A post for Women’s Week and World Physiotherapy Day 

Small Business Grant Win: Extending the scope of Telehealth in rural and regional Queensland

Today (8th September) is World Physiotherapy Day, plonked right in the middle of Women’s Health Week and it is a good time to chat about an exciting new project that we have undertaken. In the weeks that followed us closing the door on 25th March, 2020 to face-to-face consultations with patients and pivoting (new 2020 Word of the Year, only just pipping unprecedented) to completely Telehealth consults, the Queensland Government encouraged small businesses to apply for Small Business Grants to the value of $10,000.

Not knowing what the future held and having ten staff to continue to employ, I decided to apply for a grant based on trying to extend the reach of Telehealth to rural and remote areas in regional Queensland.

As a background to the choice of our application for rural and regional Queensland Telehealth, we know that incontinence and pelvic floor dysfunction is a silent epidemic with women with severe incontinence experiencing more health issues, restrictions or limitations than women without severe incontinence. For example, 2 in 3 people (76.6%) with severe incontinence were restricted or limited in their physical activity or physical work, compared with 44.8% of people without severe incontinence. We know that incontinence is socially isolating, causes anxiety and depression and limits physical exercise, thus compounding their emotional and psychological burden. If these issues are not addressed it will mean that the problem progresses and ultimately affects our older age with around 77% of nursing home residents in Australia being affected by incontinence. 

And those stats are just about urinary incontinence. They don’t address vaginal or rectal prolapse, faecal incontinence or pelvic pain- the stats of which are also massive.  Childbirth is definitely implicated, but also we know that women who have had Caesarean births or are nulliparous (never had a baby) may eventually have some pelvic floor dysfunction, if they remain uninformed about the science of the bladder, bowel and pelvic floor.

So we know we need to get the message out there about good bladder and bowel habits and the role that pelvic health physiotherapy plays in treating these conditions. At my practice, we had already been doing quite a lot of telephone consults for regional women (men and children) prior to COVID19, but the rapid switch to 100% Telehealth once we temporarily stopped our face-to-face consultations meant that I had to make the process more user-friendly for my staff and the patients and therefore adapted our handouts and information to a user-friendly platform which was well received by both the physios and the patients.

My books enhance any education we give at the Telehealth consultations

Fortunately, education is the cornerstone of effective pelvic health treatment once a comprehensive assessment has been undertaken. Therefore Telehealth lends itself nicely to the majority of the requirements for effective treatment of our patients. We acknowledge there are some drawbacks when we cannot immediately follow the education with an internal examination, but we have ensured that the patients are asked probing questions by the physio in their assessment regarding:

• What can they feel when they attempt a pelvic floor contraction?
• Do they feel lift and squeeze or do they feel descent or bearing down?
• Are their other pelvic muscles working overtime?
• Are their abdominals ‘overswitching on’?
• Are they holding their breath to do the contraction?
• They are given many cues to check for correct activation of their muscles
• Do they have a vaginal bulge which may indicate a prolapse which can alter their ability to empty their bladder (meaning any frequency they may be suffering is related to residual urine left in their bladder rather than an overactive bladder).
• They are asked to fill in a bladder diary and return it to us as soon as possible.

All of this close questioning is to ensure ‘we do no harm’ with our telehealth treatment plans.

We also immediately started streaming our supervised exercise classes also because the patients who attended our classes at Hampstead Road and the studio at 194 Gladstone Road were devastated that we had to stop them so abruptly. This has been a revelation. They work so well that, until there is a vaccine, we will not be having our group classes in the small gym at Hampstead Road, but we will be still having some occasional small dance classes at Gladstone Road – althought the majority are still streamed.

But Telehealth does have its drawbacks. Obviously we are unable to do that very important internal assessment to assess the status of the pelvic floor muscles (are they weak? is there a possible avulsion injury? or are they overactive with tender points? is there a prolapse?) or the ultrasound to see if patients are completely emptying their bladder, but there is so much that we can do that the pluses definitely outweigh the minuses. What has happened is many of the patients have eventually had other reasons to come to Brisbane and have had a face-to-face appointment with their physiotherapist and the necessary examinations and then their consultations have continued back in their own homes via further Telehealth appointments.

What began as a less than suitable substitute, became a fantastic way to reach women (men and children) who live more remotely and who may have had no idea that there was an effective treatment for their very distressing bladder, bowel, pain or pelvic floor problem available.

The wonderful news is that in August, we heard that we had won the grant and so began our journey of offering Telehealth Pelvic Health services to regional and rural Queensland. The grant money cannot be used for wages to provide the Telehealth services. It is designed to set up the infrastructure so to speak, of developing this type of service. Since this news arrived, I have been doing a lot of thinking and researching about how to do this in a way that is inclusive to all the hardworking and fantastic pelvic health physiotherapists in rural and regional areas and also about the opportunity this presents to amplify the value of pelvic health for women, men and children throughout Queensland.

In the beginning we will be offering Telehealth appointments throughout regional and rural Queensland and then trying to link with pelvic health physios who are in the vicinity of the towns where the patients may be located so they can have a face-to-face internal pelvic assessment. Of course if patients are coming to Brisbane for other appointments, we can tee up a face-to-face with them then.

If pelvic health physiotherapists are interested in being on a register of rural and regional contacts please email me on admin@suecroftphysiotherapist.com.au (perhaps with some indication of the courses you have covered).

The evidence is strong that pelvic floor muscle training and education about good bladder and bowel habits should be the first line of treatment for many pelvic health conditions. A study by Doumoulin et al 2018: Compared with no treatment or inactive control treatments, women with stress urinary incontinence (SUI) who were in Pelvic Floor Muscle Training (PFMT) groups in this study were 6 times more likely to report being cured or improved. (PFMT 72% Placebo/Control 11.4%). Another study by Fitz et al in 2017 showed the success rate for PFMT for SUI varies between 60-75% when performed in the outpatient setting under the supervision of a physiotherapist. With the availability of Telehealth, this supervision can also be via the computer and even by streamed classes when the ideal situation of seeing a patient face-to-face is thwarted by the tyrrany of distance such as we see in Australia. 

We can also recommend some strategies to ensure there is safety around Telehealth appointments.

For example screening for a Urinary Tract Infection (UTI) can be undertaken if there is access to a GP – request a microurine if there is increased urinary urgency and urge incontinence as this can be worsened if there is an infection. It also helps to check for the clarity of the urine (cloudy urine can signal infection) and colour (it should be pale yellow- the more concentrated the urine the more irritating for the bladder). If your urine is clear, a nice pale yellow, there is no odour and no stinging when you void or blood in your urine, then it is unlikely there is infection. 

Another important ‘revealer’ of important data is to undertake a 48 hour bladder diary to see what you can hold in your bladder – measured volumes should preferably be between 350-500mls for the adult bladder. This bladder diary gives us an amazing amount of information – the capacity of the bladder; the degree of urge with each void (from zero urge, mild, moderate, to busting); the spacing of the voids throughout the day; the number of urinary leaks and at what volume of the bladder; the number of voids at night and the amount of fluid voided through the day versus the night; the balance of your fluid input versus your fluid output; the types of fluid that you are drinking; the total volume of your intake; the times you are drinking etc.

Access to getting an ultrasound in a regional centre can also reveal voiding dysfunction – if with questioning symptoms seem to indicate retention of residual urine.

If you are suffering in silence with urinary incontinence, if prolapse is interfering with your farm work, or if constipation is a daily burden – now is an opportunity to seek help. The strategies taught via Telehealth are simple and easier than you think to implement. If you would like to make a booking for Telehealth, contact our secretaries on 0407659357.

If you want to make a headstart on things prior to making an appointment, these things are comprehensively covered in my two books Pelvic Floor Essentials (if you haven’t had or not intending to have surgery) and Pelvic Floor Recovery: Physiotherapy for Gynaecological and Colorectal Repair Surgery(the surgical book). You can check them out on my book website.

Finally, thank you to the Queensland Government for our Small Business Grant and if you are a business struggling as a result of COVID19, check our the Qld Govt website for future small business grants.