Physical Therapy Treatment for Pelvic Floor Disorders: Interventions and Home Programs
TINA M ALLEN, PT PRPC BCB -PMD
UNIVERSITY OF WASHINGTON MEDICAL CENTER HERMAN & WALLACE PELVIC REHABILITATION INSTITUTE
Co-Faculty
Heather S. Rader, PT, DPT, PRPC, BCB-PMD Sher Pelvic Health and Healing- Orlando, FL Herman and Wallace Pelvic Rehabilitation Institute
Kathryn Rice, PT, DPT University of Washington Medical Center –Seattle, WA Disclosures
I have no relevant financial relationships or affiliations with commercial interests to disclose. What Does a Pelvic Rehab Provider Do?
During history taking, the focus is on finding functional deficits and figuring out the patient’s habits and goals
Medically screen for needed referral to physician
Specifically assess the muscles, fascia, ligaments, nerves, and other tissues of the pelvis, and nearby joints that may be involved
Pelvic floor muscle assessment of coordination, endurance, resting state of muscles (may include Biofeedback and/or internal exam) Lee, 2011 Specific Muscle Layer Palpation/Assessment
Layer 1: Superficial muscles Ischiocavernosus, bulbocavernosus, superficial transverse perineal, external anal sphincter
• Layer 2: Urogenital diaphragm Sphincter urethra, compressor urethra, sphincter urethrovaginalis, deep transverse perineal
• Layer 3: Pelvic diaphragm Levator ani, coccygeus Hip muscles: obturator internus, piriformis
Female Pelvic Anatomy
National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health.
Male Pelvic Anatomy Perineum and Pelvic Floor - Superior View Bladder and Pelvic Floor
National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health.
Pelvic Floor Function - 5 S’s
Support Sphincteric Sexual Stability Sump pump/Lymphatic return Also, posture, balance and breathing! Kegel 1944, Hodges, Sapsford, Lee, Massery
Contract/Relax/Bulge/Maintain some tension throughout the day
Specific Tests & Measures
PFM testing via external and internal techniques gives information about: Strength, endurance, coordination Symmetry and bulk Awareness Presence of pain or tension
Specific Pelvic Floor Muscle Strength
ICS – Normal, Overactive, Underactive, Non- Functioning (Haylen, 2010) Laycock assessment/PERFect: Power/Endurance/Repetitions//Fast twitch/every contraction timed (Laycock, 2002) 2/5/5//10 Compare right to left to central strength Correlate to scaring, nerve injury, hip/back injury Adapt to function “if you only perform kegels at stop lights you are only continent at stop lights” Typical Substitutions
Holding of the breath Use of thighs and gluteals Use of toes, upper chest Bulging of the abdomen, bearing down through pelvic floor
Verbal Cues for Pelvic Floor Muscle Contraction
Say more than “Squeeze” “Close the openings, lift up and in” (pull a tampon up and in) “Contract as if you were trying to hold back gas, stop urine from flowing” Elevator image “Wink the anus” “Move the clitoris/penis” “Pull the underwear in” “Bring your “sits bones” together, lift your perineum off the chair”
Clinical Concept in Pelvic Rehabilitation
Strengthen or lengthen? Does patient need more strength or better coordination? Does patient have shortened, tight muscles that need more relaxation? Determine actual function before implementing a strategy
Rehab Clinical Interventions
Uptraining To increase muscle activity (SUI, UI, Prolapse, FI) Downtraining To decrease muscle activity (pain, IC/PBS, UI, Constipation) Coordination training Timing and sequencing of contractions Functional training (Sports, walking across the street, lifting children)
Uptraining/Coordination
We know from studies and pelvic rehab clinical experience At least 40% of people can’t do a pelvic floor contraction with verbal or written instruction alone (Bump 1991, Scott 2013) Continent women recruit muscles in a superficial to deep muscle pattern while incontinent women and men will recruit in reverse and are not able to recruit in various positions (Devereese 2007, Scott 2013) Training in isolated pelvic floor muscle strengthening decreases symptoms of bother regarding pelvic organ prolapse vs training in preemptive contraction alone (Braekken, 2010)
Uptraining/Coordination
Teach recruitment pattern (superficial to deep) Teach Pre-emptive contraction (“the Knack”) Ashton-Miller et al., 1998 Progress to functional postures (“if you only perform kegels at stop lights you will only be continent at stop lights”) Progress to dynamic/daily tasks SEMG is beneficial Home Electrical Stimulation can be beneficial Can progress to usage of other home devices including: vaginal weights, home devices (Kgoal, Pericoach, Elvie, Iease) Indications for Down Training
Common Findings (King 1991, Loving 2014, Tu 2008, Montenegro 2010, Fitzgerald 2011, Neville 2012, Hetrick 2003): Short, tight muscles in pelvic floor, pelvis, low back, and lower extremities contribute to pain. Postural dysfunction : often holding /contracted posture is noted Dyscoordination of pelvic muscles on observation Weak pelvic muscles on digital exam Possible urgency/frequency of urination
Down Training/ Coordination
Teach awareness and relaxation practices Retrain Posture/reduce holding patterns Manual Therapy techniques (clinic and home) General Stretching/Lengthening program Progress to maintaining improved resting level with increasing dynamic tasks (fitness, social, intimacy and work) Biofeedback/SEMG maybe helpful **In General; Avoid PF strengthening until normal resting level is achieved** Home usage of dilators, wands maybe helpful Stretching/Lengthening for the Pelvic Floor Pain and the Brain
Rehab approaches are increasingly following biopsychosocial models and instructing patients in behavioral modification practices to overcome chronic pain patterns As-Sanie et al., 2012 Movement based approaches such as Feldenkrais, Somatic exercises, Yoga, Qigong, Tai Chi can be very helpful for our patients with pain.
How to Refer to Pelvic Rehabilitation
Find a local clinic who offers pelvic rehabilitation Provide a referral and/or script that states “Physical Therapy evaluate and treat” Emphasize the value of pelvic rehab to the patient Pelvic rehab provider lists at: http://www.hermanwallace.com and clicking on the “Products and Resources” tab to find the “Practitioner Directory http://www.womenshealthapta.org/pt-locator/
Muscle Layer Demo
Layer 1: Superficial muscles Ischiocavernosus, bulbocavernosus, superficial transverse perineal, External Anal Sphincter
• Layer 3: Pelvic diaphragm Levator ani, coccygeus Hip muscles: obturator internus, piriformis