Download - Women’S Health Physical Therapy W07
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Women’s Health Physical Therapy
Amy Flory PTApril 14, 2009
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Terminology used conforms to the definitions recommended by the International Continence Society, except where specifically noted.
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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
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Pelvic floor muscle anatomyDeLancey 2004
• Pelvic diaphragm– Levator ani
» Pubococcygeus» Puborectalis» Iliococcygeus
– Ischiococcygeus (coccygeus)
• Sphincter urethrae• Perineal membrane
– Compressor urethrae– Urethrovaginal muscle
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Pelvic floor muscle anatomyDeLancey 2004
– Superficial genital muscles• Bulbocavernosus (bulbospongiosus in men)• Ischiocavernosus• Superficial transverse perineal
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Pelvic anatomy
• Associated muscles (close proximity, facilitative, synergistic—Bo 1994)– Piriformis– Obturator internus– Adductors– Gluteals– Transverse Abdominus (TrA)– Multifidus– Respiratory diaphragm
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Pelvic anatomy
• Organs– Bladder• Detrusor (parasympathetic innerv)• Trigone (sympathetic innerv)
– Uterus – Rectum– Prostate
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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
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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
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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
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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
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Financial Implications
• Cost to nursing facilities is high, with estimates as high as $10-20 billion/year• Supplies• Caregiver support• Laundry
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Neurological control
• Bladder fills>stretch receptors>micturation reflex• Midbrain inhibits reflex until appropriate social
setting to void• Sphincter relaxes>detrusor contracts>voiding
occurs
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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
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Neurological Control
• Spinal Cord Center• S2-S4 (vertebral level T12, L2, L3)• Coordinates the external urethral sphincter with
bladder contraction
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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
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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
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Professional responsibilities
• State practice act• Terminology• Referral sources know your procedures• Specific training• Ethical and professional behavior
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Professional responsibilities
• Patient education– Anatomy and equipment– Tests to be used– Verbal consent– Observing assistant available– Mirror for observation available
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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
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PT treatment for UI
• Urge incontinence– Strengthening– Coordination– Bladder retraining• Urge-delay techniques• Voiding schedule
– Bladder irritants education– Electrical stimulation
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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
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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)
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Palpation lab
• In side lying – Adductors– Pubic ramus– Ischial tuberosity– Levator ani– Ischiococcygeus– Internal obturator
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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
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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
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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)
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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
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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
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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
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Gestational diabetes
• More than half go on to have Type II diabetes– Great opportunity for intervention/prevention – Lifestyle changes– Exercise
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Implications for post-partum physical therapy
• Musculoskeletal pain complaints• Abdominal muscle• PFM rehabilitation• Clogged milk ducts• UI that persists more than 3 months
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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
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Pelvic pain origins
• Gynecologic (dysmenorrhea, endometriosis)• Urinary (painful bladder syndrome, interstitial
cystitis)• Gastrointestinal (irritable bowel syndrome)• Musculoskeletal• Psychiatric• Multiple (vulvodynia, prostatodynia)
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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)
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Musculoskeletal pelvic pain
• Chronic pelvic pain (CPP)• Overactive/non-relaxing PFM– Levator ani syndrome– Tension myalgia– Vaginismus
• Coccygodynia
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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
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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
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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
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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
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Physical therapy evaluation
• Musculoskeletal system– Strength and flexibility– Scar mobility– Pelvic joint function– Location of trigger points and nerve entrapment
sites
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Physical therapy evaluation
• Urogenital system– Trigger points– Pelvic floor muscle function– Organ mobility
• Viscera– Mobility
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Physical therapy interventions
• Therapeutic exercise– Postural strength– Postural flexibility– General endurance– Pelvic floor strengthening, if indicated– Pelvic floor muscle coordination
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Physical therapy interventions
• Manual therapy• Therapeutic activities/self-management of
symptoms/neuromuscular re-ed• Physical modalities
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ReferencesWill follow shortly
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Thank you!
Amy Flory PT, MPTCoreBalance Therapy LLC906 W University Ave, Ste 120Flagstaff, AZ [email protected]