The Practice Gap
The Practice Gap
#43: Physiotherapy+ Chiropractic=Perfect Match. Muscles That Matter: Pelvic Floor in Women's & Men's Health-With Tove Villumstad
Tove Villumstad, a physiotherapist specializing in pelvic floor dysfunction, shares insights on the importance of interprofessional healthcare collaboration and pelvic floor health for both women and men. She reveals how proper pelvic floor function affects everything from incontinence to sexual health, highlighting the value of specialized knowledge in this often overlooked area.
• Women's health physiotherapy is the most evidence-based area of physiotherapy
• Between 20-40% of women experience pelvic floor pain during their lifetime
• Pelvic floor dysfunction affects both men and women at various life stages
• Interprofessional collaboration between physiotherapists, chiropractors, and other practitioners leads to better patient outcomes
• Manometry provides objective feedback on pelvic floor muscle function, showing patients visible progress
• Pelvic floor exercises can help patients of all ages, with significant improvements possible even for elderly patients
• Healthcare providers should be comfortable discussing intimate health concerns to properly identify and address pelvic floor issues
Check out the Camtech manometry tool and visit the Norwegian physiotherapy organization website (MFF) to find specialized physiotherapists in your area.
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Kind regards,
Elisabeth Aas-Jakobsen, DC, MSc
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Hi and welcome to the Practice Gap, the podcast for closing the gap between the practice you have and the one that you want. I'm Elisabeth, a chiropractor, a business owner, coach and entrepreneur, on a mission to help you move from frustration and overwhelm to clarity, focus and joy in practice. Hi, tove Villenstad, hello, hello, hello. I'm so happy to have you in the studio, thank you. Tove is a physiotherapist, or a mensendik physiotherapist, and also has a degree in acupuncture. Could you start by talking a little bit about yourself?
Speaker 2:Okay, thank you for inviting me. I'm Tove. I'm a women's health physiotherapist, also a men's physiotherapist, and I'm also studying sexology. Now at Oslo Meds I'm working with women's health, pelvic girdle pain and also dysfunction in the pelvic floor. I am working at Kolbotten at the clinic we call Competence Clinic for pelvic floor dysfunction. I'm also working at Akershus University Hospital in the pelvic floor department.
Speaker 1:I'm going to start by telling the audience why I have you on the show today. I've been really excited about it. Quite a few years ago I worked with Tove as a physiotherapist. After that I decided I would never work without a physiotherapist again and being a chiropractor, especially in the early days.
Speaker 1:You kind of you kind of high on yourself and you think you know a lot. So then I had no, really no idea what a physiotherapy actually therapist actually did and I had honestly not visited one myself. So when you I started working with you, it was like a light went on. Same for me, and especially with one thing, is like traditional thing, or I would think of physiotherapist as somebody who gives exercises and also some kind of muscle work. But when you came in being a men's physiotherapist, I it really I was eye-opening to me with all the different things like how you sit, how you walk, how you stand and all the little movement patterns you have in everyday life, which just made a huge difference, especially for my patient, who are basically a lot of pregnant women and after children, and of course I know there's a lot of discussion about posture.
Speaker 2:But for me it was an eye-opening. It's a lot about for me as a physio, a mensendick, it's a lot about educating the patient, the woman, and I believe working together with a chiropractor or osteopath or a manual therapist is so important for us as well. Because even if I examine a patient and I find that the pelvic girdle is not move, doesn't move properly, sometimes it's enough for me to just oscillate, that I call it. But most of the times they need more treatment so that the function in the pelvic girdle is is working. And when the pelvic girdle is working properly, then I can teach them why did this happen and what can they do themselves, that the pain and the dysfunction is not coming back. And for that I need to educate them in a proper way to sit and stand etc. And, as you say, it's a lot of discussion about the posture. But when the patient experience themselves that standing in another position makes the pain come back, then human being is so intelligent that they will change their behavior.
Speaker 1:My favorite thing when I worked with you was in the beginning, especially then, after a while, you get used to it. The patients came back and they're super excited and they're like, oh, now I understand why this is always coming back, which made my life super easy, because then I don't get the question that I always get Elisabeth, why is this subluxation keep coming?
Speaker 2:back. So educate them and make them understand. That's the most important thing that we can help them help themselves.
Speaker 1:I know at least in Norway and I think other places in the world also, there can be differences. I know a lot of my colleagues. They work really well with physiotherapists and then there's physiotherapists who can't stand chiropractors. Do you have any thoughts? Why this?
Speaker 2:is oh, that's a good and big question. I don't know, because for me, different profession is so important. We shouldn't think that me myself can help the patient. We need each other, because you are excellent in like mobilize and adjust the joints. I'm not able to, and most of the time we need both of them. Maybe we also may need a massage therapist, maybe we need a psychologist, maybe we need some surgery. But we have to work together. We shouldn't be, oh, you shouldn't go to the chiropractor. I don't want you to go there until we know if my treatment is helping you. Maybe these all these small things helping the patient, maybe that's what's needed. So I don't understand why so many. I think, like you said in the beginning, you think that you are, you can treat many. I think, like you said in the beginning, you think that you can treat everything, but I think the more you learn, the more you understand.
Speaker 1:You don't know If you would give advice for young physiotherapists or young chiropractors early in life how to collaborate with physiotherapists. What are your suggestions?
Speaker 2:Be curious. Maybe you can find a chiropractor and maybe you can come be with them one day, see how they work, have a discussion about the patient, learn from each other. So be curious, visit someone. Maybe you have a patient. You think maybe I can't help this patient. The pelvic girdle pain doesn't disappear and then you can find I have a chiropractor next door. Can I come with you, ask the patient, can I come with you to see the treatment and maybe then ask the other profession? Can you explain for me what are you doing, what are you thinking, and that's a good idea.
Speaker 1:And try the treatment yourself.
Speaker 2:Yeah, experience the treatment. And actually I think I've learned the most about other professions and other people by being a patient myself. It's wonderful when you have some ills and pains, because they really teach you so much. You will be such a more complete treater if you also experience being a patient.
Speaker 1:Why did you become a mensendik physiotherapist?
Speaker 2:Actually, I was working in Sweden in a hospital, an anthroposophic hospital, and there was a physio and she was a mensendik physiotherapist and I worked with her sometimes and I thought her work was so great and she was a mensendik and I'm actually born in Sweden. I wanted to go to the mensendik and mensendik school was the only place in Oslo, so that's actually why I came to Norway in the first place. Sadly, the Mensen Dick education now is not longer exist.
Speaker 2:Does it exist anywhere in the world? I know Sweden. A couple of years ago tried to start like one year study in the university in Lund, but I don't think there is anymore. So I don't think there is any Mens. So I don't think there is any Mennsendik anymore.
Speaker 1:That's really sad. So who should we reach out to here? If anyone is listening here and is an indication, some of our researchers in Norway that are Mennsendik.
Speaker 2:They have to because they are doing the research in treating with Mennsendik physiotherapy, but they can't use that word because no one understands what it is. So they call it something else.
Speaker 1:What do they call it?
Speaker 2:I don't remember now. I will think about it while we talk. Maybe it's coming back to me.
Speaker 1:So then you went. Is that the reason why you moved to Norway? Yes, definitely. And what happened? Why did you stay? Of course, the love?
Speaker 2:Of course, yes, definitely. And what happened, why did you stay? Of course the love, the love, of course the love. Yes, yeah, yeah, my father is also Norwegian, so it was not that a big step to go, that's a big step okay, and then you developed this.
Speaker 1:Actually, why did you take acupuncture?
Speaker 2:For me, physiotherapy. Of course it's a good education, but I think it's just like you call it a ground education. Of course it's a good education, but I think it's just like you call it a ground education. You have to learn more I just seek for more knowledge.
Speaker 2:That's why I started with women's health. It was actually a coincidence. I was working with a colleague of yours, cecilia Lote, and we had such a great work together about the patient, and she was about to start working with you in Beckenaband your first clinic I think it's 15-16 years ago and then she asked me why don't you come with us, start starting with us? So I did, and then I understood that, oh, I need to learn more about women's health and started to take education courses, seminars, and the more I learned, the more interesting it became.
Speaker 2:So it's thanks to you and your colleague. What is women's health? Yes, actually the word is a little bit wrong because we also treat men. They also have a pelvic floor, but mostly, of course, it's women's health and then it's a lot of things in women's health. What we talk most about and what I treat mostly is dysfunction in the pelvic floor could be incontinence it could be both urine and fecal and incontinence and pelvic organ prolapse and also a lot of pain in the pelvic floor, for example, pain during intercourse, and then it's, of course, pelvic girdle pain during pregnancy and after pregnancy. Of course it's like osteoporosis, it's heart diseases, a lot of thing.
Speaker 1:But yeah, the pelvic girdle and the pelvic floor, it's what our work was mostly so neuromuscular skeletal conditions in the pelvic floor area can give a lot of different problems. Yes, so by treating the muscular part, which basically you do, you can help a lot of these patients.
Speaker 2:Yeah, like incontinence and pelvic organ prolapse, maybe after delivery or after menopause, mostly come from weak pelvic floor muscles. Like pain, it's a lot of pain, patient, we know definitely the reason, but having pain it causes that you spontaneously activate your muscles, not only in the pelvic floor but activating the muscles. Of course, if you always have tension in the muscles, the muscles will be painful. And there's also about educating these women, because they are so afraid and they think they will never have been able to have intercourse. How could they give birth to a kid so much? Having pain in this area, of course also, as I say, make more tension in other parts of the body, especially the pelvic joint and the lumbar spine was in in the neck, everything. And then we need to be more professions that take care of everything. So at what time?
Speaker 1:point in history did it in general become more focused on pelvic floor?
Speaker 2:dysfunction. Actually it was. I think it's like four or five years ago they started a clinic here in Oslo have a lot of social explanation about a machine that you could sit on that has a vibration, that they said that this would make your you don't have more incontinence a pelvic organ prolapse.
Speaker 1:So it's like you sit on it's like you remember the bands from the 70 you put on your butts to get the bust muscle.
Speaker 2:Yeah exactly, I don't think even it was electric stimulation, it was just like a vibration so and then it was like a huge reaction from the health professionals and and that actually was a good thing, because so from something weird always something good comes out. What do you say?
Speaker 1:all the publicity is good publicity yeah, yeah is the muscles in the pelvic garden. Women and men, are they different in the pelvic floor floor.
Speaker 2:It's very similar what's the?
Speaker 1:do you know the reason why, instead of just call it it more in general term, some kind of pelvic floor health? Yeah, why have we chosen the word women's health? Because it's not health.
Speaker 2:Yeah, I know it's a good question and it has been discussed in all the European and worldwide societies why, what? What name should we have on this? Should we have? But what should it be? Yeah, so so we named our clinic. In Kolbotn we have just clinic for pelvic floor dysfunction, not women's health, because I treat also a lot of men.
Speaker 1:On the other hand, I think we need also some attention yeah, and just sometimes I feel, almost in this world where there's the women's part, are okay, how am I gonna, how am I gonna set this in a nice way just once, just by calling it women's health? It's like I feel that it's immediately just degraded to something less.
Speaker 1:It's, it's, it's it's just, oh, it's just women's health problems, at least now, yeah for it, yeah and I think that's a little sad, definitely sad, and especially if I feel that triggers some kind of emotion, I mean it has to become. That is sad, that I actually even think of that, because that's the world we live in, because it's not heroic medicine, it's not heart surgery.
Speaker 2:It's sad but like you named your clinic, it's the Becken and Barn. I think most people think that it's for the Becken.
Speaker 1:in Norwegian is pelvic Pelvic yeah.
Speaker 2:They think that it's mostly for women. I mean, when I worked here we were, so we have to tell them it's also for men, yeah.
Speaker 1:It's the same thing. Men have the pelvic curtain.
Speaker 2:So if I didn't say to people that I was working as a women's health physiotherapist, I think they didn't know what to do. There's a lot of physios that don't work with women's health. How about?
Speaker 1:just to keep on going a little bit on that. Do health? How about just to keep on going a little bit on that? Do men have menopause?
Speaker 2:Yeah, of course they also have hormone changes. How do the hormone changes change to muscle? They don't have that much estrogen as we have. The change in the muscles for us women is mostly because of estrogen, so the changes in these muscles is not that big for the men, it's more about their prostata.
Speaker 2:So if they have been operated, for example, they lose some of their continence by removing the prostata. So then they have to learn also doing the Kegels or the pelvic muscle contraction, because they don't know how to do it For women who are menopausal they don't know how to do it. For women who are menopausal.
Speaker 1:How much of the problems that affects the pelvic girdle is due to a change in activity level in general for the women, compared to just hormonal changes?
Speaker 2:When you say pelvic girdle, you mean pelvic floor muscle Pelvic floor. Yeah, pelvic floor. It doesn't need to have anything with their activity level. As physical activity it's a lot about the tissues changing. We know in the menopause everything is a little bit lower. The pelvic floor muscle is a normal muscle. You can train that muscle all the life.
Speaker 2:So when you are 70 and way past menopausal age, there's no reason why you can't work on your no, and I love working with this because I have patients every week that is 70 and they come using a lot of big pads and after maybe three months they don't need to.
Speaker 1:That's why I like working with this, so it's something from for the whole life, because in the, how many, what percentage of really young women do you see? Do you see?
Speaker 2:I mean with, with the problems related to the pelvic floor maybe 50, 50 I will say and mostly of the young, young women it's visiting me because of pain. Then we have, like in the 30s they come because of maybe after delivering they have some problems with maybe incontinence or they don't know if they contract the muscles correctly. But the young women is mostly pain and I just want to say that I think this is interesting and fun because women's health is the most evidence-based treatment in physiotherapy. Wow, yeah, yes, and we have some amazing women in norway who have done research that is worldwide known. So, yeah, it's really cool.
Speaker 1:So if I'm a chiropractor who's been working a while, I have a lot of women. What are some questions that I should ask the patient who I might not? Do about their pelvic floor other than pain yeah, because I know that a lot of people they don't tell that they're leaking. I mean, what are some good?
Speaker 2:questions yes, that.
Speaker 1:I can use.
Speaker 2:I don't know what you're doing here now, but in our clinic we, if they order like online, they will have a form that they can fill out before they come. We like them to do that. And then we have questions about incontinence. We have questions about sexual function, bowel movement, yeah, all these things. And then when we read them it's also easier to continue oh, I can see here you have some incontinence, can you tell me about that? Then they are also prepared about the question, especially about the sexual dysfunction and function, because if they didn't answer the questions in the paper, you can also say I can see you didn't answer her. Is that because you don't want to talk about it? And also an open question, because if you ask, do you have incontinence?
Speaker 1:Either say yes or no.
Speaker 2:But if you can say yes, you just delivered a baby. Very often you have some problems with incontinence or pain or feeling of heaviness. How is that for you? Then they have the opportunity.
Speaker 1:And for the younger practitioner out there it might be uncomfortable to ask about sexual dysfunction and incontinence. What are some?
Speaker 2:advice. You have to be confident yourself about these questions. So I'm taking now some education in sexuality in the university and we love to talk about. Imagine you have a patient, or to start with some work with a friend, where you start, okay, you have some pain during intercourse. Can you tell me? Is it the penetration or when is it so you practice?
Speaker 1:For the different problems. If you would just briefly use men as an example, tell what the different questions give. What kind of information does it give to you, especially the difference between really tight muscles and not very active muscles? Do you have some pinpoints, like if they say yes to this, this might be.
Speaker 2:Yeah, if they come to me and they tell me that, yeah, I have pain with the intercourse, it's pain during penetration, during penetration, I then can understand there is something in the external pelvic floor muscle. If they have deep pain when having intercourse, you can think, okay, this is the deeper muscle and you maybe expect that you have active pelvic floor muscles, and then you have to talk about okay, but do you have any? Do you want to have the intercourse? What about the feelings? Because if you experience every time, but you have any, you want to have the intercourse. What about the feelings? Because if you experience every time that you have pain, of course you tighten the muscles, you're not open, you don't lubricate.
Speaker 2:Yeah, maybe I didn't answer questions, but when you believe, if you have the symptom of a pelvic organ prolapse, then we know that the hiatus, the opening of the vagina, is larger in diameter. We also call some of this pain. They have different names. They have vulvodynia, they have vaginism. Vaginism is like you have a specimen in the pelvic floor muscle. Of course that's tight when you examine.
Speaker 1:Are these kind of problems? Are they increasing, or is it that we have a focus on it and people have name for it? Do you know about that, Is it?
Speaker 2:historically where we are. There is a huge number of women who experience pain in the pelvic area during their life. I think it's between 20 and 40% of every women have had experience of pain in the pelvic floor. I think maybe it's because we have more open about it, it's more in the social media. But I also believe that it's a lot about actually, for example, porn. I think porn is a good thing for very many, but the porn now it's so much more hard. It's available for so young women and men and in this we know that the porn now is so much harder. And the women they think that, okay, why didn't I turn on? Why didn't I have orgasm? So they're not into having sex, but they think that they have to have and of course, that's painful. Then they think, oh, if I don't give my partner intercourse or sex, they will leave me. They're not confident enough or young people growing up, it's, it's tough.
Speaker 1:So if the listeners, the audience out there, want to know how to, how can they find? What are the questions they can use to find good physiotherapists who are actually interested in this area there are lists on the Norwegian physiotherapy organization MFF.
Speaker 2:There is a list of physiotherapists that have interest in pelvic girdle, that have interest in pelvic floor dysfunction, and they have a list with anal dysfunction and a list with men, so you can find them. And there is also a websiteet q u e n t e t, so for your norwegian listeners, I will put that in there.
Speaker 1:But I'm thinking we have a lot of list audience from around the world. How is, in general physiotherapy, this, this kind of specialty?
Speaker 2:in the rest of the world. I think it's about the same as in Norway. There are great women's health physiotherapists around the world.
Speaker 1:Does anyone any other profession care about this area? Oh, yes, definitely.
Speaker 2:Of course, we have a lot of great gynecologists and sexologists. Yeah, definitely, great gynecologists and sexologists yeah, definitely. And, of course, the fastlege that we have here in Norway, the doctor that your regular doctor. They're not supposed to have all this information about dysfunctions. So I think a good doctor is one who knows who they can send to well, okay, and then I know that you have this really cool thing that you kind of gadgets we love gadgets that you have basically developed with someone else.
Speaker 1:Can you talk a little bit about that?
Speaker 2:gadget. Yeah, it's a manometry. Manometry it's a gadget that can measure the maximal voluntary contraction in the pelvic floor muscles or also the endurance, but also you can see the resting tone in the muscles. So for me that's an important information. Either, if it's because of a weak pelvic floor muscle, I can see whether they actually contract the muscles correctly. So that gives me a lot of information, but also for the patient and it also motivates the patients. It's like a small probe. It looks like a small, small balloon that you insert in the vagina and then you ask them to contract the muscles and then you can have to contract the muscles and then you can have a graph on the computer that you can see how strong they are, how long they can hold the contraction and what's happening after they do contraction. Does the resting value go down? For that I can say what your home exercise should be. And then I say to the patient now you can do this at home and in one month you can come back to me and we can have a look whether you become stronger and I can also see what kind of exercise should they have, because if they have, like a stress incontinence, they have incontinence where they cough or sneeze. Maybe I can see there that their contraction is going so slowly. So maybe their home exercise is like you have to practice, like doing a quick exercise and maybe, if you have like pelvic organ prolapse, you can go for a walk, but after half an hour you will feel heaviness. So maybe then they can work more with the endurance.
Speaker 2:For women with pain very often they have heard from the doctor that, oh, you should not work with exercise in the pelvic floor because you're already strong, you're already painful. But what we often see is like when they do the exercise, the resting value in the muscles it decrease, and that will the patient see. And then I can tell them did you feel different in the pelvic floor now? Yeah, maybe it's different now. Okay, this is how it should feel like. And then I can also say to them you can see here, it's not dangerous, it's good for you, because if you have tight muscles, of course you don't hold the tight muscles, you try to activate so you have the circulation. So you can have a lot of information from that measurement tool. That's very cool and the patient must love it they love it.
Speaker 2:Yeah, because it changes.
Speaker 1:It's like you can actually yes there's so many things with the muscle work, or even yeah, and we can't see this muscle. You can see it, you can't see it.
Speaker 2:and and very many people come and they're like, oh, I'm so excited. And and ask them do you feel any progression? And they say, oh, maybe. Oh, I'm so excited. And I ask them do you feel any progression? And they say, oh, maybe I can feel a little bit less incontinence, for example, and maybe I can hold a little bit longer. And then we do the examination and then we measure, and then it was oh yeah, you can see here, you're much stronger now. You can hold for a longer time. Ok, well then what I felt was correct. And then so, oh, now I'm motivated, now I can continue, because very often you don't know whether it's like, yeah, maybe it's no effect. And you do it for a week and then you stop and yeah, starting again.
Speaker 2:So, yeah, it's very motivating for most of the patients. So for those physios out there in the world can they buy this little instrument.
Speaker 1:Yes, they can do.
Speaker 2:Yes, yes, I'll put that show.
Speaker 1:And let me make a little commercial for this it's very, very cool. You should check it out. I will put the webpage on the bottom.
Speaker 2:I can also add that in the first place, this tool was developed by Kari Böe, a professor here in Norway for 30 years ago when she was doing her PhD, and it was also made, of course, by an engineer, and the engineer died a couple of years ago. And Kari Böe, that is a professor and do a lot of research she can't have interest in a tool that is used.
Speaker 2:And it was like old-fashioned tool. So, together with two engineers, I bought the Comtech and developed it to what it is today. It's very easy to use.
Speaker 1:It's very cool and all the physiotherapists that I work with now in the clinic they use it and everyone loves it.
Speaker 2:So that was a little conversion at the end of this podcast.
Speaker 1:I am so happy that you came tova, thank you for watching me yeah. And then to wrap up a little bit, so if, if you are a young chiropractor or physiotherapist, go visit a physiotherapist or a chiropractor be curious and see what they do and get treated yourself, because that is super helpful.
Speaker 1:And if you get more interest in the pelvic floor muscles not the pelvic garden, like if that and there it's super interesting. There's so much musculoskeletal problems that may arise that can give tons of problems for the people from young age to old age. There's never too late to start and it can affect both men and women and, if you are interested, the coolest measuring tool ever for this must be the Camtech balloon. Yeah, and does that wrap?
Speaker 2:the most important things. I just want to add something, because if someone there is that's curious, that you and me, because we have talked about this many times it should be so interesting. Interesting to see how adjustment in the pelvic joint should affect the activity in the, your ability to activate the pelvic floor muscle, because the pelvic floor muscle insert from the coccyx. Yes, yes.
Speaker 1:That sounds like great. I know there are some research done on it. I think Heide Hovek did something, I don't know what kind of measuring tools they did. However, I think that's a great idea and that should be a study that needs to be done.
Speaker 2:Perfect.
Speaker 1:Thank you. Thank you, torben, see you soon.