Role of Physiotherapist in Obstetric and Gynecological Conditions Purvi K Changela
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Women's Health Care in Physical TherapyChapter 1

Chapter Outline
  • • The physiotherapists as health promoters
  • • Awareness on utilization of maternal health education and services
  • • Barriers to utilization of maternal health services
  • • Quality of maternal health services
  • • Changing definition of women's health - implication for health care
  • • Role of physiotherapist in women's health education
  • • Role of physiotherapy in health related quality of life
 
INTRODUCTION
  • The term “women's health” typically connotes reproductive function and, in particular women's capacity to produce and nurture children. This focus is a legacy of the medical conception of women's health that emerged in the second half of the 19th century, when ideas about biological determinism and fundamental differences between the sexes were becoming prominent.
  • Women's health is based on an all-encompassing view of health whereby, McComas and Harris (1996) point out that “Women's health involves women's emotional, social, cultural, spiritual and physical well-being, and it is determined by the social, political and economic context of women's lives as well as a woman's biology.”
  • Women's Health is one of the major concerns world wide. The focus of the women's health has been increased from year 1975 which is called as the “International Year Of Women's Health” encompasses a broad spectrum of issues that can be treated by physiotherapy and other healthcare team.
  • A focus on health issues relevant to females has been increasing over last two decades. The multiple roles that women play tend to give low priority to their personal lives. Women always place the needs of other before their and hence priority to their health, exercise or any form of relaxation is given least preference.
  • Women undergo many physiological, hormonal and emotional changes throughout their life span. From adolescence to menarche, marriage to child bearing years and later menopause and beyond a women's body is undergoing several changes thereby influencing the health of various systems and the mind.2
 
THE PHYSIOTHERAPISTS AS HEALTH PROMOTERS
  • Women have specific health care needs during their lifecycle. Physiotherapists play a vital role in health promotion through the provision of preventive services like health education, counseling, and the screening of risk factors. Physiotherapy practice for women's health has traditionally been limited to the area of prenatal and postnatal care was broadened to encompass social, cultural, economic and other issues.
  • The women's health physiotherapist recognized as an important team member with specific role in specialized training (Fig. 1.1) in the assessment and treatment of a range of health conditions that can affect women.
  • Physiotherapist should be trained to assess and evaluate the effect of injury, disease or disorders related to women's health by the use of tools which are safe, valid, reliable and provide treatment plan to restore or enhance their function. Hence they are an important member of multidisciplinary team addressing various issues which are fundamental to her well-being and peruse a healthy life.
 
AWARENESS ON UTILIZATION OF MATERNAL HEALTH EDUCATION AND SERVICES
  • India being the second most populous country in the world and rated as below income class by World Bank, has health Missions—“National rural health mission”, “Janani Suraksha Yojana” and “Reproductive child health Phase-II”, which seeks to improve access of rural women and children to public health services. Their main objective is to reduce infant and maternal mortality and reduce total fertility rate. The Union Government released the Draft National Health Policy (NHP) which takes into account new diseases and revolutionary changes in medical science and strengthen the primary health care network all over the country.
  • McComas and Harris (1996) suggested that physiotherapists have a major and important contribution to research and 3also practice in women's health. They also noted that there is a need to alter our approach to these tasks by moving beyond our traditional biomedical perspective to embrace a model that includes the social, political, and economic contexts of women's lives.
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    Fig 1.1: Services related to women's health issues
  • However, many health issues which affect the morbidity and mortality of the women like osteoporosis, urinary incontinence and obesity are not considered in many developing country's health missions. Hence, we should take the initiative to make the services available to rural and urban poor women along with the privileged women of our country.
  • Effort should be made by our national body, local branches and individual therapist to highlight a role of women's health physiotherapist in prevention and treatment of dysfunction related to health in women to the gynecologist, endocrinologist, general practioners and associated health care providers.
 
BARRIERS TO UTILIZATION OF MATERNAL HEALTH SERVICES
  • Many literatures found a high level of association between certain predisposing and enabling factors of utilization of women's health services.
  • Several studies have investigated the common barriers to utilization of healthcare services such as: lack of finance; social-economic status; cultural influences; lack of transport; lack of access to health services among others.
 
QUALITY OF MATERNAL HEALTH SERVICES
  • Women's lack of awareness can range from lack of understanding what health services are to lack of knowledge of the location of a healthcare service site.
  • In this area, the approach to implementation should ensure quality standards of health care by providing essential packages of training, monitoring and impact evaluation.
  • Strategies should also ensure the regular provision of essential professional skills and availability of supplies and equipment with respect to the concepts of appropriate technologies, cost-effective interventions and a holistic approach.
  • Implementation of objectives in this area should ensure that health systems are adequately updated and organized at each level of care. Legislative reforms and/or implementation of existing laws should take place where necessary and health systems should be modified accordingly so as to address the health needs of mothers and newborns in a holistic way.
  • By setting up a Medical Grants Commission to provide resources for upgradation of the existing government medical colleges and ensuring an improved standard of medical education, the policy envisages to improve the health care delivery system.
 
CHANGING DEFINITION OF WOMEN's HEALTH-IMPLICATION FOR HEALTH CARE
  • Women's health is an important issue that has been neglected in the past. Today, however, women's health is taking on a higher position in society and many health care resources for woman and children have been developed. This shows that specialized health needs of a woman and children are being adequately met by the medical community of which physical therapist is also an important member of the team to improve and maintain 4functional independence and physical performance.
  • Public health camps and awareness program should be organized to provide information to women regarding various health issues, the risk factors associated and prevention by changes in lifestyle and empowering them to take the decision of their health.
  • It is important for the physiotherapist working in this area to recognize that women have particular health needs which are related to her biological functions, her role in society and demands place at workplace.
  • Through research and consultation, a series of evidence-based health priorities have been identified that represent the major challenges associated with death and burden of disease for women in the next 20 years. Physiotherapy has a distinguished role to play in health related dysfunction in women the major component related to :
    1. Obstetrical health
    2. Gynecological health
    3. Other health related issues.
 
ROLE OF PHYSIOTHERAPIST IN WOMEN's HEALTH EDUCATION
Physiotherapy specialty practice involves a widespan of life in women, right from childhood to old age.
 
Physiotherapy in Adolescent and Puberty
  • This is the age when girls are more prone to obesity, polycystic ovarian diseases (PCOD), depression, mood disorders, etc. as this is a very vulnerable age where a transition, adolescence and puberty takes place leading to verifying hormonal changes, regular exercise regimens along with right diet advice can help in easier transition.
  • Since children of their age group enjoy group sessions and high energy, high impact activity. Therapist can recommend group therapy classes like Dance therapy where they can get a platform to the girls and boys to dance through to fitness.
  • Counseling is also an option for those who may not be able to cope with stress through exercise with an open mind. Physiotherapists play a significant role to play in addressing high risk factors that are encountered during pubertal age.
    Goals of physiotherapy care are:
    1. Health education—Physiotherapy expert should visit schools and sports club regularly to impart health education program amongst prepubertal students, their parents, teachers and coaches to the importance of appropriate levels of exercises, participating in sports and good nutrition for long term health and wellness.
    2. Postural awareness training—to build the necessary kinesthetic awareness of appropriate joint position in combination with positive input regarding self-image, back care and lifting techniques are essential components of treatment.
    3. Supervised flexibility program—for all the muscles who have propensity to develop tightness must be emphasized. Stretching exercises to the hamstrings, qaudratus lumborum, dorsolumbar fascia, hip flexors, iliotibial band, gastrosoleus, upper trapazius, adductor and medial rotator of shoulder should be done on daily basis. During the visit the expert physiotherapist should conduct regular assessment of mobility and body fat levels and accordingly give guidance for health promotion.5
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    4. Strengthening program—of muscles developing stretch weakness for transverse abdominis and multifidus to improve core stability, qaudriceps, rotator cuff muscle, scapula depressors and retractors, erector spinae and gluteal muscles.
    5. Aerobic training include agility exercises which is documented to be one of the most effective preventive mode for prevention of obesity.
    6. Proprioceptive training—to provide positive afferent feedback and agility training is necessary.
    7. Advice on preventive measures—warm up and cool down session should be a part of training and avoiding rapid increases in the intensity, frequency and duration of the session is must.
    8. Pain relief strategies—local application to the injured area with ultrasound, moist heat, cryotherapy, transcutaneous electrical nerve stimulation (TENS) can be advocated.
  • Dysmenorrhea is extremely common in adolescent girls and is the leading cause of school absenteeism. Premenstual syndrome a cluster of physical and psychological symptoms occuring in association with the menstual cycle can impair the quality of many young women's life. Studies report regular exercises have fewer premenstual symptoms and pain associated than non exercises. Also spinal manipulative therapy and TENS has been advocated for pain relief.
 
Physiotherapy in Reproductive Age
  • Most women in these days during to stressful urban lifestyles and improper food intake are prone to risks of infertility, obesity, psychiatric disorder, thyroid fluctuations, anxiety, stress, aches and pain.
  • A women's health physiotherapist cater to such needs by putting women of this age group under evaluation/assessment of their health condition understanding their working environment and role in society. Accordingly after ruling out all the possible risk factors, a prescription as well as implementation of Tailor made exercise or a group sessions is usually advised.
  • Pilates plays a major role in stabilizing symptoms if any, preventing further symptoms and ailments or just giving and maintaining good heath for women of this age group.
 
Physiotherapy During and After Pregnancy
  • Pregnancy is not a disease but a stage of the women's life during which various physiological, hormonal bio-mechanical alterations are taking place in the women's body throughout the 9 months to accommodate the needs of the growing fetus.6
  • A women's health physical therapist cater to the needs of the women keeping in mind the demands of the growing fetus with extreme care and precautions developed an antenatal exercise program from the early to the later stage of pregnancy along with education on labor and beyond.
  • At early stages of pregnancy focus in on measures taken to get the mother to be comfortable in acceptance of her changing physical condition, avoiding aches and pains anxiety if any, and promotion of breathing capacity since the diaphragm in under pressure due to the space occupied by the growing baby.
  • Later stages of pregnancy and the second part usually consists of teaching ways to avoid any pregnancy related problems, correcting postures avoiding complications and exercise to wade of any symptoms of the musculoskeletal changes mainly focusing and preparing for labor and child birth.
 
Physiotherapy During the Stages of Climacteric and Menopausal Age
  • This is stage of transition where again a lot of hormonal and psychological changes are taking place in women's body as mention below (Fig. 1.2).
  • At a climacteric stage menstruation gradually becomes irregular, scanty and shows as spotting before it gradually stops leading to menopause which leads to atrophy of ovary leading to risk factors like:
    1. Obesity
    2. Depression
    3. Stress incontinence, urgency of urine
    4. Aches and pains in body due to reduce calcium levels
    5. Osteoporosis
    6. Ligament laxity.
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Fig 1.2: Women's health issues in climacteric age
  • A thorough assessment of the physical, physiological and mental condition, certain specific exercise prescription is prepared catering to the all the needs taking precautions of any hazards of7 exercises that need to be restricted in some individuals, e.g. Isometrics may be good for osteoporosis but the same may by contraindicated in women associated with cardiac ailments.
  • Major problems also seen in this age group are of pelvic floor weakness leading to prolapsed of uterus/rectum or even incontinence of urine/feces. In such cases an objective assessment of pelvic floor musculature is done to achieve a functional diagnosis. Use of IFT, electrical stimulation, pelvic floor exercises equipments to regain pelvic floor strength like vaginal cones, etc. along with lifestyle changes is usually recommended. The pelvic floor health also plays a major role in women sex life.
  • Menopausal women is very often referred for the physiotherapy for musculoskeletal impairments due to degenerative process but physiotherapist should plan a comprehensive assessment and treatment plan keeping in mind the dysfunctions like breast and cervix cancer, chronic pelvic pain, vasomotor changes.
 
ROLE OF PHYSIOTHERAPY IN HEALTH-RELATED QUALITY OF LIFE
  • Any health issues related to women's health need to be addressed with special care because dysfunction or disability imposes much more negative psychosocial impact on women when compared with man. Therefore, physiotherapist, aspiring to established specialty practice in women's health should not ignore quality of life related to health issue in women (Fig. 1.3).
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    Fig 1.3: Women's health research
  • Women experience life passages of menses, pregnancy, childbirth, and menopause. Each stage of women's life presents with unique challenges to maintain an optimal quality of life. Over the past two decades increasing moves toward ‘measuring’ health outcome have influenced much8 of health care and indeed much of the physiotherapy profession. But the level of understanding and incorporation into physiotherapy practice is variable despite increasing national and international professional guidelines.
  • Physical therapy for women's health understands this and was established especially to meet the needs of women. The mission is to provide physical therapy to improve wellness, health, and quality of life for women in a respectful, kind, and gentle way.
 
SUMMARY
  • A number of health issues in women's lifespan can be treated effectively by physiotherapy care. The therapists will be able to address her physical, psychological and emotional needs through the depth of understanding women's biopsychosocial needs.
  • Physical therapy plays an important role in management of the dysfunctions that takes place during adolescence, childbearing years, menopause and beyond and plan out different interventions which would improve women's functional independence and quality of life. Physiotherapists are “concerned with promoting health and well-being, preventing impairments, functional limitations and disabilities and providing interventions to restore integrity of body systems essential to movement and maximizing function.”
  • The Women's health physiotherapist need to make knowledge and skill base known, strengthen a role in education, prevention, treatment and wellness to contribute to the movement in the health care that aims to meet the needs of the women's health.
  • Many physical therapists have specialized training which will benefit women with a variety of medical conditions. These therapists use every facet of their physical therapy training to evaluate and treat female clients, promoting and enhancing health through the life span. All treatments are individually designed after thorough evaluation.
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