Transcript Components of a Rehabilitation Program

Principles of pelvic floor
rehabilitation in chronic
disorders of postpartum
period
T. Ahadi MD
Assistant professor of
Physical Medicine
and Rehabilitation
Common musculosketal problems in
postpartum phase
Diastasis Recti
Low Back Pain
Posterior Pelvic Pain (PPP)
Symphysis pubis dysfunction(SPD)
Pregnancy associated OP(PAO)
Varicose Veins
Pelvic Floor Dysfunction
Joint Laxity
Compression Syndromes
change in arch support, ligamentous support of feet and ankles
Rib pain(stitch)
Trigger points
Neck pain and headaches due to changes in posture
Tightness and pain in the hamstrings
Anatomy
1-First layer(Endopelvic fascia)
2-Second layer(pelvic diaphragm)
3-Third layer(Urogenital diaphragm)
Levator Ani Muscles
Pubococcygeus
Iliococcygeus
Puborectalis
Ischiococcygeus
Function
• Provides support for the pelvic organs and
their contents
• Withstands increases in intra-abdominal
pressure
• Provides sphincter control for the bladder and
bowel
• Functions in reproductive and sexual activities
Pelvic floor dysfunction in postpartum phase
• Urinary incontinence or fecal incontinence, Constipation
Involuntary loss of bladder or bowel contents; often a result of
both neuromuscular and musculoskeletal impairments;may
occur in combination with prolapse.
• Prolapse. A supportive impairment; descent of any of the pelvic
viscera out of their normal alignment because of muscular
and/or ligamentous deficits and increased abdominal pressure
often worsens over time and with subsequent pregnancies.
• Pain/trigger points/hypertonus. May be related to delayed healing
of perineal lacerations, scar tissue adhesions, or generalized
spasm throughout the pelvic floor tissues. Functional limitations
include dyspareunia(pain with intercourse) and difficulty
with elimination.
Contributing Factors
Trauma to muscular structure and fascia: particularly
vaginal delivery,
The pudendal nerve can be compressed and
stretched up to 20% of its length during the second
stage of labor.
Episiotomy
multiple deliveries,
prolonged second stage of labor,
use of forceps,
third-degree perineal tears,
birth weight over 8lb
constipation,
obesity
Urinary incontinence
40-80% of all pregnant women experience some
form of incontinence during pregnancy.
7%-35% UI in postpartum
SI is more common in pregnancy and postpartum
Other forms are frequency,urgency and urge
incontinency,mixed type
Reduction in the prevalence of incontinency
postnatally in women who had performed pelvic floor
exercises antenatally.
The use of PFE’s is the main non-surgical treatment
for PFD and has been shown to be more than 80%
effective
Fecal incontinency/ Disordered defecation
Fecal incontinency is very much less common
-Sphincter Disruption:Most common cause of incontinency in
young woman
-Sphincter denervation(Compression or stertching of pudendal
nerve)
Prevalence of constipation in pregnancy 11% to 38%
(progesterone)
Constipation in postpartum period more probably is related to
Pelvic organ prolapse(rectocele),
Rectosphincteric dyssynergia(5%),
functioal Dis(IBS,slow transit)not related to pregnancy
Prolapse
About 11%of woman to the age of 80
have surgery for POP
Significant risk factor is vaginal delivary,
Other Rf: age, obesity,hystrectomy
Chronic pelvic pain
Pelvic floor hypertonicity & overactivity
Pelvic Myofascial pain
Chronic pelvic pain (CPP) refers to pain below the umbilicus of
at least six months' duration that is severe enough to cause
functional disability or require treatment.
The prevalence of CPP ranges from 4 to 25 percent
Different etiology(Gynecology,urinary,GI,musculskeletal,
Psychological, Neurological)
pelvic myofascial pain is caused by involuntary spasm of the
pelvic floor muscles and trigger points(eg, piriformis, levator ani
syndrome, iliopsoas, obturator internus)
The etiology includes any inflammatory painful disorder,
childbirth and poor posture, pelvic surgery, and trauma
Clinical manifestation
Pelvic/abdominal pain (often with severe
dysmenorrhea)
Urinary tract symptoms (eg, frequency,
urgency, incontinence, nocturia, dysuria,
incomplete emptying, bladder pain)
Vulvovaginal discomfort
Dyspareunia
Rectal fullness or constipation, dyschezia
Coccygodynia
Pelvic floor rehabilitation
PFR is used for increasing in strength and
function of pelvic floor muscles and one
of the most important treatment methods
for Pelvic floor dysfunction
Pelvic floor muscle training versus no treatment, or
inactive control treatments, for urinary incontinence
Main results
Fourteen trials involving 836 women met the inclusion criteria;
twelve trials (672) contributed data.
Women who did PFMT were more likely to report they were
cured or improved than women who did not.Women who did
PFMT also reported better continence specific quality of life than
women who did not. PFMT women also experienced fewer
incontinence episodes per day and less leakage on short officebased pad test. Of the few adverse effects reported, none were
serious.
Authors’ conclusions
The review provides support for the widespread recommendation
that PFMT be included in first-line conservative management
programmes for women with stress, urge, or mixed, urinary
incontinence. Statistical heterogeneity reflecting variation in
incontinence
2010 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Fecal Incontinency
Case series report positive patient outcomes, often in
over 70% of patients.1,2
Case series methodology were weak. In addition,
outcome measurements were often poor, or proxy
measures, such as anal sphincter pressures
1-Heymen S, Jones KR, Ringel Y, et al. Biofeedback treatment of fecal incontinence: a critical
review. Dis Colon Rectum 2001;44:728–36.
2- Norton C, Kamm MA. Anal sphincter biofeedback and pelvic floor exercises for faecal
incontinence in adults: a systematic review. Aliment Pharmacol Ther 2001;15:1147–54.
Biofeedback and/or sphincter exercises for the
treatment offaecal incontinence in adults
Main results
Eleven eligible studies were identified with a total of 564 participants. In all but
three trials methodological quality was poor or uncertain.
No study reported a major difference in outcome between any method of
biofeedback or exercises and any other method, or compared to other
conservative management. There are suggestions that rectal volume
discrimination training improves continence more than sham training and that
anal biofeedback combined with exercises and electrical stimulation
provides more short-term benefits than vaginal biofeedback and
exercises for women with obstetric-related faecal incontinence.
conclusions
The limited number of identified trials together with their methodological
weaknesses do not allow a definitive assessment of the possible role of anal
sphincter exercises and biofeedback therapy in the management of people with
faecal incontinence.
The 11 trials reviewed were of very limited value because they were generally
small, of poor or uncertain quality, and compare different combinations of
treatments.
Biofeedback and/or sphincter exercises for the treatment of faecal incontinence in adults (Review)
Copyright © 2009 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Conservative management of pelvic organ
prolapse in women
Main results
Three trials of relevance to this review were identified. The
largest of these, of pelvic floor muscle training in preventing
anterior prolapse from worsening, had significant limitations.
A small feasibility study (which is to be followed up with a
larger trial) randomised 47 women to pelvic floor muscle
training or control and found suggestions of better outcomes .
The third trial evaluated peri-operative physiotherapy for
women undergoing surgery for prolapse and/or incontinence.
The authors report that urinary symptoms, pelvic floor muscle
function and quality of life were improved more in the
treatment group than the control group, but data were not
provided to allow this to be assessed.
Authors' conclusions
Despite there now being reports of three eligible trials in this
update, the evidence available is not significant to guide
practice. There is some encouragement from a feasibility study
that pelvic floor muscle training, delivered to symptomatic
women in an outpatient setting, may reduce severity of
prolapse. Further evidence from larger, better quality
randomised control trials is however still necessary.
2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Evidence
Hagen S. and et al in a systematic
review at 2004 showed that pelvic floor
muscle training,to symptomatic women
in an outpatient setting, may reduce
severity of prolapse.
Evidence
Hay-Smith EJ in a systematic review in
2008 provide that there is some evidence
that PFMT in women having their first
baby can prevent urinary incontinence
in late pregnancy and postpartum. In
common with older women with stress
incontinence, there is support for the
widespread recommendation that PFMT
is an appropriate treatment for women
with persistent postpartum urinary
incontinence.
Biofeedback for pelvic floor
dysfunction in constipation
Clinical review between January 1965 and September
2003
Conclusion: more than 70% of adult patients
complaining of pelvic floor dyssynergia are likely to
benefit from biofeedback training and so this is the
treatment of choice for the problem
The few studies with long term follow up,a certain
percentage of patients (up to 50% and more)
continued to report satisfaction even at 12-44
months after treatment.
Clinical review, BMJ VOLUME 328 14 FEBRUARY 2004
ASSESSMENT & INVESTIGATION
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History taking and physical examination
Pelvic floor muscle assessment
Assessment of prolapse
Urine testing
Assessment of residual urine
Symptom scoring and Q.O.L assessment
Bladder diaries
Pad testing
Urodynamic testing
Other tests of urethral competence
Cystoscopy
EMG-NCV
Imaging
Evaluation(Cont)
Pelvic muscle trigger points: pelvic
muscles should be examined for tone and
tenderness both at rest and during active
contraction. Normally, palpation of these
muscles should be pain-free, both in the
relaxed and contracted state.
Abdominal trigger points: Rising head
while in the supine position for abdominal
trigger points
postural abnormalities: anterior tilt of the
pelvis can create hypertonicity and
imbalanced pelvic muscles
Pelvic floor rehabilitation
The following options are often used in
combination with Kegel exercise for
urinary stress and urge incontinence:
1. Life style changes
2. Behavioral therapy (Patient Education)
3. Pelvic floor muscle training (Kegel exercise)
4. Biofeedback
5. Electrical Stimulation
6. Extracorporeal Magnetic Innervation
7. Myofascial release techniques
Life style
Weight loss
Smoking cessation
Caffeine
Fluid management
Behavioral therapy
Improving voluntary control of bladder function by
Bladder training (forUUI) with urge inhibition
technique /timed voiding (for SUI)
First step is bladder diary
The longest comfortable interval is chosen.patient is
instucted to empty the bladder according the
interval.Interval is gradually increased (till 2-3 hours)
Bladder Diary
Time
Voided Activity
Leak
Volume
Urg
Intake
e (Amount/Typ
e)
"urge suppression" technique
Stop all movement immediately and stand still.
Sit down if possible.
Squeeze your pelvic floor muscles quickly and tightly several
times.
Squeezing your pelvic floor muscles this way signals the
bladder to relax and increases your feeling of being in control.
Take a deep breath and relax.
Shrug your shoulders and let them go limp.
Concentrate on suppressing the urge feeling. Some women find
distraction an effective technique.
When the strong urgency subsides, walk slowly and calmly to
the bathroom.
Remember: Going to the bathroom is not an emergency!
How to teach PFE’s
(Kegels) Correctly!!!
Verbal descriptions are only 40% effective.
Palpate perennial tissues through clothes,
should feel tissues move away from finger.
Watch patient kegel(give pt. a mirror)
Place finger inside patient’s vagina and pt
squeeze
Biofeedback device
Benefits of PFE’s
Exercised muscles recover better from
trauma. (Cesarean deliveries,
episiotomies, forceps/vacuum,
prolonged second stage of labor, etc.)
Decreased swelling and pain in
perineum
Prevention and/treatment of Urinary
Incontinence
Improved sex life
Components of pelvic floor exercise
1-kegel Exe.
2-Lumbo-Pelvic Stabilization Exe.
3-Abdominal muscles Exe
4-Knack Maneuver
Volitional contraction of the pelvic floor muscles just
before and throughout a cough, can be used to reduce
stress-related urine leakage significantly
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Kegel Exercises
1.Patient position: Supine or Side lying ,
sitting or standing
2. Instruct the woman to tighten the pelvic
floor as if attempting to stop urine flow,
each contraction is held 5 seconds with
an equivalent relax . The bladder
should be empty when performing this
exercises
Kegel Exercises
3.The pelvic floor muscles are
highly fatigable. Contractions
should not be held longer than 5
seconds and with a maximum of
10 repetitions per sessions.
4.The exercises are repeated three to
five times per day, every other
day.
Other new methods with swiss ball:
Fast twitch muscle fiber training with quick fast twitch
muscle contraction, which can be done by bouncing on
the ball.
Slow twitch muscle fiber training requires holding the
contraction at the end for 5 seconds.
Stretching exercise
There are 35 muscles which attach directly to
the pelvic girdle and sacrum and contribute
to their movement and function
Core stabilization EX
a.
Quadruple position with posterior pelvic tilt
b.
Leg is raised only until it is in line with the
trunk
Abdominal EX
The abdominal EX can be started whenever woman
feels able and get the OK from physician
Start with transversus Ex because its role in pelvic
stabilty(Supine,sidelying sitting,standing ,Avoid prone
kneeling up to 6 weeks if there is bleeding because of
air embolus)
After strenghtenig of transverse musle perfom curl- up
• takes 6 weeks to return to pre-pregnant shape
•
Wait 6 weeks to start aerobic exercises
Biofeedback:
Biofeedback Transformation of physiological
processes into visual, acoustic and / or
sensual information
● It provides Moment-to-moment
information about a
biologic function
Direct palpation
Vaginal cones
EMG system
Pressure based biofeedback
SEMG Biofeedback
Surface ElectroMyoGraphy (SEMG) is a non-invasive technique for
measuring muscle electrical activity that occurs during muscle
contraction and relaxation cycles.
Pelvic floor retraining
with EMG biofeedback
Goal:
to help identify pelvic floor musculature
Improve contraction
improve relaxation
Electrical Stimulation(ES):
ES is a technique for passive contraction
in patients who can not contract pelvic
floor muscles voluntarily.
ES can be administered through vaginal
or anal electrodes.
Two major purpose wit ES:
1. Motor excitement
2.Analgesic
ES(cont.)
ES with high-frequency stimulation (50-100 Hz) is
used to treat SUI by directly stimulating a
contraction.(With vaginal or anal electrode)
The mechanism is probably changing
muscle reaction or increasing bulk or strength.
ES with low-frequency stimulation (5-20Hz) is
employed to activate inhibitory nerves to bladder
and reduce detrusor overactivity(vaginal or anal
electrode ,or peripheral stim)
Dual stimulation for mixed incontinence with high
frequency for the sphincter and low frequency for
the bladder
Extracorporeal Magnetic Innervation
This technology produces highly focused
pulsing magnetic fields.
patient sits fully clothed in a comfortable chair,
allowing the therapeutic fields to be easily
aimed at the muscles of the pelvic floor
Myofascial release
Components of treatment include:
Rehabilitation of extrapelvic musculoskeletal
abnormalities,postur and gait
Closure of any diastasis recti
Connective tissue manipulation
Release of scars
Transvaginal trigger point release(Barrier method)
Abdominal and guteal trigger point release
Dry needeling,ACP
Exercise(Kegels may aggravate the symptoms)
-First stretching Ex
-Then strengthening
Thanks