Download Objectives About the Presenter - The Iowa Physical Therapy

3/1/2017
Women’s Health Issues,
Male/Female Urinary
Incontinence,
& Physical Therapy
Presented by KeriAnne Schmidt, DPT
Objectives
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Review the anatomy of the Pelvis and the close relation
to our spine, sacrum, coccyx, and hips.
Learn how Physical Therapy can help patient’s with:
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Pelvic pain
Coccyx pain
Urinary Incontinence
Organ prolapse
Sexual pain and dysfunction
Pregnancy and Post-partum issues
Identify who is appropriate for pelvic floor Physical
Therapy.
Recognize the benefits of multi-disciplinary, holistic, and
integrated care to best serve chronic pelvic pain patients
Learn how to progress with strengthening of the Pelvic
Floor and Transverse Abdominis
About the Presenter
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Graduated from Clarke
University in 2009 with a DPT
Have 2 Children
 Gage (5) and Chloe (3)
Have worked in many
settings:
 Large Acute Care hospital
 Outpatient
 Home Health
 Extended and Skilled care
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About the Presenter
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At Regional Medical Center, Manchester, IA for 2 ½
years.
Personal Experience with UI after delivering Chloe
 Always had an interest in this specialty
First Women’s Health CEU Course- November 2015
Herman and Wallace Pelvic Floor training
Pelvic Floor 1 Certification- November 2016
 Internal examination and treatments/interventions
Pelvic Floor 2a Certification- February 2017
 Male pelvic floor internal exam, further examination
skills
Pelvic Floor 2b and Capstone- 2017-2018
Abdominal Wall
Abdominal Wall
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Transverse Abdominis
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Origin: Internal surfaces of 7th to 12th Costal
cartilages, thoracolumbar fascia, iliac crest,
and lateral third of the inguinal ligament.
Insertion: Linea alba with the aponeurosis of
internal oblique, pubic crest, and pecten pubis
via conjoint tendon.
Actions: compresses and supports abdominal
viscera.
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Deep Abdominal Wall
Multiple Functions of the
Abdominal Wall
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Abdominal and pelvic organ support
Orifice support (cardiac sphincter - esophagus,
inferior vena cava, aorta, inguinal canal)
Breathing
Voiding, defecation
Movement control (stability)
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Abdominals work synergistically with the pelvic floor
muscles and diaphragm to provide control to joints of
the pelvis, lumbar spine and the lower thorax through
multiple mechanisms
Cresswell et al 1993, Hodges et al 1996 – 2014,
Sapsford et al 2001, Smith et al 2007 Stuge et al 2006
Muscles Of The Hip
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Deep Hip Musculature
Unique Relationship
Muscle and Ligament
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• Sacrotuberous – pelvic floor boundary
Organs
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Female
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Male
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The Pelvis
3 Layers
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Layer 1- Perineum, External
Genitalia Muscles
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Layer 2- Urogenital
Diaphragm
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Ischiocavernosus,
Bulbospongious, Superficial
Transverse Perineal, External
anal sphincter.
Deep perineal space including
muscles, glands, urethra and
pudendal vessels.
Layer 3- Pelvic Diaphragm
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Levator Ani and Coccygeus,
Pelvic Wall Muscles, Piriformis,
and Obturator Internus
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Female Pelvic Floor
Female Pelvic Floor
Male Pelvic Floor
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The Role of Pelvic Floor
Musculature
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SUPPORT
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SPHINCTERIC
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Assists in pelvic/spinal stability
Assists in organ support along with ligaments and fascia
Reinforces urethral and anal closure during increases of intraabdominal pressure
Has an inhibitory effect on bladder activity
SEXUAL
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The PF muscles (all layers) contract the vaginal walls for sexual
sensation
Stronger muscles correlate with orgasmic appreciation
Muscles attach to the clitoris and penis and assist in erection
Exercise of these muscles can increase the ability for sexual
arousal
(Kegel 1949, Seigel 2014)
Pelvic Floor Muscle Make-up
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Slow and fast twitch muscle fibers are present in skeletal
muscles throughout the body.
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Slow twitch fibers are responsible for prolonged, sustained
muscles i.e. posture muscles.
Fast twitch fibers are responsible for quick reactions.
The endurance (slow twitch) muscle fibers are present in
the deepest of the PFM. About 30% of the fibers are
slow twitch and they assist with maintaining tone and
supporting the pelvic organs.
The fast twitch fibers make up about 70% and are
mainly responsible for rapid sphincter closure.
The ability of the pelvic muscles to
cooperatively relax and contract is
essential for normal urination, defecation,
and sexual activity.
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Synergy - Abdominal Wall, Pelvic
Floor, and Diaphragm
The 4 Muscle Groups of the Inner Core:
1. Pelvic Floor
2. Transverse Abdominis
3. Multifidus
4. Diaphragm
Abdominal Wall and Pelvic Floor
Function
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Optimal Function Requires
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Intact anatomy- Alignment of bones, integrity
and quality ligaments, nerves, muscles
Optimal timing of contraction and relaxation
(motor control of all 3 layers)
Adequate strength and endurance
(performance) for the task
What can happen to the Pelvic
Floor?- Deformation
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Deformation or Strain
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Compression Force- applied by pushing; ie
intra abdominal pressure, pregnancy, delivery,
etc.
Tensile Force- occurring because of pulling; ie
surgery, scars, delivery, etc.
Torsion- applied by twisting; ilium, sacral, or
coccyx rotations or asymmetries, external
muscle tightness, etc.
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What Can Physical
Therapy Do?
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Skin and Vulvar Care
Bladder and Bowel Empty Strategies
Pelvic Floor Exercises- Strength or Relaxation/Release
Scar Mobilization
External/Internal Massage and Trigger Point Mobilization
Manual therapy and muscle energy techniques for correction
of lumbar, pelvic, sacral, or coccygeal asymmetries
Breath work
Sexuality Education
Trunk Rehabilitation – after C- section or other abdominal
surgeries.
Posture, Positioning, and Body Mechanics
Biofeedback and External/Internal Electrical Stimulation
What Are The Goals Of Treatment?
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Address the patient’s meaningful complaints
(disability and/or pain) - driven by person’s goals
and values
Restore optimal strategies for function and
performance that relate to their meaningful
tasks
Change the person’s experience of their body
and mind
Empower responsibility towards overall health
Pelvic Pain
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You can think of muscle-based pelvic pain as a
chronic spasm or charley horse in the pelvic floor fed
by tension, pain, anxiety and protective guarding.
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No one would choose to tighten up
their pelvic muscles for an hour.
Someone with muscle-based pelvic pain
is unwittingly tightening the pelvic
muscles, often for years.
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Pelvic Pain
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If you are female, you have a 5% chance of
suffering chronic Pelvic Pain in a lifetime.
In 2000 it was found that 9.2 million women
have pelvic floor disorders but most go
undiagnosed.
43% of Women have some form of sexual
dysfunction.
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Howard, F.M., Perry, C.P., Carter, J.E., et al. “Pelvic Pain Diagnosis and
Management.” Philidelphia: Lippincott Williams & Wilkins, 2000
Pregnancy-Related Pelvic Girdle
Pain - Prevalence
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During Pregnancy
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45% combined LBP and Pelvic Girdle Pain during
pregnancy (Wu et al 2004)
20% of 2269 pregnant women suffered enough
to seek medical attention (Albert et al 2002)
Recovery of Function Postpartum
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5 – 7% fail to recover (Ostgaard & Andersson 1992)
Severe disability in 8% (Wu et al 2004)
Urinary Incontinence
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Prevalence of incontinence in general
population of females reported in 13
different studies.
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Young adult (less than 40yrs): 20% to 30%
Middle age (40-65 yrs): 30% to 40%
Elderly (65 and >): 30% to 50%
Rev Urol. 2001; 3(Suppl 1): S2–S6.
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Urinary Incontinence
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Prevalence of incontinence in Men
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3% to 11% overall prevalence rate of incontinence
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urge incontinence being the prominent symptom reported in
40% to 80% of patients
Stress incontinence in men is rare unless the patient
has undergone some type of prostate surgery or has
suffered neurological injury or trauma.
Incontinence in men increases with age and appears
to rise more steadily than it does in women.
Rev Urol. 2001; 3(Suppl 1): S2–S6.
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Who Is Appropriate For Pelvic Floor
Physical Therapy?
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Low back pain
Hip pain
Pelvic pain
Coccyx pain
Urinary incontinence
Organ prolapse
Sexual pain and dysfunction
Pregnancy and post-partum issues
Any abdominal surgery (c-section, hysterectomy, etc)
Integrated Care Model For Chronic
Pelvic Pain Patients
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Traditional Medicine
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Muscle relaxants, anti-inflammatories, antidepressants, medications for organ pain,
normalize bladder and/or bowel function,
topical creams, hormone therapy, Image
Studies
Pelvic Floor Physical Therapy
Yoga Therapy-Relaxation, Mind-Body
Connection
Psychotherapy- Depression
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Integrated Care Model For Chronic
Pelvic Pain Patients
What Pelvic Floor PT is Already
Doing
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Pelvic Pain, Pain with intercourse
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4 referrals in the last 60 days
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Both demonstrated significant decrease in reported
pain in just 2 weeks, both pain free after 4-6
sessions.
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Seen 1x/wk
All demonstrated significant tightness of some area in their
PF.
Internal trigger point release combined with deep breathing
and visual relaxation.
HEP for Self stretching using a vaginal dilator
Referrals
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2 out of 4 were for LBP/SI pain
What Pelvic Floor PT is Already
Doing
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Female Urinary Incontinence
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7 referrals in the last 30 days
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Stress, urge and mixed incontinence
2-3 moderate to large episodes daily
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After 30 days of treatment: 2-3 small episodes of incontinence
weekly.
2 patients have seen improvements in both size and
frequency of leakage after 2 weeks.
Low back pain referrals- also having urinary
incontinence.
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Seen improvement in both back pain and decreased
frequency of leakage even after 1 visit.
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What Pelvic Floor PT is Already
Doing
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Male Urinary Incontinence
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3 referrals in last 9 months
None have shown for scheduled appointment
Male Pelvic Pain
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1 referral in last 12 months
Never showed for scheduled appointment
How to perform a “Kegel”
aka PF Contraction
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Individuals sense and visualize different things to contract the
pelvic floor. Below is a list of visualizations that can be helpful
in describing a correct PFM contraction.
 Elevator (closing the openings and lifting the entire floor)
 Pulling underwear in
 Stopping urine flow
 Holding gas in
 Squeezing ‘sits bones’ together
 Pulling your tailbone to your pubic bone
 Lifting the perineum off the chair
 Pull a tampon back into place in the vagina
As the muscles become stronger, the sense of pulling up and
in can become intensified. This is an appropriate sensation.
How to perform a “Kegel”
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What not to do when performing a kegel
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There should never be a sense of bearing
down or pushing out when performing a
kegel.
If you were to put your hand on the
perineum, the tissue should not push into
your hand. During an appropriate
contraction, the tissue should move away
from the hand. The lower abdominal muscles
should not push out or the buttock muscles
(gluteals) should not tighten.
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Treatment
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Internal pelvic exam
 Assessment/observation of external genitalia
 PF strength, endurance, and coordination of all 3
layers
 Manual stretching or trigger point release
 Assessment of bladder, uterine, rectal prolpase
Biofeedback with manual, internal and external
sensors
Assessment of Pelvic alignment- MET for correction
Stretching-HS, Adductors, Gluts, piriformis, Rectus
Femoris, Iliopsoas
Treatment (cont’d)
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Ensuring a proper PF contraction/Kegel
Instruction on proper contraction of Transverse
Abdominis
Exercise progression
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Consider different positions based on strength
assessment as well as organ prolapse grade
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Supine on pillows, Supine, sidelying, seated, standing, on the
stairs, More dynamic movements, etc
Length and reps of contraction based on what was
found during the internal exam.
Try to stop the flow of urine ONLY 1x/wk
Exercise Progression (cont’d)
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TA contraction, plus adductor squeeze, then add
bridge
TA contraction plus Hooklying hip abduction with
Theraband
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Then add bridge, trying to keep hips lifted as you
abduct.
Sidelying resisted Clamshells with TA contraction
Alternating Resisted hip flexion, 5” holds
TA contraction plus SLR
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Things to Remember
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You must lengthen before you can
strengthen.
Can’t just treat the symptom, must still
examine the entire body.
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Continue to treat orthopedically
Without proper strength, the bottom of
the grocery bag will fail and all the
groceries will fall out.
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