17 th European congress of Physical Rehabilitation Medicine. 38th SIMFER congress

Transcription

1 17 th European congress of Physical Rehabilitation Medicine 38th SIMFER congress European Rehabilitation: Quality, Evidence, Efficacy and Effectiveness Venice, May

2 THE PHYSIATRIST AND URO-GYNECOLOGICAL REHABILITATION WORKSHOP Venice, May

3 INTRODUCTION and OVERVIEW Paolo Di Benedetto Rehabilitation Medicine Department Physical Medicine and Rehabilitation Institute Udine, Italy

4 PELVIC FLOOR REHABILITATION (PFR) Arnold Kegel, Californian gynecologist, popularized the idea of pelvic floor exercises in the late 1940s. But, before Kegel, other Authors suggested some types of exercises in the treatment of urinary incontinence and genital prolapse (Brandt, 1864; Vulliet, Jentzer, and Boucart, 1890; Wide, 1898; Doléris, 1903; Gellhorn, 1923; Hinman, 1935; Davies, 1938).

5 PELVIC FLOOR REHABILITATION A.H. KEGEL (1948) PUBLISHED ARTICLES - Physiologic therapy for urinary stress incontinence; - The physiologic treatment of poor tone and function of the genital muscles and of urinary stress incontinence; - Stress incontinence and genital relaxation; - Stress incontinence of urine in women: physiologic treatment; - The physiologic treatment of urinary stress incontinence.

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9 PELVIC FLOOR REHABILITATION Perineometer resistive exercise (A.H.Kegel) The strength of contraction is estimated from the impression gained through palpation or is actually measured with the aid of the perineometer. This instrument consists of a pneumatic resistance chamber to which a manometer designed to register the strength of contractions of the muscles surrounding the vagina is attached. In women with normal function of the pubococcygeus muscle the reading will amount to mm Hg, while in patients with urinary stress incontinence muscular function is poor or absent, and the manometer registers a pressure of 0 to 5 mm Hg. In order to obtain correct measurements, it is necessary that the patient confines her efforts at contractions only to the muscles in the region of perineum and vagina. Patients with lack of awareness of function of the pubococcygeus muscle will invariably try to substitute contractions of extraneous muscles, especially those of the abdominal wall and gluteal region.

10 After Kegel PELVIC FLOOR REHABILITATION * French school, and Swedish school * Biofeedback * International Continence Society (ICS) 1992: Lower Urinary Tract Rehabilitation Techniques: seventh report on the standardization of terminology of lower urinary tract function (Neurourol Urodyn 1992;11: )

11 After Kegel PELVIC FLOOR REHABILITATION * American guidelines in the management of urinary incontinence (UI) in adults (Fantl et al, 1996) * 1998: first International Consultation on Incontinence (Monaco) algorithms for initial and specialized management of UI

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15 PFR in Uro-Ginecology INDICATIONS - Urinary Incontinence - Genital Prolapse (Prevention) - Pelvic Surgery - Chronic Pelvic Pain

16 PFR: WHY? - Urinary incontinence (UI) is a frequent condition in women ( its prevalence varies between 10% and 40% in general population); - Genital prolapse, based on symptoms, accounts for 7-23%; - Chronic Pelvic Pain is an underestimated condition (but its prevalence has been estimated at 3.8% of all women, and 14.7% of women aged years).

17 PFR Non-surgical therapy should be considered as the first line of treatment for urinary incontinence: - no side effects - good results - surgical option not compromised

18 PELVIC FLOOR SKELETAL MUSCLES Slow Twitch Fibers (type I support of the pelvic viscera) Fast Twitch Fibers (type II occlusive effect on the urethra, reflex detrusor inhibition)

19 STRUCTURE/FUNCTION PFM FIBER TYPES Support for lower abdominal viscera (uterus, bladder, bowel) Sexual for orgasm Sphincteric for continence - Type I aerobic heavily myelinated slow recruiting sustaining fibers - Type II glycolitic anaerobic fast twitch - Mixed type I & II rapid and sustained closure

20 PFM FUNCTION (1) The pelvic floor supports the bladder and the urethra in the anterior compartment, the uterus and the vagina in the middle compartment, and the rectum and the anus in the posterior compartment. The integrity of the support function depends on the anatomical position of the pelvic floor muscles (PFM), on the resting tone and on the integrity of the fascia. The support activated during a rise in intraabdominal pressure is different from that at rest. When the intra-abdominal pressure rises, the PFM must respond with a contraction occurring simultaneously or before the pressure rise.

21 PFM FUNCTION (2) A contraction of the PFM results in a inward movement of the perineum and a upward movement of the pelvic organs. Two types of contraction (voluntary contraction resulting from impulses arising in the cerebral cortex, and a reflex contraction) maintain support of the pelvic organs; close the urethra anus and vagina, thus avoiding loss of urine or stool; additionally PFM contraction inhibits detrusor. A contraction of the PFM must have sufficient strength, resulting from muscle capacity and neurogenic drive.

22 PFM FUNCTION (3) We have to underline: - the endurance (tonic activity) of the PFM; - the role of PFM in sexual function; - The ability of PFM to relax for urinary voiding, defecation and for sexual intercourse.

23 PFM DYSFUNCTION (1) Dysfunction of the pelvic floor can mean : - Underactivity ( PFM do not contract when they need to) - Overactivity (PFM do not relax when they should)

24 PFM DYSFUNCTION (2) UNDERACTIVITY Primary Weakness (phasic and tonic components ) Apraxia Secondary Weakness (neurogenic, post-partum, post- surgery)

25 PFM DYSFUNCTION (3) UNDERACTIVITY Primary Weakness untrained weakness? Apraxia lack of awareness? Secondary Weakness role of the scars

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27 PFM DYSFUNCTION (4) Overactivity (nonneurogenic, neurogenic) Dyssynergic patterns

28 PELVIC FLOOR CONSEQUENCES of Occupation Sport Pregnancy Childbirth Menopause

29 PFM DYSFUNCTION CONSEQUENCES Deficit of the PFM reflex contraction Genital prolapse Urinary stress incontinence Overactive bladder Sexual dysfunction Chronic pelvic pain

30 URINARY INCONTINENCE EPIDEMIOLOGICAL STUDIES (1) Nygaard et al (1994) 158 athletes, mean age 19.9 years all nulliparous 28% urinary incontinence during sport activities (2/3 IU more often than rarely) 67% gymnastics 66% basketball 50% tennis 10% swimming 0% golf

31 URINARY INCONTINENCE EPIDEMIOLOGICAL STUDIES (2) Warren and Shantha high impact sports activities may produce urinary incontinence Greydanus and Patel adolescent gynecology: stress urinary incontinence is common in female athletes

32 URINARY INCONTINENCE EPIDEMIOLOGICAL STUDIES (3) Bø and Borgen high prevalence of stress and urge incontinence in female elite athletes, mainly in eating disordered athletes compared with healthy athletes

33 URINARY INCONTINENCE EPIDEMIOLOGICAL STUDIES (4) Thyssen et al elite women athletes and dancers 291 women, mean age 22.8 years 51,9% urinary loss (43% during sport/dancing; 42% during daily life) the activity most likely correlated with urinary incontinence was jumping

34 INTRAPARTUM INJURY LEVATOR ANI MUSCLES Muscles Tears CONNECTIVE TISSUE Breakage Stretching Pudendal Nerve Acute Denervation Loss of muscle tone Chronic Denervation Aging Connective tissue failure GENITAL PROLAPSE Proposed mechanism for acute injury to pelvic supportive structures at childbirth that may result in chronic denervation and pelvic organ prolapse (from Strohbehn, 1998)

35 PREDISPOSE gender racial neurologic anatomic collagen muscular cultural environmental INCITE childbirth nerve damage muscle damage radiation tissue disruption radical surgery normal support or function PROMOTE constipation occupation recreation obesity surgery lung disease smoking menstrual cycle infection medication menopause INTERVENE behavioral pharmacologic devices surgical abnormal support or function Model for the development of pelvic floor dysfunction in women (Bump et al, 1998) DECOMPENSATE aging dementia debility environment medication

36 JO DeLancey. Editorial. Current Opinion in Obstetrics and Gynecology 1994;6:313-6 The interaction between the pelvic floor muscles (PFM) and the supportive ligaments is critical to support of the pelvic organs. As long as the PFM function normally, the pelvic floor is closed and the ligaments and fascia are under no tension. The fascia simply acts to stabilize the organs in their position above the levator ani muscles.

37 JO DeLancey. Editorial. Current Opinion in Obstetrics and Gynecology 1994;6:313-6 When the PFM relax or are damaged, the pelvic floor opens and the vagina lies between the high abdominal pressure and low atmospheric pressure. In this situation it must be held in place by the ligaments. Although the ligaments can sustain these loads for short period of time, if the PFM do not close the pelvic floor then the connective tissue will became damaged and eventually fail to hold the vagina in place.

38 PELVIC ORGAN PROLAPSE BOAT IN DRY DOCK CONCEPT Boat in dry dock concept of pelvic organ prolapse. A) Boat is supported by water (pelvic musculature) and held in place by its moorings (pelvic ligaments and fascia). B) If the water is removed, the moorings are suddenly placed under great strain. Likewise, loss of pelvic floor tone places excessive force on the pelvic ligaments and fascia. (From Norton PA: Pelvic floor disorders: the role of fascia and ligaments. Clin Obstet Gynecol 36:927, 1993)

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40 PELVIC FLOOR REHABILITATION (PFR) KEGEL EXERCISES PELVIC FLOOR EXERCISES PELVIC FLOOR MUSCLE TRAINING

41 PFR IN URO-GYNECOLOGY TECHNIQUES - Biofeedback (BFB) - Pelvic Floor Muscle Training (PFMT) - Functional Electrical Stimulation (FES) - Endovaginal Cones - Bladder Retraining

42 TOPICS Functional Anatomy of the Pelvic Floor and Lower Urinary Tract (LUT) Stefano FLORIS Pathophysiology of LUT and pelvic floor dysfunction (PFD) Tullio GIORGINI The role of the Physiatrist in the diagnosis of PFD Pelvic Floor Rehabilitation (PFR): techniques, rationale, and protocols Paolo DI BENEDETTO Tullio GIORGINI PFR: evidence based medicine Urinary Incontinence and adapted physical activity Stefano FLORIS Paolo DI BENEDETTO