Physical Therapy Treatment for Pelvic Floor Disorders: Interventions and Home Programs

Transcription

1 Physical Therapy Treatment for Pelvic Floor Disorders: Interventions and Home Programs T INA M A LLEN, PT PRPC BCB - PMD U N I V E R S I T Y O F W A S H I N G T O N M E D I C A L C E N T E R H E R M A N & W A L L A C E P E L V I C R E H A B I L I T A T I O N I N S T I T U T E

2 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

3 Disclosures I have no relevant financial relationships or affiliations with commercial interests to disclose.

4 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

5 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

6 Female Pelvic Anatomy National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health.

7 Male Pelvic Anatomy

8 Perineum and Pelvic Floor - Superior View

9 Bladder and Pelvic Floor National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health.

10 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

11 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

12 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

13 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

14 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

15 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

16 Uptraining Rehab Clinical Interventions 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)

17 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)

18 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)

19 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

20 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

21 Stretching/Lengthening for the Pelvic Floor

22 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.

23 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: and clicking on the Products and Resources tab to find the Practitioner Directory

24 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