Physiotherapy for a lady with severe incontinence, Afghanistan
Fahima Kohistani, Afghanistan
Physiotherapist & physiotherapy trainer
I am a physiotherapist and physiotherapy trainer at the Physical Therapy Institute (PTI) and Afghan Association of Physical therapy (AAPT). I am very keen to improve my knowledge and upgrade my profession in physiotherapy field. I was initially a medical university student after I graduate from high school before the first period of Mujahedin victory. When the Mujahedin came, everything was destroyed for at least two years and we had nothing for study, work or any other hobby. We just did house work, tailoring, cooking. When I first found out about physiotherapy, I started studying with the plan to become a doctor in the future. But gradually I realized that physiotherapy is very much important field of medicine. I really love physiotherapy. I always wanted to go forward and continue studying, but I got married and first had to take care of raising my family. Finally the children were old enough that I could work more to improve my professional skills and knowledge before I get too old. I wanted to develop more in women’s health, due to my personal experience.
When I was seven months pregnant with my first child in 2003, I fell down with my legs apart in abduction and I had very bad pelvic pain and couldn´t walk very well (sacroiliac joint instability on my right side). I did not go to the doctor to get pain killers or any other medication because of my child. Instead I went through exercise therapy books at the PTI library (we had no internet facility at that time). From looking through books I found interesting exercises and topics/texts written about PPPP (peri partum pelvic pain). I used this information and became completely well. This event motivated me to study more about pregnancy related musculoskeletal disorders and its physiotherapy management. I translated some important tips and made a brochure as extra notes for physiotherapy students and also medical faculty undergraduates who came to PTI for their physiotherapy recognition cycle. It was really useful when we taught it for medical faculty undergraduates.
From that time I was keen to learn more about women health and specially PPPP. Fortunately when we did our two-year upgrading course (2007-2008) we had an Obs/Gynae physiotherapy topic. I also followed two continuing education programs taught about women health and lumbo-pelvic pain and pelvic floor dysfunction. I found it really very useful and because of its importance in the women’s health, I made a power point presentation at doctors’ level and presented it at the three main large Obs/Gynae and maternity hospitals in order to refer patients with such conditions to us. We were very encouraged by doctors and midwives.
Then I decided to make and design my private clinic such to be helpful for women, especially those with chronic pelvic floor dysfunction/lumbo pelvic pain and disorders, in addition to other facilities for patients who need physiotherapy. I focus more on exercise therapy than using modalities or machineries. Now my clinic looks like a gym. I am happy that now there is a place for women who suffer from chronic pain, and who don’t have the facility and possibilities to exercise for their wellbeing, can exercise there and come for fitness as well as for their chronic pain and complaints.
Physiotherapy for a lady with severe incontinence
A 47-year-old lady with 8 children came to our clinic for back pain, neck pain and severe incontinence since 9 years. She had 2 laminectomies for her low back pain in the last 3 years followed with hysterectomy since the laminectomies did not change her symptoms. Still her problems increased and even added incontinence and neck pain for the patient.
This lady suffered from negative changes at her social life as well, she could not go to parties or for shopping because of her incontinence and bad smell of her clothes. She said, “pain and lower limb weakness and paresthesia you can deal with, you can go everywhere with car or stop walking, still you can attend to special parties and go to bazaar. But with incontinence, even sometimes I use pampers, still bad smells make me disappointed”.
With our physical assessment, we found that her problems came from lumbo-pelvic instability and pelvic floor weakness caused by 8 normal deliveries. Also this problem increased by the laminectomy where the doctor advised her not to even bent her neck at least for one year. This prolonged bed rest limited her physiological movements and damaged core stability as well. That is why the patient did not feel well, but worse than before.
Then they decided for the 2nd laminectomy and the same problems doubled, then the hysterectomy. Now imagine her muscles around her lumbo- pelvic after 3 surgeries and prolonged bed rest. Her gait pattern was like incomplete paraplegic patients, and she had severe headache, lower limb tingling and numbness.
Anyway, for her therapy we started with: 1- self-bracing exercises first stage and for sure (TENS-heat applications) as well. 2- restoring normal motor pattern in supine position (rolling side to side)-sit to stand, standing while doing gentle exercises with her upper limb. 3- Scar management: the patient suffered from pain, hypersensitivity on that areas.
Her treatment then followed by resistive exercises for her upper limb/lower limb while focusing on normal pattern of movements (transverse abdominus muscle contractions) and pelvic floor strengthening exercises.
The patient got improvements within 12 days and she followed her exercises for 3 months and we changed her set of exercises as per her improvements. Finally after 3 months, she was 80% ok, her incontinence was 100% ok, she was happy that she could hold her urine while she is in the bazaar or at parties where toilets are not available.
As per my 18 years of clinical practice and experience, here in Afghanistan, almost 80% of back pain patients are suffering from lumbo-pelvic insufficient stability which come from multiple child bearing, hard physical activity during pregnancy, not doing exercises frequently. So how important is to increase our knowledge and improve our practice on the field of lumbo-pelvic and pelvic floor physiotherapy, in order to serve better for women health. The main point for this kind of patients with total body involvement is restoring normal pattern of movements with designing a prolonged and professional exercise program and for sure some manual therapies and electrotherapies while needed.