2/23/15 PRESENTERS ANATOMY OF THE PELVIC FLOOR

Transcription

1 ENHANCING PELVIC FLOOR FUNCTIONING THROUGH SEATING AND POSITIONING Carina Siracusa Majzun, PT, DPT Derrick Johnson, ATP PRESENTERS Carina Siracusa Majzun, PT, DPT Ohio Health, Columbus Ohio Pelvic Floor Physical Therapist Oncology Rehabilitation Program Coordinator Co-Coordinator Wheelchair Clinic Derrick Johnson, ATP Territory Sales Manager for Permobil and TiLite ANATOMY OF THE PELVIC FLOOR The bony pelvis: 1. Sacrum 2. Ilium 3. Ischium 4. Pubic bone 5. Pubic symphysis 6. Acetabulum 7. Foramen obturator 8. Coccyx Red line: Terminal line/ pelvic inlet/pelvic outlet 1

2 KINEMATICS OF THE COCCYX The coccyx follows the movement of the sacrum There is about 30 total degrees of coccyx range of motionapproximately 15 degrees in either direction Normal coccyx movement is required for pain free sitting, movement, and normal bowel function KINEMATICS OF THE COCCYX SUPERFICIAL PELVIC FLOOR MUSCLES Ischiocavernosus: Ischial tuberosity to pubic rami and undersurface of crus of the penis or clitoris Maintains male erection or erection of the clitoris Innervated by Perineal Branch of Pudendal Nerve, S2-4 2

3 SUPERFICIAL PELVIC FLOOR MUSCLES Superficial Transverse Perineal: Runs laterally from the ischial tuberosity to perineal body Supports the perineal body/ stabilizes perineum Innervated by Perineal Branch of Pudendal Nerve, S2-4 SUPERFICIAL PELVIC FLOOR MUSCLES Bulbocavernosus: Perineal body around vestibule to clitoris Bulbospongiosus in the male, empties urethra & assists male erection Initiates clitoral erection and serves as a vaginal sphincter Innervated by Perineal Branch to Pudendal Nerve, S2-4 DEEP PELVIC FLOOR MUSCLES Function: Supportive: Postural tone for pelvic organs Postural Stabilizer: Assists in core stabilization Sphincteric: Inward lift and squeeze of urethra, vagina, and anus Sexual: Contraction during orgasm Fiber type 70% slow twitch (Type I), 30% fast twitch (Type II) 3

4 DEEP PELVIC FLOOR MUSCLES Pubococcygeus: (misnomer) Pubic rami and ATLA to the anococcygeal raphe Further divisions: puboperinealis, pubovaginalis, puboanalis Elevates these structures Innervation: Pudendal nerve and S3-4 (perineal branch) and Levator Ani Nerve: S3-5 DEEP PELVIC FLOOR MUSCLES Puborectalis: Post, inf. pubic bone 3cm above archus tendineus levator ani Slings around the rectum like a lasso Maintains the anorectal angle Inferior rectal branch of the pudendal nerve DEEP PELVIC FLOOR MUSCLES Iliococcygeus: Posterior 1/2 of the archus tendineus levator ani to anococcygeal raphe and coccyx Supportive sling/ shelf that spans the pelvic outlet posteriorly Innervation: Levator Ani nerve S3-4 4

5 DEEP PELVIC FLOOR MUSCLES Coccygeus ischial spine and sacrospinous ligament to the coccyx and lower sacrum Lies on top of the sacrospinous ligament tail wagger, flexes the coccyx Innervation: sacral plexus nerves from S4 and S5 PERINEAL BODY Fibromuscular structure between the urogenital and anal triangles Links the superficial transverse perineal muscles Childbirth: During delivery SHOULD stretch and recoil Overstretch, episiotomy (incision), tears may impair recoil function, cause weakness, and lead to pelvic organ prolapse PERINEAL BODY 5

6 MUSCLES OF THE PELVIC RING Obturator Internus: Superior lateral intrapelvic wall obturator foramen, through lesser sciatic notch beneath the ischial spine and behind the ischial tuberosity, right angle to greater tuberosity Hip ER In a state of pelvic or hip dysfunction, acts as an unwilling stabilizer easily overworked Innervation: Obturator nerve L5-S2 IMPORTANT PELVIC FLOOR NERVES Pudendal nerve Through greater sciatic notch between piriformis and coccygeus under the sacrospinous ligament Back into pelvic ring through lesser sciatic notch where the 1) inferior rectal nerve branches off to innervate the posterior perineum (branching location can vary) Medial to the ischial tuberosity into Alcock s canal branching into 2) Perineal branch 3) Dorsal clitoral branch PUDENDAL NERVE 6

7 MUSCLES OF THE ABOMINAL WALL MUSCLES OF THE ABDOMINAL WALL DIAPHRAGM 7

8 RELATIONSHIP OF THE ABDOMINALS TO PELVIC FLOOR Soda Can model All of these muscles must work synergistically in order for continence to be maintained All of these muscles are important in both seated and standing posture The abdominal muscles help to maintain postural tone Abdominal muscles help to regulate intrabdominal pressure PHYSIOLOGY OF MICTURITION: KEYS TO CONTINENCE In men: Passive urethral luminal coaptation The bladder neck and preprostatic muscular cuff around urethra Urethral length (21 cm) and two sites of elevation within urethra Both sexes: Levator ani and urethral sphincter In women: Passive urethral luminal coaptation Coaptive mechanism is less effective peri-to postmenopausal due to hormonal changes reducing vascularity and mucous membrane secretion. Urethral structure including short length and steep downward angle provides little assistance in continence. There is a heavy reliance upon extra-luminal periurethral musculature. NORMAL HABITS OF URINATION Good Micturition Habits: Store then fully empty urine at an opportune time. Frequency: 4-7 X/day and 0-1 X per night (if > 65 than 2X/night) Generally one urinates every 2-5 hours 7-8 voids/24 hours Completion of urination should take at least 8 10 seconds. 8

9 POOR MICTURITION HABITS Poor Micturition Habits: Waiting 8 hours after work to void Squatting ( hovering ) over the toilet (pelvic floor muscles are contracting rather than relaxing) Rushed voiding: not allowing for muscle relaxation and full bladder emptying Preventative or Just in case voiding Failing to wipe front to back Straining to empty bladder. URINE STORAGE Bladder holds ml (16-20 oz) urine First sensation to void at ml Micturition occurs at about 400 ml but can be delayed by frontal lobe Cystometry/urodynamics: First sensation to urinate occurs at about 40% of capacity Desire to void at 70-75% This is significant when people have abnormally large or small bladder capacity PHYSIOLOGY OF MICTURITION We have several ways neurologically that we control urination We have descending neural control from the brain We have parasymptathetic and symptathetic control over the bladder We also control urination through musculature control and through postural control 9

10 PHYSIOLOGY OF DEFECATION End result of the digestive process, begins in the mouth Peristalsis- rhythmic smooth muscle contractions, moves bolus through the organs Final component- expulsion of waste material through the anal sphincter Complex process, autonomic functions and conscious awareness necessary Also highly reliant on control of the pelvic floor muscles PHYSIOLOGY OF DEFECATION: COLON Processing, Absorption and Storage Ascending colon processes and absorbs nutrients, water, vitamins and electrolytes Beneficial bacteria work to decompose fiber Descending colon stores feces, continues movement to rectum Peristalsis continues to move stool into rectal canal, causing increased pressures Distension of stretch receptors creates sensory awareness, transient urge to defecate Initial increased activity both anal sphincters and puborectalis Ongoing urgency can be counteracted by active Pelvic Floor/External Anal Sphincter contractions GENERAL FUNCTION: ANORECTAL ANGLE Normal Anorectal Angle ( ) Maintained by Puborectalis muscle (PR) Changes approximately as the PR relaxes during defecation 10

11 ANORECTAL ANGLE Ability to increase (become more obtuse) Facilitates defecation Enhanced by squatting, hip flexion 90 If caused by muscle weakness/injury, may bowel control Ability to decrease (become more acute) Indica8on of normal func8on of PR Prevents leakage with Intra- abdominal pressure Delay defeca8on DEFECATION MECHANISMS Ancillary muscle assistance IAP directed inferiorly by contractions of diaphragm, intercostals and abs Promotes intra-rectal pressure in conjunction with anal relaxation, pressure in IAS/EAS Pressure increases are suggested to be sub-maximal to reduce excessive strain to the pelvic floor musculature EAS, IAS and PR all contract to reestablish anorectal angle- closing reflex REQUIREMENTS FOR FECAL CONTINENCE Resting continence IAS/EAS intact Anorectal angle (approx 90 ) maintained by PR and sphincteric activity during IAP Intact reflexes, normal sensorimotor function 11

12 ROLE OF MUSCULOSKELETAL SYSTEM IN DIGESTION Abdominal tone In order for normal peristalsis to occur, there needs to be normal abdominal tone The contraction of the abdominal muscles can help to move food through the colon and allow for normal digestion Pelvic Floor Tone Responsible for continence Responsible for normal defecation and relaxation of the anal sphincters ROLE OF INTRABDOMINAL PRESSURE IN CONTINENCE/DIGESTION In order to maintain continence, the pelvic floor muscles need to be able to respond appropriately to increased intra-abdominal pressure In order to be able to properly urinate or defecate, the patient needs to be able to generate appropriate intra-abdominal pressure (bearing down) Patients need to be able to effectively activate the diaphragm in order to be able to generate intra-abdominal pressure SEATING AND POSITIONING Tilt Anterior Tilt Recline Power Elevating Legrest Standing Independent Repositioning Mode 36 12

13 TILT Pressure relief - Reduce risk of pressure ulcers Postural stability - Gravity assisted positioning Improved sitting tolerance - Change in position Provides position of rest - Reduces fatigue Seat to back angle remains consistent - Maintains proper position relative to devices mounted on seat 37 ANTERIOR TILT Functional access forward - Ready Position Assists with transfers - Sit to stand Tone Management Functional compensation for people with limited hip flexion 38 RECLINE Pressure distribution - Reduce risk of pressure ulcers Postural stability - Gravity assisted positioning Improved sitting tolerance - Change in position Provides position of rest - Reduces fatigue Seat to back angle changes - Risk of shearing and translation of components Ideal for bowel/bladder management 39 13

14 TILT & RECLINE Why would someone need tilt and recline compared to a tilt only system? Maximum Pressure Relief Sitting Tolerance Comfort Functional Activities Respiration Tone Management Position of Rest Medical Management 40 ELEVATING LEGRESTS Reduces LE edema (Must be combined with tilt and/or recline) Provides knee ROM - Accommodates contractures Supports LE casts & splints Improves circulation Pain Management 41 STANDING Improve range of motion and reduce the risk of contractures Promote vital organ capacity including pulmonary, bowel and bladder function Promote bone health Improve circulation Reduce abnormal muscle tone and spasticity Reduce the occurrence of skeletal deformities Reduce the occurrence of pressure ulcers Provide numerous psychosocial and quality of life benefits 42 14

15 INDEPENDENT REPOSITIONING MODE (IRM) When used, Tilt, Legrest, and Recline will move in a sequence to help the user reposition themselves back in the seat. Fully backward and fully forward seat positions can be tailored to fit the user. Ensure clients get to appropriate position Compliance with pressure relief 43 RESNA POSITION PAPER ON APPLICATION OF WHEELCHAIR STANDING DEVICES Bowel and Bladder Standing increases bowel motility by allowing for better peristalsis and normal positioning for the large and small intestine Standing improves bladder emptying by allowing for the appropriate amount of intrabdominal pressure to be created as well as positioning the detrustor muscle for the optimum position for emptying Standing helps to improve voluntary sphincter control (Netz et at 2007) Fewer UTIs and improved bowel regularity with standing (Walter et al 1999) ENHANCING THE PELVIC FLOOR Tilt and Recline By using tilt and recline you can decrease the amount of intra-abdominal pressure that is being exerted on the pelvic floor thereby increasing continenence This will allow for the increased manintnence of continence Also, you are decreasing the gravitational pull on the pelvic floor, allowing it to more effectively contract and relax- at least 30 degrees of tilt will help with decreased pull on the pelvic floor 15

16 ENHANCING THE PELVIC FLOOR Anterior Tilt Anterior tilt will allow for a more effective squatting position which will allow for more effective relaxation of the anorectal angle This will also allow better relaxation of the anal sphincters which will aid in defecation Anterior tilt/squatting position allows for increased intrabdominal pressure SQUATTY POTTY SQUATTING TO FACILITATE DEFECATION 16

17 ENHANCING THE TRUNK MUSCLES Tilt and Recline Tilt and recline can improve respiratory function by decreasing the gravitational pull on the abdominal muscles which will allow them to decrease the amount of work that they must do Will also decrease the load on the accessory breathing muscles Standing can also increase ventilation by allowing for increased space in the chest wall and improved movement of the diaphragm ENHANCING DIGESTION Tilt and Recline/Standing By positioning the patient to allow the abdominal muscles to work more effectively you can help to advance peristalsis By positioning the abdomen you are also increasing the ability for the movement of the food throught the gut by improving abdominal muscle tone Must be careful with recline- may increase GERD Standing helps to increase peristalsis and allow room for the small intestine and large intestine QUESTIONS? 17