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Megan Walker: Hello, and welcome to Market Savvy Conversations. My name is Megan Walker, your host. Today our very special guest is Tory Toogood, who is a women's health physiotherapist based in North Adelaide at her own practice, Vital Core Physio. Hi Tory, how are you today?

Tory Toogood: I'm really well, thank you Megan.

Megan Walker: Good to have you along. Today, we're going to be talking about continence and pain, from the perspective of the therapists who are listening to this conversation - other therapists, practitioners, clinicians - to empower them to have conversations with their clients when needed. Talking about difficult topics like continence, pelvic pain and so forth.

That's the context to help explain it. You're going to be far better at explaining that than me, Tory. Just start us off with your background, where you studied, your experience and if you wouldn't mind telling us a bit about your sporting achievements, that would be really interesting for people to know as well.

Tory Toogood: Sure, well I've been a practicing as a physio for over 20 years. I am Adelaide born and bred, so school was here, uni was here at the Uni of SA, which was the only physio course in Adelaide at the time, there's now a handful, the industry has exploded. I've been in private practice for almost 20 years as well so I have my own business in the Eastern suburbs and we've been there for over 18 years and our big message is that we help women throughout the ages.

Kids and adolescents through sporting populations, into pregnancy and postnatal, into pre-menopause, menopause and beyond and keeping us strong and moving throughout our lives.

 And the boys aren't excluded either, we just don't message so strongly to them, unfortunately.

Megan Walker: Did your sporting background, which I won't let you get away without mentioning, did that lead you into this field?

Tory Toogood: Well, it's interesting. I think like a lot of young physios and physio students, I always thought I would move into sports physio. I was a rower, I was on the national team for six years and I did divide my time between Adelaide and Canberra, traveling overseas with the team, working in the physio department at the AIS when I was living there for a couple of years, coming back to finish off my uni degree here and working in one of the big sports clinics here five and six days a week and just immersed in that environment.

After finishing uni and establishing a practice and marrying and having small kids, sports physio was actually really hard to do as a mum and business owner and employer and all the juggling. There's a lot of travel that's involved, a lot of weekend time that's involved and I had a bit of a think, how do I want to diversify better what I'm doing? I was also working quite long hours and I was aware of some other physios whose hands hadn't quite lasted the distance in doing the manual work and trouble with their thumbs and things.

Whilst I didn't have trouble yet, it has a way of accumulating, so particularly I think for quite a lot of therapists having children does change your perspective and that need to do it better, have more help available. I had suffered a fair bit of pelvic girdle pain in my pregnancies, so that sacroiliac joint and pubic synthesis joint soreness and the limping and then my business partner also had quite a lot of trouble with her pregnancy and pain. We were just nutting out how to do that better, which then moved into looking more at the pelvic floor and that more internal musculature of the pelvis, rather than just concentrating on the external musculature around the hip and around the low back and how all of that feeds in and just a desire to help women better than what we were able to find at the time, which is over 15 years ago. My children are 17 and 18 now.

Megan Walker: Thanks for sharing that, I love hearing how people arrived at their journey and what informed the decision and well done to you for carving out a path that was going to work for you and your family and your clients.

Tory Toogood: Yeah, there just wasn't a lot available. There were a few women's health physios here in Adelaide that were doing really good things, but there wasn't a lot of that overlap with the musculoskeletal physio therapy or in particular that perhaps sports aspect of things and so a lot of it was really working out what works best.

Megan Walker: Now, one of your great messages is all about starting a conversation. Talking about pelvic empowerment and so for the therapists and clinicians and practice practitioners who are listening, what role can they play? They might not be physios or they might be, it could be exercise physiologists, chiropractors. What role can they play in helping more women tune in and listen to what their bodies are doing?

Tory Toogood: It's really interesting. We know now that pre-menopause is probably kicking in from about a decade before menopause, so most women that are around 40 are going to be having some hormonal changes along the way. Rising levels of anxiety and depression are actually probably more related to her hormones than truly being a mental health condition and requiring therefore antidepressants or anti-anxiety medication.

It may well be that the sex hormones are more of an issue for example, but helping to normalise the fact that throughout our lives whether we're talking about adolescents, teenagers, younger adults, the very athletic population, the recreational athletic population those that have not done anything for a while and then in lockdown are suddenly exercising a lot more than they ever used to so they do get outside.

All of those things, it has an impact on her body and to pay attention, if something changes, raise it with your trusted health professional, whomever that is and I mean, personal trainers are often the person that has the most contact with someone so it is really important that they're very well armed to ask some questions, to have a little bit of an awareness of, "Oh, that's not normal for you. That's not what you had before or that thing that you have. For instance, there's no such thing as LBL okay?"

Light bladder leakage, invented by one of the pad companies. Stress urinary incontinence, if you leak a little bit, that is incontinence. It's very common, it's not normal and it can be treated pretty straightforwardly in the majority of cases. Just improving some of the coordination of those muscles. She may be weak, she may actually be too strong, it can actually be both things.

To reassure someone that if she does avoid the star jumps, because she leaks, then it's worth her knowing that there are pelvic health physios around that can help her with that.

 She can raise the conversation with their GP and make sure that there's no other reasons for it, but the pelvic health physio can be a really useful adjunct to the other work that she's doing along the way.

People with low back pain actually have a really high incidence of pelvic floor dysfunction of some sort, it could be a weakness, it could be an over activity of those muscles and that applies to men and women. There have been some studies that have actually asked the questions, "Do you have any concerns with your bladder or bowel function?"

They have found rates of getting up over 90% of people who have back pain also have some pelvic floor dysfunction.

 Yeah, so it's much more widespread, we don't talk about it enough. It gets all bundled up in shame and embarrassment and not knowing who to talk to and sometimes just an acceptance, "Oh, that's just the way it is. I've had a baby or I'm 50 now or what do you expect? It's just the way it is. Or my mum had a problem. My grandma had a problem, so it's just inevitable."

Megan Walker: What do you say to that? I've had a baby, so that's just part of the course of being a mum.

Tory Toogood: I would always point out that it's worth investigating, it's worth assessing it so that we know exactly what's going on and if there are things you can do to make it better and most women are pretty motivated. They don't like the idea that if it's like this, now, if I'm 32 years old and I'm leaking, that how much worse is it going to be? Am I going to be the stinky old lady who ends up in the nursing home who's not managing.

 Continence is actually the number two reason for admission into a nursing home, just because they're not coping anymore. Not coping with the washing, not coping with looking after the skin, too hard for the family.

Megan Walker: Yeah. Anyone on the periphery of people around, so we've already touched on personal trainers, people working in aged care, other trainers et cetera?

Tory Toogood: Anyone dealing with somebody with back pain.

 Hip pain, groin pain, particularly if they're not getting all the way better. We know that if the muscles around the pelvis are not behaving properly, then often the muscles within the pelvis are not going to be behaving properly and just like the muscles outside the pelvis that can be a tight grippy behavior where muscles are not relaxing properly and so they're not coordinating on and off properly like they should or it may be that they're inhibited, that they're weak, they can of course be damaged from childbirth or some other sort of trauma.

A lot of the time it can just be a bad pattern that has become established, a protective response of grippiness or an inhibition and so just requiring a little bit of coordination training, building awareness again, helping him or her because it does apply to men as well. Connect to those pelvic floor muscles and be able to achieve a voluntary on and off pattern again and then build some automaticity back into it.

Megan Walker: Wow. Someone who's expressing that they've got a lot of pelvic pain but without the continence experience. What's your recommendation for a personal trainer, for example, working with a lady who's got a lot of pelvic pain, what would you say is good advice there?

Tory Toogood: Well, so particularly endometriosis is one of the really common causes for pelvic pain and sometimes women with PCOS or other conditions as well so if she does have a gynae condition and one that is characterised by pain, then again just to have that awareness that those muscles probably have been acting protectively, defensively and that there is that tightening.

Although she appears weak, it's probably more a coordination issue than a frank muscle weakness and that she may actually need to work more on relaxation. The best thing to do is to get it assessed and diagnosed and then the person who does that diagnosis and gives her some strategies can work with that trainer or other health professional to just give it a little bit more guidance as to how to best get that exercise program to work for her, particularly if she loves doing pilates, for example.

It's not the best thing that we recommend for women with pelvic pain, but if she does it well and if she knows that she needs to periodically stop and let go of everything and then feel it switch on and feel it let go, for example, then she can participate in the class that she loves with the teacher that she loves and have the coffee with her friends afterwards and all of those things. All about finding the way that she can do the things that she loves to do.

Megan Walker: Yes. What's the alternative to that picture when you see people who aren't identifying with their pain? What's that behavior look like? What's their lifestyle changes that you commonly see presenting in clinic?

Tory Toogood: They just end up so upset, they feel like they're missing out on so much. They move into much more of an avoidance pattern because they haven't worked out how to get a bit of or how to grade back in. It becomes very all or nothing. We can end up seeing people who were avoiding all activity, not even walking.

 Unfortunately we can end up seeing people who are avoiding working or studying because it's just too hard to manage whether it's pain or whether it's continence and their lives get smaller and smaller and smaller and because whenever they've tried something, it feels like they've failed in whatever way. The problem has become worse or they haven't managed, instead of trying to find how can we start to get some of that going, how do we pace it appropriately?

There's an awful lot of overlap with any other sort of rehab. It's about doing bite-size amounts and gradually building it up, building in strategies to cope, to pace along the way, whether it's taking breaks, stretches to do along the way to help. Specific little exercises to do, it's not that dissimilar to rehabbing a knee.

Megan Walker: Yeah right. Okay and there's so much hope there that comes with that conversation. We've talked a lot about, empowering yourself and going and starting that conversation and that and you and I have talked separately as well about extreme pain is not normal.

I'm not a clinician, but I can imagine that with the embarrassment, particularly around the continence issue, there might be a masking, take pain relief as opposed to address underlying issues?

Tory Toogood: Oh, absolutely and particularly for those women that do have a lot of pain who may or may not have yet been diagnosed with endometriosis, but unfortunately I've even seen teenagers who are on opioid medication.

 It's not a way to manage chronic pain unfortunately and when you're on opioids, you will often then have bowel issues, constipation which will tend to make any pain issue worse. Particularly when we're talking about the pelvic pain, we've then got straining or damage to the anus because of the constipated stools. We just have this vicious cycle building up so that whole body approach and really assessing both the biological factors, so we work very closely obviously with the medical team to help manage the hormonal side of things, the medication side of things, working with a psychologist to help more with the psychological factors.

Pain catastrophisation will often go hand in hand and central sensitisation, central changes will usually be occurring when the pain has been there for more than a couple of months and for an awful lot of these pelvic pain conditions, that's exactly the case. I like to describe that we're all Goldilocks. We all need what is just right, not too little, not too much. It's about working out where there is too little and where there might be too much and just trying to bring it back towards the middle.

Megan Walker: Tory, we'll start to sort of wrap up that conversation a little bit, but I'm just thinking, in terms of advice and guidance for someone who's working with a patient or client who feels that they've got an issue there, but they don't know how to raise the subject matter.

 What's some advice, have you got some good questions that a PT or a trainer or anyone on the periphery of this could raise with that female client?

Tory Toogood: Yeah, so particularly useful at intake, at first meeting but also, I guess if they do have a problem with their back, their hip or their groin and if they report that they've got a back pain or their hip's a bit funny at the moment, to just ask if there's any concerns about their bladder or bowel function, any concerns with wee or poo depending on how simply they want to say it.

There is a great website called Pelvic Floor First, that has been put together by the Continence Foundation of Australia in conjunction with the fitness industry. There are a couple of questionnaires on there, one for men and one for women that just gives them just nine questions about lateral bowel function, which can be a useful... this is just what we do for everyone to just raise the questions, particularly if you've had somebody for a little while, I don't imagine that you'd be very comfortable a lot of the time asking on the first visit.

 Again, if somebody has back pain that they've been treated or if you're seeing movement dysfunction around the low back, the pelvis, the hip to just ask if there is any concerns with sexual function, is there any pain? For the blokes with pelvic pain there will often be some concerns with erectile dysfunction, but like I said, probably not at the first meeting would that one be made.

As you have that established relationship and just to reassure them that this is something that... It's a thing and not to be embarrassed and to hook in with your networks as a professional, to make sure that you do know a pelvic floor physio, somebody who does do women's and men's health locally that you can call or you can email and just ask for some more resources or yeah we've talked about possibly even doing collaborative treatments where the normal treating physio, chiro even the PT may be able to come in and sit in on the physio appointment or correspond more freely with the pelvic floor physio to just know how do I best help this person and support this person.

There's often going to be a lot of changes that need to happen in their training regime or coordination patterns temporarily but the idea is always to get them back to doing all the things.

Megan Walker: Absolutely. I love that idea, the mini team care arrangement that either the practitioner or even the patient has instigated to say, "Hey, can we all get together on a Zoom and talk about this and have a co- joint plan."

Tory Toogood: That's right.

Megan Walker: As a lay person, hands up, suggest it to your patients and clients, I think that's fantastic.

Tory Toogood: Yeah, that opportunity for a case conference as it were.

Megan Walker: Yes, Absolutely. I'm going to ask you two more questions or three actually, your vision for pelvic empowerment.

 

Tory Toogood: Yeah, my vision for pelvic empowerment is for everybody to feel comfortable to raise any concerns that they have with their treating professionals and for their treating professionals to feel really comfortable to refer on and to know how to direct that person to the help that they need.

There've been times where somebody says, "Oh, do you have any pain with sex?" The patient had said, yes and so they've been straight away referred to the women's health physio, but it turns out it was actually getting into position was a problem and it was a hip pain problem that was causing pain with sex, it wasn't actually a pelvic floor dysfunction. To not be too scared of the questions and if you do have that comfortable relationship, to explore it a little bit.

"In what way do you mean it's painful with sex?" For example, but that we can actually talk about wee, poo and sex much more comfortably, they are a very normal part of life. Wee and poo in particular, critically important life functions. Sex, we consider to be an ADL an activity of daily living.

 Not quite daily, maybe, but nonetheless, it's a normal thing that you should be able to do comfortably and so to include that as just, these are normal behaviors and normal things and if you've got any problem, that there is help available. I want for there to be thousands and thousands more pelvic health physios all around the country and in regional areas and for there to be adequate funding in public hospitals for enough support that there could be Medicare funding for what we do.

France have 12 visits with a pelvic health physio guaranteed after having a baby, funded by the government.

Megan Walker: Wow.

Tory Toogood: How different would most family's lives be? It's not just the mum, it's the entire family. How much better will it be if mum could get that sorted out and can be exercising and doing all the things that keep her really well, just as par for the course.

Megan Walker: Oh that's amazing.

Tory Toogood: Just part of management.

Megan Walker: In Australia, I can only imagine because I have these conversations that you're still explaining to people every day, what a pelvic floor physio is.

Tory Toogood: Yeah. Oh, the number of people that come in and say, "Oh, I brought my gear so that I can get some exercises."

Megan Walker: Oh dear, no.

Tory Toogood: Then having to explain, "Oh, it's going to look a bit like a gynae exam." We do explain very much and obviously they don't need to do anything on the first visit other than getting information, if that's what they want. If they are a bit scared of it or intimidated by it confronted about it.

Yeah, so many people said, "I never knew this was a thing." It's been a thing for over 30 years. Too many of the general public don't know, too many doctors don't know as well, so yeah.

Megan Walker: We keep having these conversations.

 Tory Toogood: More and more, better knowledge, but we need more and more and better and better awareness. We just don't have the same type of advertising budget or reach that the number of people that know that LBL, that light bladder leakage thing and those ads are so effective from the pad companies and I just wish they always said on there, pelvic health physio can most certainly help you. Not make quite so many pads.

 Megan Walker: Is there anything else I should have asked you or that you would have liked me to have asked you? Such a big topic.

Tory Toogood: Oh, look, it's such a big topic and I can talk for days across it all. I think the really big thing is if everybody can do their bit to normalise the conversations.

 This is an important part of your health and your wellbeing and when you have problems with this, it does tend to affect every part of your life.

It affects your mental health it affects your social health and wellbeing, as well as it potentially becoming a bigger physical health problem if it's meaning that you're not exercising, for example and we know that exercise is critical for health so the more we can normalize the fact that if we have any problem with our pelvic behavior, pelvic function, that there is help available and that you don't need to be embarrassed. It's not embarrassing, it's not disgusting, it's not horrible.

Megan Walker: We're human beings, aren't we?

Tory Toogood: We are human beings and this is all really normal. I'm so gratified every single day by people trusting me with their stories and allowing me to help them.

I get such a kick out of helping these men, women and children with problems and helping them feel normal. Giving them their power back to do all the things that they want to do.

Megan Walker: So incredible, I love your passion Tory. You chose the right field, so glad you made that decision. Now you're available for these case conference type things or telehealth appointments, mentoring, guidance through Vital Core Physio. Is there any other way that people can get in touch with you? They visit your website and have a look?

Tory Toogood: Yeah, they can visit the website and have a look. They can email me at Tory, [email protected] and yeah, I'm happy to engage with conversations and yeah, we can look at providing telehealth services to get part of the way there. Obviously can't do a proper assessment via telehealth, but we can get a fair portion of the way there or to work in conjunction with somebody who is more local, but perhaps doesn't have quite the same experience along the way or to do that case conferencing, some of that troubleshooting.

Megan Walker: Brilliant. Geography, no boundaries.

Tory Toogood: Yeah, it's been the upside of COVID hasn't it?

 That increased accessibility. Yeah and that we've all had to get a whole lot more tech savvy.

 Megan Walker: Tory, thank you so much. I enjoyed that conversation thoroughly and yeah, just love the confidence and the empowerment message about just start that conversation with people, don't avoid it.

 As a lay person, one, I would like someone to raise things. I think often maybe, am I getting this wrong? I wonder sometimes if people think clients have more knowledge than they do about their bodies and I think sometimes we really need the information. We really need that raised and have you thought about this or did you know this, or were you aware of this.

 Be brave, have those conversations.

Tory Toogood: Exactly and just that recognition, it's not normal. It might be common, but it's not normal and that there's things we can do to change it, to improve it and that can be very, very minimally invasive, yeah.

Megan Walker: Yeah, Well Tory Toogood, that was too good. I'm sure you've had that your entire life.

Tory Toogood: My entire life.

Megan Walker: Thank you for your time and we'll talk to you soon.

Tory Toogood: Thank you very much, Megan.

  

Links

Contact Tory for case conferencing: [email protected] 

Visit Tory's website: Physio Adelaide | Physiotherapy Adelaide | Vital Core Physiotherapy

Pelvic Floor First: Pelvic Floor First