead to pain, inflammation, and stiffness—especially when lifting your arm, sleeping on your side, or reaching behind your back. Common Causes of SIS Repetitive overhead movements (like painting, swimming, or lifting weights) Poor posture, especially rounded shoulders Muscle imbalances or weakness around the shoulder blade Sleep position, especially lying on the painful shoulder Wear and tear with age Symptoms You Shouldn’t Ignore Pain when lifting your arm or reaching overhead Difficulty sleeping on the affected side Weakness or stiffness in the shoulder A clicking or grinding feeling when moving your arm If left untreated, SIS can lead to chronic pain, limited shoulder function, and even tears in the rotator cuff. The Role of Sleep, Posture, and Lifestyle Recent research has shown that poor sleep habits and excessive phone use can actually increase your risk of developing SIS. One high-quality study from Finland used genetic analysis to find that short sleep and insomnia increase the risk by up to 66% (Lv et al., 2024). Another study found that people who used their phones excessively were over 4 times more likely to develop shoulder impingement (Lv et al., 2024). Do I Need Surgery? Not usually. Multiple systematic reviews have found that surgery is not more effective than physiotherapy for most people with SIS (Lähdeoja et al., 2020; Hanratty et al., 2012). In fact, the long-term results of tailored physiotherapy can be just as good—if not better—without the risks or downtime of surgery. Effective Treatments That Actually Work 1. Exercise Therapy Targeted shoulder exercises are the gold standard. Research shows they reduce pain and improve function, especially when they focus on strengthening the rotator cuff and scapular (shoulder blade) muscles (Hanratty et al., 2012). 2. Manual Therapy Hands-on treatments like joint mobilizations and soft tissue techniques can complement exercises and improve movement (Chester et al., 2010). 3. Postural Training Correcting slouched posture is crucial. A forward shoulder posture can compress the subacromial space and irritate tendons. 4. Sleep Position Coaching Avoid sleeping on the painful shoulder. Try sleeping on your back with a small pillow tucked behind your shoulder to reduce pressure. 5. Shockwave Therapy (ESWT) This is particularly helpful in cases of calcific tendinitis, where calcium builds up in the tendons. Studies show ESWT can help dissolve calcium and reduce pain (Xie et al., 2023). 6. Cortisone Injections Short-term relief can be achieved through corticosteroid injections. However, they should be used cautiously and not as a long-term solution. What You Can Do Right Now Avoid overhead tasks until you’re assessed Sleep on your back with shoulder support Begin gentle stretches if pain allows Book an appointment with a physiotherapist early Final Takeaway Shoulder pain doesn’t have to be part of your daily life. Subacromial Impingement Syndrome is treatable—and often without surgery. The key is early intervention, consistent exercise, posture correction, and sleep hygiene. If you’re experiencing shoulder pain, don’t wait. A customized physiotherapy plan can help restore your movement, reduce pain, and improve your quality of life—safely and naturally. References Chester, R., Smith, T. O., Hooper, L., Dixon, J. (2010). The impact of subacromial impingement syndrome on muscle activity patterns of the shoulder complex: A systematic review of EMG studies. BMC Musculoskeletal Disorders, 11(1), 45. https://doi.org/10.1186/1471-2474-11-45 Hanratty, C. E., McVeigh, J. G., Kerr, D. P., Basford, J. R., Finch, M. B., Pendleton, A., & Sim, J. (2012). The effectiveness of physiotherapy exercises in subacromial impingement syndrome: A systematic review and meta-analysis. Seminars in Arthritis and Rheumatism, 42(3), 297–316. https://doi.org/10.1016/j.semarthrit.2012.01.005 Lähdeoja, T., Karjalainen, T., Jokihaara, J., Salamh, P., Kavaja, L., Agarwal, A., … & Vandvik, P. O. (2020). Subacromial decompression surgery for adults with shoulder pain: A systematic review with meta-analysis. British Journal of Sports Medicine, 54(11), 665–673. https://doi.org/10.1136/bjsports-2019-101333 Lv, Z., Cui, J., Zhang, J., & He, L. (2024). Lifestyle factors and subacromial impingement syndrome of the shoulder: potential associations in Finnish participants. BMC Musculoskeletal Disorders, 25, Article 220. https://doi.org/10.1186/s12891-024-07345-w Xie, X., Ma, J., Feng, H., & Zhang, Y. (2023). Effectiveness of extracorporeal shockwave therapy for rotator cuff tendinopathy: A systematic review and meta-analysis. BMC Musculoskeletal Disorders, 24, 189. https://doi.org/10.1186/s12891-023-06345-3
The Biopsychosocial Approach in Physiotherapy
Introduction Pain is more than just a physical sensation and is influenced by multiple factors. These including emotions, beliefs, and one’s social environment. For years, physiotherapy primarily focused on treating pain through a biomedical lens—targeting muscles, joints, and tissues, trying to fix them. However, over time and with research, modern pain science has actually shifted towards a more holistic model known as the biopsychosocial (BPS) approach. This model was introduced by Dr. George Engel in 1977, which challenges the traditional biomedical perspective and emphasizes the complex interactions between biological, psychological, and social factors in pain and rehabilitation. So, why should physiotherapists and patients embrace this paradigm shift? Let’s explore how research shows this approach leads to faster recovery, improved pain management, and long-term well-being. The Biopsychosocial Model: A New Way of Understanding Pain What is the BPS Model? Instead of viewing pain as purely a result of structural damage, the BPS model recognizes three key influences: Biological – Muscle imbalances, nerve function, joint restrictions, inflammation, and tissue sensitivity. Psychological – Beliefs about pain, emotional regulation, stress, and fear of movement. Social – Work environment, relationships, financial stress, and cultural influences. Pain is not just a mechanical issue—it’s an experience shaped by our beliefs and environment. For Example: Two people with the same MRI findings for a herniated disc may have completely different pain experiences. One might be in constant agony, while the other feels no symptoms at all. Why? The first patient may have high stress levels, poor sleep, and have developed a fear of movement, amplifying their pain. The other, may have strong coping strategies, a supportive social environment, and positive beliefs about recovery, reducing their pain response. This highlights why treating the whole person—not just the injury—leads to better results. The Biological Component: More Than Just “Tight Muscles” Did you know, many patients believe pain is solely due to tissue damage. And while these structural issues play a role, pain is also influenced by one’s nervous system, inflammation, and movement patterns. The Key Biological Factors in Pain: Muscle Dysfunction: Weakness, hypertonicity (tight muscles), poor motor control. Central Sensitization: The nervous system becomes overly sensitive, making normal sensations feel painful. Inflammation: Chronic inflammation increases pain perception. Sleep & Recovery: Poor sleep heightens pain sensitivity and delays healing. Clinical Example: Research done by Moseley & Butler (2015), shows that gradual exposure to movement, combined with pain education, will help retrain the patient’s nervous system, allowing patients with chronic pain to move with less fear and more confidence. How Physiotherapists Can Help: Use pain neuroscience education to reframe a person’s negative beliefs about pain. Implement graded exposure therapy to reduce movement-related fear. Teach breathing and relaxation techniques to regulate the nervous system. The Psychological Component: How Thoughts and Emotions Shape Pain The brain plays a crucial role in pain perception. Did you know, if someone believes their pain is dangerous, it actually makes it feels worse? And if they feel helpless, recovery actually slows down. Addressing these kind of negative thoughts and emotions, and implementing healthy coping strategies is crucial and just as important as physical rehabilitation. Common Psychological Barriers to Recovery: Pain Catastrophization – Thinking “This pain will never go away” leads to increased distress and disability. Fear-Avoidance Behaviours – Avoiding movement due to fear of pain, causing muscle weakness and stiffness. Stress & Anxiety – Chronic stress amplifies pain perception through the nervous system. Key Research Insight: A study by Quartana et al. (2016) found that high levels of pain catastrophization correlate with increased disability and prolonged recovery. Put simply, what you think about pain affects how much pain you feel. Management for Pain Catastrophization: Use CBT-based strategies to reduce fear of movement. Teach guided relaxation and mindfulness techniques to regulate pain perception. Encourage journaling or expressive writing to process emotions linked to pain. The Social Component: The Role of Environment and Support Pain is not experienced in isolation. Work stress, family dynamics, financial struggles, and cultural beliefs all influence how we perceive and respond to pain. Key Social Factors Affecting Pain & Recovery: Support Systems: Patients with strong family and social support have shown to recover faster. Work & Postural Stress: Sedentary jobs and poor ergonomics contribute to musculoskeletal issues. Cultural Beliefs: Some cultures view pain as a normal part of aging, leading to delayed Treatment. Healthcare Access: Socioeconomic factors determine whether patients can afford therapy and implement treatment. Key Research Insight: A 2019 systematic review (Osborne et al.), found that social determinants of health significantly impact pain recovery timelines. How Physiotherapists Can Help: Address psychosocial barriers to treatment adherence. Provide accessible home exercise programs for patients with limited mobility or resources. Educate patients on ergonomics, posture, and lifestyle changes for long-term pain prevention. Lifestyle Medicine: Sleep, Diet, and Exercise in Pain Recovery Sleep & Pain Sensitivity – Poor sleep increases inflammation and reduces pain tolerance. Diet & Inflammation – Anti-inflammatory foods (omega-3s, antioxidants) reduce pain and promote healing. Exercise & Nervous System Function – Movement helps “retrain” the nervous system, making pain less threatening. Key Research Insight: Dr. David Nieman’s research shows that moderate exercise enhances immune function and reduces chronic inflammation, while overtraining increases pain sensitivity. How Physiotherapists Can Help: Track sleep habits and provide strategies for better rest. Encourage anti-inflammatory diets rich in whole foods. Use graded activity programs to prevent overuse injuries. Bridging the Gap: Helping Patients Understand the BPS Model Many patients expect only hands-on therapy or exercises. When we ask about sleep, stress, or emotions, they may wonder: Why are you asking about my sleep when I came in for back pain? What does stress have to do with my shoulder pain? The Biopsychosocial Model explained: “Your body works as a team.” If one part is weak, other parts compensate—sometimes causing pain elsewhere. “Pain isn’t just about damage.” Your brain processes pain like an alarm system—sometimes the alarm is too sensitive, making normal sensations feel painful. “We treat the whole person, not just the symptoms.” – Addressing stress, sleep, and movement