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

1. Women’s Health Physical
Therapy
Amy Flory PT
April 14, 2009

2. Terminology used conforms to the definitions recommended
by the International Continence Society, except where
specifically noted.

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. Pelvic floor muscle
anatomy
DeLancey 2004
• Pelvic diaphragm
– Levator ani
» Pubococcygeus
» Puborectalis
» Iliococcygeus
– Ischiococcygeus (coccygeus)
• Sphincter urethrae
• Perineal membrane
– Compressor urethrae
– Urethrovaginal muscle

5. Pelvic floor muscle
anatomy
DeLancey 2004
– Superficial genital muscles
• Bulbocavernosus (bulbospongiosus in men)
• Ischiocavernosus
• Superficial transverse perineal

6. Pelvic anatomy
• Associated muscles (close proximity,
facilitative, synergistic—Bo 1994)
– Piriformis
– Obturator internus
– Adductors
– Gluteals
– Transverse Abdominus (TrA)
– Multifidus
– Respiratory diaphragm

7. Pelvic anatomy
• Organs
– Bladder
• Detrusor (parasympathetic innerv)
• Trigone (sympathetic innerv)
– Uterus
– Rectum
– Prostate

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. 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. 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

12. 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

13. Financial Implications
• Cost to nursing facilities is high, with estimates
as high as $10-20 billion/year
• Supplies
• Caregiver support
• Laundry

14. Neurological control
• Bladder fills>stretch receptors>micturation reflex
• Midbrain inhibits reflex until appropriate social
setting to void
• Sphincter relaxes>detrusor contracts>voiding
occurs

15. 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

16. Neurological Control
• Spinal Cord Center
• S2-S4 (vertebral level T12, L2, L3)
• Coordinates the external urethral sphincter with
bladder contraction

17. 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

18. 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

19. Professional responsibilities
• State practice act
• Terminology
• Referral sources know your procedures
• Specific training
• Ethical and professional behavior

20. Professional responsibilities
• Patient education
– Anatomy and equipment
– Tests to be used
– Verbal consent
– Observing assistant available
– Mirror for observation available

21. 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

22. PT treatment for UI
• Urge incontinence
– Strengthening
– Coordination
– Bladder retraining
• Urge-delay techniques
• Voiding schedule
– Bladder irritants education
– Electrical stimulation

23. 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

24. 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)

25. Palpation lab
• In side lying
– Adductors
– Pubic ramus
– Ischial tuberosity
– Levator ani
– Ischiococcygeus
– Internal obturator

27. 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

28. 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

29. 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)

30. 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

31. 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

32. 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

33. Gestational diabetes
• More than half go on to have Type II diabetes
– Great opportunity for intervention/prevention
– Lifestyle changes
– Exercise

34. Implications for post-partum
physical therapy
• Musculoskeletal pain complaints
• Abdominal muscle
• PFM rehabilitation
• Clogged milk ducts
• UI that persists more than 3 months

36. 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

37. Pelvic pain origins
• Gynecologic (dysmenorrhea, endometriosis)
• Urinary (painful bladder syndrome, interstitial
cystitis)
• Gastrointestinal (irritable bowel syndrome)
• Musculoskeletal
• Psychiatric
• Multiple (vulvodynia, prostatodynia)

38. 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)

39. Musculoskeletal
pelvic pain
• Chronic pelvic pain (CPP)
• Overactive/non-relaxing PFM
– Levator ani syndrome
– Tension myalgia
– Vaginismus
• Coccygodynia

40. 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

41. 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

42. 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

43. 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

44. Physical therapy
evaluation
• Musculoskeletal system
– Strength and flexibility
– Scar mobility
– Pelvic joint function
– Location of trigger points and nerve entrapment
sites

45. Physical therapy
evaluation
• Urogenital system
– Trigger points
– Pelvic floor muscle function
– Organ mobility
• Viscera
– Mobility

46. Physical therapy
interventions
• Therapeutic exercise
– Postural strength
– Postural flexibility
– General endurance
– Pelvic floor strengthening, if indicated
– Pelvic floor muscle coordination

47. Physical therapy
interventions
• Manual therapy
• Therapeutic activities/self-management of
symptoms/neuromuscular re-ed
• Physical modalities

48. References
Will follow shortly

49. Thank you!
Amy Flory PT, MPT
CoreBalance Therapy LLC
906 W University Ave, Ste 120
Flagstaff, AZ 86001
www.corebalancetherapy.com
amy@corebalancetherapy.com