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Women’s Health Program

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1 Women’s Health Program
Delete this Text Box and Insert Your Clinic’s Header/Logo Here Women’s Health Program Physical Therapy Specialists in Pelvic Floor Dysfunction and Rehabilitation

2 Female Urogenital and Musculoskeletal Anatomy
Contents of the Pelvic Floor: Perineum Genitals Muscle Fascia Connective tissue We will begin by discussing the anatomy of the pelvic floor. It is important to understand the anatomy and structure of the pelvic floor as physical therapists evaluate and treat each patient specific to their individual dysfunction. The pelvic floor has many layers. Within the musculature there are three layers of muscle that we will delve into more detail shortly.

3 Female Perineum Superficial muscles Perineal Membrane Layer
Anal Triangle Perineal Body Within the superficial muscle layer is made up of the superficial transverse perineal, bulbocavernosus and ischiocavernosus (see diagram). Within the perineal membrane layer are the deep transverse perineal, compressor urethra and the sphincter urethra muscle. These muscles assist with sphincter control. These two layers in combination with the fascia are also known as the urogential triangle. Note the anal triangle. Within the anal triangle are two muscles: the internal sphincter and the external sphincter. The Internal sphincter may suffer trauma with childbirth. The external sphincter is voluntary. Special attention to the perineal body. This is made up of a fibromuscular node known as the central perineal tendon. It is the insertion for the urogential triangle muscles, as well as the external anal sphincter and portions of the levator ani muscles. This is the region where an episiotomy may be performed or tears during childbirth most often occurs. This can later affect sphincter control and sensation. In this diagram you can also see the gluteus maximus and a portion of the levator ani which is the deeper layer.

4 Pelvic Diaphragm Deepest Layer Function: Levator Ani Muscles
Pubococcygeus Pubovaginalis Puborectalis Iliococcygeus Coccygeus Function: Support the pelvis Support the organs Assist abdominals Sphinteric Sexual appreciation Muscle Fibers 30% fast twitch 70% slow twitch The deepest layer of muscles of the pelvic floor is the Levator Ani Muscles. These muscles act as a sling to support the pelvis and internal organs with continuous resting tone. Additionally the levator ani assist the abdominals during forced urination, expiration or any time the abdominals need assist with contracting. They assist with sphinteric closure as well. These muscle fibers consist of slow and fast twitch fibers which we will discuss more later. The coccygeus is not part of the levator ani, but it is a deep muscle of the pelvic floor and stabilizes the sacro-iliac joint.

5 Levator Ani Muscle attachments to coccyx, sacrum, piriformis and pubis
Continuous with piriformis and obturator internus This is a view from the side showing the support of the levator ani muscles. These muscles are attached to the coccyx, sacrum, piriformis and pubis. They are also continuous with the piriformis and obturator internus which is a hip rotator. Dysfunction with these muscles can cause dysfunctions with all these structures. There can also be pain referred to the hip, pubis or buttock. (see next slide)

6 Obturator Internus and Piriformis Muscles
Lateral hip rotators Hypertonus or trigger points cause vaginal, rectal or clitoral pain Piriformis syndrome Referred pain mimics other dysfunctions Hypertonus or trigger points in these muscles can manifest as vaginal, rectal or clitoral pain Piriformis syndrome-the piriformis, sciatic nerve and obturator internus form a sandwich where the sciatic nerve is impinged upon The patient reports buttock, post. thigh, rectal or radicular pain similar to a disc or piriformis muscle problem.

7 Muscle Fibers 70 % slow twitch 30% fast twitch
Both fast and slow twitch fibers are present in the levator ani muscles Fast twitch facilitate rapid sphincter closure Slow twitch maintain tone and support the pelvic organs Fast and slow twitch are assessed during evaluation and will be addressed as needed in treatment program.

8 Mobility vs. Stability Pelvic floor- function
Supportive Sphinteric Sexual Too much mobility-prolapse or incontinence Too much fixation-pain The pelvic floor needs to perform the functions as listed above. Due to the nature of the structures-layers of muscles surrounded by fascia -a balance of stability versus mobility is needed for the pelvic floor to function properly. There needs to be a certain amount of pliability allowing for urine and stool to pass, as well as stretching for reproductive functions. Additionally, there needs to be adequate muscle tone to provide stability, to support the pelvic organs, maintain continence, and prevent prolapse as well as allow for sexual appreciation. Physical therapists can address this by determining if the patient requires stretching and relaxation to assist with mobility, or strengthening and muscle reeducation to improve support and tone.

9 Indications for PT Urinary and fecal incontinence Pelvic pain
Pelvic organ prolapse To assess for a PF exercise program When would a patient be an appropriate referral to physical Therapy?

10 Contraindications for PT
Lack of patient or physician consent Under 6 wks. Post partum Under 6 wks. Post-op Severe atrophic vaginitis Severe pelvic pain Children or anyone w/o prior medical pelvic exam Sexual abuse Pregnancy

11 Physical Therapy Evaluation of The Pelvic Floor
History Observation and Manual techniques Manual Muscle test Biofeedback Clear spine/sacroiliac joint Each of these areas of evaluation will be reviewed individually on subsequent slides.

12 History Extensive questionnaire Consent form Bladder or bowel diary
3 days Frequency, intake, amount voided The therapist takes a thorough history of symptoms surrounding the pelvic floor dysfunction. This gives the therapist an understanding of whether there is stress, urge, or mixed incontinence, or what types of pain syndromes may be present. It can also help detect symptoms of prolapse. The bladder diary gives insight into whether the patient truly has urge incontinence, precipitating factors, and other lifestyle factors that may impact the treatment program.

13 Observation and Manual techniques
External assessment Palpation and Internal assessment Complete assessment of vaginal tone and size, contractility, muscle symmetry, reflexes (anal, clitoral), sensation, pain and strength Observe for cystocele or rectocele External assessment includes the skin, symmetry and color of tissues, resting position and appearance and observation of muscles performing PF contraction externally. Palpation includes checking for sensation and increased reaction to touch of superficial PF muscles. Internal assessment includes checking all layers of pelvic floor for strength, mobility, pain, symmetry and control. Therapist will also palpate muscle in all three layers of the pelvic floor. Therapist check for muscle tone, contractibility, pain and symmetry. Obturator internus is palpated when assessing levator ani muscles. Reflexes are checked to determine integrity of innervation and possible hyper-tonicity of muscles. Therapist will perform observation technique to assess if the an anterior or posterior wall prolapse exists and will grade it as mild, moderate or severe depending on how far the wall bulges in vaginal canal.

14 Pelvic Floor Manual Muscle Testing
Power: Grade 0-5 Symmetry Fast contraction Endurance Repetitions # of repeatable contractions up to 10 seconds at grade of power test Pelvic floor muscle strength is initially assessed manually with one finger internally. 0= no palpable contraction; 1=flicker contraction; 2=contraction-no lift; 3=palpable contraction and lift posterior more than anterior; 4= strong contraction and lift with compression from anterior, posterior and side walks; 5=strong lift and compression with inferior deflection of the finger. Therapist also checks for symmetry of movement; checks for quick contractions (fast twitch) up to 10 repetitions; checks for endurance of muscles which is the duration of maximal contractions at muscle grade scored (up to 10 seconds); then the repetitions up to 10 seconds of repeatable maximal contractions.

15 Biofeedback Assessment
Surface electrodes vs. vaginal internal surface electrodes Baseline reading Initial rise Stability of hold Quick contractions Ability to return to baseline Ability to repeat contraction Substitution Compare sub maximal to maximal After manual assessment, the therapist can get a better picture of the patient’s pelvic floor muscle function by performing a biofeedback assessment. This can be done at the initial visit or a subsequent visit. Therapist can determine if the patient would use a surface or internal vaginal surface electrode to perform assessment. Surface electrode is less expensive but may not give as detailed data especially if patient if very weak. Conversely, if the patient if in significant pain, an internal electrode may not be tolerated initially. The therapist gets the following data on the biofeedback assessment: Baseline reading- this is for one minute to determine if there is elevated resting tone. Resting tone should average at 2 millivolts or less. Initial rise- How quickly the patient can reach maximal contraction Stability of hold-can they maintain that level of hold for 10 seconds (then rest for 10 seconds) Quick contractions- perform 10 contractions, 2 seconds on /4 seconds off- are they able to contract quickly and relax in between holds Ability to return to baseline-can they relax in between contraction or do they not have the muscle control to do this. Ability to repeat contraction-is there enough endurance to repeat at least 10 maximal, 10 second contractions. Substitution-are they substitution with abdominals in place of pelvic floor muscles. Submaximal compare to maximal-can they partially contract the PF muscles or is it just off and on.

16 Biofeedback readouts Low Tone High Tone
Difficulty in return to baseline Unstable curve Fast vs. Slow twitch The therapist synthesizes all the information from the biofeedback assessment to assist in determining problem areas and goal planning. From the biofeedback information the therapist can see if the patient is exhibiting a high or low tone pattern. Or they do not have good control over their muscles or need help figuring out how to control them or if there is an uncoordinated learned muscle pattern. They may be using their abdominals incorrectly. The therapist can also determine if the patient needs to work on slow or fast twitch muscle contractions or both.

17 Treatment: Exercise Teaching and prescribing pelvic floor exercises
Progression Based on evaluation findings and history Accessory muscles Self Assessment Techniques: Mirror observation Self palpation-external and internal Partner feedback Therapist designs individualized exercise program depending on what findings are from evaluation. Patient may receive graded pelvic floor exercises to match their abilities and then progress in repetitions and seconds of contracting. Therapist will prescribe quick or sustained holds depending on patient’s symptoms and needs. Exercises can be concentric or eccentric. Therapist will determine if accessory muscles are necessary to gain strength or if PF muscles need to be isolated to progress. Patient may initially require assisted neuromuscular training such as manual feedback or a quick stretch to facilitate contraction. Exercises can later be progressed from supine (gravity eliminated) to sitting and standing or during functional movement (against gravity). Patient is instructed in self assessment techniques to assist in muscle re-education and to make sure they are doing exercises properly at home.

18 Treatment: Biofeedback
Surface vs. vaginal electrode Baseline tone Sustained contraction and return to baseline Isolate PFM Endurance changes Strength changes Very motivating-visual and immediate results Excellent for patients with poor motor awareness Biofeedback will be the most useful tool for the therapist treating patient’s with PF dysfunction as it gives the patient immediate feedback of how they are doing when exercising. The therapist can choose to use surface or vaginal (internal) electrodes depending on patient’s needs. Therapist can work on baseline function in patients that show high resting tone. Additionally, this is an excellent tool to help the patient isolate PFM from abdominals. Patients can work toward their goals of increasing endurance, strength, slow of fast contractions, based on the program that the therapist sets for them each visit. Patients are very motivated to use the biofeedback as they get immediate results and generally improve each treatment session.

19 Treatment Strategies-Incontinence
Stress and Urge Scheduled voiding Bladder retraining Relaxation techniques Type and amount of fluid intake Patients benefit from being placed on a voiding schedule with gradual increase in time between voids. Initially start with schedule that patient can comfortably tolerate and gradually increase time. Goal is 3-4 hours between voids. Patient uses pelvic floor muscle contraction, relaxation and behavioral techniques to gradually achieve this goal. Also encouraged is type and amount of fluid intake, as well as dietary factors that may contribute to irritable bladder.

20 Treatment Strategies Electrical stimulation Ultrasound Vaginal weights
Indications: stress and urge incontinence, pelvic floor re-education or weakness, overactive bladder Strengthening -efferent Inhibiting (TENS) -afferent Contraindications: infection, pregnancy, pacemaker, cancer, poor cognition Ultrasound Vaginal weights Electrical stimulation can be performed to the pelvic floor muscles in cases of extreme weakness or very poor muscle control. In some cases, electrical stimulation can be used as a pain relief to patients suffering from chronic pain. Ultrasound may be used to treat scar tissue externally. Some patients will benefit from vaginal weights to assist in strengthening and home re-education and functional training, e.g. having a patient use weights when transitioning sit to stand when they usually have leakage during this movement.

21 Treatment: Chronic Pain
Variety of diagnoses and indications Note high resting sEMG, trigger points, urinary frequency and urgency Techniques Modalities-cold, heat, US, ES Muscle re-education with sEMG Soft tissue mobilization, trigger point techniques Dilators Perineal massage Pelvic alignment Exercise program Scar mobility In many cases, patients with chronic pain also have high resting tone. The patient benefits from learning how to decrease muscle tone through biofeedback, inhibition with exercise and relaxation techniques. Additionally other PT modalities can be used as listed above. Soft tissue mobilization and manual stretching techniques are very effective for patient with decreased soft tissue mobility or pain with vaginal insertion. Use dilators with gradual increasing diameter

22 Treatment for Surgical Patients
Phase one: Pre-op Pelvic floor anatomy and function How diet may affect the bladder Avoidance of valsalva—proper use of lower abdominal muscles to support the pelvic girdle EMG of the pelvic floor to identify muscle and improve strength Phase two: 6 weeks post-op Gradual increase in strengthening exercise Pelvic floor strengthening program as needed Surgical patients do better after surgery if they learn how to use and improve their pelvic floor strength prior to their procedure.

23 Referral Evaluate and treat or specific orders Feedback from EMG
Usually one time per week for 6-8 wks. Covered by insurance Patient can come in for conference prior to initial assessment Thank you! Therapist can evaluate patient and make recommendations on treatment program or physician can request specific treatment. Therapist can send copy of biofeedback readout to Dr. to give information on evaluation and follow-up assessments. Treatment program is typically short and patient can improve rapidly if compliant. Reimbursable by all insurance types including Medicare (some stipulations may apply-such as patient needs to have tried to do pelvic exercises on their own and failed) Therapist may want to offer opportunity for patient to come in prior to initial visit to discuss treatment program and options.

24 References Schussler B, Laycock J, Norton P: Pelvic Floor Re-education: Principles and Practice, New York, Springer-Verlag, 1994 Wallace K: Female pelvic floor functions, dysfunctions, and behavioral approaches to treatment. Clinics in Sports Med, 13:2: , 1994 Gray, H : Gray’s Anatomy of the Human Body. Philadelphia, Lea & Febiger, 1918 Moore, K: Clinically Oriented Anatomy (ed 2) Baltimore, Williams & Wilkins, 1985 Wall LL, Norton PA, DeLancey JO: Practical Urogynecology. Baltimore, Williams & Wilkins, 1993 Pastore, E. A., & Katzman, W. B. (2012). Recognizing Myofascial Pelvic Pain in the Female Patient with Chronic Pelvic Pain. JOGNN: Journal Of Obstetric, Gynecologic & Neonatal Nursing, 41(5), Gentilcore-Saulnier, E., McLean, L., Goldfinger, C., Pukall, C. F., & Chamberlain, S. (2010). Pelvic Floor Muscle Assessment Outcomes in Women With and Without Provoked Vestibulodynia and the Impact of a Physical Therapy Program. Journal Of Sexual Medicine, 7(2), Schussler B, Laycock J, Norton P: Pelvic Floor Re-education: Principles and Practice. New York, Springer-Verlag, 1994

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