89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING

89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING

ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY

Pelvic Floor Dysfunction:

The Role of Physical Therapy

Sarah Sydnor, PT, CAPP, WCS



PT’s are Movement Specialists

Mobility StrengthMovement

Coordination



“Down There”





”4 Components to Core Strength”

Resource





Stress Urinary Incontinence Case

Mobility StrengthMovement

Coordination

NO DEFICITS 4/5 MMT in SUPINE

NO KNACK


ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY This Photo by Unknown Author is licensed under CC BY

This Photo by Unknown Author is licensed under CC BY

Urinary Incontinence

Fecal Incontinence

Pelvic Organ Prolapse

MSK Dysfunct.

Perinatal

4th Trimester

Scar Tissue

Constipation

Sexual Dysfunct.

Erectile Dysfunct.

Vaginismus

Vestibulodynia

PGAD (persistent genital arousal

disorder)

Pudendal Neuralgia

Bladder Dysfunct.

PBS (painful bladder syndrome)

Proctalgia Fugax

Neurogenic Bladder

Pelvic Floor Dyssynergia

Endometriosis

Dysmenorrhea

Pediatrics

Pelvic Floor Tension

UTI’s (urinary tract infections)

IC (interstitial cystitis)

LBP, hip pain

Sciatica, piriformis

Diastasis

https://courses.lumenlearning.com/waymaker-psychology/chapter/psych-in-real-life-consciousness-and-blindsight/

https://creativecommons.org/licenses/by/3.0/





Pelvic Organ Prolapse Case





• I

It’s NOT normal to leak urine after labor and delivery



Case Study

Prostatectomy?

Inguinal Hernia Repair?



AVOID constipation as if it IS COVID!



• I

Pain with sex is NOT NORMAL



Pudendal Nerve


ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY This Photo by Unknown Author is licensed under CC BY

This Photo by Unknown Author is licensed under CC BY

Urinary Incontinence

Fecal Incontinence

POP

MSK Dysfunct.

Perinatal

4th Trimester

Scar Tissue

Constipation

Sexual Dysfunct.

Erectile Dysfunct.

Vaginismus

Vestibulodynia

PGAD (persistent genital arousal

disorder)

Pudendal Neuralgia

Bladder Dysfunct.

UTI’s, IC, PBS

Proctalgia Fugax

Neurogenic Bladder

Pelvic Floor Dyssynergia

Endometriosis

Dysmenorrhea

Pediatrics











LISTEN FIRST

TREAT SECOND



Tough Conversations



PT Treatment•Questions•PT Orthopedic MSK assessment •Pelvic Floor Assessment•Exercises•Lifestyle Recommendations•Education•Pelvic Floor Electrical Stimulation•Pelvic Floor Biofeedback •Manual Therapy Treatment



Kegels:“Squeeze as if

stopping urine”





PT Treatment•Questions•PT Orthopedic MSK assessment •Pelvic Floor Assessment•Exercises•Lifestyle Recommendations• Interdisciplinary Recommendations

•Education•Pelvic Floor Electrical Stimulation•Pelvic Floor Biofeedback •Manual Therapy Treatment



Expectations…



PT Treatment•Questions•PT Orthopedic MSK assessment •Pelvic Floor Assessment•Exercises•Lifestyle Recommendations• Interdisciplinary Recommendations

•Education•Pelvic Floor Electrical Stimulation•Pelvic Floor Biofeedback •Manual Therapy Treatment



Onlinelibrary.wiley.com







Find a Pelvic Floor Physical Therapist



Aren’t the symptoms just all

in their head?

Is this ALL in my head?

FALSE… SO False



Case Study Problem List

•Vaginal burning symptoms for 30 years•Dysuria•Bladder Pain•Constipation•Vaginal Atrophy•Nocturia – 5 times per night•Urinary Leaking•2-4 cups of decaf coffee/green tea per day



Findings

•Highly respected professional career •Beautiful posture (abdomen tightly draw in ALL the time)•Flomax•Urodynamic Study (slow flow time, detrusor underactivity, increased electrical activity in the abdominal muscles)

•MRI defecography – Grade 2 rectocele, defecation required maximum strain



PT Treatment

Visit 1Initiated the PT evaluation and education

Visit 2External orthopedic MSK assessment FINDINGS

Maximum mobility deficits RIGHT OBTURATOR FORAMENModerate fascial restrictions LEFT BLADDER

TreatmentGENTLE myofascial release suprapubic region and RIGHT OBTURATOR FORAMENLIFESTYLE counseling: adequate fluids, wean off caffeine, notice and avoid

irritating foods



PT Treatment continuedVisit 3Pt. Subjective: After last visit, “I had no pain for 5 days, the first time in 30 yrs.” AND, “I sat in my car and cried due to memories of forced abortions when I was young, I didn’t realize I had residual anger.”

Treatment

-The majority of the treatment session was spent LISTENING-RECOMMENDATION for possible counseling/trauma therapy (she was very

receptive)-Diaphragmatic breathing exercises, body awareness, relaxation strategies,

POSTURE training (HEP)-Gentle manual therapy



PT Treatment continuedVisit 4Pt. Subjective: “4/10 vaginal burning.”

Treatment-PFM relaxation exercises-Diaphragmatic breathing-NO MANUAL TREATMENT PERFORMED

Treatment Outcome*Patient left with 0/10 pain*Patient did the work with minimal (<25%) verbal coaching*Patient with increased confidence in her own ability to manage her symptoms



PT Treatment continuedVisit 5• Pt. Subjective: “I’m drinking just under a cup of coffee per day.” (previously 2-4 cups)

“I’m doing the breathing exercises.”

“Last week I had a night were I voided only 1 time and last night I voided 2 times.”

“I feel much better because I’m getting sleep. My energy is much better and I’m doing more.”

“I just went to the bathroom and have 0/10 burning right now, I’m consistently not having burning with voiding.”

“I have spikes of pain to 8/10 and I do think it has to do with stress and if I breathe it takes the pain away.”



PT Treatment continuedVisit 5

Treatment

Started Submax KEGELS with overcompensation noted in the hips with internal rotation, glut recruitment, and lower abdominal recruitment.

Patient Affect

Laughing and Joking





Summary

It’s NOT all in their head

[email protected]

mailto:[email protected]



References

Hunter C, Dave N, Diwan S, Deer T. Neuromodulation of pelvic visceral pain: review of the literature and case series of potential novel targets for treatment. Pain Practice. 2013;13(1):3-17.

Urquhart D, Hodges P, Allen T, Story I. Abdominal muscle recruitment during a range of voluntary exercises. Man Ther. 2005;10(2):144-53.

Braekken, I, Majida M, Engh M, Bo K. Can pelvic floor muscle training reverse pelvic organ prolapse and reduce prolapse symptoms? An assessor-blinded, randomized, controlled trial. Am J Obstet Gynecol. 2010;203(2):170.

Hagen, S, Stark D. Conservative prevention and management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2011;7(12):CD003882. doi: 10.1002/14651858.CD003882

Wallace S, et al. Pelvic floor physical therapy in the treatment of pelvic floor dysfunction in women. Curr Opin Obstet Gynecol. 2019;31(6):485-493.

The American College of Obstetricians and Gynecologists Communications Office. ACOG redesigns postpartum care. http://www.acog.org. Published April 23, 2018. Accessed February 17, 2021.

Wasserman J, Copeland M, Upp M, Abraham K. Effects of soft tissue mobilization techniques on adhesion-related pain and function in the abdomen: A systematic review. J Bodyw Mov Ther. 2019;23(2):262-269.

Maldonado PA, Chin K, Garcia AA, Corton MM. Anatomic variations of pudendal nerve within pelvis and pudendal canal: clinical applications. Am J Obstet Gynecol. 2015;213(5):727

Montoya TI, Calver L, Carrick KS, Prats J, Corton MM. Anatomic relationships of the pudendal nerve branches. Am J Obstet Gynecol. 2011;205(5):504

http://www.acog.org/



Ackerman A, Lee U, Jellison F, Tan N, Patel M, Raman S, Rodriguez L. MRI suggests increased tonicity of the levator ani in women with interstitial cystitis/bladder pain syndrome. Int Urogynecol J. 2016;27(1):77-83. doi: 10.1007/s00192-015-2794-6.

Agarwal S, Chapron C, Giudice L, et al. Clinical diagnosis of endometriosis: a call to action. American Journal of Obstetrics and Gynecology. 2019;220(4):354.e1-354.e12. Shafrir A, Farland L, Shah D, Harris H, Kvaskoff M, Zondervan K, et al. Risk for and consequences of endometriosis: A critical epidemiologic review. Best Pract Res Clin Obstet Gynaecol. 2018;51:1-15. Pugsley Z, Ballard K. Management of endometriosis in general practice: the pathway to diagnosis: Br J Gen Pract. 2007;57(539):470-476. Kiesel L, Sourouni M. Diagnosis of endometriosis in the 21st century. Climacteric. 2019;22(3):296-302. Velde J, Everaerd W. The relationship between involuntary pelvic floor muscle activity, muscle awareness and experienced threat in women with and without vaginismus. Behav Res Ther. 2001;39(4):395-408.

Damon H, Guye O, Seigneurin A, et al. Prevalence of anal incontinence in adults and impact on quality of life. Gastroenterol Clin Biol. 2006;30(1):37-43. Miskin C. A Purposeful Ride. APTA Magazine. 2020-2021;11(12):60-64.

Some images taken from the World Wide Web

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89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING