Principles of pelvic floor rehabilitation in chronic disorders of postpartum period

T. Ahadi MDT. Ahadi MD Assistant professor of Physical Medicine Physical Medicine and Rehabilitationand Rehabilitation

Common musculosketal problems in postpartum phase

Diastasis RectiLow Back PainPosterior Pelvic Pain (PPP)Symphysis pubis dysfunction(SPD)Pregnancy associated OP(PAO)Varicose VeinsPelvic Floor Dysfunction Joint LaxityCompression Syndromeschange in arch support, ligamentous support of feet and

anklesRib pain(stitch)Trigger pointsNeck pain and headaches due to changes in posture Neck pain and headaches due to changes in posture Tightness and pain in the hamstringsTightness and pain in the hamstrings

Anatomy1-First layer(Endopelvic fascia)

2-Second layer(pelvic diaphragm)

3-Third layer(Urogenital diaphragm)

Levator Ani MusclesPubococcygeusIliococcygeusPuborectalisIschiococcygeus

Function• Provides support for the pelvic organs and

their contents• Withstands increases in intra-abdominal

pressure• Provides sphincter control for the bladder andbowel• Functions in reproductive and sexual

activities

Pelvic floor dysfunction in postpartum phase

• Urinary incontinence or fecal incontinence, Constipation Involuntary loss of bladder or bowel contents; often a result

of both neuromuscular and musculoskeletal impairments;may occur in combination with prolapse.

• Prolapse. A supportive impairment; descent of any of the pelvic viscera out of their normal alignment because of muscular and/or ligamentous deficits and increased abdominal pressure often worsens over time and with subsequent pregnancies.

• Pain/trigger points/hypertonus. May be related to delayed healing of perineal lacerations, scar tissue adhesions, or generalized spasm throughout the pelvic floor tissues. Functional limitations include dyspareunia(pain with intercourse) and difficulty

with elimination.

Contributing FactorsTrauma to muscular structure and fascia: particularly vaginal delivery, The pudendal nerve can be compressed and stretched up to 20% of its length during the second stage of labor. Episiotomy multiple deliveries, prolonged second stage of labor, use of forceps, third-degree perineal tears, birth weight over 8lb constipation, obesity

Urinary incontinence40-80% of all pregnant women experience some form of incontinence during pregnancy.7%-35% UI in postpartum SI is more common in pregnancy and postpartumOther forms are frequency,urgency and urge

incontinency,mixed typeReduction in the prevalence of incontinency postnatally in women who had performed pelvic floor exercises antenatally. The use of PFE’s is the main non-surgical treatment for PFD and has been shown to be more than 80% effective

Fecal incontinency/ Disordered defecation

Fecal incontinency is very much less common-Sphincter Disruption:Most common cause of incontinency

in young woman-Sphincter denervation(Compression or stertching of

pudendal nerve)Prevalence of constipation in pregnancy 11% to 38% (progesterone)Constipation in postpartum period more probably is related to

Pelvic organ prolapse(rectocele), Rectosphincteric dyssynergia(5%), functioal Dis(IBS,slow transit)not related to pregnancy

ProlapseAbout 11%of woman to the age of 80 have surgery for POPSignificant risk factor is vaginal delivary,Other Rf: age, obesity,hystrectomy

Chronic pelvic pain Pelvic floor hypertonicity & overactivityPelvic Myofascial pain

Chronic pelvic pain (CPP) refers to pain below the umbilicus of at least six months' duration that is severe enough to cause functional disability or require treatment. The prevalence of CPP ranges from 4 to 25 percentDifferent etiology(Gynecology,urinary,GI,musculskeletal, Psychological, Neurological) pelvic myofascial pain is caused by involuntary spasm of the pelvic floor muscles and trigger points(eg, piriformis, levator ani syndrome, iliopsoas, obturator internus)The etiology includes any inflammatory painful disorder, childbirth and poor posture, pelvic surgery, and trauma

Clinical manifestationPelvic/abdominal pain (often with severe dysmenorrhea)Urinary tract symptoms (eg, frequency, urgency, incontinence, nocturia, dysuria, incomplete emptying, bladder pain)Vulvovaginal discomfortDyspareuniaRectal fullness or constipation, dyscheziaCoccygodynia

Pelvic floor rehabilitationPelvic floor rehabilitation

PFR is used for increasing in strength and

function of pelvic floor muscles and one

of the most important treatment methods

for Pelvic floor dysfunction

Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence

Main results Fourteen trials involving 836 women met the inclusion

criteria; twelve trials (672) contributed data. Women who did PFMT were more likely to report they

were cured or improved than women who did not.Women who did PFMT also reported better continence specific quality of life than women who did not. PFMT women also experienced fewer incontinence episodes per day and less leakage on short office-based pad test. Of the few adverse effects reported, none were serious.

Authors’ conclusionsThe review provides support for the widespread

recommendation that PFMT be included in first-line conservative management programmes for women with stress, urge, or mixed, urinary incontinence. Statistical heterogeneity reflecting variation in incontinence

2010 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.

Fecal Incontinency Case series report positive patient outcomes,

often in over 70% of patients.1,2

Case series methodology were weak. In addition, outcome measurements were often poor, or proxy measures, such as anal sphincter pressures

1-Heymen S, Jones KR, Ringel Y, et al. Biofeedback treatment of fecal incontinence: a critical review. Dis Colon Rectum 2001;44:728–36.

2- Norton C, Kamm MA. Anal sphincter biofeedback and pelvic floor exercises for faecal incontinence in adults: a systematic review. Aliment Pharmacol Ther 2001;15:1147–54.

Biofeedback and/or sphincter exercises for the treatment offaecal incontinence in adults

Main results Eleven eligible studies were identified with a total of 564 participants. In all

but three trials methodological quality was poor or uncertain. No study reported a major difference in outcome between any method of

biofeedback or exercises and any other method, or compared to other conservative management. There are suggestions that rectal volume discrimination training improves continence more than sham training and that anal biofeedback combined with exercises and electrical stimulation provides more short-term benefits than vaginal biofeedback and exercises for women with obstetric-related faecal incontinence.

conclusions The limited number of identified trials together with their methodological

weaknesses do not allow a definitive assessment of the possible role of anal sphincter exercises and biofeedback therapy in the management of people with faecal incontinence.

The 11 trials reviewed were of very limited value because they were generally small, of poor or uncertain quality, and compare different combinations of treatments.

Biofeedback and/or sphincter exercises for the treatment of faecal incontinence in adults (Review)Copyright © 2009 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.

Main resultsThree trials of relevance to this review were identified. The largest of these, of pelvic floor muscle training in preventing anterior prolapse from worsening, had significant limitations. A small feasibility study (which is to be followed up with a larger trial) randomised 47 women to pelvic floor muscle training or control and found suggestions of better outcomes . The third trial evaluated peri-operative physiotherapy for women undergoing surgery for prolapse and/or incontinence. The authors report that urinary symptoms, pelvic floor muscle function and quality of life were improved more in the treatment group than the control group, but data were not provided to allow this to be assessed. Authors' conclusionsDespite there now being reports of three eligible trials in this update, the evidence available is not significant to guide practice. There is some encouragement from a feasibility study that pelvic floor muscle training, delivered to symptomatic women in an outpatient setting, may reduce severity of prolapse. Further evidence from larger, better quality randomised control trials is however still necessary. 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Conservative management of pelvic organ prolapse in women

EvidenceHagen S. and et al in a systematic review at 2004 showed that pelvic floor muscle training,to symptomatic women in an outpatient setting, may reduce severity of prolapse.

Hay-Smith EJ in a systematic review in 2008 provide that there is some evidence that PFMT in women having their first baby can prevent urinary incontinence in late pregnancy and postpartum. In common with older women with stress incontinence, there is support for the widespread recommendation that PFMT is an appropriate treatment for women with persistent postpartum urinary incontinence.

Evidence

Biofeedback for pelvic floor dysfunction in constipation

Clinical review between January 1965 and September 2003

Conclusion: more than 70% of adult patients complaining of pelvic floor dyssynergia are likely to benefit from biofeedback training and so this is the treatment of choice for the problem

The few studies with long term follow up,a certain percentage of patients (up to 50% and more) continued to report satisfaction even at 12-44 months after treatment.

Clinical review, BMJ VOLUME 328 14 FEBRUARY 2004

ASSESSMENT & INVESTIGATION

1. History taking and physical examination2. Pelvic floor muscle assessment 3. Assessment of prolapse4. Urine testing5. Assessment of residual urine6. Symptom scoring and Q.O.L assessment7. Bladder diaries8. Pad testing9. Urodynamic testing10. Other tests of urethral competence11. Cystoscopy12. EMG-NCV13. Imaging

Evaluation(Cont)Pelvic muscle trigger points: pelvic muscles should be examined for tone and tenderness both at rest and during active contraction. Normally, palpation of these muscles should be pain-free, both in the relaxed and contracted state.Abdominal trigger points: Rising head while in the supine position for abdominal trigger pointspostural abnormalities: anterior tilt of the pelvis can create hypertonicity and imbalanced pelvic muscles

Pelvic floor Pelvic floor rehabilitationrehabilitation

The following options are often used in combination with Kegel exercise for urinary stress and urge incontinence:1. Life style changes2. Behavioral therapy (Patient Education)3. Pelvic floor muscle training (Kegel

exercise)4. Biofeedback5. Electrical Stimulation6. Extracorporeal Magnetic Innervation7. Myofascial release techniques

Life styleWeight lossSmoking cessationCaffeineFluid management

Behavioral therapyImproving voluntary control of bladder function by Bladder training (forUUI) with urge inhibition technique /timed voiding (for SUI)First step is bladder diaryThe longest comfortable interval is chosen.patient is instucted to empty the bladder according the interval.Interval is gradually increased (till 2-3 hours)

Bladder DiaryTime Voided Activity Leak

VolumeUrg

eIntake

(Amount/Type)

"urge suppression" techniqueStop all movement immediately and stand still. Sit down if possible. Squeeze your pelvic floor muscles quickly and tightly several times.

Squeezing your pelvic floor muscles this way signals the bladder to relax and increases your feeling of being in control. Take a deep breath and relax. Shrug your shoulders and let them go limp. Concentrate on suppressing the urge feeling. Some women find distraction an effective technique. When the strong urgency subsides, walk slowly and calmly to the bathroom.

Remember: Going to the bathroom is not an emergency!

How to teach PFE’s (Kegels) Correctly!!!Verbal descriptions are only 40% effective.Palpate perennial tissues through clothes, should feel tissues move away from finger.Watch patient kegel(give pt. a mirror)Place finger inside patient’s vagina and pt squeezeBiofeedback device

Benefits of PFE’sExercised muscles recover better from trauma. (Cesarean deliveries, episiotomies, forceps/vacuum, prolonged second stage of labor, etc.)Decreased swelling and pain in perineumPrevention and/treatment of Urinary IncontinenceImproved sex life

Components of pelvic floor Components of pelvic floor exerciseexercise1-kegel Exe. 2-Lumbo-Pelvic Stabilization Exe.3-Abdominal muscles Exe4-Knack Maneuver Volitional contraction of the pelvic floor muscles

just before and throughout a cough, can be used to reduce stress-related urine leakage significantly

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Kegel ExercisesKegel Exercises

1.Patient position: Supine or Side lying , sitting or standing

2. Instruct the woman to tighten the pelvic floor as if attempting to stop urine flow, each contraction is held 5 seconds with an equivalent relax . The bladder should be empty when performing this exercises

Kegel ExercisesKegel Exercises3.The pelvic floor muscles are

highly fatigable. Contractions should not be held longer than 5 seconds and with a maximum of 10 repetitions per sessions.

4.The exercises are repeated three to five times per day, every other day.

Other new methods with Other new methods with swiss ball:swiss ball:Fast twitch muscle fiber training with quick fast twitch muscle contraction, which can be done by bouncing on the ball. Slow twitch muscle fiber training requires holding the contraction at the end for 5 seconds.

Stretching exerciseThere are 35 muscles which attach directly to the pelvic girdle and sacrum and contribute to their movement and function

Core stabilization EX

Quadruple position with posterior pelvic tilt

Leg is raised only until it is in line with the trunk

a.

b.

Abdominal EXThe abdominal EX can be started whenever woman feels able and get the OK from physicianStart with transversus Ex because its role in pelvic stabilty(Supine,sidelying sitting,standing ,Avoid prone kneeling up to 6 weeks if there is bleeding because of air embolus) After strenghtenig of transverse musle perfom curl- up

• takes 6 weeks to return to pre-pregnant shape• Wait 6 weeks to start aerobic exercises

Biofeedback:Biofeedback:Biofeedback Transformation of

physiological processes into visual, acoustic and / or sensual information

● It provides Moment-to-moment information about a biologic function

Direct palpationVaginal conesEMG systemPressure based biofeedback

SEMG BiofeedbackSurface ElectroMyoGraphy (SEMG) is a non-invasive technique for measuring muscle electrical activity that occurs during muscle contraction and relaxation cycles.

Pelvic floor retraining with EMG biofeedback

Goal: to help identify pelvic floor musculature

Improve contraction improve relaxation

Electrical Stimulation(ES):Electrical Stimulation(ES):ES is a technique for passive contraction in patients who can not contract pelvic floor muscles voluntarily.ES can be administered through vaginal or anal electrodes.Two major purpose wit ES:

1. Motor excitement 2.Analgesic

ES(cont.)ES(cont.) ES with high-frequency stimulation (50-100 Hz) is used to treat SUI by directly stimulating a contraction.(With vaginal or anal electrode)The mechanism is probably changing

muscle reaction or increasing bulk or strength.ES with low-frequency stimulation (5-20Hz) is employed to activate inhibitory nerves to bladder and reduce detrusor overactivity(vaginal or anal electrode ,or peripheral stim)Dual stimulation for mixed incontinence with high frequency for the sphincter and low frequency for the bladder

Extracorporeal Magnetic Innervation

This technology produces highly focused pulsing magnetic fields. patient sits fully clothed in a comfortable chair, allowing the therapeutic fields to be easily aimed at the muscles of the pelvic floor

Myofascial releaseComponents of treatment include:Rehabilitation of extrapelvic musculoskeletal abnormalities,postur and gaitClosure of any diastasis rectiConnective tissue manipulationRelease of scarsTransvaginal trigger point release(Barrier method)Abdominal and guteal trigger point releaseDry needeling,ACPExercise(Kegels may aggravate the symptoms)

-First stretching Ex-Then strengthening

Thanks