Latest / The STA Clinician Podcast / Ep.229: 'Pregnancy Related Back And Pelvic Pain' with special guest Michelle Lyons

Transcript

Ep.229: 'Pregnancy Related Back And Pelvic Pain' with special guest Michelle Lyons · The STA Clinician Podcast

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You're listening to the Sports Therapy Association podcast, putting evidence
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back into soft tissue therapy.
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Music.
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And we're live. Hey people, how are you doing? Welcome to episode 229 of the
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Sports Therapy Association podcast. My name is Matt Phillips,
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creator of onechatlive.com.
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And as always, this episode is being recorded live at eight o'clock on a Tuesday
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evening on the Sports Therapy Association YouTube channel and Facebook page.
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This is part three of our focus on women's health this month,
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entitled Pregnancy Related Back and Pelvic Pain.
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And I'll very shortly be joined by special guest Michelle Lyons,
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women's health physiotherapist and creator of CelebrateMooliebrity.com.
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I've just got a thumbs up from the lounge below. There we go.
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But first, a big thank you to my guests last week in part two,
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who were Christine Bird and Joe McKeown, co-founders of Menopause Movement,
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who discussed menopause, bone health, and muscle mass.
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Check out the website menopausemovement.co for details about their e-learning
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course, as well as their Instagram account, Menopause Movement,
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for some fantastic information on that. It was a great hour. I always say that.
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I'm thinking actually, and if you do want to send in some comments on this and
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also people joining us live, I'm thinking now after 230 episodes will be next
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week, we are going to have a month on disability, which I'm very excited about.
1:30
It's a topic again, which needs to be put out there. So we're going to do a
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month of March on that. But then I'm thinking.
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Maybe pause and reflect. Now, I don't know whether this is going down well,
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but I'm thinking of going through the 234 episodes, not all of them one by one,
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and just inviting people to pause and reflect on those episodes.
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Because I'm worried now we're putting out such amazing information that it's
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just, and next week, and next week, and next week.
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And we need to take a little step and go through some of these 230 and just
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kind of talk about them a little bit more.
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Because a lot of the stuff in any of them is still very relevant and we need
2:01
to think about it. So I'm thinking of that.
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What do you think people who joined us live do you think it's a good idea i'm going to invite people
2:05
who join us live or anyone basically wants to come up all you have to
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do obviously is look at the episode we need to comment
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on and then share some comments and ideas we could have one
2:13
here we could have five here whatever you like as long as you've got a mic and you're
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vaguely kind of composed when you're online that'd be
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that'd be fine anyway that's an idea and i'll put some social media posts about
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that talking about people who joined us live hi to tracy marsh says good evening
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all cecily hisslop is in the house says woohoo evening all um if you are listening
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to podcasts then basically you can join us live and your messages and questions
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can come up onto the screen for example imid tester says i'm actually here thanks
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cecily for reminding me brilliant thank
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you cecily thank you everybody who kind of at five to eight says don't forget
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this is coming up it's really useful because you know what we live in the lives
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we live in it's useful to have that little elbow and the ribs just five minutes
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before something actually worth watching is going to come on sir glenn murphy
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mbe sir glenn good evening um says is this chat happening tonight Yes,
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it is. Sorry, I was late, Sir Glenn. My apologies.
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Gary Benson, founder of the STA, is here as well. So this evening,
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everyone. Hope all is well in your world. Fantastic. And we won't talk about
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Arsenal football. No, let's not do that.
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We'll leave that. So there we go.
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Also, I just wanted to point out as well, you may have seen on social media
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today that on Wednesday, the 19th of March at 7pm,
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Sarah Packard of Women in Sports Therapy is going to start part one of a new
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menopause CPD series we're doing.
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Due to the feedback we've got principally on this month so far and the WIST
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ladies putting together this fantastic series and like I say it starts Wednesday
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19th of March at seven o'clock.
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The first session is going to be focusing on perimenopause and menopause identifying
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how the hormones change and symptoms that may present.
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If you're an STA member good news this is free that's how we roll that's how
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Gary rolls we're just giving you back your membership money which is what a
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professional association should be doing in the form of quality information.
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If you're not an STA member, then you've got a choice to make.
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You could either sign up to the STA and save yourself lots of money,
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or you could pay just the little sum of £15 to see this CPD series.
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If you are interested in signing up, then make sure you go to,
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there's a few places, you could go to the Sports Therapy Association open website.
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Page on Facebook where the link is there. And also I'm going to put on the screen
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a little short link, which if you're joining us live, you can copy down.
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Or if you're watching the YouTube video, then there you can copy this down.
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Basically it's shorterl.at forward slash MW capital P-O-I.
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So that is shorterl.at forward slash MW capital P-O-I.
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And that will take you to the link.
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If you're not a member and you sign up, then it will send you
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details on how to pay for that so very
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exciting well done great to see the women in sports therapy back
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in action and supporting the community so that's done
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and done the topic is going to stay here tonight um if you have joined us live
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like i say do feel free to ask questions in the comment section as and when
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you wish but i think now it's ready she's been waiting there patiently to bring
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up our very very very very special guest for tonight women's health physio and
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creative to CelebrateMoulyEmpathy.com,
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Michelle Lyons.
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Yay, there it goes. Yay, Michelle. Sorry to leave you there for so long.
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Watching the clock just ticking over, thinking she's going to get up and go. She's going to go.
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She'll do it, runner. Thank you so much. I was within 10 minutes.
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Thank you. Thank you for giving up your time, as always. Pleasure. How are you?
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I'm great, thanks. Yeah, just happy to be back again. Looking forward to nerding
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out and discussing all things pelvic girdle pain that are pregnancy related.
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Fantastic you have been on the show quite a few times now you're up there i
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think and if you were if you were the stig of top gear which is something i
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don't even know why i'm using that the stig of women's health you'd be yeah
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everyone else would be competing with you at the moment i was going with repeat
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offender but okay stig would be another way to go yeah yeah yeah,
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do i get yes and for people who aren't aware then you're
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lost in the show actually you lost in the show august last year which is
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episode 210 which is musculoskeletal health that menopause new
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research and then episode 163 that
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was way back talking about your trip to sydney remember that oh gosh
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health support ages ago and then
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also in 141 talking about women's health and back pain so all these episodes
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with the wonderful michelle lions are there for your free education and entertainment
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if you just go to your popular podcast app or if you want to watch them and
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go to youtube how are you feeling your last episode to celebrate mooliebrity
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podcast you were just getting out of the flu,
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aren't you, or something? I think it's a bit of a cokey. Yeah.
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You know what? It was just that really bad dose that was going around over New Year's. So we just...
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I think the whole family got it kind of just, it would go through one of us
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and then it would launch into another one and then into another one of us.
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And then we had a delightful storm come through and it knocked our power and
6:55
broadband out for weeks. We lost power for about five days.
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Broadband was down for about 10 or 12 days. So it was a rough period there over
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the new year, but onwards and upwards for 25.
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Very positive. Fantastic. And if people aren't aware of Celebrate Mulyabji podcast,
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then I've just put up on the screen there, Spotify.
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Obviously, you can listen to it in all the popular podcast apps and that.
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But I say it each time. It's something you really should check out,
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particularly if you're into women's health.
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And also, obviously, if you're not into women's health, because it will get
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you into women's health and help you understand.
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It'd be rubbish if just everybody already interested came and listened to it.
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So if you're not interested, and in fact, you really don't like the idea of
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it, this will be a nice, gentle ease into it and make you realise actually these topics are important.
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And what more could lure you in than the latest episode on dyspareunia?
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I think that pronunciation is okay.
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Matt, you're on fire. Well, I mean, when you're on, I mean, I've got muliebrity
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sorted now and now I'll do my research and now I know what dyspareunia is.
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See? So there you go. So, I mean, that's a great example, I think,
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which is basically pain during sexual intercourse and many reasons for it.
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I think that's a good example. I'm pointing that out because it's a good example
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of the taboo subjects and kind of misconceptions which you'd like to bring to people's awareness.
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Yeah, it's really important, isn't it? Because, you know, if we're going to
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be working as healthcare professionals, as therapists working with women,
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with men, people of any gender or persuasion, we just have to really get comfortable
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asking about these things, you know, because,
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menstrual health was such a topic for a long time.
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You know, asking people even about their bowel movements, you know,
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for some people can be a bridge too far, but it just gives you such good
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information and teaching people how to track their own health markers I
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think is super important because you're giving people back then some
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agency and some self-efficacy over their own health
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and well-being and really helps paint a picture then if you're
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having a problem you can say well look here's some data that I've compiled on
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myself and it just it means you're going to get a solution that bit quicker
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and you're tuned into your body as well because it's so many people kind of
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dissociated from about here down and you know as therapists working with with
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human bodies that are attached to human brains,
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we need to have this biopsychosocial approach.
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But as I like to say, physiology is queen.
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So we've got to think about when our physiology is altered, what's driving that alteration?
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And of course, then what are we going to do to help people get better?
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Because we're not mechanics coming in to fix people, but we want to show people
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how to help themselves live a better life.
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Fantastic. Well, yeah, then that's what it's all about. Yeah.
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And it's interesting that it is a case of where I think as soon as people go
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in and look at the list of topics you've got in there,
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they might be taboo subjects, which people kind of watching in the privacy of
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their own room for a while thinking, oh my God, everyone knows I'm watching this.
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But then suddenly you realize once you got rid of that silliness,
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it's like, oh my God, this can help so many people.
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And my clients come in because I think most therapists and listeners,
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if you've joined us live and correct me, most people have got these questions on their par queue.
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Is it painful when you have sexual intercourse or is it painful to go to the
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toilet? But the follow-up from that, if someone ticked yes, you're like,
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oh my God, that's never happened before.
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That was me. I mean, like that literally was me when I was a baby physio and
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I was working in sports medicine for the first time.
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Maybe the first 10 years of my career, you know, we would have kind of that
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screening, you know, we use the, let's say the Oswestry back pain questionnaire.
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And you're asking people, you know, any problems with your bowel,
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your bladder, I was the one going, please say no, please say no, please say no.
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Because I wouldn't, you know, what am I going to do if they say yes?
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And literally, then, you know, I am the person now who won't stop banging on
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about bowel movements and menstrual health and just hormonal awareness.
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Because if we're going to treat people, we have to
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treat whole people and we have to
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look at all the different factors you know they're coming to us because they're
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having a problem and so in order to serve them better we need to work on ourselves
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and just have that depth of understanding about what could be driving their
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issues I mean you know endometriosis affects one in nine people on the planet
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or one in nine women on the planet.
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So these are topics that we have to start bringing into
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the mainstream and and just get really comfortable asking
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the questions and then of course you know knowing who and when
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and how to refer on as well if that's necessary and sometimes
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it is and sometimes it isn't definitely and i
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think it can be really empowering as well for therapists because we've talked
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a lot about imposter syndrome and kind of like that fear of someone ticking
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a box you don't know nothing about so i really would encourage listeners to
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just a little bit of information will make you feel so much more powerful which
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is only going to help you and your clients and so there we go check out,
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Celebrate Mulebreti podcast and it will give you more information you ever thought
11:34
you'd ever need. That you ever want.
11:38
And I think we should get the elephant in the room as always,
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which is Mulebreti. What's this word we've said so well and rolling off our
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tongues just to let this wind aware know?
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You're so proud, Matt. We're not going to pretend that it took you two years
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to get to this point, but it's okay. It's okay.
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Mulebreti, it's an old English word and it means the art and state of being a woman.
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I think that should be celebrated. There you go. And do you know,
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I mean, each time we say this, I think I kind of expand it a little bit just
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to see if you know, basically.
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But do you know how it's linked to the word mollify?
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Go on, Matt. Really? You just said that to give you my time, have you?
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No, go for it. It's all to do with, apparently, it's from the Latin mollis,
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which is soft, which has been linked in history with women.
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So mollify means to soften something. whether it's feelings or anger.
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So there's a link there with the Latin between woman, soft, and mollified. There you go.
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You can use that on your next episode
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if you like. I will see how many conversations I can weave that into.
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My husband says it's because, you know, it's derived from mules because apparently
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I have a stubborn strength. But, you know, I prefer your version.
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Yeah, I would go with that. What does your husband know? Men, honestly.
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Can't live with him, can't live with him. Anyway, right, we'll get back to tonight's topic.
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Pregnancy-related back and pelvic pain. Very interested. As for last week,
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we had some great questions.
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So therapists in here, anything you've got, throw into the comments.
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Michelle, obviously you put some posts out there and asked people,
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what sort of questions did you find were coming back to you?
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What are the sort of areas that people wanted to know about?
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Well, you know, it ranged from the basics, kind of, you know,
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what is it and why is it happening? Is it hormonally driven?
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Is the pelvis unstable in pregnancy? Is it all about relaxants?
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And, spoiler alert, no. But I do have to explain as we go through,
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I did put up kind of a cryptic post on Instagram about prawns.
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Oh, yeah. Yeah.
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So that was me just being a little bit, a little bit, I'm not sure what the
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word is, but prawns basically stands for pregnancy-related abdominal wall neuropathy.
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So... Clever. So you did there now. See what I did there? Yeah.
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So that intrigued a couple of people. I got a lot of questions about what are these prawns?
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And yeah, so we can talk about the drivers for pelvic girdle pain during pregnancy,
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because this is an issue that affects about 75% of women in pregnancy.
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And I think what I would like to do is a bit of myth busting about it really,
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because there's so many stories that women are told about pelvic girdle pain during pregnancy.
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Like it's normal to have some aches and pains as you're going through pregnancy
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because you're going through massive hormonal changes, massive anatomical and
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physiological changes.
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Hormones are all over the place,
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but I'm not talking about the aches and pains that kind of come and go.
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When we're talking about pregnancy-related pelvic girdle pain,
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it's fairly significant pain, you know, between,
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let's say, the iliac crest and the gluteal folds
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front and back and it comes and it doesn't
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go and it's really distressing and lots of women are told that it is due to
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the hormone relaxin that's softening your pelvis it's loosening the ligaments
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your pelvis is unstable that's why it's torn there's nothing we can do about
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it until the baby is delivered and
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put up with it. And nothing that I've said in the past 30 seconds is actually true.
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It's not caused by relaxing. Your pelvis is not unstable. There's loads we can
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do about it. You don't just have to put up with it until the baby is due.
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And that's, you know, that's really, I think, the direction that I want therapists
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working with pregnant women to take because one of the biggest predictors of
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successful outcomes for working with women who have pregnancy-related pelvic
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girdle pain is a belief that it will get better.
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So if you can foster that really strong therapeutic alliance with the woman
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that you're working with, that this is going to get better before your baby
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comes, we have a plan and it's going to get better.
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That's at least 50% of what we have to do. But that does not mean that the pain
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is all in her head. The pain is very real.
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What we know is possibly going on there is that stress and anxiety about the
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pain actually turns the volume way up on us on these sensitized structures.
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So we have to take both a top-down and a bottom-up approach to pregnancy-related pelvic girdle pain.
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Once we rule out a couple of red flags, there's so much that we can do to get women out of pain,
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to get them moving, get them exercising again because what we really want to
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do is to encourage women to be physically active to be strong because honestly
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like having a baby and and then taking care of a baby it's really hard work
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so you need to be in good shape physically and mentally to be ready for that,
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and and that's what we're that's what we're here for working in women's health
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how much it's interesting you're hearing talking about the biopsychosocial important
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of trying to release stress and that's 50 of it this is obviously an obviously
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something that particularly our soft tissue therapists, listeners,
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massage therapists can help with.
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100%. There's often fear and the idea that you could cause miscarriages,
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that you shouldn't touch this person, you've got to spend a lot of money on a course,
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which seems like a real shame because it sounds like one of the great things
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which could help relieve pain is just a bit of time to leave stress.
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You know, massage does that?
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Absolutely. Absolutely. Especially, you know, kind of just focusing on breath work,
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focusing on movements you know find a movement that doesn't hurt
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let's focus on that let's turn down those messages
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of threat of nociception that are coming in you
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know I think what we have to do is we have to remember that we're we're
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dealing with somebody who's maybe got a very upregulated nervous system imagine
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you've got really significant pain and you're having difficulty getting
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out of bed going to work getting in and out of a
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car it can really just take over your life and obviously you can't take pain
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medication while you're pregnant so what do you do and you've been to your doctor
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and again this is not anything against GPs because they have to know a little
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bit about a lot of different things the thinking used to be that your pelvis was unstable so you know,
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Times have moved on and our research has moved on and our successful outcomes
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are improving now when we've got this new understanding of what's actually driving
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pregnancy-related pelvic girdle pain.
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So the first thing is to give hope and belief and the patient has to believe
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that you as the therapist do actually know what you're talking about.
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So we do want to look at some of the physical drivers that could be contributing
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to the pain and you'll be shocked I know to hear that the pelvic floor is one
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of those drivers and that I will be talking a little bit about that as well.
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But it's basically like the sacroiliac joints and the pubic symphysis joint,
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if we think about those joints within the pelvis, they're not becoming unstable.
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It's not due to relaxin, first of all, because relaxin peaks around 16 weeks of pregnancy.
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And most women with pregnancy-related pelvic girdle pain will be from maybe
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kind of mid to the end of the second trimester into the third trimester.
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You've got a changing center of gravity.
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You've got, you know, your estrogen levels have gone up about a thousand fold.
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And estrogen does have some effect on the ligaments, but also on inflammation.
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But what we actually know the biggest risk factors for developing pregnancy-related
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pelvic girdle pain in the first part are parity.
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So it's more common with second and subsequent because, you know,
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when you're having your first baby.
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You probably don't have much to take care of in the way of small children.
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If this is your first pregnancy, your first delivery.
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But when you're going to your second or your third and you have some toddlers,
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you have small children, they're demanding creatures.
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Your resilience might be lowered a little bit.
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Maybe you're not sleeping well. And we know sleep is disastrous in terms of
19:45
pain and catastrophizing.
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But also we have some issues, you know, constipation is super common during
19:52
pregnancy, particularly if you put on iron supplements, you know,
19:55
because again, Again, iron deficiency anemia is also common during pregnancy.
19:59
So a lot of these things can kind of come together and you get this perfect
20:02
storm where you've got tissues that are sensitized.
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Actually, hang on, for those of us who are watching, you can see here, here's my little model.
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So you can see her baby here growing.
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And so your stomach muscles are on a huge stretch.
20:16
You're carrying all this extra weight in front. Breasts are getting bigger.
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Everything is pulling you forward and down. and now you're hanging on maybe
20:23
some glutes that are just not up to that task.
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You're stressing out about this. Your pelvic floor is activated.
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Adductors are switched on. Everything is up like this. Your breathing is up
20:35
here. You're stressing. You're not sleeping and you're probably a bit constipated.
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So you're just kind of, you know, everything is inflamed. Your nervous system's wound up.
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So the first thing we can do is just get people back into their bodies again, breathing,
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and calm things down are there
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certain drivers that we have to be aware of absolutely you know
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things like round ligament pain we want to to check
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and see could that be what's going on we want to rule
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out things like dvt and we can talk about some of the science for that and you
21:05
know even a neck of femur fracture but generally what we want to do is we want
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to get the message across that your pelvis is stable you are safe we have a
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plan we will get you out of this we're going to use manual therapy to calm things
21:18
down, to have a conversation with the nervous system.
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And then we're going to work on building you back up and getting you ready for
21:25
your life and for your goals as well.
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So it's calm things down, build things back up again.
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I think it's an example. I'm listening to you and thinking it's such a great
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example of where multidisciplinary care for the patient really works.
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Because there's obviously red flags, like we'll talk about shortly,
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which need to be ruled out.
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You can't just tell. Everything's going to be fine. Don't worry about it,
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because that would be a crime in many cases.
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But if you're working with someone who it's in
21:52
their sphere of practice to actually check those things out
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and then your speciality is relaxing the person down and
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calm down that kind of sensitized nervous system then what a great and also
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both speak in the same language so neither of you are chucking that nociceptive
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language in there yeah yeah wouldn't it but obviously that doesn't happen that
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much um hannah tabram here is giving personal experience of when i had pelvic girdle pain.
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I couldn't even lie down to sleep without being in pain. It was awful. Yeah.
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It can be nasty. It can be absolutely nasty. And that's why,
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you know, what we see looking at the research, even around pregnancy-related
22:29
pelvic girdle pain, what we have to do is we have to come up with ergonomic
22:33
strategies for movement that are not going to provoke an already wound up nervous system.
22:39
So for example, if somebody's complaining of let's
22:42
say a lot of anterior pelvic girdle pain pain around pubic symphysis
22:45
well we can figure out like if they're having pain when
22:48
they're going from sit to stand what happens when
22:51
they go from sit to stand and they're supporting the bump does
22:54
that lessen the pain because that's going to tell us okay so
22:57
maybe it's around ligament pain so we need to actually create a little bit more
23:01
thoracic mobility a little bit more space here maybe some gentle abdominal work
23:06
even starting with some pelvic tilting to get a little bit more lumbopelvic
23:10
mobility and teach people how to go from sit to stand without breath holding and bearing down.
23:16
And it can be just, you know, working even with people via telehealth,
23:21
you know, you can just kind of teach them how to do that and give them back
23:26
confidence in their own body again.
23:28
So what I'm saying here is absolutely not to minimize the pain of pelvic girdle
23:33
pain because it can be horrendous.
23:35
But what I'm saying is here's what we know works really well you know are you
23:40
sleeping are you constipated because we know for women and back pain and we've
23:45
talked about this before mass you know for women with back pain there's a huge
23:49
correlation with pelvic floor muscle overactivity stress and constipation,
23:55
And if you're constipated and you're worried about your pregnancy,
23:58
because, you know, again, not every pregnancy is a happy one either.
24:01
All of these things can kind of drive that nervous system wind up because,
24:06
you know, pain, pain's not really an issue of tissue problems.
24:11
It's more of a subjective experience of how much danger your brain thinks you're
24:16
in and it's trying to protect you.
24:18
And the pelvic floor muscles, of course, are really psychologically sensitive.
24:21
And if we remember, like they're attached front and back to the pubic symphysis and
24:24
to the coccyx so if they're trying to protect you
24:27
they're like this and they're holding on for dear life and
24:31
that can really along with kind of those central factors the stress the anxiety
24:36
that's happening because you're in pain and no one's telling you how to get
24:39
out of pain that kind of keeps the whole cycle going so what we need to do is
24:43
kind of stop let's break this cycle I know what's happening with you.
24:49
It's real. I believe you. And I have a plan to help you.
24:54
And just kind of getting people out of this and back into their body again and
24:58
in a position where they're back in control of their own body again,
25:02
because it can just really feel like this.
25:05
Honestly, for your first pregnancy, especially, it can feel like this alien
25:08
has taken over and, you know, you're in pain and everything is scary and big.
25:13
And what we want to do is actually enable women to enjoy their pregnancy and
25:17
to prepare really well for labor and delivery and afterwards.
25:21
So it's to get those messages across, I think, to not only to our community
25:27
of therapists and to our medical colleagues, but also to the women that we're working with as well.
25:32
Absolutely seek help if you're having pelvic girdle pain during your pregnancy.
25:37
And let's make sure that we're providing evidence-based care to get people moving
25:42
and to get them happy and healthy again.
25:45
Great advice. Brilliant advice. Thank you, Hannah. Thank you for sharing.
25:48
I'm interested, Hannah, if you get a moment, was there anything that you were
25:53
shown by a healthcare professional or did you discover it by yourself,
25:56
which helped you in particular?
25:58
That'd be nice if you can, if you want to share that, then follow up with that maybe.
26:03
I've just got to say hello as well. I'm presuming that this could be the booby
26:06
physio herself in the room. It could well be.
26:09
It might be somebody else behind the account, but Siobhan O'Donovan could well
26:12
be here in the room with us.
26:13
So there you go people who got questions about boobs and you
26:16
can start that little comment off in your own time there thanks for
26:19
joining us i'm really i'm really like i love it
26:22
when you drop clinical pearls like if somebody is having problem going from
26:25
sit to stand and maybe just supporting the weight or a
26:28
little bit of movement are there any other little things like that because
26:31
that's the sort of thing which once we get rid of this kind of
26:33
fixer structurized idea once you
26:36
get rid of that and think there might be such simple ways of
26:39
educating the person that could help are there some other gems which
26:42
you could let our people know yeah i well i
26:45
think you know the first thing is to remember that
26:48
with the female pelvic floor we're lucky in
26:51
that we can palpate the coccyx externally so palpating your own tailbone externally
26:56
and i know we've talked about this before as well can give you a really good
26:59
indication of whether the pelvic floor is contracting and relaxing fully and
27:03
then following that with the breath so just reaching around feeling the coccyx
27:07
externally through your clothes?
27:09
Can you close and lift everything up and in? And can you relax it back down again?
27:15
As you know, I am rather obsessed with bowel movements because I think constipation
27:21
is often a hidden driver of pelvic girdle pain and back pain generally as well.
27:26
And honestly, if you can teach somebody how to have a good bowel movement during
27:31
pregnancy without straining and breath holding and huge strain,
27:36
you know, pushing down, if you can teach people how to have happy, healthy,
27:40
easy bowel movements, it's actually great preparation for labor and delivery.
27:43
And it means that your pelvic floor and your gut microbiome are working well.
27:48
So making sure that we're asking about that.
27:51
But what the pelvis doesn't like when it's sensitized is going from sit to stand
27:58
from a very low chair up to standing.
28:01
It doesn't like one leg being in one place and the other leg being somewhere else.
28:05
So like, you know, the way we get in and out of cars, you know,
28:08
can you put one foot in and then the hips go in and then the other leg comes in as well.
28:12
So just even simple things like backing up to the seat of the car and sitting
28:17
down. And actually, here's my top tip, sitting down on a plastic bag on the
28:21
car seat, and then you can just kind of swivel the legs and keeping your knees together. Brilliant.
28:26
And it works a treat. You know, it's something simple like that can really just,
28:31
again, calm down the danger signals that the brain is receiving.
28:35
So we want to just, you know, not get women into the habit of keeping the knees
28:40
then glued together. We're doing that to kind of get from A to B.
28:43
And then when they're sitting, you know, we've done a little bit of breath work.
28:46
We've done maybe a little bit of thoracic mobility, a little bit of ball work,
28:49
and then getting them used to even sitting kind of, you know.
28:53
Internally and externally rotating the hips just to start creating safe movement
28:57
patterns in the nervous system.
29:00
We want to think about using pillows for positioning, for sleeping particularly.
29:05
Oftentimes a pillow under the bump, a pillow between the legs and one in behind
29:10
your back, you know, so you don't roll over out of that position too quickly while you're asleep.
29:14
Because getting a good night's sleep is just foundational in terms of calming
29:18
down the inflammation and giving you the headspace to deal with this.
29:23
Making sure you're hydrated, you know, again, really, really important. Strength training.
29:29
Is, you know, it's good for us mentally as well as physically.
29:33
And we're seeing so much research coming out now about the benefits of strength
29:36
training in pregnancy particularly.
29:38
So, you know, all of those things are great for just calming things down.
29:43
And as I said, then you've got a little bit more bandwidth to look at building
29:47
things back up again in terms of getting back into exercise again.
29:51
But it's the calming things down, first of all,
29:54
you know, maybe she has, you know let's say
29:57
an old appendix scar you know she had surgery and
30:00
things are just not stretching well teaching her how to
30:02
do a little bit of gentle scar massage herself you
30:05
know making sure there's really good thoracic mobility so you know Siobhan of
30:10
course will will give me a little pat on the back if I if I say you know making
30:14
sure she's wearing good breast support because they can increase dramatically
30:18
during pregnancy but that can be a real restriction on thoracic mobility if
30:23
she's not well supported there?
30:25
Can she rotate properly? Can she do some side bending?
30:29
Is she wearing comfortable shoes? Because your shoe size goes up by a half to
30:36
a full shoe size towards the end of pregnancy because progesterone actually
30:40
relaxes the connective tissue and then you're carrying an extra fluid volume.
30:44
If you're wearing uncomfortable shoes, I mean, we know that a quarter of the
30:47
bones in our body are in our shoes, or in our feet, sorry, which are probably in our shoes.
30:53
So making sure that the feet are mobile and happy and healthy and well supported
30:58
as well, again, gives that support up the chain towards the back.
31:03
For some people, a belt works really well, but it's not because the pelvis is
31:09
unstable and you need to hold it in place. You get as much compression probably
31:14
from a pair of good leggings or support underwear.
31:17
But a simple test to do can be just to get a scarf and just tie it around the.
31:23
The greater trochanter so going the whole way around and just
31:26
kind of squeezing it tight as if it was a belt going around here and
31:30
if that if that feels better if that level of compression feels better you kind
31:34
of go ah then that's great you need a little bit of support here a little bit
31:39
of supportive compression input here that's going to get you out of pain and
31:43
then we work on building up some strength around the glutes particularly but
31:47
if that compression makes you feel worse,
31:50
then it's probably because the muscles are a little bit overactive and they're
31:54
already like this, all very tensed up.
31:57
So now we need to work on calming those muscles down, muscles like pectineus and the adductors.
32:03
So I find getting people into side-lying is a great place to do a little bit
32:06
of soft tissue work on those adductors.
32:09
You can do a little bit of external work on their pelvic floor.
32:12
You can do some work kind of around the shoulder girdle,
32:15
even to get them side-lying over like a gorgeous ball
32:18
that's kind of partially deflated just to get a little bit of a
32:21
passive side bend in when you're doing a little bit of soft
32:24
tissue work because we're not breaking up adhesions or we're
32:26
not hammering out trigger points again we're conversing with the nervous system
32:30
telling it it's safe and that we're restoring a little bit of proprioceptive
32:34
input as well because there can be huge sensory motor disruption during pregnancy
32:40
because your body is just literally changing so much over the space of those 40 weeks.
32:45
So it's not relaxing.
32:48
Estrogen could play a role, but actually the hormone probably most linked to
32:51
pelvic girdle pain is cortisol, our big stress hormone.
32:55
There's so much in there. I'm hoping people are taking notes down.
32:59
I'm going to have to watch this again. There's so much you said in that 10 minutes.
33:03
There's one thing I wanted to work on or pick
33:06
up again with you is you mentioned strength training this is
33:09
this is really interesting because again it's you've made
33:12
it quite clear that it might be a case of let's calm things
33:14
down first of all depending how they are when they come through the door in which case
33:17
I imagine if they are bracing up and if things really tense then the last
33:20
thing I want to do is add another exercise that's going to tense up even more
33:23
so have me an idea of how you could progress on
33:26
what exercises yeah take them from that calming down to building
33:29
them up well sometimes you know I find it's just good to get really right back
33:33
to basics again because oftentimes you tell somebody to relax the muscle and
33:38
they're like I don't know how if I knew how to do that I would do it you know
33:41
but sometimes after you do a contraction you will get a relaxation of the muscle,
33:47
and if you have them sitting comfortably you know two feet on the ground lower
33:52
back supported and now you have them doing some bicep curls you know,
33:57
That should not be provocative unless they're breath holding and bearing down.
34:02
That should not be provocative for their pelvic girdle pain.
34:04
But what it is doing is it's giving them a sense of empowerment that,
34:08
look, I can do this. I am strong.
34:10
I am, you know, I'm still me in the midst of all this.
34:14
So the key is to find movements that are non-provocative, that are not threatening
34:18
to their nervous system.
34:21
And apart from that, anything goes. I mean, obviously, we don't want them exercising
34:24
in supine and doing the heavy lifting there. but the research generally shows
34:28
that, you know, women are not delicate flowers when they're pregnant.
34:32
You know, what we're trying to do is just work with them to find out the movements
34:37
that are going to be productive in terms of strength training.
34:40
And so particularly working the back line and glutes, glutes all day,
34:45
as far as I'm concerned, not so much, maybe kind of hip external rotation.
34:50
I have a deep seated problem with clams as an exercise for many reasons.
34:55
So I'm not a big fan of that but working glute
34:58
med working glute max you know but really
35:01
focusing on getting people back into their bodies can you feel when
35:04
the muscle contracts can you feel when it let goes and it
35:07
lengthens so we're restoring that full range of motion and really looking at
35:11
those big power muscles that she's going to need you know so again the rotator
35:17
cuff muscles getting her doing some you know some some seated rows even to start
35:22
off with where she's been at before in terms of her exercises?
35:25
Is she starting from zero or was she lifting quite heavy weights,
35:28
you know, before pregnancy and this pelvic girdle pain came along?
35:32
So it's about reverse engineering where she wants to get back to again.
35:37
But again, those big power muscles on a stable base of, you know.
35:42
Strong mobile feet and ankles, because remember, our balance mechanisms,
35:47
you know, we've got our eyes, we've got our inner ears, and then we've got our feet and our ankles.
35:50
But when you're eight and a half months pregnant, you can't actually see your feet or your ankles.
35:55
So we need to make sure that we're doing a bit of balance work as well,
35:58
because is her sense of instability and decreased balance, is that what's driving
36:02
the pelvic floor muscle overactivity and sensitizing some of those structures
36:07
around the pelvic girdle?
36:09
So you have to do a little bit of detective work with this as well,
36:12
but it's all about the person in front of you. You know, what was she doing beforehand?
36:16
When did this start? What does she want to be able to do.
36:19
And it might just be something as simple as go from sit to stand,
36:22
you know, without significant pain.
36:24
But at the back of every pregnant woman's mind is like, how is labour and delivery going to go?
36:28
And what's going to happen to me afterwards when I have a baby to look after?
36:31
And I also have a toddler at home already.
36:33
And so it's meeting her where she's at in terms of her current life sentence,
36:37
life sentence, sorry, not saying having a toddler is a life sentence.
36:42
Or is it her contextual factors, let's say, her life circumstances is what I meant to say, I think.
36:50
And then, you know, creating a bespoke approach for her.
36:56
Amazing that's really refreshing to hear like and i think
36:59
that should empower a few therapists as well i love the idea that when
37:02
it comes to well we need some strength training people again with
37:05
their binoculars facing the wrong way are going to be focusing on the pelvic
37:08
floor we need to do something which involves contraction here and that when
37:12
you're saying no get them to do some rowing some bicep curls because i love
37:15
it for two ways physiologically i get the idea that after contraction comes
37:19
a relaxation which is a great idea and that's going to affect the whole body.
37:22
And also that empowerment, like you're mentioning, the idea that this will make
37:26
them empower and with that will come a certain relaxation of the other muscles.
37:30
But also, you know, if we're thinking about kind of the role of inflammation
37:32
here in pelvic girdle pain, we know that muscles contracting produce myokines,
37:38
which are anti-inflammatory compounds.
37:40
So strength training is just this win-win-win situation, but we want to make
37:44
sure it's not a threatening or provocative type of strength training.
37:49
So it is bringing a little bit of nuance to the conversation.
37:52
You're not going to hand somebody a photocopied sheet of, this is what I want everybody to do.
37:57
It's, what about you? What do you need? And let's create a plan together.
38:02
Because you are not a passive recipient of me fixing you like some deity, you know.
38:08
Let's work together to come up with a plan that meets your needs,
38:12
that's actually going to achieve your goals.
38:15
Very cool. Very cool. Hannah came back and sadly, I would say,
38:19
kind of confirmed some of the things you had mentioned.
38:22
She says, not a lot, to be honest. She was told to keep her knees together,
38:25
which is not the easiest thing to do.
38:27
Don't try to do too much. She's in a plastic bag. She had the plastic bag one,
38:29
so you can't paint in that anymore.
38:31
For swiveling in the car, blah, blah, blah, blah, blah, blah,
38:33
blah. It could vanish. It would vanish instantly once you had the baby,
38:37
which it did not. He's only a child.
38:39
I was told my pelvis was unstable and that there wasn't much that could be done
38:42
about it, which is a shame.
38:44
But that kind of confirms why we're having this conversation.
38:49
It's, you know, and that's kind of my goal for having this conversation is that
38:53
we go back out into the world, all of us, and do this myth-busting and really help women get help.
39:01
Because I can't imagine how stressful that must have been for Hannah,
39:04
you know, to deal with all of that and to worry, is the next movement I make
39:09
going to cause more pain?
39:11
Is my pelvis unstable? Is it literally going to fall apart?
39:14
And what, am I going to be like this for the rest of my life?
39:17
You know, and of course, when you're told that it will go away after you have
39:20
your baby and it doesn't, what does that mean?
39:23
Like that, that can be very distressing.
39:27
So we really have to be very careful with the language and with the messaging that we're using.
39:32
And there's been lots of great papers, you know, coming out over the past couple
39:35
of years that, you know, there was an infographic that came out last year.
39:39
And I want to say, you know, the three key messages are that your pelvis is
39:42
stable, that you are safe and that this is self-manageable.
39:46
We can teach you how to do this for yourself.
39:49
You know, maybe, you know, a bit of manual therapy, maybe a belt,
39:53
you know, with those two kind of circumstances that we talked about.
39:57
But this is all manageable. And so let's take a breath and let's jump in.
40:05
Is this, I'm interested, it just comes to my mind as well. I think this is still
40:08
the case, but traditionally midwives or doula, is that correct pronunciation,
40:14
would be somebody who would provide this emotional support, a non-medical professional
40:17
maybe, but it would be there, maybe with a lot of these little tricks which
40:20
aren't being given by the healthcare professionals.
40:23
They're less and less providers, are they? you're kind
40:25
of left much to yourself and you're not so which is
40:29
a saying that might add to the problem as well you haven't got these individuals to
40:32
support you emotionally I think so and I think even kind of
40:35
going back further than that I mean you know it is a sad
40:37
fact that you know the NHS is very overstretched and you
40:40
know I remember when I was going through my
40:43
training 150 years ago but just talk it's
40:47
true talking to colleagues you know in the UK and they
40:49
were very involved in antenatal classes and the midwives
40:52
would be there and there were you know the physio department would
40:55
run run antenatal exercise classes and you
40:58
could have one-on-one sessions and like a lot of
41:01
that has unfortunately evaporated but we now have podcasts and youtube and you
41:09
know and social media but i think you know the greatest service that we can
41:13
do particularly as as women who have been through this is to, you know,
41:19
support other women going through it and really working in women's health.
41:23
Let's bust these myths, you know, that your pelvis is unstable and there's nothing
41:27
you can do about it. You know, there's so much that you can do.
41:31
It's looking at that person in front of you. Yes, she's pregnant.
41:35
Okay. So, but almost to a degree, so what? We won't get you exercising in supine. But apart from that...
41:43
You know, what have you got in your toolbox? What have you got as a therapist in your toolbox?
41:48
And let's use that, you know, to bring her back to herself again,
41:53
because it's such a scary time.
41:56
I almost don't want to go to the, I'm thinking that I do. Okay,
41:59
so that's all said and done.
42:00
Don't scare the hell out of anything. But now we're going to talk therapists, bear that in mind.
42:03
But I do want to talk about what you said, the red flags that should be ruled out.
42:07
Because sometimes to relax and take that on a board, you have to know what the
42:10
red flags are, be aware of them.
42:12
Obviously, we'll go through them one by one in case our listeners see some kind
42:17
of symptom where they do need referring on.
42:19
But I wanted to ask you, we've had the expression diagnostic overshadowing used
42:25
quite a few times on the show, particularly when we were talking to Alistair
42:29
Beverley, the learning disability physio.
42:31
And he was very quick to point out, as he's such a great person,
42:34
that this isn't just about disabled people either. This is happening particularly with women.
42:37
And he spent quite a long time talking about that and also the elderly.
42:40
And I guess what we're talking about here is this could very much happen with
42:43
pregnant women as well, where you think that, oh, this is just because you're
42:47
sensitized and when really there could be symptoms which are nothing to do with
42:50
the pregnancy and are being overshadowed.
42:52
Well, that's just it. I mean, I will tell you, the general kind of awarenesses
42:57
that we want to have around working with women with pregnancy,
43:00
obviously looking out for any signs of preeclampsia or any issues with gall
43:04
bladders or livers, itchy palms and things like that, blurred vision,
43:08
blood pressure checks and things like that.
43:11
But I think we have to be very careful in that you're pregnant,
43:17
pelvic girdle pain is normal because your pelvis is unstable because of relaxing.
43:21
It'll get better once you have your baby versus this is all in your head.
43:26
It's very stress related. It's anxiety.
43:30
Subtext, your pain is not really real.
43:34
And, you know, if you're being given a message that nothing is going to help
43:37
you, then you don't have that hope that you're going to get better.
43:43
And that's a huge barrier to actually getting better.
43:46
So, you know, we talked about how parity is a risk factor, but previous trauma
43:51
is a huge risk factor for developing pregnancy-related pelvic girdle pain because
43:56
your nervous system is already a little bit sensitized.
43:59
It might not have that same resilience and then we
44:02
think about you know things like job dissatisfaction
44:06
we also know that things like you
44:09
know being overweight or obesity or smoking
44:12
because again they're very inflammatory conditions as well those are risk factors
44:16
but the lack of hope you know it's the lack of hope that will actually really
44:20
influence how well you will do if you're working with somebody who knows what
44:26
they're talking about in terms of pelvic girdle pain.
44:30
The two big red flags I would say that I would love people to kind of take away
44:36
from this is to make sure that somebody has actually done a visual exam.
44:43
Because it could, it's rare, but I've seen it twice in my career.
44:47
It could be a DVT that's causing that anterior pelvic girdle pain.
44:52
So I would, even if you don't look, always ask, is there any redness,
44:57
any swelling, or any kind of a pulsatile feeling in or around the labia?
45:02
Because that's not pelvic girdle pain. That could be a DVT, particularly,
45:07
let's say, if they've been on bed rest, you know, for a couple of weeks beforehand.
45:11
So there's a whole list of wells criteria that tell you your risk for a DVT.
45:15
So always ask if you're seeing somebody coming into you with anterior pelvic
45:20
girdle pain around the symphysis pubis, any redness, any swelling,
45:24
any heat or any sense of pulsation there, because again,
45:29
that would be a straight call to the GP and let's get that checked out in case it's a DVT.
45:36
And the other one just to be aware of if somebody was at high risk of transient
45:41
osteoporosis of their hip.
45:43
So somebody who's maybe got a very low BMI. This could be somebody maybe with a history of reds.
45:49
It could be somebody with a long history of steroid use.
45:53
It could be somebody with a history of alcohol use or just very low bone mineral
45:58
density to start out with.
45:59
And that pain will be quite deep again in
46:02
the groin kind halfway along that inguinal crease and
46:06
if our sensory motor patterning is disrupted it
46:09
could manifest as kind of that anterior pelvic girdle
46:12
pain there's a couple of tests that can be done for
46:15
that you know in terms of the patellar
46:18
pubic percussion test where you put a stethoscope over the pubic symphysis and
46:22
you tap their patella and you compare that on both sides to see what the noise
46:25
transmission is like or you can do a fulcrum test where you get them sitting
46:29
on the edge of the bed and you put your arm under their femur and you apply
46:33
a little bit of downward pressure over the distal end of their femur.
46:36
So it just gives a little bit of a torque to the neck of femur.
46:41
Again, that's literally a fracture, but it's manifesting again as that anterior pelvic pain.
46:46
So unless you have those two kind of as your differentials, let's rule those
46:50
out straight away before we do anything else.
46:53
Again, I'd say you're probably doing your patients, your clients to service.
46:57
So those would be kind of the two big ones around pelvic girdle pain.
47:02
That I'd want people to keep an eye out for. Excellent. No, great information.
47:05
Because that's empowering as well. Even if they don't happen much,
47:08
the fact you know and you ask a question, I think, empowers you and it opens
47:11
the door to other questions because they're going to be impressed.
47:13
It's probably a question they've been asked before.
47:15
So what did you say, sorry, the symptoms for the transient osteoporosis were?
47:19
Pain around the hips? So again, just deep anterior pain, like kind of,
47:23
you know, in that kind of medial, you know, the kind of that crease,
47:26
that inguinal crease at the top of the thigh.
47:29
So it'd be kind of right under the bump, but coming down towards the pubic symphysis.
47:32
If we think about where the neck of the femur is, again, so anybody who's got
47:36
like that low bone mineral density to start out with and who's maybe has a history
47:41
even of an eating disorder because if the baby's not getting enough nutrients,
47:46
it's all about the baby when you're pregnant.
47:48
It will literally suck the calcium out of your bones.
47:52
Lovely. That is a horror film waiting to be made. It's a horror film many women
47:56
have made from that. Yeah.
47:59
So it's a masquerade then. It's a case of looking at the case history and checking
48:03
whether pain which might be blamed on pregnancy could be linked to.
48:07
So especially for that unremitting pain, you know, that's really,
48:11
you know, with weight bearing particularly, you know, walking is difficult,
48:15
going from sit to stand is difficult and it's really, really hard for them to
48:18
get a comfortable position.
48:20
Now transient osteoporosis of the hip, It generally does resolve after the baby is on the other side.
48:27
But again, nutrition is key for this as well. And then working to hopefully
48:32
improve bone density afterwards.
48:34
It's not as rare as we would like to think.
48:39
Okay. A very great couple of questions and things to look out for.
48:44
I can't believe it's already 8.52. Ellie, I don't think we've got time to go
48:49
into what Michelle's dislike for clams are.
48:52
I mean, could there be an elevator pitch? Is it going to put you off on? Is that going to cause?
48:56
Because they lead to very short, they can lead.
49:00
Okay, I'll open my mind a little bit. They can lead to very short,
49:04
tight hip external rotators.
49:07
They don't effectively strengthen hip abduction as they've been sold to do.
49:11
They're a very inefficient way of targeting glute med, but they can lead to
49:14
very short, tight, deep hip rotators, which can be irritating not only for the
49:19
sciatic nerve, but also for the pudendal nerve.
49:22
So it's that external rotation as you abduct the hip that might not target as well.
49:27
There's so many better ways to target hip abduction and glute med and glute max.
49:33
And also any exercise i feel where you have to lie down to do it really diminishes
49:41
its its efficacy i'm allergic to
49:44
calling patients or clients compliant or non-compliant i think that's so,
49:49
demeaning but i would say and especially for somebody with pelvic girdle pain
49:53
it will take them about a half an hour to get into a lying down position and
49:57
then coming back up out of it So any exercise strategy that you can do that
50:01
is standing or even in a forward lean position works really,
50:05
really well because that's going to offload the pelvic floor a little bit.
50:08
So just leaning forward onto the kitchen counter and then starting,
50:12
you know, some gentle pelvic tilting.
50:16
Think of different ways in standing and that are mobile and that are functional
50:19
of working glute med and glute max that do not involve lying down and doing
50:24
clams because they're silly.
50:26
Brilliant. You controlled yourself well there. That was very good. That's great.
50:29
And again, it's an issue because in particular, there's a lot of over-the-top
50:35
use of clams and do a clam, do a clam, and you start thinking this is the exercise
50:39
without thinking, hold on, what's going to suit the person in front of me? So it's not surprising.
50:43
Kelly follows that up with another great question. Thanks, Kelly,
50:45
for these questions. Kelly Kington says, is there a CBD course that would be
50:48
recommended for sports therapists for pregnancy women's health?
50:50
Funny you should say that, Kelly. There might be.
50:54
There might be. What are you up to, Michelle? What have you got to offer these wonderful people?
50:58
Yeah, so look, if anybody wants to take a deeper dive into this,
51:02
probably the best place is the online Female Hormonal Health Masterclass.
51:07
And it's got three separate modules. One is on menstrual health,
51:10
one is on maternal health, and there's a big deep dive on pelvic girdle pain.
51:13
And then the other one is on menopausal health.
51:15
So you get the three big life stages. There's an exercise library.
51:19
There's manual therapy.
51:20
There's an exploration of the pathophysiology and things to be on the lookout for behind there.
51:28
So that's where that's all going. And of course, as always, I'm happy to offer
51:32
STA members a discount if they want to contact me.
51:35
Yeah, of course. Got to look after.
51:39
So yes, check out CelebrateMoolieBriti.com. And also Instagram,
51:45
Michelle Lyons underscore Moulie Ebrity.
51:47
And just shoot me an email if you would like to get a discount for any of the courses.
51:51
Just send me an email, michellelyonsphysio at gmail.com. Tell me you're an STA
51:55
member. Know the secret password if you're an STA member.
51:58
And yeah, we'll set you up. Fantastic. That's amazing.
52:02
Right. Well, look, 8.56. We got through quite a lot, I think.
52:06
Your answers just include so much information.
52:07
It really is a case of, I should have warned people in their notes just to bring
52:10
a pad and pen just to write things down. And there's so much in there.
52:13
So thank you so much for that.
52:15
Also, Facebook active on there. I mean, you are very active.
52:18
I've commented and commended you a lot on your social media.
52:21
You're always putting gems out there. So you're definitely somebody who's worth following.
52:25
Thank you, Mr. Philip. No, that's fine. And also, people don't forget the podcast as well.
52:29
Just a great way if you are running or cycling or driving, as long as you're
52:35
keeping your eyes on the road.
52:36
It's just you can learn so much. I'm definitely getting back into podcasts.
52:39
I have a bit of an absence because you can multitask.
52:42
That's it. Like you go to the gym, you just pop in, pop it in your ears and
52:46
away you go. You can pick up so much. So it's great. Yeah.
52:49
Right. Thank you so much. So thank you everyone who joined us live.
52:52
What have we got coming up?
52:54
Well, we have to say it's part four next week, the last part,
52:57
but I'm sure we'll have another focus on women's health because the feedback is fantastic.
53:01
But in part four, we're going to welcome Dr.
53:04
Gemma Parry, who's going to be with us, who's a performance specialist and research
53:08
associate at the University of Bath.
53:10
People who went to therapy expo last year may have caught her presentations there.
53:14
And Dr. Gemma Parry is going to be talking about developing female athletes, women are not small men.
53:20
And that's something we've talked about a lot on the show with other physios,
53:24
Angela Jackson and other people.
53:25
It's such a great quote. And if you haven't heard that yet, if that's not a
53:28
coin that's dropped somewhere, it's something you can use with your clients,
53:31
something that can change your shift from thinking.
53:33
Because unfortunately it is, and throughout history with research being kind
53:37
of quite patriarchal, it has been a case of women are just little men,
53:41
just do a little bit less and they'll be fine.
53:42
And it's so far from the truth so also just
53:46
so i don't forget i would ask you to check
53:49
out the wist cpd series it's going to be happening like
53:52
i say on wednesday 19th of march at 7
53:55
p.m is going to be the next one it's free for sta members so
53:58
don't miss out on that possibility and if you do want
54:00
to pay for it you've got two options sign up for 15 pounds at
54:03
the link or join the sta which and i can guarantee that
54:07
the latter is probably the cheaper way of doing it because i
54:09
think if you join you've come to like three episodes or something it's ridiculous
54:13
i'm always having a go at gary for doing that gary also says i've spoken to
54:18
matt earlier about having am i about to read this out gary i suppose so it's
54:20
up on the screen now a dedicated page on our website for approved cpd yes we're
54:23
going to start doing that um so we'll be in touch with michelle for that.
54:28
Just because yeah we need to help this information get out there and be a the
54:32
conduit that we love to be for quality cpd just to save people money because
54:36
there's so much out there which you could wait for money on there's something
54:40
good out there we need to look after your your your budget so you can put more
54:45
into your businesses and help all these lovely people out there need your help so,
54:48
Can I just jump in before we wrap up?
54:51
I just say a big thank you to you and to Gary, because you have both been great
54:56
male allies and advocates for advancing women's health.
54:59
And it really kind of, it's great.
55:02
Just, it's so encouraging to be in a place where men who have platforms like
55:08
yours are out there kind of spreading the good word and having the conversations.
55:13
And yeah, we're just really happy that you're doing it. So thank you.
55:16
That's very kind of you and nice really not necessarily at
55:19
all we really are standing on the shoulders of
55:22
amazon goddesses as i like to put it that's all
55:25
we're doing no it's it's an
55:28
absolute pleasure and one of the and one of the greatest kind of things
55:31
we get is just the the feedback we get from members saying that was
55:34
amazing episode learn so much please more michelle more michelle or
55:37
whatever it is we do get them so it's thank
55:39
you for saying it's really cool but i couldn't think of
55:42
a better way to spend my time right people thank you so
55:45
much for joining us people join us live if you listen to the
55:48
podcast then do please one way you can really help
55:51
this information get out there and collaborate with other health care professionals
55:54
it's quite simply leaving a rating and review it's not so we can just shine
55:58
our trophies or anything like that it's just because if you do subscribe to
56:02
youtube for example it just helps our information appear higher in the google
56:07
index so if someone does put in menopause they're going
56:09
to get Michelle's comments on the topic out there rather than
56:12
somebody who's just paid I don't know Russia people
56:15
no I can't say but a load yeah it's
56:19
just paid a load of bots to to just kind of like raise their rankings you know
56:23
who they are they've got like millions and millions of likes you think how have
56:26
they got these millions of likes and to combat that we need good-hearted people
56:29
like you just to take a moment of time in your busy life just to subscribe leave
56:34
a rating and a review for a mild.
56:36
Small, fried podcast like this.
56:38
Because there's 2,000 of you or so who download episodes. So if all of you could
56:42
actually leave a rating and a review, then we could fight the powers that be
56:46
and get this quality information out. And that's what it's all about, sisters and brothers.
56:50
It's all about fighting the oppressors.
56:53
Rise up. That's what it is. Rise up. Yes. Right. And together we can celebrate Muli Ebrity. Right.
57:00
That's it, people. Thank you, everyone, who joined us. And if you are free next
57:04
Tuesday, then join us for part four, either on YouTube or the Sports Survey
57:08
Association Facebook page. Thanks very much, Michelle, once again.
57:12
Pleasure. And thank you very much. See you soon.
57:15
Music.