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Ovulation Pain or Mittelschmerz

Posted: Thursday, December 19, 2013 at 8:00:22 AM EST by Alyssa Tait

 Can you feel when you're ovulating?

That niggling pain is back again, low down in the left of your lower abdomen. It’d be nice to just sit down and put your legs up, but you’ve got to keep working.  That time of month again – no, you’re not due for your period for another two weeks! This is mid-cycle pain. Not only do you get period pain, but you’re hassled in the middle of the month by more pain! Why?

That cyclic stabbing pain in one side of the lower abdomen that some women experience is known as ‘’Mittelschmerz’’ (meaning middle pain) or ovulation pain. It is typically described as occurring at mid-cycle. However, this is dependent on the length of the cycle. It would be more accurate to say it occurs approximately 2 weeks before the menstrual period – that is, at the time of ovulation.

Ovulation pain tends to switch sides from month to month (depending on which ovary you are ovulating from, obviously). For most women it lasts a few hours or less – just enough to let them know they are ovulating. For some women, it lasts for more days. And for some very unlucky women, it is severe and can be accompanied by other symptoms such as nausea or even vomiting.

The precise cause of Mittelschmerz is uncertain. It may be due to the enlargement of the follicle before the egg bursts forth in ovulation, or the rupture of the follicle itself, with the spilling of its contents into the surrounding tissue. Whatever it is, if it is anything more than a minor nuisance, you may want to have it looked into.

Severe Mittelschmerz is often due to endometriosis, a condition where the inner lining of the uterus (the endometrium) ends up implanted in places it shouldn’t be. Endometriosis can only be definitively diagnosed with a laparoscopy – a relatively invasive procedure. Women with endometriosis usually have painful and heavy periods as well, and sometimes pelvic or abdominal pain at other times of the month. This can imitate irritable bowel syndrome.

In my experience, cyclical abdominal or pelvic pain is more likely to occur when there are ‘’tissue restrictions’’ around the organs involved (in this case, the ovary, fallopian tube and uterus). For example, endometriosis causes adhesions (scarring) within the tissue which causes it to tighten up and be less flexible. As your pelvic organs contain smooth muscle and are designed to be very mobile, these restrictions can result in you feeling things you shouldn’t (such as pain) – or feeling sensations more strongly than necessary. Tissue restrictions that can be palpated by an experienced physiotherapist are certainly present where there is endometriosis, but many women I see with these problems do not have a diagnosis of endometriosis (yet, anyway).  In my experience, ovulation pain, period pain and other pelvic or abdominal pains can be successfully treated by gently easing these tissue restrictions. This involves a form of tissue release known as visceral manipulation, or visceral-specific myofascial release. Visceral manipulation is very gentle and performed through the abdomen by a physiotherapist who has trained specifically in this technique. It can provide relief within just a few sessions.

Contact us for an assessment using this approach and possible visceral manipulation treatment, or just to make an enquiry.

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About Alyssa Tait

Alyssa runs Equilibria Physiotherapy & Nutrition, a clinic focusing on integrative solutions for pelvic health issues including all types of pelvic pain, bladder and bowel control issues, fertility, and irritable bowel syndrome.

Alyssa’s website www.equilibriahealth.com.au is an information hub related to all things relating to the function of the female pelvis.

She aims to help as many people as possible restore balance to their pelvis through education, effective treatment and empowering lifestyle choices.

Alyssa enjoys playing the clarinet and rollerblading, though (much to the gratitude of her patients), not while she is consulting.

Connect with Alyssa  |  Facebook  |  Google Plus | linkedin | Twitter

Connective Tissue Dysfunction in Vulvodynia and Chronic Pelvic Pain Part 2: Evaluation and Treatment

Posted: Saturday, August 16, 2014 at 6:30:48 PM EST by Alyssa Tait

Connective tissue dysfunction in vulvodynia is often missed, and needs to be treated.

Confused about connective tissue? Picture a whole lot of fruit in a plastic bag, sitting in a bowl of jelly.

apricots, plums, grapes and so on. The fruit can be moved and jiggled around within the jelly, even within the plastic bag.

Now imagine a several layers of cling wrap around each piece of fruit. The wrinkles of the cling wrap stick to each other. The fruit doesn’t move so well. The jelly doesn’t get swished around so much, and hardens up.

Your muscles and organs are the fruit, and the connective tissue is the cling wrap.

If it gets tight and thick, it restricts movement. Any restriction of movement in your body, whether in muscles, skin, nerves or organs, can create dysfunction and pain. (The jelly is what is called the interstitial fluid of your body – the fluid you never noticed unless it increases, causing swelling and possibly pain and even abdominal bloating).

The connective tissue around the organs is called visceral connective tissue. Treatment of this connective tissue is known as visceral manipulation, and can be a very useful component of treatment of vulvodynia and chronic pelvic pain.

A specific type of connective tissue restriction will be very familiar to you:

The most common type of connective tissue restriction is a scar.

When scars are deeper in the body, they are often called adhesions (but they are the same thing by a fancier name). Connective tissue mobilisation is a brilliantly effective technique for tight scars and adhesions, which are sometimes playing a part in vulvodynia (especially when there has been surgery, such as an episiotomy or Caesarean scar, or endometriosis).

What does connective tissue mobilisation (CTM) feel like?

CTM feels like a skin-rolling type of massage. It can be very relaxing and soothing. It can also be quite uncomfortable, especially when there is dysfunction. In fact, if CTM doesn’t feel that comfortable, it’s probably a good sign you’ll benefit from it! Sometimes one side of your body will feel fine and the other uncomfortable – guess which one needs the treatment?

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However, slow and gentle is the key. Too much CTM too soon can stir you up – irritate local nerves, irritate the skin, even cause bruising. But the right kind and amount of CTM is wonderful for freeing up tight tissues and helping them move the way they should, improving circulation and skin condition and helping to desensitise your nervous system. The health professional treating your connective tissue should therefore be very familiar with your condition – and especially with central sensitisation – and plenty of experience in treating it.

Getting treatment for vulvodynia?

Make sure you ask whether your connective tissue has been checked, and if it would benefit from treatment. Treating your muscles, nervous system and connective tissue together and restoring their normal movement and function will get you the best results.

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About Alyssa Tait

Alyssa runs Equilibria Physiotherapy & Nutrition, a clinic focusing on integrative solutions for pelvic health issues including all types of pelvic pain, bladder and bowel control issues, fertility, and irritable bowel syndrome.

Alyssa’s website www.equilibriahealth.com.au is an information hub related to all things relating to the function of the female pelvis.

She aims to help as many people as possible restore balance to their pelvis through education, effective treatment and empowering lifestyle choices.

Alyssa enjoys playing the clarinet and rollerblading, though (much to the gratitude of her patients), not while she is consulting.

Connect with Alyssa  |  Facebook  |  Google Plus | linkedin | Twitter

How To Make Your Own Probiotics at Home

Posted: Thursday, August 7, 2014 at 12:46:03 PM EST by Alyssa Tait

Probiotics…research is overflowing on their importance for good gut health and proper immune system function, to name two.

All probiotics are not alike, however, and strain specificity is important. This means that to treat a specific condition, use of the specific strain of flora supported by good research is the only way to go.

However, there are also major potential benefits from simply increasing the number and variety of probiotic organisms in your diet – and this is where fermentation comes in.

This couldn’t be easier than making your own sauerkraut at home.

(Trust me – I burn pans when I'm boiling water, so if I can do it successfully, then anyone can!)

Haven’t eaten sauerkraut, or feeling a bit dubious? Think of it just like a tangy pickle that can add some tasty zing to just about any savoury food (and immediately multiply – exponentially – its health benefits). Purple cabbage makes a gorgeous sauerkraut and is ridiculously high in vitamin C and antioxidants.

And even if you are on a low FODMAPs diet (for example, for irritable bowel syndrome), you may find that sauerkraut works for you where non-fermented cabbage doesn’t.

This is because the FODMAPs are dramatically reduced in the fermentation process.

Best of all, it’s cheap, and all you need is a cabbage, a jar, and some salt.

Simple Steps To Making Sauerkraut

  1. Slice whole cabbage into strips and put in a large bowl.
  2. Add 1 tsp salt. (I love to add a tablespoon of caraway seeds as well).
  3. Massage the salt into the cabbage for 10 minutes. Squeeze the cabbage hard!
  4. (Set the kitchen timer and consider this your upper body workout for the day)
  5. By the end of ten minutes, there should be fluid coming out of the cabbage.
  6. Pack the cabbage into a jar, squishing it down firmly with (for example) a pestle or end of a rolling pin.
  7. MOST IMPORTANT STEP: All the cabbage leaves must be UNDER the fluid. If any are above the fluid level, you will have a mouldy mess! Best method is to leave a glass or heavy ceramic tea strainer in the jar to weight the cabbage down – it keeps the cabbage leaves firmly pressed under the top of the fluid.
  8. Put the jar on a shelf out of the way, covered with a tea towel to keep out any bugs.
  9. After 24 hours, if there is not enough fluid covering the cabbage, add just enough brine to cover, in the ratio of 1 tsp salt to 1 cup water.
  10. Leave to ferment for 7 days then put a lid on it and refrigerate.

Give it a try – you’ll be hooked!

 

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About Alyssa Tait

Alyssa runs Equilibria Physiotherapy & Nutrition, a clinic focusing on integrative solutions for pelvic health issues including all types of pelvic pain, bladder and bowel control issues, fertility, and irritable bowel syndrome.

Alyssa’s website www.equilibriahealth.com.au is an information hub related to all things relating to the function of the female pelvis.

She aims to help as many people as possible restore balance to their pelvis through education, effective treatment and empowering lifestyle choices.

Alyssa enjoys playing the clarinet and rollerblading, though (much to the gratitude of her patients), not while she is consulting.

Connect with Alyssa  |  Facebook  |  Google Plus | linkedin | Twitter

I'm in pain...do I need a physiotherapist, or an integrative nutritionist?

Posted: Tuesday, November 11, 2014 at 12:49:11 PM EST by Alyssa Tait

(Or: An Open Letter to My Dear Patients)

The majority of people I see are referred to me by a health professional (usually a GP, specialist, physio or osteopath) for my expertise as a physiotherapist.

This is the field in which my training started.

It is also the field in which I specialised (in pelvic floor dysfunction) and then sub-specialised (in pelvic floor pain syndromes).

The expectation of patients, therefore, is often that I will be treating them using physical or manual means.

Most of you know I am dually trained in physiotherapy and integrative nutrition, but this can be hard to get your head around, especially when you are expecting a certain type of treatment when you come.

The longer I am in practice, though, the better I get at pinpointing which approach is going to work best for you. This is usually obvious to me within the first session.

The surprising thing is, sometimes this may not match your expectations. Your condition (or symptoms) may seem to fit entirely within the realm of the physical – the biomechanical – the anatomical – the structural – or whatever you would like to call it.

But particularly with conditions involving pain, the lines start to get blurry.

For example, despite its obvious nutritional nature  -

I can treat irritable bowel syndrome from a physical or manual therapy standpoint, using techniques like visceral manipulation and connective tissue mobilisation.

And conversely, despite the obvious role of physiotherapy  -

I can treat vulvodynia from a nutritional or biochemical standpoint.

Most commonly, I like to take a joint approach (as well as recommending any other types of input you may benefit from).

I will always take into account your preferences. Occasionally I see a strong need for nutritional intervention, but the patient lets me know they do not want to go this direction…sometimes just with the non-verbals!

I was recently interviewed for the magazine of the Australian Physiotherapy Association about this combination approach I take. I was quoted as saying:

The vast majority of patients are really excited when they know there is another angle that their health can be looked at from. If we broaden the vision a little bit, then it gives us more scope for treatment.

My hope for you as my patient is that you will keep an open mind. I have seen many people be surprised by the success of an approach they didn’t initially expect when they walk through the door.  I hope you will let my dual training work as an advantage for you.

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About Alyssa Tait

Alyssa runs Equilibria Physiotherapy & Nutrition, a clinic focusing on integrative solutions for pelvic health issues including all types of pelvic pain, bladder and bowel control issues, fertility, and irritable bowel syndrome.

Alyssa’s website www.equilibriahealth.com.au is an information hub related to all things relating to the function of the female pelvis.

She aims to help as many people as possible restore balance to their pelvis through education, effective treatment and empowering lifestyle choices.

Alyssa enjoys playing the clarinet and rollerblading, though (much to the gratitude of her patients), not while she is consulting.

Connect with Alyssa  |  Facebook  |  Google Plus | linkedin | Twitter

Do Probiotics Work?

Posted: Tuesday, December 2, 2014 at 10:22:50 AM EST by Alyssa Tait

A (Greatly Truncated) Response to the Question of Whether Probiotics are Overrated

Probiotics: myth or miracle?

It’s the kind of grab-your-attention, oversimplified, dichotomized headline we are used to in the media. But, I was grateful to be asked for my opinion on an article of this name:

http://www.theguardian.com/lifeandstyle/2014/nov/30/probiotics-myth-or-miracle-prebiotics

So here is the quick 10-minute version of my opinion on this, straight from my Facebook response.

This article is better than I expected from the headline - at least they correctly cited some conditions there is evidence for treating with probiotics, such as IBD and traveller's diarrhoea. Until the concluding line! Just focus on consuming good quality yoghurts, my foot! Do they exist?! Aside from the ones you make yourself, that is. There are two problems with this statement.

Problem number one: numbers in yoghurt are too low.

For therapeutic effect - that is, not just to "stay healthy" (never mind that most people trying to "stay healthy" have symptoms or conditions they could be treating nutritionally) but to treat a condition, you simply need higher numbers than are in yoghurt - especially standard store-bought yoghurt. Problem number two: strain specificity. While a healthy gut has hundreds of different species and strains (and by extension we can assume we need to be consuming these, unless of course we have a perfect gut microbiome handed down from a mother with a perfect microbiome, have never had antibiotics etc) to actually treat a health condition (such as ulcerative colitis) the specific strains used in the research are necessary. Assuming that taking Inner Health is going to correct all our microbiomial shortcomings is analagous to taking a multivitamin and expecting it to correct the health problems arising from the epigenetic problems from the MTHFR polymorphism (i.e. doesn't work).

probiotics

This article has picked and chosen a couple of conditions there is evidence for. Actually, there is evidence for probiotic treatment of urinary tract infections, thrush, bacterial vaginosis, (for more information on these, subscribe to our newsletter and tick "vaginal health, thrush and BV") allergic rhinitis, eczema, diarrhoea from chemotherapy, cow's milk protein allergy, irritable bowel syndrome, lactose intolerance, diarrhoea from radiation, viral gastroenteritis. The bottom line is strain specificity.

Asking "do probiotics work?" is like asking "does physiotherapy work, or is it overrated?" Work? For what? What kind of physiotherapy approach/technique? We don't give staged basal expansions (i.e. breathing exercise) for patellar maltracking (i.e. a biomechanical problem at the knee). Choose the intervention according to clinical reasoning, basic science, clinical experience and, ideally and where available, the evidence base. We need to remember that a lack of available evidence to show effect is not the same as availability of evidence showing no effect.

And make no mistake: with the very real problem of antibiotic resistance, the price we pay for being too skeptical about probiotic therapy is prohibitively high.

Sure, there's a lot more research to be done. But there is research available, and not making ourselves aware of it (and thus failing to educate our patients) is a mistake. I am so glad to see physios interested in the concept of the microbiome and probiotic therapy. What I find discouraging is the idea that people will read an article like this on probiotics and fail to change their habits (overusing antibiotics, failing to incorporate fermented foods into the diet, not considering probiotics and adjuncts to therapy for their particular health condition) due to a misinterpretation that the probiotic thing is overrated and a fad.

And by the way, as the article points out, prebiotic foods ARE incredibly important...but they can only feed what is there. If you lack bifidobacteria - as I see frequently on stool analyses of my patients - then eating artichokes and onions is not going to make them magically materialise. Take home message: don't just lucky dip and hope for the best. See a functional medicine practitioner! Or at least read their blogs :)

Perhaps start with this one on the role of the microflora in a healthy and balanced vagina.

http://www.equilibriahealth.com.au/Blog/equilibria-blog/Post/the-healthy-and-balanced-vagina

And please…tell me about your experience with probiotics by commenting below!

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About Alyssa Tait

Alyssa runs Equilibria Physiotherapy & Nutrition, a clinic focusing on integrative solutions for pelvic health issues including all types of pelvic pain, bladder and bowel control issues, fertility, and irritable bowel syndrome.

Alyssa’s website www.equilibriahealth.com.au is an information hub related to all things relating to the function of the female pelvis.

She aims to help as many people as possible restore balance to their pelvis through education, effective treatment and empowering lifestyle choices.

Alyssa enjoys playing the clarinet and rollerblading, though (much to the gratitude of her patients), not while she is consulting.

Connect with Alyssa  |  Facebook  |  Google Plus | linkedin | Twitter

Getting Off The Pill Step 4

Posted: Thursday, January 8, 2015 at 5:47:58 PM EST by Alyssa Tait

Prepare by taking your nutrition and your health in hand

Are you scared to take the plunge and get off the Pill?

There is no need to be! In this post I'll talk about covering your bases to make the transition as smooth as possible.

Hopefully be now you have followed the first three steps in getting off the Pill.

Step 1 – understanding how the Pill works (and its relatives the Mirena, Depo Provera and Implanon)

Step 2 – being aware of the side effects of the Pill (and its relatives)

Step 3 – considering the different alternatives available

And now it’s time for the fourth step – setting some good habits in place to minimise the chance of side effects of coming off the Pill.

So what kind of side effects of coming off the Pill are we talking about?

There are two types of side effects when coming off the Pill.

Problems that were already there before, which are masked by the Pill

First of all, anything that was there before you went on the Pill in the first place: acne, irregular periods, painful periods. My recommendation here is to see a good naturopath, integrative nutritionist or functional medicine practitioner. They can help solve the puzzle of why you had these issues in the first place, and help bring your system back into balance.

For example, polycystic ovarian syndrome (PCOS) is the most common hormone disorder in younger women. The main symptom is irregular or infrequent periods. If this is why you went on the Pill fifteen years ago as a teenager, then there is a good chance you have this, and it should be investigated. PCOS will also make acne more likely and more severe. When I see women who have known PCOS and are deciding to come off the Pill, we put into place an action plan for their hormones before they even stop it, which includes stress management, exercise, dietary changes and nutrient supplementation. Once they come off the Pill, I add herbs to help regulate their hormones.

And then there is the problem of painful periods (dysmenorrhea). The great news is that herbal medicine can be very helpful for period pain. So can a gentle form of abdominal massage called visceral mobilisation. Additionally, nutrients are important. Supplementing with omega 3 fatty acids and zinc are just two things I use to improve period pain. I often use a combination of these techniques with women coming off the Pill to lower the chance of their returning periods being painful.

New problems, caused, promoted or triggered by the Pill

The main one we’ll talk about here is  the fertility issue. Let’s say you’re coming off the Pill because you want to fall pregnant. It is important you don’t try to fall pregnant immediately when coming off the Pill. There are a few reasons for this.

Nutrient depletion

The Pill depletes a number of nutrients from the body including zinc, magnesium, vitamin C and vitamin B6 (and more). Even more critically, it depletes folate, and it’s essential that you have good folate levels for at least 3 months before you fall pregnant, as folate is essential in the cell division processes that will ultimately lead to a healthy baby.

Hormonal imbalance

It often takes several months for the hormones to balance out after the Pill. While a 2014 study showed that a quarter to a half of women ovulated within three weeks after stopping the Pill, the rest of them didn’t!

But fertility is more than a return of bleeding, hormone balance and even ovulation. You can have all three of these back but still not be fertile if your cervix is not producing the right kind of mucus to help the sperm survive. A 2011 study compared women who had just stopped the Pill with women who had not been on it for a year. It showed that quality of mucus produced by the cervix was indeed compromised in women who had come off the Pill. Getting to recognise and interpret your mucus patterns is probably the most important aspect of understanding your fertility.

If you have chosen the Billings Ovulation Method as your new method of contraceptive, you’re in luck, as this system acquaints you with your mucus signs. If you have decided to forego contraception as you’re planning to fall pregnant, I would strongly recommend you learn the Billings Method and use it to track your returning fertility before trying to fall pregnant.

It’s important when coming off the Pill that you get some good habits in place. These include good stress management, a healthy, high-vegetable, unprocessed diet, and regular exercise. This will go a long way towards making it an easy transition.

What actions are you taking to prepare your body for coming off the Pill?

 

 

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About Alyssa Tait

Alyssa runs Equilibria Physiotherapy & Nutrition, a clinic focusing on integrative solutions for pelvic health issues including all types of pelvic pain, bladder and bowel control issues, fertility, and irritable bowel syndrome.

Alyssa’s website www.equilibriahealth.com.au is an information hub related to all things relating to the function of the female pelvis.

She aims to help as many people as possible restore balance to their pelvis through education, effective treatment and empowering lifestyle choices.

Alyssa enjoys playing the clarinet and rollerblading, though (much to the gratitude of her patients), not while she is consulting.

Connect with Alyssa  |  Facebook  |  Google Plus | linkedin | Twitter

Annoying Abdominal Adhesions: Start Here

Posted: Monday, July 25, 2016 at 1:34:11 PM EST by Alyssa Tait

Abdominal Adhesions: when pain after surgery persists and a technique to resolve it

You’ve had abdominal surgery.

Now you’ve got persistent abdominal pain.

Not the result you were after.

Well, don’t look back now – most likely, you had to have the surgery – it was the best or only choice available to you. And you can’t go back, only forward!

So how to move forward with this abdominal pain after surgery when you’ve had all the medical checks, and they tell you it’s “just” adhesions?

Well, first things first.

What are adhesions? “Adhesions” is really just a fancy name for scar tissue, but doctors often use it to refer to scar tissue they assume is more extensive or more restrictive as a way of explaining your pain. Occasionally, they’ll use the word “adhesions” because they actually found them when doing your surgery, as in

Boy, everything was a mess in there!” or

Gosh, everything was stuck to everything else!

(These comments don’t do anything for your confidence, and may actually play a role in worsening the pain you experience via some complicated brain mechanisms. For more about that, see my post on chronic pain in the pelvis and the brain. But back to the story.)

Adhesions form in an estimated 50-100% of cases of surgery (I know, a pretty broad statistic.) They start forming within hours of the surgery. When they become a problem (i.e. are assumed to be responsible for ongoing abdominal pain after surgery) – the suggested treatment is: surgery. (Yes, strange but true.)

But there is another technique that works.

(And whether or not you need to have surgery for adhesions or not, it is always a good idea to have this technique done after to maximise recovery).

Visceral manipulation is the technique.

It’s a mouthful to say but very easy to have done, providing you can find an appropriately-trained therapist.

Visceral manipulation is something I do a lot of in clinical practice in Brisbane, Australia. More to come on this wonderful technique, but in the meantime, make an appointment with us or track down a therapist trained in visceral manipulation closer to you.

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An Interview with Alyssa Tait - Adhesions, Chronic Pain, and the Nervous System

Posted: Tuesday, September 13, 2016 at 1:14:04 PM EST by Alyssa Tait

It's not often someone gives me the floor for 45 minutes to talk about the web of connections linking adhesions, pain, visceral manipulation, the gut and the nervous system...

Stephen Anderson's questions were so thought-provoking, I just kept talking!

Here's the interview: Alyssa Tait on Pelvic Pain, Adhesions, and SIBO

This interview will either be a great cure for insomnia, or a useful insight into how my brain sees this broad and fascinating field.

We traversed the physical, the emotional and even the metaphysical!

Listen here.

We covered all sorts of topics...

...the curious pathway of my career and how it led me to visceral manipulation

...the emotions and your organs

...chronic abdominal and pelvic pain and visceral manipulation

...adhesions, and how they are more than just structural, but neurological as well

...endometriosis and how these adhesions differ from surgical adhesions

...central sensitisation in chronic pain and its links to visceral hypersensitivity in irritable bowel syndrome

....the power of the words "let's see" in therapy

Have a listen now!

Stephen's highlights and insights include...

....the power of the nervous system to increase neurological tone as a means of self-protection, and how this might impact the function of the organs

...the importance of engaging in fun, nurturing and nervous-system relaxing activities to take care of ourselves

....the need as practitioners to be careful with our language with our patients and not be "part of the problem".

Please listen, and give your rating or review on itunes!

 

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About Alyssa Tait

Alyssa runs Equilibria Physiotherapy & Nutrition, a clinic focusing on integrative solutions for pelvic health issues including all types of pelvic pain, bladder and bowel control issues, fertility, and irritable bowel syndrome.

Alyssa’s website www.equilibriahealth.com.au is an information hub related to all things relating to the function of the female pelvis.

She aims to help as many people as possible restore balance to their pelvis through education, effective treatment and empowering lifestyle choices.

Alyssa enjoys playing the clarinet and rollerblading, though (much to the gratitude of her patients), not while she is consulting.

Connect with Alyssa  |  Facebook  |  Google Plus | linkedin | Twitter
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