Transcript Pelvic Floor Muscle Dysfunction in COPD

Pelvic Floor Muscle
Dysfunction in COPD
Liz Childs
Pelvic Floor Physiotherapist
Wellington
Outline
PFM anatomy / function
 Relationship PFM and breathing
 Teaching PFM exercises
 Lifestyle modifications
 Effective huff / cough technique
 Where / when to refer on

Pelvic floor anatomy – female
Pelvic floor anatomy - male
Function PFMs
Support pelvic organs
 Contribute to continence via:
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◦ closure urethra & anus
◦ support bladder neck
◦ closure anorectal angle
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Role in voiding, evacuation
Sexual role – arousal, erection, orgasm, ejaculation
PFM – part of the core
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Functional unit
◦ Spinal stability
◦ Intra-abdominal
pressure
◦ Continence
◦ Breathing
What happens to the pelvic floor
during breathing?
Inspiration: diaphragm contracts, flattens, moves
caudally  incr IAP  downward pressure
exerted on PFM
 Expiration:
◦ Rest / quiet breathing: passive process, elastic
recoil lungs, chest wall, muscle relaxation
◦ Forced exp: diaphragm and abdominals
contract  incr IAP  upward mvt diaph,
downward pressure PFM
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Inspiration
(Talasz et al, 2010)
Forced expiration / cough – no
abdominal or PFM co-contraction
(Talasz et al, 2010)
Forced expiration – with ab and
PFM co-contraction (Talasz et al, 2010)
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Reduces pressure on pelvic floor
Practice…
Huff
Cough
PFM dysfunction

Urinary incontinence
◦ Affects 1 in 3 women
◦ Increased prevalence in COPD

Pelvic organ prolapse
◦ Affects 50% women
Stress urinary incontinence – what
happens when you cough or sneeze
Urge urinary incontinence
Involuntary loss of urine associated with urgency
= detrusor contraction
(can be related to anxiety)
Urinary incontinence in respiratory
disease

Degree of urinary incontinence is greater in
those with chronic cough due to CF, COPD
compared with general population (Button BM,
Sherburn M, Chase J, et al 2005)
Evidence PFMT

Pelvic floor muscle training should be offered, as first
line therapy, to all women with stress, urge or mixed
urinary incontinence
Level 1 evidence, Grade A recommendation,
ICI 2012
Pelvic organ prolapse
Pelvic Organ Prolapse
High quality evidence (8RCTs) supporting
PFMT
 Significant improvement in
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◦ Symptoms
◦ Stage
ICI 2012 – Level 1A evidence for PFMT
Risk factors for PFM weakness 
lifestyle modifications
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Chronic cough
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Breathing retraining
Sputum clearance techs, cough suppression
The “knack” – PFM with cough, huff
Support perineum
Constipation / straining
◦ Fibre, fluid, exercise
◦ Bowel routine
◦ Defaecation training
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Obesity
Heavy lifting
◦ How much is too much?
◦ Technique
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Fatigue
Inappropriate exercise
◦ Promote pelvic floor safe exercise
Patients with COPD
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Chronic coughing  strain pelvic floor
Reduced exercise levels weak muscles
◦ PFM ,diaphragm, abdominals
Evidence:
◦ Women with stronger PFMs are able to generate greater
pressure in forced expiratory techniques / coughing
(Talasz et al, 2010)
◦ COPD/ CF patients: PFM training and Estim resulted in
improved PFM strength, reduced symptoms
(Button et al, 2005)
◦ Teach “The Knack”
 PFM contraction just before huff/cough leads to reduced urine
leakage
(Miller et al, 1998)
Teaching PFM Exercises
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Squeeze and Lift
◦ As though trying to stop flow of urine or stop
passing wind
Must feel the release
 Hold 2-3 sec, increase as able
 Repeat up to10 times
 Do this several times a day
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Practice….
Pelvic floor training
Recommendations
(Guidelines for the Physiotherapy Management of the adult, medical, spontaneously breathing patient.
Thorax, 2009)
Question patients about their continence status
 All patients with chronic cough, irrespective of
continence status, should be taught to contract their
pelvic floor muscles before forced expiration &
coughing (The Knack)
 If problems of leakage are identified, patients should
be referred to a physiotherapist specialising in
continence
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Asking the question
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Embarrassment / Shame
◦ Patient
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Language to use
◦ Patient / health professional
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Let people know
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Continence problems are common
Help is available
Being dry is normal
Continence products
When to refer on
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Symptoms of incontinence or prolapse
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Wet pants, frequency, urgency
Soiling
Bulging at vaginal entrance
Heaviness, dragging
Suspect overactive pelvic floor
◦ Symptoms may include
 Pain – pelvis, genital
 Constipation
 Voiding difficulty
Referral
Women’s Health Physiotherapists in most
DHB’s
 Private Pelvic Floor Physiotherapists in
many centres
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◦ NZ Continence Association
www.continence.org.nz
List of continence service providers
Conclusion
PFM dysfunction is under reported
 Subjects are unlikely to seek help on their
own
 Impact on an individual’s ability and/or
willingness to perform certain activities
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 Exercise
 Airways clearance techniques and lung function
manoeuvres
 Social outings
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Education in pulmonary rehab groups