PELVIC FLOOR PHYSICAL THERAPY. Colleen Sandro, MS, PT, COMT, BCIA-PMD
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1 PELVIC FLOOR PHYSICAL THERAPY Colleen Sandro, MS, PT, COMT, BCIA-PMD
2 Objectives Understand Physical Therapy evaluation and treatment for pelvic floor dysfunction Become familiar with Physical Therapy outcomes for pelvic floor patients
3 Pelvic Floor Physical Therapy Incontinence Urge and stress incontinence Urinary and fecal incontinence Pelvic Organ Prolapse Pelvic Pain Voiding Dysfunction Constipation Hesitancy, incomplete voiding
4 Pregnancy and Post Partum PT Pregnancy related musculoskeletal problems Back pain Pubic pain Sciatic/Radicular pain Post partum musculoskeletal problems Diastasis recti Incontinence
5 Normal Pelvic Floor Function Support for pelvic organs Sphincter closure for continence Sexual function Spine and pelvis stabilization Resting tone for urination Descent for stool evacuation
6 Categories Pelvic Floor Dysfunction Low Tone or Weak Uncoordinated High Tone or Pain
7 Pelvic Floor Weakness Incontinence Symptoms/Diagnoses Pelvic Organ Prolapse Back Pain
8 Physical Therapy For the Low Tone or Weak Patient Increase muscle recruitment and strength for support Improve sphincter closure pressure for continence Improve reflex inhibition of bladder to control urgency Core strength for support and stability
9 Uncoordinated Pelvic Floor Constipation Symptoms/Diagnoses Hesitancy/Incomplete Voiding Pelvic Floor Dyssynergia
10 Pelvic Floor Pain/High Tone Diagnoses Pelvic Pain Back Pain Coccydynia Dyspareunia Pudendal neuralgia Non-relaxing pelvic floor Levator ani syndrome Tension myalgia of pelvic floor Endometriosis Prostatitis Interstitial Cystitis Irritable Bowel Syndrome
11 Pelvic Floor Pain/High Tone Symptoms/Diagnoses Vulvar Pain Syndromes Vulvodynia (burning, itching, redness) Vestibulitis (pain to touch - vestibule) Vaginismus (muscle spasm/hypertonus) Vulvar Vestibulitis Syndrome/Vestibulodynia Rosenbaum, J Sex Med 207; 4:4-13, Pelvic Floor Involvement in Male and Female Sexual Dysfunction and the Role of Pelvic Floor Rehabilitation and Treatment: A Literature Review
12 Body Systems Involved With Pelvic Pain Urologic Gynecologic Urogynecologic Gastrointestinal Neurologic Psychological Vascular Lymphatic Endocrine Musculoskeletal (Prendergast, S, Weiss, J, 2003)
13 Incidence of Pelvic Floor Involvement in Chronic Pelvic Pain 90% of women with vestibulodynia demonstrated pelvic floor pathology (Reissing, 2005) 50% of patients with chronic pelvic pain have pelvic floor muscle spasms or dysfunction (Jensen 2011) 34% of 200 women had diagnosis of tenderness of pelvic floor muscles as a primary cause of chronic pelvic pain (Montenegro, 2010) 22% of patients with chronic pelvic pain had tenderness of levator ani (pelvic floor muscle), (Tu, et al, 2006)
14 Physical Therapy For the High Tone or Pain Patient Improve muscle resting tone Improve tissue mobility Restore joint and muscle balance
15 Pelvic Floor Physical Therapy Evaluation
16 Physical Therapy Evaluation History/Intake Pelvic Floor Exam (external/internal) Screening Exam Thoracic-lumbar-sacral/lower extremities Patient Education Pelvic floor exam Pelvis and pelvic floor anatomy
17 Physical Therapy Evaluation Muscle Ligament Joint Nerve Connective tissue Fascia Scar Tissue
18 Physical Therapy Evaluation Posture/Movement Patterns/Walking Mobility (joint glide) spine/pelvis/hips Soft tissue assessment (tenderness/tone) Lower extremity flexibility Hip assessment Abdominal assessment External pelvic floor muscle exam Internal pelvic floor muscle exam Biofeedback/Electromyography (EMG)
19 External Pelvic Muscle Exam Pelvic Clock
20 Internal Pelvic Floor Muscle Exam Symmetry Endurance Contraction Repeated Quick Contractions Ability to Isolate Ability to Relax Muscle Thickness Tenderness Tone Lift Closure
21 Pelvic Floor Muscle Exam 0= No contraction 1= Flicker 2= Weak Contraction/Closure; No Lift 3= Moderate Squeeze/Closure with Lift 4= Good Squeeze with Lift and Endurance 5= Strong Squeeze with Lift and Deflection of Examiner s Finger Laycock--modified Oxford Grading System
22 Is more lift better? Is lifting through a larger distance a measure of greater pelvic floor force, or might it indicate a stretched or ruptured fascia within which the pelvic floor can lift a greater distance? Bo, Sherburn, Phys Ther 2005
23 Pelvic Floor Recruitment >30% of women are unable to effectively recruit their pelvic floor muscles at the initial evaluation Common substitution patterns include contraction of: gluteal, hip adductors, abdominals, breath holding (Bo, K. and Sherburn, M, 2005) 49% not able to contract pelvic floor in a way that increased urethral closure pressure (Bump et al, Am J Obs Gynecol, 1991)
24 Transversus Abdominis and Pelvic Floor Muscle A strong PFM contraction resulted in strong and simultaneous recruitment of transversus abdominis and internal oblique... (Neuman, P and Gill, V.) Pelvic floor muscle alone demonstrated significantly higher elevation displacement than transversus abdominis or pelvic floor plus transversus abdominis (transabdominal ultrasound measurement)
25 Physical Therapy Treatment
26 What To Expect Physical Therapy Treatment 6-12 sessions 1-2x/week 45 minutes duration Private setting Insurance coverage
27 Physical Therapy Treatment Incontinence Pelvic Floor Muscle Recruitment and Strengthening Biofeedback Training Electrical Stimulation Weighted vaginal cones
28 Biofeedback Electromyography (semg)
29 Pelvic Floor Biofeedback Endurance Holds
30 Pelvic Floor Biofeedback Quick Contractions
31 Electric Stimulation Muscle Recruitment (50 Hz) Bladder Inhibition (12 Hz)
32 Vaginal Weight Training
33 Pelvic Floor Muscle Training & SUI Hypothesis of Mechanisms Aim & Rationale PFM strength training Build structural support of pelvis Elevate levator plate to permanently higher position Enhance hypertrophy and stiffness of pelvic floor muscle and connective tissue Facilitate more effective automatic motor unit firing (neural adaptation) Prevent descent during increases of abdominal pressure Bo, Kari, Int Urogyn J, 2004
34 Skeletal Muscle Exercise Prescription Effective muscle strength training in skeletal muscles, exercise scientists recommend: Three sets of 8-12 Slow velocity Close to maximum contractions 2-4 days/week (several studies concluded higher dosage PFM training effective for Incontinence) May take 5 months to achieve results American College of Sports Medicine Position Stand 1998
35 Pelvic Floor Muscle Exercise Prescription Daily Endurance Contractions 3 sets of 10 close to maximum contractions hold 6-8 seconds Quick contractions 3-6 months to maximize pelvic floor strength (Bo, Mokved, Fjortoft, Obstetrics & Gynecology, 2002)
36 Pelvic Floor Muscle Training Exercise Prescription Individualize Proper Technique Endurance contractions Support stiffness Quick contractions Coordination Pre contractions Urge Control
37 Pelvic Floor Pre-Contraction Contract before cough Reduced urine leakage 98.2% with medium cough 73.3% with deep cough Miller et al, 1996, J Am Geriatr Soc 46: , 1998
38 Pelvic Floor Pre-Contraction Vesical neck mobility 5.4 mm without voluntary contraction 2.9 mm with voluntary contraction Conclusion: pelvic floor voluntary contraction stabilizes the bladder neck during increases of abdominal pressure Bo, Kari, Int Urogy J 2004
39 Behavioral Training Voiding Diary Voiding interval Amount Voided Fluid Intake/Food Cause of Leakage Amount of Leakage Padding Urgency Stool type/frequency
40
41 Behavioral Training Urinary Urge Control Patient Education Waves of Urges Pelvic Floor Muscle Contractions Distraction Techniques
42 Behavioral Training Foods that can contribute to urinary urgency/frequency/leakage Caffeinated beverages Alcoholic beverages Artificial sweeteners Highly spiced foods Tomato based products Citrus and fruit juice
43 Behavioral Retraining Foods that can cause bowel irritability Milk or milk products Fried or greasy foods Tomato based foods Artificial sweeteners Caffeinated beverages Chocolate Citrus fruit/juice Eggs Salads alcohol
44 Behavioral Training Fecal Incontinence and Urgency Holding On Technique On toilet In bathroom Gradually increase time and distance from toilet
45 Outcomes Pelvic Floor Muscle Training & Urinary Incontinence Effective treatment for Stress and Mixed Urinary Incontinence Recognized as first line of treatment Cure and improvement rates 56%-70% Cure (<=2 g leakage on pad tests) 44-49% Cochrane Review, 2010
46 Outcomes Fecal Incontinence Pelvic Floor Muscle Training A systematic review found sufficient evidence for the efficacy of biofeedback and/or electric stimulation combined in treating fecal incontinence Vonthein, et al, Int J Colorectal Dis, Joanna Briggs Institute Best Practice Recommendations
47 Do I have to do this forever? Outcomes Long Term Pelvic Floor Muscle Training & SUI Exercise science has shown less effort needed to maintain than to build muscle strength Intensity of contraction important 2x/week sufficient to maintain strength
48 Outcomes Long term Pelvic Floor Muscle Training & SUI Maintenance PFM exercise program (1 or 4 times/week) 6 month follow up Urodynamic Stress Urinary Incontinence 60.7% prior to intervention 42.8% after intervention 35% at 6 month follow up (not statistically significant) Post intervention status was sustained for all outcomes in both groups Borello-France, et al, Phys Ther, 2008
49 Physical Therapy Treatment Pelvic Organ Prolapse Pelvic floor strengthening with biofeedback Positioning Inverted lying Body mechanics Lifting Bed mobility Avoidance of breath holding
50 Outcomes Prolapse Pelvic Floor Muscle Training 330 experimental group; 324 control group Rate of worsening of genital prolapse 72.2 % in control group 27.3% experimental group Pelvic floor muscle exercise effective to prevent worsening in women with severe genital prolapse Not significantly different with mild prolapse Piya-Ant, et al, J Med Assoc Thai, 2003
51 Outcomes Prolapse Pelvic Floor Muscle Training (PFMT) PFMT Stages l and ll pelvic organ prolapse 47 women Randomized controlled trial Blinded pelvic organ prolapse quantification Questionnaire Symptom severity Quality of life Improved prolapse stage 45% vs 0% Subjective improvement 63% vs 24% Data support trial of PFMT for prolapse Hagen et al, Intl Urogyn J, 2009
52 Physical Therapy Treatment for Pelvic Pain (Needle Tower by Kenneth Snelson, 1968)
53 Pelvic Pain Treatment Manual Techniques Soft tissue techniques Joint mobilization Therapeutic Exercise Abdominal bracing/gluteal strengthening Lower extremity flexibility Neural Mobilization Pelvic Floor Biofeedback Relaxation Training Therapeutic ultrasound (deep heat) Education
54 Structure vs Function Functional Therapy To maximize the body s flexibility, endurance, strength Structural Therapy To remove barriers to movement and improve the patient s potential to function
55 Functional Therapy Strength Stretching/ROM Mobility Exercises Postural Training ADL Balance Training Endurance Training Cardiovascular
56 Structural Therapy Joint Mobilization Connective Tissue Mobilization Strain-Counter strain Muscle Energy Technique Lymphatic Drainage Neural Mobilization Craniosacral Therapy Myofascial Release Visceral Mobilization
57 The nature of the barrier determines which manual technique should be used. (D Ambrogio/Horton) Barrier-Technique Articular=muscle energy, joint mobilization Muscular=SCS, ischemic compression Fascial superficial=conn tissue mob/mfr Fascial deep=visceral mob/fascial release Fascial deepest=craniosacral therapy Lymphatic=lymphatic drainage Neural=neural mobilization
58 Muscular Strain Counter strain (Jones Technique) Slacken tissue Trigger Point release Compress tissue Thiele's massage Lengthen tissue
59 Soft Tissue Techniques Urogenital Triangle Sup Transv Perineal Ms Bulbocavernosus Ishiocavernosus Anal Triangle EAS Urogenital Diaphragm Sphincter urethra Pelvic Diaphragm Levator ani (pubococcygeus/puborectalis/iliococcyg) Ishiococcygeus Obturator Internus
60 Soft Tissue Techniques Superficial Layer (
61 Soft Tissue Techniques Superficial Layer Weiss, Jerome, Pelvic Floor Myofascial Trigger Points: Manual Therapy for Interstitial Cystitis and the Urgency-Frequency Syndrome 2011
62 Soft Tissue Techniques Middle Layer Weiss, Jerome, Pelvic Floor Myofascial Trigger Points: Manual Therapy for Interstitial Cystitis and the Urgency-Frequency Syndrome 2011
63 Soft Tissue Techniques Deep Layer Obturator Internus Weiss, Jerome, Pelvic Floor Myofascial Trigger Points: Manual Therapy for Interstitial Cystitis and the Urgency-Frequency Syndrome, 2011
64 Fascia Superficial layer Connective Tissue Mobilization/Skin Rolling
65 Fascia Deep layer Visceral mobilization/fascia release (Ramona Horton, PT)
66 Premise of Visceral Mobilization Organs are required to expand, displace, glide and rotate with the normal requirements of digestion, elimination and somatic activities Any restriction, fixation or adhesion to another structure implies structural impairment of that organ and tissues
67 Neural Dynamics of Fascial Plasticity CNS-Activation of fascial mechanoreceptors cause a change in muscle tone mainly through resetting of the gamma motor system, not as much on the alpha ANS-Activation of fascial mechanoreceptors lowers sympathetic activity resulting in plasma extravasation, activation of the anterior lobe of the hypothalamus and altering the tone of the intrafascial smooth muscle cells
68 Fascia With visceral mobilization/fascial release, a change is not brought about through the force applied, but through the stimulation of mechanoreceptors contained within the fascia
69 Fascial Release sigmoid colon for treatment of mechanical constipation (Ramona Horton, PT)
70 Fascial release Urogenital Triangle (Ramona Horton, PT)
71 Fascial Release Obturator Foramen (Ramona Horton, PT)
72 Related Muscles Diaphragm Psoas - Iliacus Abdominal Adductor Hamstring Quadratus Lumborum Lumbar Paraspinal Multifidus Gluteal Internal and External Trigger Points and typical referral patterns A Headache in the Pelvis David Wise, Ph. D Rodney Anderson, MD maherrehabilitationinstitute.com/wst_page17.html
73 Flexibility Exercises.
74 Flexibility Exercises
75 Pelvis ROM- Coordination
76 Nerve Flossing Sciatic Nerve Pudendal Nerve
77 Diaphragm Breathing
78 Outcomes - Manual Therapy 52 Subjects (45 women/ 7 men) 10 Interstitial Cystitis 42 urgency-frequency syndrome Conducted over 5 years ( ) Results 83% (35/42) mod to complete resolution (Urg-Freq) 70% (7/10) mod to marked improvement (IC) Conclusion Pelvic floor manual therapy effective reducing pelvic floor hyper tonus reducing symptoms urgency-frequency-ic (Weiss, J, 2001)
79 Outcomes Myofascial Physical Therapy (FitzGerald, et al 2009) 48 subjects (23 men/24 women) Patients: chronic prostatitis/chronic pelvic pain syndrome or interstitial cystitis/painful bladder syndrome 2 groups Myofascial Physical Therapy or Global Therapeutic Massage 10 treatments (1x/week)
80 Outcomes Myofascial Physical Therapy (FitzGerald, et al 2009) 57% Myofascial Physical Therapy Statistically significant 21% Global Therapeutic Massage Findings indicate a beneficial effect from myofascial Physical Therapy
81 Outcomes Pelvic Floor Massage (M.L.L.S., Montenegro, 2010) 6 women with chronic pelvic pain Treatment Pelvic floor massage technique, 5 minutes 1x/week, 4 visits Results 1 st visit 1month f/u Tenderness Score Visual Analog Scale McGill Pain Scale
82 Modalities Ultrasound (external) Electric Stimulation Hz Pain Internal or external sensors theprogp.com
83 Pelvic Floor Biofeedback common findings in patients with pain Elevated baseline/resting tone Poor awareness of contraction Slow return to baseline after contraction Low peak of contraction Decreased endurance
84 Pelvic Floor Biofeedback (semg) patients with high tone muscles have poor ability to relax and contract Bernstein,AM, 1992
85 Pelvic Floor Biofeedback treatment for patients with pelvic pain Down-training to decrease electrical output of hypertonic pelvic floor muscle Relaxation Training with Biofeedback Visualization Diaphragm breathing Relaxation techniques
86 Biofeedback with Vaginal Dilator Training Syracusemedicalintropkg.jpg
87 Outcomes Biofeedback Glazer et al, Treatment of Vulvar Vestibulitis Syndrome with Electromyographic Biofeedback of Pelvic Floor Musculature. J Reprod Med April 40 (4) , subjects 16 weeks home biofeedback pelvic floor Instruction and re-evaluations with physical therapist for correct technique
88 Outcomes - Biofeedback 83% Self reported improvement 78% patients resumed intercourse (22/28) 50% cure rate 68% reduction in resting tone 95.4% improvement in muscle contraction Results maintained at 6 months
89 Dysfunction related to Constipation Non-relaxing PFM/Rectal hypersensitivity Mega Colon/Rectal hyposensitivity Slow transit constipation Paradoxical pelvic floor contraction Behavioral patterns/bowel habits Prolapse/laxity
90 Physical Therapy Treatment Constipation Healthy bowel habits Toilet positioning Dietary factors Manual techniques Biofeedback Sensation training Diaphragm breathing
91 Healthy Bowel Habits Bowel Diary Eat breakfast Eat regularly timed and portioned meals Drink warm fluid in the morning Fiber recommendation and examples Fluid recommendation Exercise/Activity
92 Toilet Position and Mechanics Feet supported Stool under feet Legs apart Exhale Expand abdomen
93 Manual Techniques Slow Transit Constipation External Colon Massage (Abdominal massage) Soft tissue techniques Anterior abdomen Fascia, muscle Pelvic floor
94 Rectal Sensation Training Decrease sensitivity protocol Increase sensitivity protocol mega colon
95 Pregnancy Related Musculoskeletal Diagnoses Lumbo-sacral pain Radicular pain SIJ dysfunction Pubic symphysis dysfunction Upper back pain Prevalence pregnancy related LBP or Pelvic Girdle Pain 24-90%
96 Pregnancy PT Treatment Education Body mechanics Manual techniques Soft tissue techniques Therapeutic exercise
97 Pregnancy PT Outcomes Systematic Review of Physical Therapists Treatment of Lumbopelvic Pain During Pregnancy. 22 articles RCT, Treatment Exercise therapy Education Manual therapy
98 Pregnancy PT Outcomes Conclusion Positive effect on pain, disability, sick leave Evidence based recommendations can be made for the use of exercise therapy for the treatment of lumbo-pelvic pain during pregnancy July 2014, Journal of Orthopedic & Sports Physical Therapy
99 Post Partum Physical Therapy Diastasis recti Pubic symphysis dysfunction SIJ dysfunction Pelvic pain/dyspareunia Incontinence
100 Post Partum Diastasis Recti Rehabilitation Per Diane Lee in The Pelvic Girdle: We do not yet have studies indicating the best rehabilitation approach for a diastasis recti abdominis (DRA) If forces transmitted through the diastasis recti abdominis can provide stability in the thoracolumbar spine and pelvis, patient may recover function despite DRA...the goal is not to close the diastasis but rather to generate tension through it.
101 Post Partum Diastasis Recti Rehabilitation Abdominal exercise progression What to do What to avoid Kinesiotape Education in body mechanics to minimize increase of intra-abdominal pressure
102 Rectus Abdominis Training
103 Recommended abdominal exercises
104 OhioHealth Locations Pelvic Floor Physical Therapy Doctors Hospital Dublin Health Center Eastside Health Center Grady Memorial Hospital Powell Rehabilitation Riverside Methodist Hospital Southwest Health Center Upper Arlington Westerville Medical Center
105 Contact Information Colleen Sandro, MS, PT, COMT, BCIA-PMDB OhioHealth Neighborhood Care (614)
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