Physiotherapy for Endometriosis

Annika Cost is a physiotherapist specializing in endometriosis.

Dr. Nadine Rohloff: Today, I am in conversation with Annika Cost, a physiotherapist specializing in women’s health, particularly endometriosis. A warm welcome to you, Annika!

Annika Cost: Good afternoon! I want to start by introducing myself. I completed my bachelor’s degree in physical therapy in Frankfurt and later pursued a Master’s in “Musculoskeletal Rehabilitation” near Brussels in Leuven. Upon returning to Frankfurt, I worked in an extensive physiotherapy practice, but two pivotal experiences prompted me to establish my practice in Frankfurt Sachsenhausen, focusing on women’s health. One was a friend experiencing bladder incontinence post-pregnancy, and the other dealt with severe endometriosis symptoms. These encounters drove me to delve deeper into pelvic floor issues and specialize in women’s health.

Dr. Nadine Rohloff: It is not easy to find physiotherapists specializing in the pelvic floor, let alone those focusing on endometriosis. The link between endometriosis and relief through physical therapy is often overlooked. What do you think that is?

Annika Cost: Many, including physicians, are unaware of available treatments. Limited research on endometriosis and physical therapy contributes to this lack of awareness. Health insurance companies often hesitate to fund such treatments due to the scarcity of specific studies, further limiting exposure among medical professionals.

Many Applications for Physiotherapy in Endometriosis 

Dr. Nadine Rohloff: What symptoms of endometriosis might lead a doctor or patient to consider physiotherapy? Can you provide general guidance on when treatment is beneficial?

Annika Cost: Treatment options vary based on symptoms. Endometriosis-induced pain typically affects the pelvic floor and surrounding structures. Physiotherapy benefits anyone experiencing pain, serving as a valuable therapy component by addressing muscles, joints, and mobility. It can also be effective against bladder weakness or digestive issues. Additionally, many find it helpful for preparing for or recovering from surgery.

Dr. Nadine Rohloff: How does therapy assist in preparing for surgery?

Annika Cost: Mental preparation for surgery is crucial, but optimizing the body’s structures is equally essential for a smoother rehabilitation phase. A fit and healthy body going into surgery tolerates the procedure better. Understanding the pelvic floor, practicing good abdominal breathing, or learning to relax these areas can significantly ease post-surgery pain.

Physiotherapy Procedure for Endometriosis

Dr. Nadine Rohloff: For those unfamiliar with physiotherapy, especially in the context of endometriosis, how does a treatment session proceed, particularly with you as an endometriosis therapist?

Annika Cost: I begin with a detailed discussion about the current condition, covering factors such as past surgeries, complaints, and movement restrictions. I then perform vaginal palpation of the pelvic floor, a crucial step for reliable assessments of tensions, asymmetries, trigger points, mobility, and strength. Importantly, this is only done with explicit consent from the patient.

Dr. Nadine Rohloff: Can you elaborate on the examination process, especially concerning the pelvic floor’s response to tensing or relaxing?

Annika Cost: Certainly, I gently insert a gloved finger using the customary ultrasound gel, feeling and providing a description of the procedure to guide the patients through it. I instruct them to tense up, relax, cough, and perform other relevant actions. The examination is akin to a standard muscle function test. If preferred, the process can be observed with the assistance of a hand mirror. I understand that many women may not have had the opportunity to explore this aspect of their anatomy, so I am more than happy to explain the specific locations and actions during the examination.

Individualized Approach to Endometriosis Physiotherapy

Dr. Nadine Rohloff: Is physiotherapy for endometriosis standardized or tailored to individual findings?

Annika Cost: Due to the diversity of symptoms and foci, there is no one-size-fits-all therapy. After the examination, I discuss my observations with the patient, clarifying how my treatment plan aligns with their goals. The therapy plan includes stretching, relaxation, and mobilization exercises tailored to each patient’s unique complaints and problems.

Dr. Nadine Rohloff: Many women with endometriosis experience pelvic floor tension. In physiotherapy, pelvic floor training is standard. Can you share insights from your clinical experience on how this fits into the overall treatment and what exercises are involved?

Annika Cost: In clinical practice, I frequently observe a prevalence of pelvic floors exhibiting tension rather than weakness, although these two conditions are not mutually exclusive. Despite this, the primary focus of treatment revolves around promoting relaxation in the pelvic floor. Consequently, traditional pelvic floor exercises are less suitable, particularly in the initial stages of endometriosis treatment, as they tend to generate more tension than alleviate it. The key is to acquire the skill of consciously relaxing the pelvic floor, a process that may require time and patience. It is important not to become discouraged if success is not immediate.

Moreover, the pelvic floor can sometimes develop fixed points. I guide my patients in self-directed practices involving breathing techniques and exercises to address such issues. I emphasize empowering them to continue these practices at home independently, eliminating the necessity of frequent office visits. Although releasing tension through breathing and relaxation exercises may take longer, the approach is more sustainable.

To facilitate this process, I integrate stretching and movement exercises designed for the entire pelvic region, encompassing the hip, abdominal, and back muscles and the fascial pathways within the pelvic floor.

Pelvic Floor and Bladder Function in Endometriosis

Dr. Nadine Rohloff: You mentioned bladder function being affected by endometriosis. What therapeutic options address this issue?

Annika Cost: Elevated tension in the pelvic floor can contribute to bladder floor irritation, potentially leading to a premature urge to urinate. To address this, it is beneficial to maintain a record by creating a table to track fluid intake over two days. Simultaneously, use a measuring cup to document urine output. Considering potential routine variations, this practice should be observed on weekdays and weekends.

Additionally, take note of specific occurrences such as an intense urge to urinate accompanied by only a few drops expelled, instances where urgency prevented reaching the toilet in time, or any associated pain. Afterward, analyze these observations collectively. This process aids in identifying potential improvements. It could reveal patterns, such as inadequate fluid intake or consumption of inappropriate beverages.

Ensuring sufficient water or unsweetened tea intake is crucial, and distributing fluid consumption throughout the day is advisable. Even minor adjustments can lead to significant improvements in managing symptoms.

Dr. Nadine Rohloff: Does pain during emptying or filling often arise in surrounding areas, leading to a quasi-treatment of pelvic floor adhesions and the surrounding muscles?

Annika Cost: On the one hand, yes, and on the other hand, a sense of urgency can develop from pain, even when it is not necessarily due to bladder filling. The bladder holds about 600ml, with the first sensation occurring at around 150ml and a natural urge arising at 300-400ml. If I have the urge to go but expel 80ml, coupled with preceding pain, it is often because the pelvic floor was tense beforehand. The tension irritates the bladder, triggering the urge. Habits like going to the toilet early, such as before leaving the house to avoid discomfort while on the road, can condition the bladder. Strategies to postpone urgency often address and improve these habits.

Dr. Nadine Rohloff: Physiotherapy is commonly associated with exercise therapy involving movement exercises. However, many women with endometriosis experience discomfort after physical activity. Which movements and sports are beneficial for endometriosis, and which should be avoided due to potential exacerbation of problems and pain?

Annika Cost: The crucial aspect is finding enjoyment in exercise. I always inquire about the types of sports the patients enjoy rather than focusing on the quantity. The initial goal should be to rediscover the joy of exercise. Although it may take time, I am reluctant to impose blanket bans on exercise. While it is temporarily advisable not to exhaust during severe pain or acute exhaustion, there are no sports inherently excluded due to endometriosis. The key is to listen to your body: anything that overloads it is not recommended. Adequate exercise can relieve pain, reduce inflammation, and promote well-being. It is less about the sport and more about maintaining a healthy amount of exercise. In essence, anything enjoyable is allowed.

Dr. Nadine Rohloff: Certain sports involving frequent body shaking can sometimes pose issues for endometriosis, such as Zumba, which many women enjoy but often report problems afterward. Ultimately, individuals must determine what works for them. So, rather than outright renouncing activities with some aspects like shaking, would you advise avoiding only those that cause pain or worsen discomfort?

Annika Cost: That is precisely how I would summarize it. Sports like Zumba and other high-impact activities such as jumping rope or jogging can stress the pelvic floor. A tense pelvic floor, subjected to shaking and increased tension, tends to cause more pain. However, it is possible to engage in such activities cautiously with effective therapy and conscious relaxation. For instance, one could split the activity into half an hour of stress and another half-hour dedicated to conscious relaxation and loosening of the pelvic floor. Many patients have successfully adopted this approach to enjoy their preferred sports moderately.

Stress as an Influencing Factor

Dr. Nadine Rohloff: Stress often plays a role in endometriosis, especially with pelvic floor tension. How do you address stress in the patients you care for?

Annika Cost: Stress is a common element in some form for all of my patients. The condition is a significant stress factor, compounded by the everyday stresses from household, work, and family responsibilities. The uncertainty surrounding when and how pain will recur and its potential impact on daily life adds further stress. Managing stress is an integral part of therapy. I work to identify stressors that can be alleviated, such as redistributing tasks within one’s social environment. If this proves insufficient, increasing stress tolerance becomes necessary. Breathing exercises, meditation, or walks in nature are effective methods to achieve this.

Dr. Nadine Rohloff: This also applies to physiotherapy in our current complex times, where we cannot always go where we want. Can one do exercises at home to manage stress, especially for the pelvic floor?

Breathing Exercises for Stress

Annika Cost: I recommend a simple yet effective breathing exercise that involves sitting upright with feet flat on the floor, knees bent at a 90-degree angle, and arms hanging relaxed. Inhale through the nose for four seconds and exhale through the nose for six seconds. The emphasis is not on exact time intervals but on making breaths longer than usual, with longer exhalations. Aim for regularity and a favorable ratio rather than precise seconds when counting in your head. Ideally, practice this for twelve minutes to achieve maximum benefits. However, even shorter durations, such as a minute, can bring immediate relief during acute stress.

Dr. Nadine Rohloff: Nature and medicine operate on a gradual principle rather than a yes-no approach. Everything leading up to the maximum has an effect. Your explanation is lovely, and I already feel much more relaxed.

Exercise for the Pelvic Floor

Annika Cost: To relax the pelvic floor, learning how to let it loose is beneficial. One trick is to consciously tense the pelvic floor, causing it to lift and move slightly forward. From this position, it becomes easier for most people to deliberately let go and feel the relaxation compared to a neutral position. Focus on relaxation: Tension serves only to locate the pelvic floor correctly and consciously soften and loosen it. While sitting on a chair, place your hands between your legs to feel the pelvic floor tense up when tightened. It rises slightly; when released, it sinks back.

The key is to listen to yourself and feel whether the pelvic floor is tense. If there is no good reason for tension, such as the urge to urinate, it is advisable to let the pelvic floor relax.

Here is another exercise:

You are performing a deep knee bend while keeping the pelvic floor loose. This is a beneficial mobility exercise for the hips and the pelvic floor. Ensure your feet remain flat on the floor to avoid excessive tension. If your heels cannot reach the floor, place a book underneath. It becomes easier if your feet are spaced apart. Gently rock back and forth while consciously maintaining a loose pelvic floor. This allows the pelvis to open down a bit and stretch.

For those with knee problems, the exercise can be done lying on your back by pulling your legs in.

Dr. Nadine Rohloff: Those are quite a few things to practice. Thank you very much for being here today, and I hope more people will discover the benefits of physiotherapy.

Annika Cost: My pleasure!

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Dr. med. Nadine Rohloff