Women’s Health Physical Therapy

Amy Flory PTApril 14, 2009

Terminology used conforms to the definitions recommended by the International Continence Society, except where specifically noted.

Pelvic floor muscle disorders• Normal PFM• Underactive PFM (urinary or fecal

incontinence, pelvic organ prolapse)• Overactive PFM (obstructive

voiding/defecation, constipation, dyspareunia, PP)

• Non-functioning PFM (Any PFM symptom may be present)

Messelink 2005

Pelvic floor muscle anatomyDeLancey 2004

• Pelvic diaphragm– Levator ani

» Pubococcygeus» Puborectalis» Iliococcygeus

– Ischiococcygeus (coccygeus)

• Sphincter urethrae• Perineal membrane

– Compressor urethrae– Urethrovaginal muscle

Pelvic floor muscle anatomyDeLancey 2004

– Superficial genital muscles• Bulbocavernosus (bulbospongiosus in men)• Ischiocavernosus• Superficial transverse perineal

Pelvic anatomy

• Associated muscles (close proximity, facilitative, synergistic—Bo 1994)– Piriformis– Obturator internus– Adductors– Gluteals– Transverse Abdominus (TrA)– Multifidus– Respiratory diaphragm

Pelvic anatomy

• Organs– Bladder• Detrusor (parasympathetic innerv)• Trigone (sympathetic innerv)

– Uterus – Rectum– Prostate

Pelvic organ support

• Peritoneum (minimal)• Relative negative abdominal pressure due to

respiration (decreases functional weight of organs up to 50%)

• Pelvic floor muscles and connective tissues

Take home message: If you’re teaching core/trunk stabilization exercises, you MUST be certain your patient is also contracting their PFMs, or prolapse and stress incontinence will worsen!! Kisner book, p803

Pelvic anatomy

• Supportive connective tissue/ligaments– Disrupted with abdominal incision

• Pubovesical ligaments (lower abdomen)• Peritoneal fascia• Pelvic and endopelvic fascia

– Disrupted with pregnancy, ablated with hysterectomy• Cardinal ligament• Broad ligament• Round ligaments• Uterosacral ligaments

Pelvic anatomy

• Innervation– Perineal branch of pudendal n.– Inferior rectal branch of pudendal n.– Pudendal n.– 3rd and 4th sacral nn.– Ventral rami sacral nn.– Autonomic nervous system– Somatic nerves

Urinary Incontinence—Incidence• UI is often key factor in determining the need for

nursing home placement• 50% all institutionalized elderly in US suffer from UI• 46% young female athletes with UI• 42% girls 15-18 with UI• 31% women 42-50 • 38% women community-dwelling 60+

Dockter 2007, Dockter 2008, Burgio 1991, Dionko 1986

Financial Implications

• Cost to nursing facilities is high, with estimates as high as $10-20 billion/year• Supplies• Caregiver support• Laundry

Neurological control

• Bladder fills>stretch receptors>micturation reflex• Midbrain inhibits reflex until appropriate social

setting to void• Sphincter relaxes>detrusor contracts>voiding

occurs

Neurological Control

• Sensory nerves• Parasympathetic S2-4: stretch receptors• Sympathetic T9-L2: filling sensation to cortex

• Motor nerves• To detrusor muscle: sympathetic S2-S4• To bladder neck: sympathetic T11-L1

Neurological Control

• Spinal Cord Center• S2-S4 (vertebral level T12, L2, L3)• Coordinates the external urethral sphincter with

bladder contraction

Types of Incontinence

• Stress (involuntary leakage on effort or exertion, or on sneezing or coughing)

• Urge (involuntary leakage accompanied by or immediately preceded by urgency)

• Mixed • Overflow (loss of urine secondary to over-

distention of the bladder)• Functional

Informed consent

• APTA recommends no additional informed consent document for assessment and treatment of the pelvic floor muscles

• Informed consent– Alternatives– Prognosis– Effectiveness of treatment

Professional responsibilities

• State practice act• Terminology• Referral sources know your procedures• Specific training• Ethical and professional behavior

Professional responsibilities

• Patient education– Anatomy and equipment– Tests to be used– Verbal consent– Observing assistant available– Mirror for observation available

PT treatment for UI

• Stress urinary incontinence– Strengthening• Vaginal/anal weights• Biofeedback• Electrical stimulation• Progressive resistive exercises

– Coordination• Isolation• Co-contraction• Contraction during body movement

PT treatment for UI

• Urge incontinence– Strengthening– Coordination– Bladder retraining• Urge-delay techniques• Voiding schedule

– Bladder irritants education– Electrical stimulation

PFM functions

• Maintain continence• Support pelvic contents• Control and elevate intra-abdominal pressure

(IAP)• Stabilize the sacroiliac joints• PFM are activated in a manner consistent with

lumbopelvic control

“Due to their role in modulation of IAP and their mechanical effect on the pelvis, the PFM are likely to have a role in other functions that involve control of the abdominal contents” Paul Hodges, PhD, MedDR, BPhty

Consequences of dysfunction

• Respiratory disease and incontinence are more strongly associated with LBP than are elevated BMI and physical activity combined (Smith, Russell, Hodges 2005)

• Women with, or who develop, SUI or breathing disorders are more likely to have LBP or develop it (Smith, Russell, Hodges 2005b)

Palpation lab

• In side lying – Adductors– Pubic ramus– Ischial tuberosity– Levator ani– Ischiococcygeus– Internal obturator

Musculoskeletal dysfunction in the pregnant patient• Low back pain– SIJD primarily– Generalized sprain/strain– Lumbar disc pathology

• Upper back/neck pain• Thoracic outlet/inlet syndrome• Carpal tunnel syndrome• Incontinence• Pelvic pain

PT treatment for SIJD (pregnancy)

• Alignment: Muscle Energy Techniques• Treat muscle and soft tissue• Therapeutic Exercise• Education/Self-Care and Comfort measures• External supports if appropriate• PLAN: 2-4 visits and then prn till delivery

SIJ activity precautions• Avoid standing with weight on one foot• Keep weight equal on both feet when getting in/out of vehicle

and moving sit to/from stand• Avoid stairs; if necessary, take one stair at a time• Place a pillow between knees when sleeping on your side; a

pillow under your knees and thin pad under low back when lying on your back

• Avoid sleeping semi-prone (frog-legged)• ABSOLUTELY avoid combos of: sitting, twisting, bending (such

as reaching into the back seat of the car, lifting small child from the side of a chair)

Treatment for general LBP/disc

• Exercises to decrease cumulative strain throughout the day– Anterior/posterior pelvic tilts– Lateral pelvic tilts

• Positioning to decrease strain– Quadruped, change positions frequently

• Activation of TrA and modified pelvic tilts to “neutral spine”

• Supports

Pre-partum guidelinesfor positioning and exercise• ACOG guidelines– http://www.acog.org/publications/patient_educat

ion/bp119.cfm• Do not exceed 5 minutes supine after 1st

trimester (tilt pelvis to left to decrease vena cava compression)

• Limit single-leg stance and postures• Limit width of stance in asymmetrical yoga

postures

Post-partum guidelinesfor positioning and exercise• Avoid buttocks higher than head for 6 weeks

post-partum• TrA contractions may be initiated immediately• Rectus abdominus exercise and rotational

exercises MUST be avoided if there is a diastasis

• Limit single-leg stance and postures• Limit width of stance in asymmetrical yoga

postures

Gestational diabetes

• More than half go on to have Type II diabetes– Great opportunity for intervention/prevention – Lifestyle changes– Exercise

Implications for post-partum physical therapy

• Musculoskeletal pain complaints• Abdominal muscle• PFM rehabilitation• Clogged milk ducts• UI that persists more than 3 months

Pelvic pain statistics…

• PP most common form of chronic pain in women of childbearing age in U.S.

• Women with pelvic pain report lower QOL than other types of chronic pain (e.g. back pain)

• Hysterectomy most common surgery in U.S.; C-section 2nd-most common

• ½ of U.S. women age 30 have had Chlamydia, which causes PID—a risk factor for CPP and infertility

Pelvic pain origins

• Gynecologic (dysmenorrhea, endometriosis)• Urinary (painful bladder syndrome, interstitial

cystitis)• Gastrointestinal (irritable bowel syndrome)• Musculoskeletal• Psychiatric• Multiple (vulvodynia, prostatodynia)

Gynecologic origins

• 24%-86% of cases of pelvic pain• Endometriosis is diagnosis in 52% of these• Intra-abdominal adhesions in 10%-51%• Endometriosis, adhesions and fibroids do not cause

pain in all patients• 50% of women have no known historical cause for

adhesions• More than 50% of adhesions have nerve fibers in

them (Tulandi 1998, Kligman 1993)

Musculoskeletal pelvic pain

• Chronic pelvic pain (CPP)• Overactive/non-relaxing PFM– Levator ani syndrome– Tension myalgia– Vaginismus

• Coccygodynia

Chronic Pelvic Pain

• Continuous or episodic pain in the area of the pelvis (true and false) for at least 6 months

• 10-40% of all gynecologic consults• Multifactorial etiology– Poor posture– Decreased flexibility and strength– Core muscle weakness– PFM dysfunction– Pelvic joint pain and dysfunction

Musculoskeletal structures referring pain to pelvis, abdomen• Hip• Lumbar ligaments, facets and disks• Sacroiliac joints• Abdominal muscles• Iliopsoas• Piriformis• Pubococcygeus• Internal/external obterators• Quadratus lumborum

Pelvic Pain progression

• Painful episiotomy• Pelvic floor muscle spasm/tension• Pain referred to abd wall, low back, hips and

thighs• Pelvic visceral hyperalgesia• Postural changes• Adaptive muscle imbalances• Spine pathology, abd trigger points

Indications for physical therapy

• Initial conservative management of CPP• PFM dysfunction• Dyspareunia• Vaginismus• Scarring of the abdominal and/or vaginal walls• History of abdominal or vaginal surgeries

Physical therapy evaluation

• Musculoskeletal system– Strength and flexibility– Scar mobility– Pelvic joint function– Location of trigger points and nerve entrapment

sites

Physical therapy evaluation

• Urogenital system– Trigger points– Pelvic floor muscle function– Organ mobility

• Viscera– Mobility

Physical therapy interventions

• Therapeutic exercise– Postural strength– Postural flexibility– General endurance– Pelvic floor strengthening, if indicated– Pelvic floor muscle coordination

Physical therapy interventions

• Manual therapy• Therapeutic activities/self-management of

symptoms/neuromuscular re-ed• Physical modalities

ReferencesWill follow shortly

Thank you!

Amy Flory PT, MPTCoreBalance Therapy LLC906 W University Ave, Ste 120Flagstaff, AZ 86001www.corebalancetherapy.comamy@corebalancetherapy.com