Download The Pelvic Floor

Chapter 19
The Pelvic Floor
Copyright 2005 Lippincott Williams & Wilkins
Anatomy and Kinesiology
Skeletal Muscles
Superficial
1. Anal sphincter – Provides fecal
continence.
2. Superficial perineal muscles – Aid in
sexual function.
3. Urogenital diaphram – Part of
continence mechanism.
Deep
4. Pelvic diaphragm – Coccygeus assists
to stabilize sacrum, levator ani muscles
support pelvic viscera.
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Pelvic Floor Muscles
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Related Musculature
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Pelvic Floor Function
1. Supportive – Supports pelvic
organs.
2. Sphincteric function – Provides
closure (via slow twitch fibers) of
urethra, vagina, and rectum.
3. Sexual function – Pelvic Floor
Muscles (PFMs) provide
proprioceptive sensation.
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Physiology of Micturition
Physiologic process of urination and
involves complex set of somatic and
autonomic reflexes.
PFMs and detrusor muscle coordinate activity
upon bladder filling.
Urgency increases as bladder fills.
PFMs relax and detrusor contracts, urine flows
out, and PFMs then return to resting levels.
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Anatomic Impairments
1. Birth injury – Tear,
overstretch, crushing of
PFMs
2. Neurologic dysfunction –
Disk herniation, spinal cord
injury (SCI), diabetes, radical
pelvic surgery, CNS disease
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Psychological Impairments
Motivation – Perception of disability WRT
incontinence varies across patients.
Sexual abuse – Higher incidence of
incontinence and pelvic pain.
Knowledge of symptoms (low selfesteem, self-mutilation, etc.) is crucial!
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Examination/Evaluation
Risk Factors – Screening Questionnaires
Brief
1.
2.
3.
Do you ever leak urine or feces?
Do you ever wear a pad because of leaking urine?
Do you have pain during intercourse?
Affirmative responses to these questions directs
practitioners to use a more detailed questionnaire.
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Screening Questionnaires – Detailed
 The more detailed questionnaire is administered to
patients with pelvic, back, or hip pain who are recovering
slower than expected.
 Affirmative answers to the detailed questionnaire can
distinguish patients with:
 supportive dysfunction
 stress incontinence
 urge incontinence
 organ prolapse
 hypertonia, incoordination, obstruction, urinary retention
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Results of the Internal Exam
Muscle performance (including
power and endurance)
Resting tone between contractions
Coordination
Trigger points, sensory
impairment, scars, adhesions
Internal exams are contraindicated
in some cases (pregnancy, etc.)
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Therapeutic Exercise Interventions for
Common Impairments
Impaired Muscle Performance
 Pelvic floor muscles – Treatment is
active Pelvic Floor Exercises (PFEs).
 Abdominal muscles – Patient is taught
not to “bear down.” Focus on
lumbopelvic core.
 Hip muscles – Piriformis, obturator
internus, and hip adductors, often
underlying hypertonus of PFMs.
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PFEs
Dosage – Based on principles of
overload and specificity
Duration – Progress to 10-second
contractions
Rest – Work:rest, 2:1, graduate to
1:1 as quality and endurance
improve
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PFEs
Slow twitch muscle repetitions Individualize
dosage.
Starting 3 sec/5–10 reps.
Fast twitch muscle repetitions
Contractions are held less than
2 seconds.
Sets
Several times throughout the day.
30–80 contractions per day.
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Activity
Posture – Graduate exercises from horizontal to
standing and functional activity.
Accessory muscle use – Eventually, patients
should learn to contract PFMs without
accessory muscles (abdominal muscles,
adductors, etc.).
Patient education – Location, function, and
importance of PFMs should be explained.
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Patient Education
Kegel Exercises:
1. Supportive – Hold pelvic organs in.
2. Sphincteric – Stop urine, feces, gas
from escaping until reaching the toilet.
3. Sexual – Increase sexual feelings for
women and men, assist men in
maintaining erection.
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Sample Exercise Prescription
Duration of ST contractions (5 sec)
Rest between ST contractions (10 sec)
Repetitions of ST contractions (5 times)
Repetitions of FT contractions (10 times)
Sets per day (4–6)
Position (gravity eliminated)
Accessory muscle use (not at this time)
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Pain
PFMs – Treatment should focus on
normalizing tone.
– Manual soft tissue manipulation
– Surface EMG feedback
– Electrical stimulation, ultrasound, hot or
cold on the perineum to treat spasm
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Role of Hip and Trunk Muscles in
Pelvic Pain
Trigger Points
 Adductors, PFMs, obterator internus, piriformis,
iliopsoas, abdominal
 Soft tissue mobilization, modalities, therapeutic exercise
for stretching, strengthening, and patient education
regarding body mechanics and postures
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Joint Mobility and ROM
Spasm of PFMs is often related to
lumbopelvic mobility impairments.
– SI, pubic symphysis
hypo/hypermobility may cause
secondary impairment of PFM
hypertonus.
– Unilateral PFM spasms may
perpetuate pelvic joint mobility
impairments.
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Adhesions, Scar, Connective Tissue
Adhesions – May cause SI joint mobility impairments.
Treatment – Specialized visceral mobilization.
Scar – May cause adhesions, spasm, or pain-inhibited
PFM weakness.
Treatment – Soft tissue mobilization, friction massage,
electrotherapy, hot, cold, PFEs, biofeedfack.
Connective tissue – Muscle strain may result in
irritation and shortening of fascia and tendons.
Treatment – Soft tissue mobilization, therapeutic
exercise, modalities (i.e., US, ES, HPs).
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Posture Impairment
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Coordination Impairment
Related to inappropriate patterns of timing and
recruitment of PFMs and abdominal muscles.
Inability to contract and relax PFMs at
appropriate times.
Lack of coordination of PFMs during ADLs is
observed with stress incontinence.
Activation of TrA and LM occurs with PFMs –
training this synergy can be useful to restore
coordination to PFMs.
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Clinical Classification of PFM
Dysfunction
1.
2.
3.
4.
Supportive dysfunction
Hypertonia dysfunction
Incoordination dysfunction
Visceral dysfunction
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Supportive Dysfunction
 Impaired performance of PFMs
 Treatment (TMT) – PFE with facilitation
 Incoordination of PFMs
 TMT – PFE with SEMG feedback during ADLs
 Pain in PFMs
 TMT – Origin of pain must be treated
 Joint mobility impairment of lumbopelvic joints
 TMT – Soft tissue/joint mobilization, muscle energy
techniques, therapeutic exercise
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Hypertonia Dysfunction
May result from many possible physiologic
impairments such as pelvic joint dysfunctions,
hip muscle imbalance, abdominopelvic
adhesions and scars.
Interventions vary widely and are based on
underlying impairments.
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Incoordination Dysfunction
Neurologic syndrome
 For example, detrusor sphincter dyssynergia results
from neurologic lesion in the spinal cord between the
brainstem and T10.
Non-neurologic syndrome
 Characterized by absent or inappropriate patterns of
timing and recruitment of PFMs.
 Often related to disuse and decreased awareness of
PFMs and abdominal muscles.
 Functional limitation includes stress incontinence
during coughing, sneezing, lifting.
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Visceral Dysfunction
Disease or abnormality in mobility or motility of the
abdominopelvic visceral tissues that leads to pain and
musculoskeletal impairments.
 Urge incontinence is the most widely seen visceral
dysfunction directly related to the PFMs.
 Visceral mobilization techniques are used to restore
normal mobility to organs.
 Combine with postural training, comprehensive
therapeutic exercises involving PFMs, abdominal and hip
musculature.
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Therapeutic Exercise Interventions for
Common Impairments
Incontinence
 Stress incontinence
 Urge incontinence
 Mixed incontinence
 Overflow incontinence
 Functional incontinence
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Stress Incontinence
Involuntary leaking of urine on effort or
Exertion, such as coughing, laughing,
sneezing, and lifting.
PFEs
SEMG/pressure feedback
Vaginal cones
NMES
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Urge Incontinence
Urge incontinence is defined as leaking urine
associated with a strong urge to urinate.
 Bladder training
Avoid bladder irritants
PFEs
SEMG/pressure feedback
Low-frequency NMES
Medications
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Mixed Incontinence
Mixed incontinence is a combination of stress
and urge incontinence symptoms.
PFEs
Bladder training
Avoid bladder irritants
SEMG/pressure feedback
Vaginal cones
NMES
Medications
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Overflow Incontinence
Overflow incontinence results from a failure to
empty the bladder fully.
Medical evaluation may be needed
Advanced PFM rehab with SEMG/pressure
feedback
NMES
MFR
PFEs
Bladder training
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Functional Incontinence
Functional incontinence is defined as the loss
of urine because of gait and locomotion
impairment (inability to get to toilet quickly).
Gait training
Transfer training
Strengthening exercises for lower & upper
extremities
Environmental modifications (velcro-open
pants, skirts/dresses, absorbent garments)
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Additional Diagnoses
1.
2.
3.
4.
5.
6.
7.
8.
Organ prolapse
Chronic pelvic pain
Levator ani syndrome
Coccygodynia
Vulvodynia
Vaginismus
Nonrelaxing puborectalis syndrome
Dyspareunia
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Adjunctive Interventions
Many other interventions are used in
conjunction with exercise for the treatment of
pelvic floor dysfunction.
Biofeedback
Basic bladder training
Scar mobilization
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Biofeedback
It is necessary to provide all patients with some
form of biofeedback whether it is a finger in the
vagina, a mirror, or surface EMG.
Surface EMG and pressure biofeedback are two
methods of machine biofeedback.
SEMG – Provides precise information regarding
quality of contraction(s), recruitment patterns,
and resting/baseline tone.
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Surface Electromyography (SEMG)
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Basic Bladder Training
 Scheduled voiding to regain normal voiding patterns.
 Used in cases of urgency, frequency, urge incontinence,
or mixed incontinence.
 Patient keeps a record of time of day he or she urinates
in the toilet, time of incontinence, and cause of
incontinence.
 Average voiding interval is determined.
 Voiding interval is adjusted based on improvements in
continence.
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Scar Mobilization
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Summary
 Pelvic floor tissues include four skeletal
muscle layers.
 Pelvic diaphragm is the largest group of
PFMs and is 70% ST, 30% FT.
 Three functions of pelvic floor are
supportive, sphincteric, sexual.
 All patients should be screened for PFM
dysfunction using brief questionnaire.
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Summary (cont.)
 Patients can be given self-assessment tests and selfawareness exercises.
 Impairments that affect PFMs include impairment in
muscle performance of PFMs, abdominal muscles, hip
muscles, trunk muscles; pain; joint mobility, etc.
 PFMs have four clinical classifications.
 Incontinence types include: stress, urge, mixed,
overflow, and functional.
 Teaching PFMs involves thorough patient education.
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