9/29/2019
High Tone Pelvic Floor Dysfunction
October 2019
Types of PFM dysfunction
Two categories of pelvic floor muscle dysfunction seen in the literature: • Hypertonicity, known as high-tone pelvic floor (HTPFD). Sometimes referred to as levator myalgia.
• Hypotonicity, known as low-tone pelvic floor (LTPFD).
• Hypertonic pelvic floor muscles are shortened, painful, have trigger points or tender points, taut bands, high resting baselines, and may be in spasm.
High tone PF dysfunction - HTPFD
HTPFD is related to the following (not and exhaustive list): • Pelvic pain – including chronic pelvic pain (CPP) • Dyspareunia • Interstitial cystitis (IC) • Vulvodynia/vaginismus • Endometriosis • Scars, adhesions • Lichens schlerosus • Irritable bowel syndrome (IBS) • Prostatitis • Pudendal neuralgia • Coccydynia • Bowel, bladder and intimacy issues • Can result from trauma to hip, sexual abuse
1 9/29/2019
Definition of HTPFD
• High-tone pelvic floor dysfunction is defined as hypertonicity of the levator ani complex and pain upon attempted penetration, squeeze, or palpation of the vaginal and pelvic musculature.
Rogalski MJ et al (2010). Int Urogynecol J 21:895–899
Prevalence
• While the prevalence of HTPFD is unknown, it is largely believed to be under diagnosed.
• Contributing factors include an elusive presentation, anxiety or embarrassment causing hesitation in seeking care, and lack of provider awareness of the condition.
• Has a significant impact on QOL
Crisp et al., Int Urogynecol J. 2013;24(11):1915-23.
Hypertonic Pelvic Floor Dysfunction - Defined
• Resting EMG ≥2.0 microvolts (μv)
sEMG excepted from Hetrick et al., Neurourol Urogyn. 2006;25(1):46-9.
2 9/29/2019
Patient Presentation
• Symptoms may manifest as muscle pain in the groin, low back, or gluteal region, which may radiate to the hip and sacrum.
• The patient may complain of dyspareunia (painful penetration), urinary or bowel dysfunction, and elimination difficulty
• These women/men may present with pelvic pain characterized by an increase in pain with internal examination, which may lead to unprovoked vaginal/pelvic pain due to levator hypercontractility.
Chronic Pelvic Pain
• Chronic pelvic pain is defined as pain that occurs below the umbilicus (belly button) that lasts for at least six months. It may or may not be associated with menstrual periods.
• Chronic pelvic pain may be a symptom caused by one or more different conditions.
Chronic Pelvic Pain (CPP) “A Headache in the Pelvis”
“lower genitourinary symptoms, particularly pain in the perineum or genitalia, voiding symptoms, such as dysuria or frequency, and sexual dysfunction…”
National Institutes of Health Definition Krieger; JAMA 282:236, 1999
3 9/29/2019
Introduction
• Pelvic pain has multifactorial etiology
• Overlapping cerebral representation for somatic and visceral structures
• Multiple stakeholders involved in evaluation and management
Pelvic pain statistics…
• Most common form of chronic pain in women of childbearing age in U.S at per annum cost of $881.5 million on outpatient management
• Women with pelvic pain report lower QOL than other types of chronic pain (e.g. back pain)
• Hysterectomy most common surgery in U.S.; C-section 2nd-most common
• According to the CDC the three most common reportable STIs—chlamydia, gonorrhea and syphilis
• It is estimated that 1 in 20 sexually active young women aged 14-24 years has chlamydia.
• In women, undiagnosed and untreated chlamydia and gonorrhea can lead to pelvic inflammatory disease. (PID) – risk factor for CPP and infertility
Differential diagnosis
• Trigger points/Myofascial pain syndrome • Referred visceral pain • SI joint dysfunction and other osseous elements of the hip, back and pelvis • Nerve entrapment post-surgery • Hip girdle restriction • Lumbar radicular pain
4 9/29/2019
Gynecologic origins
• 24%-86% of cases of pelvic pain • Endometriosis is diagnosis in 52% of these • Intra-abdominal adhesions in 10%-51% • Endometriosis, adhesions and fibroids do not cause pain in all patients • 50% of women have no known historical cause for adhesions • More than 50% of adhesions have nerve fibers in them (Tulandi 1998, Kligman 1993)
Myofascial pain syndromes
• Hypersensitive, painful, taut bands in skeletal muscle
• Characteristic referral pattern of pain on palpation
• Associated autonomic dysfunction?
Harden R et al., Clin J Pain 2000
5 9/29/2019
Active TP
• A focus of hyperirritability in a muscle or its fascia that is symptomatic with respect to pain; it refers a pattern of pain at rest and/or on motion that is specific for the muscle
Associated TP
• Associated TP - A focus of hyperirritability in a muscle or its fascia that develops in response to compensatory overload, shortened range, or referred phenomena caused by trigger point activity in another muscle.
• AKA: Satellite and Secondary TP’s
6 9/29/2019
Latent TP
• A focus of hyperirritability in muscle or its fascia that is clinically quiet/dormant with respect to spontaneous pain; it is painful only when palpated.
Potential Causes of TPs
• Acute/chronic injury or illness • Excessive repetitive movements • Chilling of the muscle • Nervous tension or stress • Tender point of long duration • Active primary point causing secondary TP • Latent TP activated by any of the previous
Initiators of myofascial pain
• Postulated – chronic microtrauma – sleep disorders/ fatigue – macrotrauma – systemic influences (thyroid, nutritional dysfunction) – psychosocial stress
Travell & Simons Myofascial Pain and Dysfunction, 1992
7 9/29/2019
Dyspareunia
• Dyspareunia, a persistent or recurrent vulvovaginal pain associated with sexual intercourse.
• Prevalence in premenopausal women range from 10% to 20%
• As many as 60 percent of women experience dyspareunia when the term is broadly defined as episodes of pain with intercourse.
Interstitial Cystitis
Interstitial cystitis (IC), is a bladder condition that usually consists of multiple symptoms: •Recurring pelvic pain •Pressure or discomfort in the bladder/pelvic region •Urinary frequency •Urinary urgency
IC may also be referred to as painful bladder syndrome (PBS), bladder pain syndrome (BPS), and chronic pelvic pain.
2 subtypes •Ulcerative – Hunner’s ulcers -which are red, bleeding areas on the bladder wall •Non-ulcerative (90%) - presents with pinpoint hemorrhages, also known as glomerulations, in the bladder. www.ichelp.org
Vulvodynia & Associated Symptoms
• Vulvodynia is chronic vulvar pain without an identifiable cause.
• Most women with localized vulvodynia have Provoked Vestibulodynia (PVD), in which pain occurs during or after pressure is applied to the vestibule, e.g., with: – sexual intercourse, – tampon insertion, – a gynecologic examination, – prolonged sitting, and/or – wearing fitted pants. https://www.nva.org/what-is-vulvodynia/
8 9/29/2019
Vaginismus
• Vaginismus is vaginal tightness, due to involuntary spasm of the pelvic floor muscles and perineal muscles that surround the outer third of the vagina. This leads to discomfort, burning, pain, penetration problems, or complete inability to have intercourse.
• This involuntary spastic contraction is a reflex response that is stimulated by imagined, anticipated, or real attempts at vaginal penetration.
• May be due to surgical or sexual trauma – Protective response
https://www.vaginismus.com/vaginismus-symptoms/
Vaginismus – Associated Symptoms
• Burning or stinging with tightness during sex
• Difficult or impossible penetration, entry pain, uncomfortable insertion of penis
• Unconsummated marriage
• Ongoing sexual discomfort or pain following childbirth, yeast/urinary infections, STDs, IC, hysterectomy, cancer and surgeries, rape, menopause, or other issues
• Ongoing sexual pain of unknown origin, with no apparent cause
• Difficulty inserting tampons or undergoing a pelvic/gynecological exam
• Spasms in other body muscle groups (legs, lower back, etc.) and/or halted breathing during attempts at intercourse
• Avoidance of sex due to pain and/or failure
https://www.vaginismus.com/vaginismus-symptoms/
Endometriosis
• It occurs when tissue similar to the endometrium (the lining of the uterus) is found outside the uterus on other parts of the body.
• Endometriosis affects 176 million women worldwide, and 1 in 10 girls and women in the US.
• Endometriosis usually causes symptoms during reproductive years (~12-60 years old), however many women and girls are undiagnosed.
• Endometriosis affects women equally across all racial/ethnic and socioeconomic backgrounds.
https://www.endofound.org/endometriosis
9 9/29/2019
Endometriosis – Associated Symptoms
• Most common is pain which usually occurs during menstruation.
• Other symptoms include: – “Killer cramps” – cramps that do not go away with NSAIDS and/or impede the activities of daily living – Long periods – periods that last longer than 7 days – Heavy menstrual flow – having to change your pad or tampon every hour to two hours throughout most of your period – Bowel and urinary disorders – including but not limited to painful urination or bowel movements, frequent urge to urinate, or diarrhea – Nausea or vomiting – Pain during sexual activities – Infertility
https://www.endofound.org/endometriosis
Irritable Bowel Syndrome
• IBS affects the large intestine. • It can cause abdominal cramping, bloating, and a change in bowel habits – Constipation – Diarrhea • It affects women x2> men • Usually in those <45 yrs
Pudendal Neuralgia
• Pudendal Neuralgia is a painful neuropathic condition that is caused by inflammation of the pudendal nerve
• Pelvic pain with sitting that may be less intense in the morning and increase throughout the day.
• Symptoms may decrease when standing or lying down. The pain can be perineal, rectal or in the clitoral /penile area; it can be unilateral or bilateral.
http://www.oswego.edu – Society for Pudendal Neuralgia
10 9/29/2019
Coccydynia
• Persistent coccyx (tailbone) pain
• More common in women than men
• Usually caused by trauma ie a fall or childbirth
• Can also be caused by tumor or infection (rare)
• An estimated 90% of coccydynia cases resolve with non- surgical treatments, and coccyx pain will often get better with no treatment at all
Nathan. JBJS 2010; Lirette , The Ochsner Journal. 2014
Current treatment options
• Physical therapy – Manual therapy – Biofeedback – Behavioral modification – Dry needling/manual tx of trigger points • Pharmacological including Botox injections • Acupuncture • Trigger point injections ( wet needling)
Pelvic Floor Examination
• Physical examination of the pelvic floor muscles (PFMs) including palpation of the puborectalis, pubococcygeus, iliococcygeus, and coccygeus muscles can aid in diagnosis
11 9/29/2019
Methods of Palpation - Digital
http://contemporaryobgyn.modernmedicine.com/ http://brazjurol.com.br/november_december_2013/Gameiro_847_852.htm • Two fingers places the vaginal tissue under tension and distorts the anatomical relationship (Kegel 1952)
• Stretching the tissue may produce an enhanced response (Chiarelli 1989).
• The initial phase of passive muscle stretching is associated with a reflex rise in tone (Jahnke et al 1989)
• Unknown whether wide diameter device or 2 finger palpation stretches
• PF either inhibiting or facilitating (Bo and Sherburn 2005)
• One digit if lumen contact is circumferential or two if contact is not complete (Bo & Finckenhagen 2001, Frawley 2006)
Where to Palpate
• PFM located in the distal third of the vagina, index finger inserted up to proximal interphalyngeal joint (Kegel 1948, 1952)
• Two digits, 4-6 cms into the vagina with palm facing down (Brink et al. 1989)
• Index finger 4-6cms inside vagina positioned at 4 o’clock and 8 o,clock (Laycock & Jerwood 2001)
Palpation @ 1 & 2 (11 & 12) o’clock
• Spasm of the bulbocavernous and ischiocavernosus muscles can causes entrance dyspareunia and restriction of the introitus
Sarton J. J Sex Med. 2010.
12 9/29/2019
Palpation @ 4 & 8 o’clock - Pubococcygeus
Kegel (1952) • The index finger introduced to about the second joint and normally meets resistance in all directions.
• Pubococcygeus, largest and strongest muscle in the pelvis
• When atrophied and weak the muscle “sags like a hammock” and all that can be felt is slight tension at the vaginal outlet during a contraction Sarton J. J Sex Med. 2010.
Palpation of OI @ 3 and 9 o’clock
• OI often forgotten about
• Patient reports they feel like they are sitting on a golf ball or the sensation of stool in the rectal/anal area.
• Can also refer pain to the urethra.
• On palpation should reproduce their pain exquisitely.
A Headache in the Pelvis……
https://pelvicpainhelp.com/history-of-the-wise-anderson-protocol-3/
13 9/29/2019
Trigger points and where they refer - Men
Anderson et al., 2009. J Urol..
The Wand – Home treatment
http://www.nytimes.com/2013/12/31/health/a-fix-for-stress-related-pelvic-pain.html
Alternatives…….
http://www.pelvictherapies.com/
14 9/29/2019
Dilators, Biofeedback
Goldstein et al., J Sex Med 2011;8:1287-1290
What the Research says……
• 10 Thiele’s massages (2 per week x 5 weeks) in addition to ischemic compression to tender points (10 – 15 seconds per tender point)
• The technique consisted of massage from origin to insertion along the direction of the muscle fibers with an amount of pressure tolerable to the subject 10 – 15 times per session to the coccygeus, iliococcygeus,pubococcygeus, and obturator internus muscles
• A statistically significant improvement was seen in the Symptom and Problem Indexes, QOL scale and Modified Oxford scale (except for coccygeus)
Oyama IA et al. Urology. 2004
15 9/29/2019
• Complete resolution, marked and moderate improvement were achieved in 35 cases (83%) of patients with urgency – frequency
• Combined rate of marked and moderate improvement was 70% (7 of 10 cases) with IC.
• The PT treated the urinary and anal sphincter, pubourethralis, vaginalis and rectalis, iliococcygeus, obturator internus and piriformis muscles by compressing, strumming at right angles to the muscle fibers and stretching the muscles
Weiss JM. J Urol. 2001
Manual techniques used…..
• N=81 women with IC or painful bladder syndrome randomized to 2 treatment groups: 10 sessions of either Massage and Myofascial release to pelvic floor @ 11 centers around the USA
• The global response assessment response rate was 26% in the global therapeutic massage group and 59% in the myofascial physical therapy group (p=0.0012)
FitzGerald MP et al. J Urol. 2012
16 9/29/2019
• Pelvic floor physical therapy has been shown to be a beneficial treatment for HTPFD, yet many patients do not have access to this treatment.
• Insurance noncoverage and time constraints being the top barriers.
• Fair number of participants expressed anxiety about the treatment or felt they received unclear explanations of the treatment
Zoorob D et al. Female Pelvic Med Reconstr Surg. 2017 Jan 31[Epub ahead of print]
References 1. Crisp CC, Vaccaro CM, Estanol MV, Oakley SH, Kleeman SD, Fellner AN, Pauls RN. Intra-vaginal diazepam for high-tone pelvic floor dysfunction: a randomized placebo-controlled trial. Int Urogynecol J. 2013;24(11):1915-23. 2. Rogalski MJ, Kellog-Spadt S, Hoffmann AR, Fariello JY, Whitmore KE (2010) Retrospective chart review of vaginal diazepam suppository use in high-tone pelvic floor dysfunction. Int Urogynecol J 21:895–899 3. Gyang A, Hartman M, Lamvu G. Musculoskeletal causes of chronic pelvic pain: what a gynecologist should know. Obstet Gynecol .2013; 121 (3): 645–650. 4. Goldstein AT, Burrows LJ, Kellogg-Spadt S. Intralevator injection of botulinum toxin for the treatment of hypertonic pelvic floor muscle dysfunction and vestibulodynia. J Sex Med. 2011 May;8(5):1287-90. 5. Hetrick DC, Glazer H, Liu YW, Turner JA, Frest M, Berger RE. Pelvic floor electromyography in men with chronic pelvic pain syndrome: a case-control study. Neurourol Urodyn. 2006;25(1):46-9. 6. Laumann EO,Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors.JAMA, 281 (1999), pp. 537–544 7. Mercer CH, Fenton KA, Johnson AM, et al.Sexual function problems and help seeking behaviour in Britain: national probability sample survey. BMJ. 2003; 327: 426–427 8. Glatt AE, Zinner SH, McCormack WM. The prevalence of dyspareunia. Obstet Gynecol. 1990;75:433–6. 9. Doggweiler R, Whitmore KE, Meijlink JM, Drake MJ, Frawley H, Nordling J. et al. A standard for terminology in chronic pelvic pain syndromes: A report from the chronic pelvic pain working group of the international continence society. Neurourology and Urodynamics. 2017;36:4, 984-1008. 10. Fischer, A. (1997). New Approaches in Treatment of Myofascial Pain." Phys Med Rehabil Clin North Am 8: 153- 169. 11. Graven-Nielsen, T. and Mense S. The peripheral apparatus of muscle pain: evidence from animal and human studies.Clin J Pain. 2001; .17(1): 2-10. 12. Harden, R. N., S. P. Bruehl, et al.. Signs and symptoms of the myofascial pain syndrome: a national survey of pain management providers. Clin J Pain. 2000;16(1): 64-72.
References
13. Nathan ST. Fisher BE. Roberts CS. Coccydynia: A Review of Pathoanatomy, Aetiology, Treatment, and Outcome. J Bone Joint Surg [Br] 2010; 92-B: 1622-7. 14. Lirette LS, Chaiban G, Tolba R, Eissa H. Coccydynia: An Overview of the Anatomy, Etiology, and Treatment of Coccyx Pain. The Ochsner Journal. 2014;14(1):84-87. 15. Kegel AH 1952 Stress Incontinence and Genital Relaxation. CIBA Clinical Symposia Feb-Mar Vol. 4, No. 2, pages 35-52. 16. Bo K, Finckenhagen HB. Vaginal palpation ofpelvic floor muscle strength: intertester reproducibility and the comparison between palpation and vaginal squeeze pressure. Acta Obstet Gynecol Scand. 2001;80:883-887. 17. Bo K, Sherburn M 2005 Evaluation of the female pelvic floor muscle function and strength. Phys Ther;85:269- 282 18. Kegel AH 1948 Am J Obstet & Gynecol. 1948 56, 238-249. 19. Brink CA, Sampselle CM, Wells TJ, Diokno AC. Gillis GL. A digital test for pelvic muscle strength in older women with urinary incontinence. Nurs Res. 1989; (8): 196-199 20. Brink CA, Wells TJ, Sampselle CM, Taillie ER, Mayer R. 1994. A digital test for pelvic muscle strength in women with urinary incontinence. Nurs Res. 1994: (43): 352-356. 21. Sarton J Assessment of the pelvic floor muscles in women with sexual pain. J Sex Med. 2010 Nov;7(11):3526-9. 22. Anderson RU, Sawyer T, Wise D, Morey A, Nathanson BH. Painful myofascial trigger points and pain sites in men with chronic prostatitis/chronic pelvic pain syndrome. J Urol. 2009 Dec;182(6):2753-8. 23. Anderson R, Wise D, Sawyer T; Nathanson BH. Safety and Effectiveness of an Internal Pelvic Myofascial Trigger Point Wand for Urologic Chronic Pelvic Pain Syndrome. The Clinical Journal of Pain. 2011; 27 (9). 764- 768 24. www.primalpictures.com – Anatomy TV
17 9/29/2019
References
25. Zoorob D, Higgins M, Swan K, Cummings J, Dominguez S, Carey E. Barriers to Pelvic Floor Physical Therapy Regarding Treatment of High-Tone Pelvic Floor Dysfunction. Female Pelvic Med Reconstr Surg. 2017 Jan 31[Epub ahead of print] 26. Oyama IA, Rejba A, Lukban JC, Fletcher E, Kellogg-Spadt S, Holzberg AS, Whitmore KE. Modified Thiele massage as therapeutic intervention for female patients with interstitial cystitis and high-tone pelvic floor dysfunction. Urology. 2004 Nov;64(5):862-5. 27. Weiss JM. Pelvic floor myofascial trigger points: manual therapy for interstitial cystitis and the urgency-frequency syndrome. J Urol. 2001 Dec;166(6):2226-31. 28. FitzGerald MP, Payne CK, Lukacz ES, Yang CC, Peters KM, Chai TC et al. Interstitial Cystitis Collaborative Research Network. Randomized multicenter clinical trial of myofascial physical therapy in women with interstitial cystitis/painful bladder syndrome and pelvic floor tenderness. J Urol. 2012 Jun;187(6):2113-8.
Pediatric Incontinence Urology and Colorectal Conditions
October 2019
Objectives
• Discuss common bladder and bowel conditions in the pediatric population • Introduce treatment interventions for bladder and bowel conditions
18 9/29/2019
Pediatric Anatomy and Physiology • Same as the adult
Normal Urinary Control in the Infant
• Bladder acts as a reflex organ which responds to stretch receptors in the bladder wall • Receptors initiate detrusor contraction with a low volume of urine • No CNS awareness or voluntary control
Normal Urinary Control in the Infant
• Contraction of detrusor meanwhile sphincter relaxes • Awareness of bladder sensation and control occurs between 1-2 years of life
19 9/29/2019
Urinary Control Begins
• Contraction of external urinary sphincter which inhibits detrusor contractions • Then child recognizes relaxation of external sphincter in order to void • Sphincter must remain relaxed until voiding is complete
Voluntary Control
• Occurs between 2-3 years of life • Bladder volume increases, detrusor hyperactivity decreases, and involuntary Voiding is inhibited with sphincter contraction
Normals for Pediatric Patients
• Voids occur every 2-5 hours • 5-8 restroom trips per day • Should be able to hold bladder all night >5 y/o
20 9/29/2019
When it’s not working…
First…
• Rule out UTI or recurring UTIs • Rule out upper urinary tract pathology • Rule out neurological findings – Tethered cord • MD examination • Possibly urodynamics or other bladder tests
Common Symptoms in Childhood
• Overactive bladder • Nocturnal enuresis • Voiding dysfunction • Dysfunctional elimination • Giggle incontinence • Voiding postponement • Fecal soiling • Constipation
21 9/29/2019
Impact of Bladder and Bowel Issues in Pediatrics • Poor self-esteem • Frustration • Anger • Shame • Guilt • Feelings of failure • Humilitation • Embarrassment
Overactive Bladder
• Urgency, urge incontinence, small voided volumes, frequency, high flow rates • May have nocturia or nocturnal enuresis • Giggle incontinence – Wet when laughing – Urge leakage
Nocturnal Enuresis
• Also known as “bedwetting” • May or may not have daytime bladder symptoms • Bladder- brain dialogue is impaired
22 9/29/2019
Voiding Dysfunction
• Also known as “diurnal enuresis” • Wet episodes during the day, urgency • Rule out a UTI • Also consider constipation or incomplete bladder emptying as contributory
Stress Urinary Incontinence
• Seen in young athletes – Gymnastics, soccer, dance, cheer, track • Need to develop pelvic floor strength • Learn to breathe correctly • Remember pelvic floor should not be rigid but rather bounce with strenuous activities
23 9/29/2019
Dysfunctional Elimination
• Daytime wet episodes, urgency, infrequent voiding, fecal soiling, difficult defecation • Incomplete bladder emptying • May have sphincter/pelvic floor dyssynergia with urination or defecation • Constipation!
Voiding Postponement
• Child refuses to toilet when she/he obviously needs to • Usually an acquired and behavioral postponement until incontinence occurs
Fecal Soiling or Incontinence
• Encopresis – Expulsion of normal bowel movements in inappropriate places by a child aged 4 years or older • Soiling is an involuntary leakage of a small amount of stool • Children may have poor rectal sensation, disordered defecation, incomplete emptying • Constipation!
24 9/29/2019
Bristol Stool Chart http://nutritionnavigator.biz/wp-content/uploads/bristol_stool_scale_paeds.jpg
Sensory Processing Disorders
• Maedica (Buchar). 2012 Sep;7(3):193-200 • 54 children with Austism Spectrum Disorder • Reported: – 48% GI issues – 57% Incontinence – 57% Sleep disorder – 94% Eating disorder – 74% Anxiety/fear – 89% Behavioral disorder
Treatment Goals
• Normalizing voiding and defecation dynamics by teaching pelvic floor and sphincter relaxation during elimination • Regulate volume • Train to empty at appropriate times
25 9/29/2019
Intervention Strategies
• Begin with education of child and parents/family • Use age appropriate visual aids • Motivation – Identify 3 positive and 3 negative aspects of bladder/bowel issues • Reward charts
Behavioral Techniques
• Fluid intake • Voiding intervals • Toileting position • Bedwetting alarm
Behavioral Modifications for Pediatrics • Set up schedule to void 5-6 times a day • Management of constipation • Adequate fluid intake • Stop fluids 2 hrs before bed
26 9/29/2019
PT Intervention
• Biofeedback – Teach PFM awareness and coordination to achieve PFM recruitment and relaxation with minimal accessory muscle activity • Train optimal voiding mechanics and posture • Bowel management • Exercise
Perianal Electrode Placement
Toileting Position with squatty potty
27 9/29/2019
References
• Haslam J, Laycock J. Therapeutic Management of Incontinence and Pelvic Pain, 2nd ed. London: Springer, 2008. • Bo K, Berghmans B, et al. Evidence-based physical therapy for the pelvic floor: bridging science and clinical practice. Philadelphia: Churchill, Livingstone, & Elsevier, 2007. • Irion J, Irion G. Women’s health in physical therapy. Philadelphia: Lippincott, Williams, & Wilkins, 2010 • Rogers J. Daytime wetting in children and acquisition of bladder control. Nurs Child Young People. 2013; 25 (6): 26-33. • Jansson U, Hanson M, et al. Voiding pattern and acquisition of bladder control from birth to age 6 years- a longitudinal study. J of Urol. 2005; 174 (1): 289-293. • Shepard JA, Poler JE Jr, et al. Evidence-Based Psychosocial Treatments for Pediatric Elimination Disorders. J Clin Child Adolesc Psychol. 2016 Dec 2:1-31. doi: 10.1080/15374416.2016.1247356.
Bladder and Behavioral Retraining
October 2019
28 9/29/2019
Goals of Bladder Retraining
• Break the cycle of urgency and frequency, using consistent, incremental voiding schedules • Try to restore bladder capacity to normal levels
Indications for Bladder Retraining
• Urgency and frequency • Urge incontinence • Stress incontinence • Nocturia • Incomplete bladder/bowel emptying
How does it work?
• Patients likely acquired a greater awareness of bladder function and inhibition over involuntary detrusor contractions • Increase pelvic floor muscle activity in order to postpone urination
29 9/29/2019
Gather the Information
• Bladder diary – Time of urination – How much? Volume? # of seconds? – Leaks and reason for the leak – Type and amount of fluid – # of pads
Instructions for Bladder Training
• Complete bladder diary • Select the longest voiding interval that the patient feels comfortable with • Empty the bladder first thing in AM, every voiding interval, and at bedtime • Instruct patient in urge suppression techniques • Gradually increase the voiding interval when the patient feels comfortable – Increase by 15-30 minutes
Urge Suppression Techniques
• Stop to gain control • Quick Pelvic floor muscle contractions – reciprocal inhibition of the Detrusor muscle • Distraction to another task • Focus on deep breathing and relaxation • Positive self-statements • Stop, be still, sit if able, relax, distract, kegels, and once urge passes if interval is up, then slowly walk to the bathroom; if interval is not up, then wait to next prescribed interval time
30 9/29/2019
Urge Suppression Techniques Cont
• Change attitude “when you gotta go, you gotta go” • Begin with wearing absorbent pads to avoid embarrassment • Try this technique during the night
Delayed Voiding
• Not a set interval • Rather, delay voiding for 5-10 minutes when urge hits • This can build confidence and sense of control
Fluid Modification
• Educate on overall fluid intake • Avoid bladder irritants – Avoid: caffeinated beverages incl. soda, coffee, tea, chocolate, smoking, alcohol, medications with caffeine – Minimize: milk and milk products, citrus fruits and juices, artificial sweeteners, spicy foods, tomato based products, sugar, honey or corn syrup – Good: water, grape juice, water, apple juice, water, and cranberry juice AND water
31 9/29/2019
Fluid Management
• Patients may want to restrict fluids at certain times of the day to manage frequency of restroom trips • Some patients reduce their overall fluid intake leading to concentrated urine – Should drink 6-8 8oz glasses per day (approx. 1500mL) – Water formula based on body weight • Body weight divided by 2= total fluid intake (caffeine and alcohol do not count towards total) • Total fluid intake x .66 = total water intake • Conversely, if patients drink an excessive amount of fluid, then fluid restriction may be an appropriate measure – Abnormally high fluid intake (greater than 2000mL)
Additions to Bladder Training
• Consider a bladder medication • Eliminate caffeine • Prompt voiding at specific times • Bowel regularity • PFM retraining
Appropriate Toileting Techniques
• Sit on toilet • Wide base of support • Relax to void • Push in suprapubic region • Lean forward • Avoid straining
32 9/29/2019
• Keep in mind that bladder retraining takes weeks/months for successful completion • Patient compliance is critical to success • Goal is to empty before bladder contraction causes leakage
References
• Ostle Z. Assessment, diagnosis and treatment of urinary incontinence in women. British Journal of Nursing 2016; 25 (2): 84-91. • Bardsley A. An overview of urinary incontinence. Br J Nurs 2016; 13 (18): S14-21. • Giarenis I, Cardozo L. Managing urinary incontinence: what works? Climacteric 2014; Dec 17: S2:26-33. • Hersh L, Salzman B. Clinical management of urinary incontinence in women. Am Fam Physician. 2013; 88 (7): 427. • Health Quality Ontario. Behavioral interventions for urinary incontinence in community- dwelling seniors: an evidence-based analysis. Ont Health Technol Assess Ser. 2008; 8 (3): 1-52. • Burgio K. Update on Behavioral and Physical Therapies for Incontinence and Overactive Bladder: The Role of Pelvic Floor Muscle Training. Current Urology Reports. 2013; 14 (5): 457-464. • Cardozo L. Systematic review of overactive bladder therapy in females. Can Urol Assoc J 2011;5(5Suppl2):S139-S142.
33 9/29/2019
Documentation, Reimbursement, and Marketing
October 2019
Documentation
• Demonstrates skilled care and medical necessity • Serves as a record of patient care, including the individual’s status, PT management, and outcomes of PT intervention • Demonstrates compliance with federal, state, and local regulations • Demonstrates appropriate service utilization 101 and payment for payers
Documentation
• Record must be sufficient to determine services were provided on specific dates (daily flow sheet, etc.) • If it is not documented then it didn’t happen • Summary notes (every 10 days) accepted as documentation of medical necessity • Payers will review documentation for fraud and abuse
34 9/29/2019
What Payers Look For
• Why is the same • The patient’s notes information written each stopped on a certain DOS, DOS when the patient is but there is nothing progressing? documented that the • Is skilled physical therapy patient’s problem was care required when the resolved? Was the patient flow sheet records discharged or non- increasing weight and compliant? repetitions? • What do the abbreviations • How can I tell if the patient mean? has functional improvements? Does decreased pain, strength, or ROM demonstrate function?
Documentation Do’s and Don’ts
• On each date of service, record total treatment time as well as the breakdown of time spent with each service provided • Although documentation of un-billed services that are not part of the total treatment minutes is not required, including this provides a more accurate description of all patient services to comply with state/local policies and for liability purposes • Exercise flow sheet is part of the medical record- DO NOT leave this out
Documentation Do’s and Don'ts
• Documentation should support the units billed • Be consistent with your billed units and total treatment time • Follow Medicare guidelines as these seem to be the most specific and 8-minute rule helpful in determining billed units
35 9/29/2019
Setting Goals
• # of urinary incontinence episodes per week/month in “x” of weeks • Independence in a home exercise program • MMT strength increase • Normalize pelvic floor resting tone • Demonstrate appropriate isolation of endurance and/or quick kegels with appropriate relaxation between contractions • Able to complete an ADL/recreational activity without urinary leakage • Voiding interval no sooner than every 90 minutes • Independence in urge suppression techniques in order to override urge to urinate for 10 minutes
106
Setting Goals
• Hold a pelvic floor contraction for 10 seconds x 10 repetitions • Demonstrate coordination between transversus abdominis and pelvic floor contraction • Increase strength of lower abdominals to 4/5 • Reduction in pain (name location) by 50% • Maintain a neutral pelvis during a particular activity • Demonstrate appropriate body mechanics with lifting, exercise, work related activities, etc • Decrease or eliminate need for incontinence pads • Sleep uninterrupted by urgency (0-1 time<65 y/o; 1-2 107 times>65 y/o)
ICD 10 Codes
• Choose PT code and then secondary medicine code – I.e. disuse atrophy (N81.84); stress urinary incontinence (N39.3) • Choose the most specific diagnosis
108
36 9/29/2019
ICD 10 Codes
• See attached WH codes
109
CPT Codes
• Common codes in women’s health PT – 97110 Therapeutic Exercise – 97112 Neuromuscular Reeducation – 97140 Manual Therapy – 97530 Therapeutic Activities – *90911 Perianal Biofeedback
110 • *Not reimbursable by most insurances
Timed Codes
• Reporting minutes spent by a qualified provider (PT or PTA) in direct contact with the patient • Total reported minutes should reflect total direct contact time with the patient • Documentation should support the codes and units billed during a visit
37 9/29/2019
Timed Codes: Therapeutic Procedures • Therapeutic Exercise promotes • Aquatic Therapy is strengthening, flexibility, range of therapeutic exercise in motion, and endurance water to facilitate – 97110 movement. Should • Neuromuscular Reeducation progress to land based describes activities that promote exercise program improvement in balance, – 97113 coordination, kinesthetic sense, posture, & proprioception • Gait training is skilled – 97112 interventions to promote ambulation with/without an assistive device – 97116
Timed codes cont
• Massage describes • Manual Therapy techniques that are hands-on include effleurage, techniques to petrissage, and/or improve tissue tapotement in order extensibility, joint to promote mobility, promote relaxation, lymph drainage, decrease pain and and distract tissue trigger point surfaces when tenderness appropriate – 97124 – 97140
Timed codes cont
• Therapeutic • Cognitive Skill Activities focus on Development dynamic activities – 97532 to promote function • Sensory – 97530 Integrative Techniques for pediatric and/or neurologically impaired populations – 97533
38 9/29/2019
Biofeedback
• Per session • 90901: by any modality – Visual – Auditory • 90911: perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry
Biofeedback
Application of Surface Neurostimulator
• 64550 • Non-invasive pain control device • Typically reported for fitting of and instruction in use of TENS unit • Home use after in- office trial and instruction
39 9/29/2019
Women’s Health Marketing
• Who do we market to? – Patients/clients – Physicians and other healthcare providers – Community – Other PT/OTs – Media – Gyms 118 – Yoga studios – Moms’ groups/Mom’s day out
Know Your Audience
• Women make 80-90% of health care decisions for their family • 2 out 3 health care dollars are spent by women • Women account for 80 out of every 100 cents spent in a drugstore • How to market to women from the “Lipstick Economy”: – Emotion reigns over rational thinking – Social media is word of mouth – All research starts online – Families are not nuclear anymore – Don’t use pink
Determine Potential Referral Sources
• Physicians • Employers • Managed care companies • Hospitals • Local fitness centers • Chiropractors • Other therapists • High schools and grade schools
40 9/29/2019
Follow Up on Leads
• New patients • Physician recommendations from patients • Look to those you already know
Making Contact
• Personal visits and calls • Media exposure • Internet • Written messages
Personal Calls and Visits
• Plan your meeting • Listen and get to know your customer • Be aware of time constraints • Attend a physician’s visit with a patient • Contact a patient who has a “big” event in his/her life
41 9/29/2019
Personal Selling
• Open an encounter • Explore and confirm the customer’s needs • Present solutions • Respond to objections • closure
Media Exposure
• “health-byte” rather than sales pitch • Radio interviews • Morning talk shows • Live Q & A on the radio or tv • Consider health tips in newspaper or magazine
Internet
• Interactive web site • Sponsor a chat line with a MD or other health care providers • Provide service lines on your web site • Post newsletters • Provide email address
42 9/29/2019
Written Messages
• Send a hand written note to a new patient • Thank a physician for a new referral • Hand deliver the initial evaluation or discharge summary • Send email or letter to a discharged patient to check in
Marketing Requires Persistence
• 2000 sales people • Therefore: showed that 80% of – make 5-7 contacts for all new sales happen a potential sell after the 5th contact – Don’t be pushy • But, 48% gave up – Educate vs. sell after the first contact and 42% after the second contact • Only 10% persisted after the fourth contact
43 9/29/2019
Marketing to Physicians
• Few ask very • Give something away technical questions or • Take your business when you get to know cards and referral them pads • You must have • Brochures confidence in your • Know the background services information for a • Consider what is the particular physician worst thing that could • Invite a physician to happen speak at an • Rehearsal educational seminar
Marketing
• Why would a • What makes a patient come to a private practice small private successful? practice? • What is a private • Are patients driven practice “known to come to a small for”? practice vs. large hospital based PT because a MD says to?
Understanding Your Market
• Do you market the same services the same way to different consumers? • How do you build customer loyalty? • What does one consumer value in their PT compared to another?
44 9/29/2019
Generational Marketing
• Can compliment marketing strategies through identifying the – Right customer – Right service – Right time – Right message – Right medium
Maccracken et al. Matching the Market: Using Generational Insights to Attract and Retain Consumers. Thomson Reuters; Jan 2009
Greatest/Silent Generation
• Born before 1942 • Physician directs me • Longer and more frequent patient visits • “The customer is always right”
Baby Boomers
• 1943-1960 • Engage me • Seek out counsel from and bring information to their physicians and research MD’s recommendations • Often making decision for their aging parents
45 9/29/2019
Generation X
• 1961-1981 • Educate me • Curious and seek information • Likely to switch healthcare providers based on recent experiences • Broad view of healthcare providers
Millennials
• 1982-present • Connect with me • Uses technology to assist with healthcare decisions • Looking for personal relationship • Likely to switch providers based on recent experiences
What Do Consumers Value?
• Academic medical center – Greatest/Silent and Baby Boomers • Internet – Generation X and Millennials • Compassionate care – Generation X and Millennials (all) • Family/friend recommendations – Generation X and Millennials • Another doctor recommendation – Greatest/Silent and Baby Boomers
46 9/29/2019
Media Responsiveness
• Direct mailings – Greatest/silent and Baby Boomers • TV ads – Greatest/silent • Web, Facebook, twitter – Generation X and Millennials
What sets you apart from your competitor?
Value Based Purchasing of Healthcare Services
Value
• Function of quality, efficiency, safety and cost • Consumers want to make sure every dollar spent is accountable for quality and medical necessity
47 9/29/2019
Goals of Value Based Purchasing
• Improve clinical quality • Address problems with overuse, underuse, and misuse of services • Encourage patient-centered care • Make performance results transparent to and useable by consumers
Keckley• et Avoid al. Value Based Purchasing:unnecessary A costs in the delivery of strategic overview for healthcare industry stakeholders.care Deloitte Centers.
Impact on Consumers
• Make decisions based on greatest value for their buck • Employers may contract with providers using VBP design • Consumers may compare costs, access, outcomes, safety, and user experiences
Marketing Considerations
• Budget • Women make the majority of healthcare decisions for their families – Influence their family and friends – Interested in preventative health – Want meaningful relationships with their healthcare providers
48 9/29/2019
Marketing to Women
• Women love to talk • Women are 3x more likely to recommend a particular service to their friends • Women are more interested in taking control of their bodies through conservative, alternative ways • Women look for time savers and least amount of stress • Ambience of your clinic • Look for ads in women’s magazines (i.e. Women’s 145 Edition)
Marketing Yourself
• Let your patients get to know you • Network, communicate, and engage • Marketing is a process, a series of winning and favorable gestures to physicians and clients! • TAKE TIME TO ACKNOWLEDGE AND REMEMBER PERSONAL EVENTS
For more information
• Check out APTA website at www.apta.org • LINDA MACCRACKEN, MBA GARY PICKENS, PHD MEREDITH WELLS, MS. RESEARCH BRIEF Matching the market: Using Generational Insights to Attract and Retain Consumers; Jan 2009.
147
49 9/29/2019
Case Studies OCTOBER 2019
Case Study #1
• Healthy 39 y/o female presents to PT with stress and urge urinary incontinence • Urogynecologist performed UDS which identified incomplete bladder emptying • She has to wear a pantiliner everyday, which is generally wet by the end of the day • She leaks with sneezing, coughing, laughing, running (4-6 miles most days of the week), chasing her kids • She gets a very strong urge to go to the bathroom; in sitting she can suppress the urge, otherwise she leaks urine • Decreased her water intake to 2-3 glasses per day • PMHx: 2 vaginal deliveries, and a recent endometrial ablation • Also she suffers from frequent bouts of constipation
50 9/29/2019
Anatomy Review
Bladder and the PF Muscles Pelvic Floor Musculature • PF Muscles have 3 functions – Support – Sphincteric – Sexual • During bladder filling, the PF remains contracted, preventing leakage • At a certain bladder capacity, stretch receptors indicate the need to use the restroom and the PF relaxes, while the bladder contracts to empty urine
Continence
• Based on urethral resistance pressure that is greater than the intravesical (bladder) pressure • Urethra is viscous/mucous lining assisting with continence
Physiology of Continence
• Storage Cycle – bladder stores 400-600ml & fills at a constant rate – 1st sensation to void at 150-200ml – detrusor muscle is elastic and relaxed with filling – postponement due to inhibition at sacral center – Pelvic floor muscles contract to suppress urges and inhibit bladder contractions
51 9/29/2019
Physiology of Continence
• Emptying – at 400-600ml stretch receptors send strong sensation to brain – signal returns via somatic track and you walk to the restroom – pelvic floor relaxes – Post-void residual of 5 to 50ml
When the system fails….
• Inability to control • When we feel an urine with an increase “urge” our bladder is in intraabdominal contracting pressure • Uninhibited bladder • Leakage with contractions sneezing, coughing, • So if the PF is weak, and laughing; sudden we have limited ability unexpected increase to suppress the “urge” in abdominal to urinate pressure • URGE • STRESS INCONTINENCE!! INCONTINENCE!!
Complications with Constipation
• Increased pressure in rectum puts additional strain on the pelvic floor • When the bowels are full and not properly emptied, the bladder capacity is limited • Constipation typically leads to val salva or straining during defecation • Often the pelvic floor does not relax when you val salva and therefore this ultimately strains/weakens the pelvic floor
52 9/29/2019
Bristol Stool Chart
This is our goal!
Fluid Intake
Appropriate fluids What to avoid • Should drink 6-8 eight ounce • Caffeine in coffee, tea, and soda glasses of water or take your body • Smoking weight in lbs. divide by 2= total • Alcohol ounces you should drink each day • Chocolate • Water is the best thing for the bladder • Some people may find spicy foods, dairy products, and tomato based • Do not restrict fluids because of products to be an irritant urgency and frequency
Urodynamic Testing
• Urodynamic testing is any procedure that looks at how well the bladder, sphincters, and urethra are storing and releasing urine • Most urodynamic tests focus on the bladder’s ability to hold urine and empty steadily and completely • Urodynamic tests can also show whether the bladder is having involuntary contractions that cause urine leakage • Performed by the urologist, urogynecologist, or gynecologist
53 9/29/2019
Subjective History
• What is your primary complaint? • Do you leak when you sneeze, cough, or laugh? • Do you have a strong urge to urinate and if you don’t get to the restroom quickly, will you leak? • How often do you use the restroom? • How many restroom trips do you make each day? Night? • Have you wet the bed in the last year? • Do you experience leakage when you are under stress, anxiety, or in a hurry? • Does running water or cold temperatures cause you to leak? • Do you use any protective undergarments?
More Questions
• How often do you leak urine? Feces? • Do you have any pain with urination or defecation? • Do you strain to urinate or defecate? • Have you had any blood in your urine? • Do you find it difficult to start your urine stream? • Do you feel like you empty your bladder all the way? • Do you have any dribbling after urination?
What can Physical Therapists do to treat the bladder?
54 9/29/2019
Tests and Measures
• Screen lumbar • Posture and sacral spine • Slumped sitting or • Pain standing • Increased lumbar • Look for palpable lordosis or tenderness at thoracic kyphosis introitus, posterior • Pelvic alignment pelvic floor, or sphincter or • Sensory Integrity compressor • Able to identify urethrae pressure and light touch
Muscle Performance for the Pelvic Floor Muscles
• Manual Muscle Testing (Pauline Chirarelli, PT) – 0- no contraction – 1- flicker, only with muscles stretched – 2- a weak squeeze, two second hold – 3- a fair squeeze, definite “lift” – 4- a good squeeze, good hold w/ lift and repeatable – 5- a strong squeeze, good lift, repeatable • Performed transvaginally or rectally • Quick vs. Endurance kegels
What were the findings?
• Manual muscle testing of • Slight increase in lumbar the pelvic floor= 1/5 lordosis and thoracic • Poor ability to identify a kyphosis pelvic floor contraction • Level pelvis • She is able to illicit a 1-2 • Elevated resting level on second kegel contraction EMG recording • Normal sensation to light – 8.3uV (normal is 2-3uV) touch and deep pressure in the pelvic floor • Denies any palpable pain at the introitus or pelvic floor
55 9/29/2019
Assessment
• Significant pelvic floor weakness with poor identification of “kegel” exercises • She has limited ability to suppress the urge and cannot stop the incontinence with stressful activities • Now affecting her quality of life – Limiting her running and avoiding playing with her kids • Elevated resting level likely contributes to incomplete bladder emptying • Is she prone to urinary tract infections if she does not empty appropriately?????
How about a bladder repair…
According to an article in Rev Urol 2003, states that the mainstay for SUI is behavioral and surgical therapies…
So why NOT surgery?
• We know that if there is incomplete bladder emptying prior to surgery, then a bladder repair may worsen symptoms – According to Kristensen, Eldoma et al found that following a TVT procedure, 34.3% had to self-catheterize and 8% had an indwelling catheter upon discharge from the hospital. Voiding dysfunction pre-operatively had a 1.8 fold odds of difficulty with voiding post-op (Int Urogynecol J Pelvic Floor Dysfunct 2010 Nov; 21 (11)) • A bladder repair is not appropriate for urge incontinence – Urge incontinence is treated by OAB meds and behavioral techniques (Indian J Urol 2010 Apr; 26(2): 270-8) • She is still of child bearing years
56 9/29/2019
Is she a good candidate for PT?
• Motivated to keep up with exercise program • Very active with kids, regular aerobic program • Trying to avoid surgery and OAB medications • Still childbearing age
Interventions
• EDUCATION • Bladder retraining • Kegel exercises • Body mechanics • Core strengthening • Manual traction • Toileting techniques • Muscle Energy • EDUCATION Techniques (MET) • Home exercise program • Relaxation techniques • EDUCATION
Biofeedback Assisted Training
• Biofeedback provides visual and auditory feedback • Allows patient to see immediately if they are contracting the right muscle • Am J of Phys Med Rehab 2001: Pages et al found that biofeedback therapy resulted in better subjective outcomes and higher contraction pressures of the PF muscles than exercises alone
57 9/29/2019
Treatment Plan
• Plan to see patient 1x/week for 6 weeks • Emphasize a home exercise program • Bladder retraining – Timed voiding to reduce the # of voids – Appropriate fluid intake – Toileting techniques with focus on PFM relaxation • Weight training for the pelvic floor • Biofeedback training for the pelvic floor
Expected Outcomes in 8-12 weeks
• LTG #1: Run for 30 minutes without urinary incontinence • LTG #2: Increase pelvic floor strength to 3/5 or greater • LTG #3: Demonstrate appropriate urge suppression techniques so that she is able to make it to the restroom without leakage at least 75% of the time • LTG #4: Patient will be able to play with her kids without restrictions related to urinary incontinence • LTG #5: Patient will demonstrate ability to empty her bladder with a residual volume < 50mL
Billing and Coding
• ICD10: • Visits scheduled – SUI for 30-45 minutes – N39.3 • 1x/week • CPT Codes: • Billed for 2-3 units – 97001- evaluation of ther ex – 97110- therapeutic ex – 97140- manual therapy
58 9/29/2019
Actual Outcomes
• Patient seen for 4 • Can hold a 10-second visits over 4 weeks kegel contraction • No leaking with • Denies urge running or chasing incontinence her son • Compliant with her • Resting level dropped exercises from 8.3uV to 3.7uV • Patient is • Making 6-7 restroom DISCHARGED with trips per day independent home • Improved endurance exercise program in the PF
Home Exercise Program
• 80 kegels per day- combo of quick and endurance • Suppress urgency with kegels and distraction techniques • Education on bladder irritants, but appropriate fluid intake • Core stability exercises
Costs involved
Physical Therapy Bladder Sling Repair • 4 PT visits • Sling $2200 • Based on Medicare Fee Schedule= • With Mesh $850 $375 • With Paravaginal Defect Repair $850 • Physician’s Total= $3900 • Then consider hospital charges
59 9/29/2019
Case Study #2
• 42 y/o female, c/o urinary incontinence and overactive bladder for the past 10 yrs., pain with intercourse • No significant PMH. • Goal-reduce symptoms of incontinence • Elevated PF resting tone, PF MMT 4/5 however short pelvic floor, hypertonicity in bilateral bulbocavernosus and iliococcygeus muscles, poor relaxation between contractions
Case Study #2
• Treatment – Therapeutic exercise-phasic and endurance PF contractions, PF accessory muscle exercises – Vaginal dilators for relaxation at the introitus – Neuromuscular Re-education – Bladder Retraining – Urge Suppression Techniques
Case Study #2
• Outcomes-8 visits to date – Normal resting tone of PF to 2.9uV from 7.8uV – Decreased urgency and frequency to urinate
60 9/29/2019
Research
• Dumoulin and Hay-Smith found that pelvic floor muscle training be included in the first-line conservative management programs for women with stress, urge and mixed urinary incontinence. (Cochrane Database Syst Rev. 2010 Jan 20;(1):CD005654)
• Fritel and Fauconnier, et al report that pelvic floor muscle training is the treatment of first intention for pre- and postnatal urinary incontinence and bladder training is recommended at first intention in cases with overactive bladder syndrome. (Eur J Obstet Gynecol Reprod Biol. 2010 Jul;151 (1):14-9. Epub 2010 Mar 16)
• Hung and Hsiao, et al found that over 90% of women in their test group were cured or improved after four months of diaphragmatic, deep abdominal, and pelvic floor muscle retraining. (Prog Urol. 2010 Feb;20 Suppl 2:S104-8)
Case Study #3
• 17 y/o female with dx of urinary incontinence complicated by spina bifida. Pt reports no urge to urinate. Diurnal and nocturnal enuresis. Uses 3- 4 adult incontinence undergarments per day. • Self-catheterizing 6x/day. Pain with intercourse. • PMH-spina bifida • Patient’s Goal-improve bladder control before college • PF MMT 1-/5, poor identification of PF, no contraction elicited with quick stretch to pubococcygeus bilaterally, no EMG activity noted in PF
Case Study #3
• Treatment – Contigen injections – Therapeutic Exercise-phasic and endurance PF contractions, PF accessory muscle exercises – Manual Therapy-soft tissue mobilization – Neuromuscular Re-education with e-stim for PF strengthening – Vaginal Dilators
61 9/29/2019
Case Study #3
• Outcomes-11 visits to date – Pt can elicit a PF contraction (MMT= 2+/5) with little compensation of gluts or abdominal muscles as recorded by EMG – Decrease in nocturnal enuresis and incontinence following contigen injection by physician – Pain-free intercourse – Pt using home NMES unit – Returning to MD for evaluation for bladder sling
Research
• Ab and Dik, et al found that the functional obstruction due to detrusor/sphincter dyssynergia has been by-passed chronically in children by intermittent catheterization and oxybutynin. However detrusor overactivity recurs immediately after withdrawal of medications. (Neurorurol Urodyn 2004; 23(7): 685-8) • Thirty children with myelomeningocele with moderate-severe intractable incontinence, detrusor overactivity, and high detrusor end-fill pressure were randomly assigned to a control or treatment group. The Rx group received interferential electrical stimulation for 20 min, 3x/wk. Seventy-eight percent gained continence immediately after Rx and 60% had persistent continence still 6 months later. (Urology 2009 Aug; 74 (2): 324-9)
Case Study #4
• 51y/o male presents to the clinic with perineal pain which began 2 yrs ago, insidious onset. • Pain is described as a “ball” in his perineum when he sits; it can be sharp but usually a nagging sensation which intensifies at the end of the day. Urine stream stops and starts and burning sensation with intercourse • Symptoms provoked by sitting longer than 2 hours, light touch to the perineum, working out, prolonged walking, and vibration when in the car. • Extensive testing such as CT, PET, MRI, UDS= WNL • PMHx: colon resection in 1993 followed by 12 months of chemotherapy; Meds: miloxocam
62 9/29/2019
Case Study #4
• Objective Findings: – Extremely high resting tone on EMG (22.7uV) – Palpable trigger point in bilateral ischiococcygeus (right worse than left) – Hypertonicity in superficial transverse perineal muscle, myofascial adhesions along perineum from scrotum to anus – Seated slumped posture
Case Study #4- Treatment
• 8 visits to date and patient reports >70% improved • After 2 visits, patient’s resting level decreased from 22.7uV to 4uV and patient able to sit for 4 hours before pain intensified • Treatment includes: – Myofascial release including trigger point release to bilateral ischiococcygeus and superficial transverse perineal muscle – Postural awareness with corrected seated position with lumbar support and feet on the ground – Home exercises for stretching the adductors, hamstrings, and piriformis, pelvic floor downtraining and inhibition at the beginning of treatment but then uptraining with kegels – Iontophoresis using dexamethasone to perineum – TENS to perineum
Research
• Hetrick, Ciol, rothman, et al performed a physical therapy musculoskeletal exam on 62 men with CPPS (Type IIIA and IIIB) and 89 healthy men w/o CPPS. PT identified a significant difference in muscle spasm, increased muscle tone, pain with internal transrectal palpation of the PFM, and pain with palpation of levator ani and coccygeus muscles in men with CPPS, although strength testing for the lower abdominal and oblique muscles was not significantly different between the groups. (J of Urol 2003; 170: 828-31) • Anderson, et al published pain sensation referral patterns: ie. Pubococcygeus/puborectalis and rectus abdominis trigger points reproduced penile pain more than 75% of the time, whereas external oblique trigger points elicited suprapubic, testicular, and groin pain in at least 80% of the patients (J Urol 2009 Dec; 182(6): 2753-8)
63 9/29/2019
Research on CPPS
• Two case studies presented by Van Alstyne et al who failed pharmacological treatment, were sent to PT for manual therapy, progressive muscle relaxation, flexibility and aerobic exercises appeared to be beneficial in reducing pain and improving sexual function (Phys Ther 2010 Dec; 90(12): 1795-806) • Randomized double blind design used to assess TENS in the symptomatic management of chronic prostatitis (Int Braz J Urol. 2008 Nov-Dec; 34(6): 708- 13) • Articles on iontophoresis found for Peyronie’s disease for non-surgical treatment as well as plantar fasciitis and Achille’s tendonitis
Case Study #5
• 54y/o female with extensive past medical history for interstitial cystitis • Has seen many urologists, gynecologists, and urogyn’s in Omaha, San Diego, Rochester, Michigan, NYC, DC, etc • Diagnosed with IC in 2001, but PMHx includes: IBS, chronic constipation, rectal fissures, fibromyalgia, TMJ, depression, latex allergy • She is menopausal since 2004 • Medical treatment has included distillations, instillations with DMSO, anti-depressants, nerve and pain meds, pudendal nerve blocks, trigger point injections to the pelvic floor, trial of Interstim, and most recently botox injections and valium suppositories
Case Study #5- IC
• Pain is located in the vagina and labia; dyspareunia, dysuria and urinary frequency hourly • Symptoms aggravated with any type of clothing that touches the perineum, as well as sitting, bending, lifting, pushing, pulling, and intercourse • She must alter the way she dresses and can no longer work full-time despite being a business owner • She has been seen by several physical therapists prior to her referral to Peterson Physical Therapy
64 9/29/2019
Case Study #5- IC
• Objective Findings: – Trigger points throughout bilateral iliococcygeus, ischiococcygeus, elevated resting level – Pelvic malalignment, lumbar flexion 80%, lumbar extension 50% – Decreased flexibility in piriformis, hamstrings, hip flexors – PFM MMT= 1/5
Case Study #5-IC
• Treatment – Biofeedback assisted pelvic floor downtraining for relaxation – Lumbopelvic stabilization, lower extremity flexibility, and pelvic floor exercises – Manual therapy techniques: myofascial release, visceral mobilization, trigger point release, contract/relax techniques, manual stretches for lower extremities – Continues to be seen in and out of physical therapy, 2x/wk – Most recent round of physical therapy, after 3 visits able to wear pants for 2-3 hours and intercourse less painful
Ideas on Flexibility
65 9/29/2019
Research
• Bassaly et al correlated myofascial pain with IC patients and pelvic floor dysfunction (Int Urogynecol J Pelvic Floor Dysfunct. 2010 Oct 26) • Weiss evaluated the effectiveness of manual physical therapy in patients with IC and found that 70% had moderate to marked improvement (J Urol. 2001 Dec; 166(6): 2226-31) • Oyama, Rejba, et al looked at transvaginal manual therapy in pelvic pain patients. Treatment was provided 2x/wk for 5 weeks and used Q of L questionnaires to evaluate improvement. Manual therapy appears to be helpful in improving irritative bladder symptoms and decreasing pelvic floor tone (Urology. 2004 Nov; 64 (5): 862-5)
Additional Research
• At the 2004 International Consultation on IC in Rome, Dr. Kristine Whitmore presented that 30- 70% of patients with IC have high tone pelvic floor dysfunction, IBS, female sexual dysfunction, or endometriosis. She underscored the importance of a multi-disciplinary therapeutic approach for IC patients. (Int Urogynecol J (2005) 16: S2-34) • Lukban and Whitmore, as well as Thiele and Lilius, eluded to an association of poor posture and poor, prolonged sitting with high tone pelvic floor dysfunction (Clin Ob & Gyn (2002) 45 (1): 271-85
Case Study #6
• 8 y.o. Female with daytime dribbling, urgency and nocturnal enuresis • Hx of recurrent bladder infections (5 in the past year) • Dilitations: 2 in the past three years • Changes underwear at least once per day • ADHD on medications • Ditropan, TID x 2 years • Voiding once per hour • Fluid Intake: 12- 16 diet Pepsi, 8 oz water, 16 oz. Milk, 8 oz orange juice
66 9/29/2019
Case Study #6
• Treatment – Accessory muscle instruction – Locating the pelvic floor through external biofeedback – Fluid modification / bladder irritants – Post-voiding techniques for bladder inhibition – Bladder retraining / urge suppression techniques
Case Study #6
• Outcomes- 4 visits to date – Dry most nights (13 of 14) – MVC of PF to 9 seconds – No longer is drinking soda and increased water intake to 24 oz. per day. – Dry 5 of 7 days – Voiding every 2 plus hours while awake
67 9/29/2019
Research
• Zaffanello and Glacomello, et al found that combined therapy (enuresis alarm, bladder retraining, motivational therapy and pelvic floor muscle training) is more effective in treating childhood nocturnal enuresis than each component alone or than pharmacology. (Minerva Urol Nefrol. 2007 Jun;59 (2): 199-205)
• Lordel and Teles, et al found that 13 of 16 pediatric patients who underwent parasacral transutaneous electrical nerve stimulation were cured of their overactive bladder. (J Urol. 2010 Aug; 184 (2):683-9. Epub 2010 June 18)
68