Document 6430604

TREATING PELVIC MUSCLE
DYSFUNCTION THROUGH
PELVIC FLOOR PHYSICAL
THERAPY
Kendra L. Harrington, PT, DPT, BCIA-C, PMDB
[email protected]
202-782-5716
OBJECTIVES
• Identify the benefits of pelvic floor physical
therapy in the multidisciplinary care of pelvic
muscle dysfunction.
• Evaluate patients who could benefit from a
referral to pelvic floor physical therapy.
• Appreciate key pelvic floor physical therapy
treatment options for pelvic muscle
dysfunction.
DEFINING PELVIC FLOOR PT
• Sub-specialized position within the field of PT
• Examine & treat musculoskeletal and
neuromuscular problems in order to reduce
pain, regain function, and prevent further injury
or loss of motion within the pelvic complex
• Large role of Pelvic Floor PT is patient
education
HISTORY OF GYN PT
• 1977: Elizabeth Nobel (front runner of
Women’s Health PT) founded the Section
on Obstetrics & Gynecology of the APTA
– Focused on the healthcare of women before, during,
and after pregnancy
• 1995: Section changed its name to the
Section on Women’s Health
– Focus on the health of women across the lifespan from
the young athlete to the elderly
– *also treat men
• Currently over 2,000 members of SoWH of
more than 60,000 APTA members
FUNCTIONS OF THE PELVIC
FLOOR MUSCLES
• SUPPORTIVE
• SPHINCTERIC
• SEXUAL
PELVIC FLOOR
DYSFUNCTION
TWO MAIN TYPES:
1. SUPPORTIVE
2. HYPERTONUS
SUPPORTIVE DYSFUNCTIONS
• Increased risk for pelvic organ prolapse
• Common associated symptoms:
– Urinary Incontinence
and/or
– Fecal Incontinence
COMMON DIAGNOSES
ASSOCIATED WITH
SUPPORTIVE DYSFUNCTIONS
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Urinary Incontinence; unspecified
Stress Urinary Incontinence
Urge Incontinence/Detrussor Instability
Mixed Incontinence
Urinary Urgency/Frequency
Fecal Incontinence
Cystocele/Rectocele
Uterine Prolapse
MULTIPLE RISK FACTORS
OF INCONTINENCE
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Immobility commonly associated
with chronic degenerative disease
Diminished cognitive status
(Alzheimer’s Disease)
Blocked bladder outlet/urethra
Medications
Smoking
Fecal impaction/Chronic
constipation
Environmental barriers
Low fluid intake/dehydration
Asthma, allergies, COPD
Depression
Pelvic or abdominal surgeries
Birth defects (Spina Bifida)
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High-impact physical activities
Diabetes
Stroke, Multiple Sclerosis, SCI
Obesity
Dietary influences
Pelvic muscle weakness
Weak urethral sphincter muscle
Overactive/Under active bladder
Estrogen depletion/Menopause
Pregnancy, vaginal delivery,
and episiotomy
UTI’s
Vaginal infection or irritation
UI STATS
• Stewart et al (2003)
– >34 million people in US affected by OAB
• NAFC Quality of Care (www.nafc.org) 16
September 2005:
– 1 in 4 women over age 18 experience episodes of UI
– 1 in 5 adults over age 40 are affected by overactive bladder or
urgency/frequency with associated incontinence
• NAFC Quality of Care (Vol 23, 1st Quarter, 2005):
– 66% of men and women ages 30-70 have never discussed their
bladder health with their health care provider
– One third think loss of bladder control is a natural part of aging
and is something to accept
• Smith et al (2006)
– Only 1 in 4 symptomatic women will seek treatment
• Subak et al (2006)
– women with severe UI pay $900/year for incontinence
routine care
– *all out of pocket expenses (laundry, dry cleaning,
pads, toilet paper/paper towel)
• The Society of Women’s Health Research Survey
in 2002:
– Lifetime medical costs for each woman treated for SUI
reached nearly $60,000
• Hu et al (2004)
– $19.5 billion cost to the U.S.
HYPERTONUS DYSFUNCTIONS
• Common side effect is pain
• Symptoms may include back, peri-vaginal,
rectal, lower abdomen, coccyx, posterior
thigh pain; vulvar/clitoral burning
• PFM may have resultant weakness
secondary to constant bracing/holding
COMMON DIAGNOSES
ASSOCIATED WITH HYPERTONUS
DYSFUNCTIONS
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Coccygodynia
Anismus
Pain in Pelvic Region/Joint
Painful Episiotomy
Vaginismus
Proctalgia Fugax
Anal or Rectal Pain
Levator Ani Syndrome
Anal Spasm
Interstitial Cystitis
Vulvodynia
Pelvic Pain
Vulvar Vestibulitis
Dyspareunia
OTHER COMMON PT/GYN
DIAGNOSES
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Constipation
Sacroiliac Dysfunction
Obstetrical Low Back Pain
Prostatitis
Male Dyspareunia
Prostadynia
Painful Scar
PT/GYN EXAMINATION
• SUBJECTIVE
• OBJECTIVE
SUBJECTIVE: GENERAL
HISTORY
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Age
Sex
Chief Complaint
Drug/Latex Allergies
Patient’s Goals
Perceived Severity of Problem on Quality of
Life
• Current Exercise Level
• Occupation (lifting, straining, heavy carrying)
SUBJECTIVE: URINARY
HISTORY
• Water intake: 64 fl oz normal
• Frequency of day voids: every 2-4 hours (68x/day) is normal
– Increased frequency could indicate cystocele
– Does frequency fluctuate throughout the day?
• Sleep interrupted: 0-1x/night normal
– up to 2x/night for over age 65 normal
• Wear pads: type and thickness
– # per day
– Change when wet (if perineum constantly damp/wet,
increase chance of skin irritation/infection)
– Amount of pad wetness: dry, damp, saturated
• Frequency of leaks
• Amount of leak:
– few drops/small (usually associated with SUI)
– large (usually associated with Urge Incontinence)
• Hard to initiate urine flow: outlet obstruction/overflow
incontinence
• Slow urine stream: possible result of prolapse
• Intermittent stream (start/stop): possible prolapse
• Blood in urine
• Urgency: may have overstretching of bladder base due to
a cystocele
• Strain to pass urine: possible result of prolapse
• After urinating:
– Completely Empty/Still Feel Full: could be a cystocele or
decreased bladder contractility
– Residual dribble upon standing: overflow incontinence/outlet
obstruction
SUBJECTIVE: BOWEL HISTORY
• Regular Bowel Movements & Frequency
– Chronic constipation can lead to pudendal nerve damage
• Consistency of BM: normal is similar to a ripe banana
– Loose
– Hard: increase risk of fissures, hemorrhoids, tearing anal
sphincter
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Experience Fecal Incontinence
Frequency of Incontinence
Type of Incontinence: flatus, liquid, formed stool
History of suppressing urge: increased risk of pelvic floor
tension
• Strain during BM: increased risk of rectal prolapse
• Completely evacuate: may indicate prolapse if incomplete
emptying
• Use of assistive devices: enemas, suppositories,
laxatives, stool softeners, manual
– Laxative abuse may result in rectal prolapse
SUBJECTIVE: PAIN HISTORY
• Description: constant, intermittent, dull,
ache, burning, sharp, shooting
• Location
• Current Pain Level
• Pain with Activity
AGGRAVATING/RELIEVING
FACTORS ON PROBLEM
• Aggravating Factors:
– Sitting, standing, bending, walking, coughing,
laughing, sneezing, intercourse (pain or leakage;
leakage=detrussor instability), BM, urinating, tight
clothing, menses, exercise, lifting, time of day, change
in position
* If lying down position worsens symptoms of prolapse,
need to further evaluate to r/o tumor, neurological
involvement, obstruction, and infectious disease
• Relieving Factors:
– Lying (normal for prolapse issues), sitting, standing,
heat, cold, medications, massage
SUBJECTIVE: GYN
HISTORY
•Looking for increased risk of PFM dysfunctions:
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Menopausal state
Dysmenorrhea
Fibroids
Cysts
Dyspareunia
Frequent UTI’s
PID/STD’s
Frequent yeast
infections
– Current pelvic
infections
– Hemorrhoids
– Endometriosis
– GYN cancer
– Urine retention
– Urethral obstruction
– Currently pregnant
– Prolapse
SUBJECTIVE: PREGNANCY
HISTORY
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Gravida/Parity
Miscarriages
Type of births
Episiotomy/Tearing
Long labors
Rapid birth
Large babies
Forceps/vacuum/suctioning
Position of delivery: on your back is an
antigravity position
• Painful episiotomy/infection
SUBJECTIVE: MEDICATIONS
• Medications that Contribute to Incontinence
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Diuretics
Sedatives and hypnotics
Pain relievers
Antihistamines/Anticholinergics
Cold remedies
Antipsychotics
Antidepressants
Alpha adrenergic agonist
Alpha adrenergic antagonist
SUBJECTIVE: GENERAL PMHx
• Key questions: refer to incontinence risk
factor list
• Cancer: affects certain modality use
• Pacemaker: affects certain modality use
• Any abdominal, low back, pelvic
trauma/injury including surgeries
OBJECTIVE
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Postural Assessment
Gross ROM/Strength of Extremities
Abdominal Strength
Mobility
SI Joint Screen
Soft Tissue Assessment
OBJECTIVE: UROGYN PT EXAM
• External
• Internal
EXTERNAL PT/GYN EXAM
• Skin integrity
– Scars (dry, intact, scab, open, no drainage, pain,
mobility)
• Introitus
– WNL, asymmetrical, tight, loose
• Provocation
– Pelvic clock: look for pain, tenderness, trigger
points, hypo/hypersensitivity
• Excursion
– WNL, Nil
• Color
• Urogenital Reflexes
– Anal sphincter, bulbocavernosus, cough
• Edema
EXTERNAL EXAM CONT…
• Ability to do/isolate Kegel
• Accessory Muscle Recruitment
– Abdominals
– Gluteals
– Hip adductors
• Breath holding
INTERNAL PT/GYN EXAM
• APTA Section on Obstetrics and Gynecology,
1993:
“Internal examination of the pelvic floor
muscles is consistent with physical therapy
practice. It complies with national physical
therapy policies requiring the performance of
test and measurements of neuromuscular
function as an aid to the evaluation and
treatment of a specific medical condition.”
INTERNAL PT/GYN EXAM
CONT…
• Tone
– WNL, increased, decreased
• Urogenital Sensation
– Intact, diminished, absent (R/L/ant/post)
• Trigger Points
– Levator ani, obturator internus, puborectalis/coccygeus
• SC Joint Mobility
– WNL, diminished
• Prolapse
– Cystocele, urethrocele, rectocele, enterocele, uterine
• Pelvic Floor Muscle Strength
– Laycock’s Scale: Power, Endurance, Reps, Fast Contractions
– Brink’s Scale
PRECAUTIONS FOR INTENAL
EXAM
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Pregnancy or post-partum before 6 weeks
Active infection
Abuse
Children
Post-op less than 6 weeks
Frail vagina
S/P radiation
Menstruation
Hemorrhoids
BIOFEEDBACK
• Method of providing instantaneous and
continuous information through visual
and/or auditory reporting in order to retrain
automatic/subconscious physiological
responses
• Increases the patient’s ability to perform an
isolated muscle activity (limit use of
accessory muscles)
• Benefits of using biofeedback is that
muscle testing can be performed in
functional positions, motivates patients,
provides an objective measure
BIOFEEDBACK CONT…
• Various electrodes
– Surface electrodes (Peri-anal &
Abdominals)
– Internal vaginal probe
– Internal rectal probe
• Precautions/Contraindications
for Internal Probes:
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Menstruation
Vaginal Infection
UTI
Hemorrhoids
Pregnancy
Postpartum before 6 weeks
Post-op before 6 weeks
Frail vagina
Vaginal/Rectal pain*
S/P Radiation
Vaginal/Rectal Stenosis
PATIENT EVALUATION WITH
BIOFEEDBACK
•
Normal resting tone of PFM:
– Supine/Hooklying: 2mv
– Sitting: 2mv
– Standing: 3-4mv
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Normal resting tone of
abdominals:
– Supine/Hooklying: 2-5mv
– Sitting: 2-5mv
– Standing: 5-10mv
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Accessory muscle use
Breath holding
Quick rise
Muscle endurance
Return to baseline
PFM during functional
activities: coughing, jumping,
lifting
COMMON PT INTERVENTIONS
• Behavioral Therapy
• Bladder Exercises
• Therapeutic Exercise
• Biofeedback Training
• Electrical Stimulation
BEHAVIORAL THERAPY
• Anatomy & Function of the PFM
• Definitions of UI
• Normal bladder functioning
• Fluid Management
– Swinthinbank, Hashim, & Abrams (2005)
• “Just in case”
• Bladder dietary irritants
• Urge suppression techniques:
– Affects Bradley’s Reflex Loop #3: Vesical-sacral-sphincter loop
BLADDER DIETARY IRRITANTS
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Alcohol
Apples/Apple Juice
Beans
Sugar/Artificial Sweeteners
(added to many processed
foods)
Cantaloupe
Chilies
Chocolate/Cocoa Bean
Cranberries
Grapes
Guava
Cigarettes/Tobacco
Lemons/Lemonade
Milk & Dairy Products (Yogurt,
Aged Cheeses, Sour Cream)
Peaches
Pineapple/Pineapple Juice
Plums
Onions
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Tomatoes/Juice/Paste
Vegetable Fat
Vinegar
Vitamin B Complex
Coffee (including decaf)
Hot or Iced Tea (including decaf)
Wheat, Rye, Corn, Oat, Barley,
and their derivatives
Soda/Carbonated Beverages
(including caffeine free)
Spicy Foods (Mexican, Peppers,
Thai, Indian, Cajun,
Southwestern)
Honey/Corn Syrup
Barbecue Sauce/Chili
Caffeine
Citrus Foods/Juices (Orange,
Grapefruit, Lemon/Lime)
Nuts (Walnuts/Peanuts)
Strawberries
Spices: especially HOT spices
URGE SUPPRESSION TECHNIQUES
• WHAT TO DO WHEN THE URGE STRIKES:
– Stop what you are doing; sit down if possible; stay calm; take a few
deep breaths
– Perform 2 or 3 quick pelvic floor muscle contractions (Kegels)
– Apply pressure on the area of skin between your vaginal/testicle
and anal openings (just like children do when they have to urinate
badly). If you are in public and cannot place your hand down in the
pelvic region, try one of these tips:
• Sit on a towel roll
• Sit on the heel of your foot
• Lean against the corner of a desk or table
– Distract your mind:
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Balance your checkbook
Sort your mail
Count down from 100 by sevens
Make a quick phone call to someone
Talk to yourself in a calming manner
– Wait until the urge subsides
– SLOWLY walk to the bathroom; DO NOT RUSH
RESEARCH RELATED TO
BEHAVIORAL THERAPY
• Burgio et al (2000)
– 80.7% improvement after 8 weeks of
behavioral therapy
– 68.5% improvement after 8 weeks Ditropan
– Behavioral therapy with added
medication=88.5% improvement
– Medication therapy with added behavioral
therapy=84.3%
RESEARCH RELATED TO
BEHAVIORAL THERAPY
• Khan & Tariq (2004)
– Review of studies of behavioral therapy for
SUI or UUI results in improvement rates
from 78-94%
• Smith et al (2006)
– Given the relatively low costs & risks of
behavioral and/or medical therapy, these
should be the first step in treatment for
urinary urgency/UUI
BLADDER (RE)TRAINING
• INDICATIONS:
– Various urinary incontinence
– Patients with mental cognition intact
• CONTRAINDICATIONS:
– Overflow incontinence/Urinary retention
– UTI
• EVALUATION:
– Bladder diary
• High test-retest reliability for urinary frequency and
UI episodes
BLADDER (RE)TRAINING
• Habit training (retraining):
– Used in nursing home
– Goal: have patient void before time of usual
accidents/keep patient dry
• Timed voiding:
– Set time to void within normal bladder capacity that is
not changed
– Goal: establish a predictable pattern of urination
• Scheduled voiding:
– Used most often in outpatient clinic
– Voiding intervals are progressively increased as
urgency and UI decreases
RESEARCH RELATED TO
BLADDER (RE)TRAINING
• Borello-France & Burgio (2004)
– 1970’s Frewen found 82-86% cure rate with
intense 7-10 day bladder retraining with
anticholinergic & sedatives in women 15-77
y/o
– Less intense outpatient programs have
cure rates of 44-90%
THERAPEUTIC EXERCISE
• Kegels
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30-80/day
Concentric vs. Eccentric
Multiple Positions
Slow vs. quick vs. elevator (Miller et al., 1998)
Position (Borello-France et al., 2006)
• Core Strengthening Exercises
• Physiological Quieting Exercises
– Used for urge incontinence/nocturia
RESEARCH RELATED TO
THER EX
• Balmforth et al (2006):
– After 14 weeks of PFMT & Behavioral
modification, significant elevation of the
bladder neck position was noted and
displacement of the bladder neck on valsalva
was reduced
– This suggests levator “stiffness”.
– These changes in anatomy resulted in
clinically significant reduction in UI &
improved QOL.
• Hay-Smith et al (2002)
– Use of PME to treat SUI are unclear &
inconsistent with respect to PME variables
• Daily practice?
• PFM contraction duration?
• Frequency of contractions prescribed each day?
• Hay-Smith & Dumoulin (2006)
– Kegel exercise programs are more effective if
steps are taken to ensure that patients are
exercising the correct muscles and are given
support in sticking with the exercises
• Borello-France & Burgio (2004)
– Improvement and cure rates found between
50-90% for PME
• Neumann et al (2006)
– Women with weaker PFM have
>improvements in UI symptoms
• Neumann et al (2006)
– Treatment programs < 3 months may result in
improve UI as well as increased PFM strength
• Good for patients with financial or time restraints
VAGINAL WEIGHTS
• Indications:
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Pelvic floor laxity/weakness
Pelvic floor disuse atrophy
Stress incontinence/urge incontinence
Mild to moderate genital prolapse
Decreased PFM proprioception
Sexual dysfunction
Poor coordination of pelvic floor/abdominals during ADL’s
• Contraindications:
– During intercourse
– Any reason that Urogyn PT examination would be contraindicated
• Uses:
– PFM strength grade: 0-2 (supine); 3 (upright); 4-5 (strenuous
activities/ADL’s)
• Types:
– Vaginal cones
– Feminine personal trainer
– Pressure sensor
RESEARCH RELATED TO
VAGINAL WEIGHTS
• Cammu & Van Nylen (1995)
– 47% of women assigned to vaginal weight group withdrew from
the study (caused unpleasant feeling, too time consuming, or
caused muscle fatigue)
• Bø et al (1999)
– Looked at PME alone vs. vaginal weights
– No adverse events with PME alone; pain, infection, and
compliance with weights
– 93% adherence in PME only compared to 78% in vaginal weight
group
– Also found PFM strength increased & UI decreased more in
PME only group
• Herbison et al (2002)
– Systematic review found little evidence to support vaginal
weight training as superior to PME alone
BIOFEEDBACK
• Findings:
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Poor awareness of contraction
Minimal peak contraction
Minimal net rise of 0-3mv
Difficulty with initiation of contraction
Difficulty sustaining contraction
Fatigues easy, poor endurance
Increased abdominal contraction
Accessory muscle use or muscle substitutions from
feet, knees, jaws, eyes
– At times, may have an elevated resting tone due to
breath holding
• Treatment Techniques:
– Uptraining/Coordination Training
RESEARCH RELATED TO BF
• Khan & Tariq (2004)
– BF is helpful as an adjunct to PME, but no evidence
that PFMT with BF is more effective
• BF is a teaching technique; real improvement in muscle
strength and UI depends on patient participation & effort in
therapy
• Neumann et al (2006)
– There is no benefit in adding adjunct therapies (BF,
ES, or abdominal muscle training) to a PFMT
program
– BF is useful for patients with poor PFM
proprioception or decreased motivation to exercise
(also noted in Hay-Smith et al., 2002)
ELECTRICAL STIMULATION
• Uses:
– Decreased PFM awareness
– Weakness: 50Hz
– Overactive bladder: 5-10Hz (bladder inhibition: Bradley
Loop #3)
• Duration: 30 min max; daily or at least 3x/week for 12
treatments
– Stress incontinence: 10-50Hz
• Slow twitch activated at 10-20Hz; Fast twitch activated at 3050Hz
• Duration: 3x/week for 30 min for 12 treatments
• Initially start with 15 min to assess patient tolerance
– Mixed UI:
• 15 min @ 10Hz
• 15 min @ 50Hz
– Side effects reported: vaginal irritation, pain, bleeding,
vaginal infection, and UTI
RESEARCH REGARDING ES
• Amaro et al (2005)
– There was significant improvement in PFM strength
from both effective & sham ES
– Larger decrease in UUI with sham device, however
greater subjective improvement & satisfaction in
treatment rates in actual stimulation group
• Bo (1998)
– ES may be most appropriate for patients who are
initially unable to contract their PFM
– Once PFM activation is possible, PME alone may be
more effective
COMMON RX FOR HYPERTONUS
DYSFUNCTIONS
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Patient Education
Biofeedback
Manual Therapy
Dilator Program
Electrical Stimulation
Therapeutic Ultrasound
Therapeutic Exercise
PATIENT EDUCATION
• Anatomy/Function of PFM
• Home care techniques for pain management
• Explanation of Common GYN Hypertonus
Diagnoses
• Pelvic Pain Reference
• Vaginal Lubrication
• Vulvar Care Reference
– Low oxalate diet
– Techniques for Personal Care
– Avoid Sensitizing Agents
• Use of “U” shaped cushion for pain relief while
sitting
BIOFEEDBACK
• Findings:
– Elevated resting baseline
– Minimal peak of contraction
– Minimal net rise
– Difficulty returning to baseline
– Use of accessory muscles secondary to
resultant weakness
– Decreased awareness of muscle
release/contraction
• Training technique:
– Downtraining
MANUAL THERAPY
• Myofascial Release (vaginally or rectally)
• Theile’s Massage (vaginally or rectally)
– Oyama et al (2004)
• Found to be effective in improving irritative
bladder symptoms and decreasing PFM tone in
patients with IC & hypertonicity
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DTM to tender hip/thigh musculature
MET’s
SC/SI joint mobilizations
Scar tissue massage
Visceral mobilization
DILATOR PROGRAM
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Used to decrease PFM tone
Used to stretch PFM
Return to pain-free intercourse
Allows patients to perform home internal vaginal
MFR
• Progress in size
• Used 3-4x/week (skipping one day between each
use)
• Program:
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Static stretch x 10 min
MFR x 5 min (R) and (L)
Kegels (5/20 second work/rest phase) x 10 reps
Insert/remove with one minute stretch x10
ELECTRICAL STIMULATION
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Used with pain/hypertonicity
Increase blood flow to PFM
Assists in muscle relaxation
Often use IFC (TENS home unit if beneficial)
Contraindications:
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See PT/GYN examination
Urethral obstruction
Residual volume >200cc
History of urine retention
Vaginal, rectal, or urinary infections
Acute inflammation or danger of hemorrhage
Pelvic cancer
Fistula
Complete peripheral muscle dennervation
Pacemaker
ULTRASOUND
• Indications:
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Episiotomy
Perineal laceration
Dyspareunia due to soft tissue adhesion
Vaginismus
Hemorrhoids
Gynecological surgery scars
Vulvodynia
Fractured coccyx
Post-partum day one: used for scar healing and
reduce swelling
ULTRASOUND CONTINUED
• Expected Outcomes:
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Decreased pain
Increased circulation
Increased extensibility of tissues
Reduced swelling and reduced hemorrhoid size
Enhanced healing of tissue
Decreased spasm
Stimulated tissue repair
• Contraindications:
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Pregnancy
Infection of perineal tissues
Anesthetized areas
Vascular abnormalities (DVT/emboli)
Patients with hemophilia
Ultrasound application over the ovaries
THERAPEUTIC EXERCISE
• Physiological quieting exercises
• Initiation of stretching trunk/lower extremities
• Kegels (double resting phase)
• Core Strengthening Exercises
SUMMARY
• The PFM serves 3 main functions
• Dysfunction of the PFM can lead to prolapse
or UI
• It is within the scope of PT practice to
perform an internal PFM examination
• PT’s can play an active role in resolving
symptoms of UI
REFERENCES
•
Balmforth JR, Mantle J, Bidmead J, Cardozo L. A prospective observational
trial of pelvic floor muscle training for female stress urinary incontinence.
BJU Int. 2006;98:811-17.
•
Brink C, Wells TJ, Sampselle CM, Tallie ER, Mayer R. A digital test for pelvic
muscle strength in women with urinary incontinence. Nurs Res.
1994;43:352-356.
•
Bo, K. Effect of electrical stimulation on stress and urge urinary
incontinence. Acta Obstet Gynecol Scand. 1998;77:3-11.
•
Bø K, Sherburn M. Evaluation of female pelvic-floor muscle function and
strength. Phys Ther. 2005;85:269-282.
•
Bø K, Talseth T, Holm I. Single blind, randomised controlled trial of pelvic
floor exercises, electrical stimulation, vaginal cones, and no treatment in
management of genuine stress incontinence in women. BMJ. 1999;318:487793.
•
Borello-France D, Burgio KL. Nonsurgical treatment of urinary
incontinence. Clin Obstet Gynecol. 2004;47:70-82.
•
Borello-France DF, Zyczynski HM, Downey PA et al. Effect of pelvic-floor muscle
exercise position on continence and quality-of-life outcomes in women with
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RESOURCES
• Section on Women’s Health (APTA):
www.womenshealthapta.org
• National Association for Continence: www.nafc.org
• Society of Women’s Health Research:
www.womenshealthresearch.org
• Agency for Health Care Policy & Research (AHCPR):
www.ahcpr.gov
• American Urogynecologic Society: www.augs.org
• www.womhealth.org