Women’S Health Physical Therapy W07

1,591 views
1,413 views

Published on

4/14/09 presentation to NAUPT 1st year doctoral students.

Published in: Health & Medicine
0 Comments
2 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
1,591
On SlideShare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
56
Comments
0
Likes
2
Embeds 0
No embeds

No notes for slide

Women’S Health Physical Therapy W07

  1. 1. Women’s Health Physical Therapy Amy Flory PT April 14, 2009
  2. 2. Terminology used conforms to the definitions recommended by the International Continence Society, except where specifically noted.
  3. 3. 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
  4. 4. Pelvic floor muscle anatomy DeLancey 2004 • Pelvic diaphragm – Levator ani » Pubococcygeus » Puborectalis » Iliococcygeus – Ischiococcygeus (coccygeus) • Sphincter urethrae • Perineal membrane – Compressor urethrae – Urethrovaginal muscle
  5. 5. Pelvic floor muscle anatomy DeLancey 2004 – Superficial genital muscles • Bulbocavernosus (bulbospongiosus in men) • Ischiocavernosus • Superficial transverse perineal
  6. 6. Pelvic anatomy • Associated muscles (close proximity, facilitative, synergistic—Bo 1994) – Piriformis – Obturator internus – Adductors – Gluteals – Transverse Abdominus (TrA) – Multifidus – Respiratory diaphragm
  7. 7. Pelvic anatomy • Organs – Bladder • Detrusor (parasympathetic innerv) • Trigone (sympathetic innerv) – Uterus – Rectum – Prostate
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. Financial Implications • Cost to nursing facilities is high, with estimates as high as $10-20 billion/year • Supplies • Caregiver support • Laundry
  13. 13. Neurological control • Bladder fills>stretch receptors>micturation reflex • Midbrain inhibits reflex until appropriate social setting to void • Sphincter relaxes>detrusor contracts>voiding occurs
  14. 14. 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
  15. 15. Neurological Control • Spinal Cord Center • S2-S4 (vertebral level T12, L2, L3) • Coordinates the external urethral sphincter with bladder contraction
  16. 16. 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
  17. 17. 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
  18. 18. Professional responsibilities • State practice act • Terminology • Referral sources know your procedures • Specific training • Ethical and professional behavior
  19. 19. Professional responsibilities • Patient education – Anatomy and equipment – Tests to be used – Verbal consent – Observing assistant available – Mirror for observation available
  20. 20. 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
  21. 21. PT treatment for UI • Urge incontinence – Strengthening – Coordination – Bladder retraining • Urge-delay techniques • Voiding schedule – Bladder irritants education – Electrical stimulation
  22. 22. 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
  23. 23. 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)
  24. 24. Palpation lab • In side lying – Adductors – Pubic ramus – Ischial tuberosity – Levator ani – Ischiococcygeus – Internal obturator
  25. 25. 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
  26. 26. 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
  27. 27. 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)
  28. 28. 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
  29. 29. Pre-partum guidelines for 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
  30. 30. Post-partum guidelines for 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
  31. 31. Gestational diabetes • More than half go on to have Type II diabetes – Great opportunity for intervention/prevention – Lifestyle changes – Exercise
  32. 32. Implications for post-partum physical therapy • Musculoskeletal pain complaints • Abdominal muscle • PFM rehabilitation • Clogged milk ducts • UI that persists more than 3 months
  33. 33. 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
  34. 34. Pelvic pain origins • Gynecologic (dysmenorrhea, endometriosis) • Urinary (painful bladder syndrome, interstitial cystitis) • Gastrointestinal (irritable bowel syndrome) • Musculoskeletal • Psychiatric • Multiple (vulvodynia, prostatodynia)
  35. 35. 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)
  36. 36. Musculoskeletal pelvic pain • Chronic pelvic pain (CPP) • Overactive/non-relaxing PFM – Levator ani syndrome – Tension myalgia – Vaginismus • Coccygodynia
  37. 37. 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
  38. 38. 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
  39. 39. 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
  40. 40. 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
  41. 41. Physical therapy evaluation • Musculoskeletal system – Strength and flexibility – Scar mobility – Pelvic joint function – Location of trigger points and nerve entrapment sites
  42. 42. Physical therapy evaluation • Urogenital system – Trigger points – Pelvic floor muscle function – Organ mobility • Viscera – Mobility
  43. 43. Physical therapy interventions • Therapeutic exercise – Postural strength – Postural flexibility – General endurance – Pelvic floor strengthening, if indicated – Pelvic floor muscle coordination
  44. 44. Physical therapy interventions • Manual therapy • Therapeutic activities/self-management of symptoms/neuromuscular re-ed • Physical modalities
  45. 45. References Will follow shortly
  46. 46. Thank you! Amy Flory PT, MPT CoreBalance Therapy LLC 906 W University Ave, Ste 120 Flagstaff, AZ 86001 www.corebalancetherapy.com amy@corebalancetherapy.com

×