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Physical Therapy Program for Pelvic Floor Dysfunction PowerPoint Presentation

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Slide 1-

Physical Therapy Program for Pelvic Floor Dysfunction Jennifer Shifferd, MSPT, CLT WCS
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History of Pelvic Floor Program Section on Women’s Health was begun in the American Physical Therapy Association >35 years ago. The section started with a focus on treating women in the childbearing year with pelvic floor disorders post partum. Overtime, our interests expanded to women throughout the lifecycle. With our emphasis on specializing on anatomy and function of the pelvic floor, care is available to men with similar dysfunctions. Many physical therapists also care for the pediatric population with problems of daytime incontinence and bedwetting. Pelvic floor program established at University of Michigan Hospital in fall of 1999.
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PROGRAM GROWTH University of Michigan Hospital Burlington Building Canton Health Center Northville Health Center
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PROGRAM DEVELOPMENT CLINIC RESIDENCY IN WOMEN’S/MEN’S HEALTH Obstetrics, osteoporosis, oncology and pelvic floor dysfunction
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PROGRAM DEVELOPMENT Pediatric Pelvic Floor Program Milestones is offering pediatric pelvic floor. Currently they have two trained pediatric pelvic floor therapists on staff. Pediatric services are also being offered at Canton Clinic as well. Kim Erickson is the lead and liaison for pediatric pelvic floor program.
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Common Diagnoses Referred Urinary / Fecal Incontinence Dysfunctional Voiding / Constipation Prolapse Vulvodynia / Vestibulitis Vaginal / Rectal / Pelvic Pain Lower Quadrant Abdominal Pain Abdominal / Pelvic Floor Scar Tissue Post Prostatectomy Oncology Pre / Post Natal Care Pediatric Pelvic Floor Dysfunction Gender Reassignment
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Functions of the Pelvic Floor The pelvic floor is part of our core musculature. Functions include; Visceral support Sphincteric support (urethral meatus and anus) Sexual-contracting muscles to respond to arousal and to enhance enjoyment.
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Pelvic Floor Pain Pelvic floor muscle spasm occurs from trauma to and or around pelvis, back and abdomen including; joint malalignment, pelvic fracture, habitual postures, strenuous physical activity, childbirth, sexual abuse, surgery and pelvic inflammation.
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Pelvic Floor Dysfunctions Dyspareunia Vulvodynia/Vulvar Vestibulitis Vaginissmus Levator ani syndrome Anismus Coccygodynia LBP/herniated disc Pudendal Nerve Entrapment Scar adhesions Interstitial Cystitis Endometriosis Trauma/PTSD
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Pelvic Floor Dysfunctions Dyspareunia- pain with thrusting or penetration Symptoms; pain with initial entry, pain with deep penetration, friction with thrusting Grades of Severity; Discomfort, but has intercourse Frequently limits intercourse Incapacitating problem, abstinence
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Prevalence of Dyspareunia As many as 60 percent of women experience dyspareunia when the term is broadly defined as episodes of pain with intercourse. Women with symptoms severe enough to require medical attention comprise a much smaller group. Many of those with persistent symptoms do not seek medical attention. LORI J. HEIM, LTC, USAF, MC, Eglin Air Force Base, Florida Am Fam Physician. 2001 Apr 15;63(8):1535-1545.
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Postpartum Sexual Function Vaginal dryness Anal sphincter lacerations less sexual activity Decreased libido Only small % postpartum women with sexual problems seek medical attention
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Changes in Pelvic Floor Following Breast Cancer Treatment Vaginal dryness, discomfort with intercourse The vulval area also changes with ageing, as fatty tissue reduces and the labia majora (outer lips of the vagina) and the hood of skin covering the clitoris may contract. If sensitive areas become more exposed, chafing can occur. Pelvic floor muscles become weaker and urination may become more frequent and difficult to control.
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Gynecologic Cancer Common sequelae post surgery and radiation treatments; Constipation diarrhea Urinary incontinence Vaginal dryness Dysparuenia Vaginal and rectal stenosis Urinary frequency and urgency
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Post Menopausal Changes Decrease in estrogen levels as women approach and pass menopause leads to dryness and thinning of vaginal tissues that can cause intercourse to be painful. Without sufficient lubrication can lead to tearing and bleeding of vaginal tissues.
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Pelvic Floor Dysfunctions Vaginissmus is the involuntary tightness of the vagina during attempted intercourse. May be due to surgical or sexual trauma Protective response
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Pelvic Floor Dysfunctions Vulvodynia- chronic vulvar discomfort Symptoms; burning, stinging, irritation or rawness Causes; yeast infections, STD’s, eczema, lichens, chemical induced reaction (spermicides, detergents, vaginal sprays, deoderants), chronic alteration of vaginal ph, vulvar trauma, surgery
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Pelvic Floor Dysfunctions Vulvar Vestibulitis- pain at vestibule 3-9 o’clock (Q-tip test) Symptoms; severe pain with palpation to vestibule or vaginal entry Causes; STD’s, high levels of oxylates, surgery, ph imbalance of vagina most experts do not recommend surgery for women with this disorder unless symptoms are severe and other treatments have not been effective. Low oxylate diet and calcium citrate may reduce symptoms by decreasing oxylate levels in urine. Some women have pain because they have sensitivity to plant oxalates, which form crystals and lodge in the vulvar tissue but this theory is controversial and has not been scientifically validated.
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Pelvic Floor Dysfunctions Levator Ani Syndrome- spasm of deepest muscle layer Symptoms include pain, pressure or ache in vagina and rectum Referred pain to thigh, coccyx, sacrum and lower abdomen Repeated straining during defecation can promote pain/throbbing Men often misdiagnosed with prostatis Can lead to erectile dysfunction
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Pelvic Floor Dysfunctions Anismus-pain in rectum, anus restricting anal opening Causes; hemorrhoids, fissures, trauma
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Pelvic Floor Dysfunctions Coccygodynia- pain in coccyx and rectal region Causes; most often due to injury from fall, arthritic changes, pelvic floor muscle spasm, birthing in lithotomy position
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Pelvic Floor Dysfunctions LBP-low back pain due to herniated disc, foraminal stenosis, surgery, degenerative disc disease may contribute to pelvic floor muscle spasm, weakness and decrease in bowel and bladder control with extensive nerve compression. Large herniations can compress the cauda equina, leading to symptoms/signs of saddle anaesthesia, urinary retention and incontinence Cauda equine contains the nerve roots L1-L5 and S1-S5
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Pudendal Nerve Entrapment Sites Between Sacrotuberous and Sacrospinous ligaments At the pudendal canal, the pudendal nerve can be compressed by the falciform process of the sacrotuberous ligament If thickened, the obturator fascia also may act as an entrapment site Obturator internus-can compress nerve at Alcock’s Canal
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Pelvic Floor Anatomy
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Pelvic Floor Dysfunctions Scar adhesions-restricted mobility of myofascial tissue of abdomen, LB, pelvic floor Symptoms; burning pain Causes; tearing with child birth, episiotomy, LB and abdominal surgeries
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Pelvic Floor Dysfunctions Interstitial Cystitis- ulcerations of inner bladder Symptoms; bladder, abdominal and pelvic floor pain, urinary frequency, urgency Increased muscle tightness closes down urethra and gives sensation of having to go to the bathroom.
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Pelvic Floor Dysfunctions Endometriosis- tissue that lines uterus grows outside of uterus. Tissue becomes trapped, irritating surrounding tissue, forming adhesions. This can become painful especially during menses.
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Current Challenges in Female Veteran Health PTSD (in both men and women) > risk for UTI due to poor hygenic conditions, decreased access to bathrooms, postponed urination, fluid restriction POP due to strenuous activity Eileen M. Resnick, Monica Mallampalli, and Christine L. Carter. Journal of Women's Health. August 2012, 21(9): 895-900. doi:10.1089/jwh.2012.3644.
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Physical Therapy Evaluation Physician referral required by state law Evaluation: History Spinal/ postural assessment Pelvic floor muscle strength Pelvic floor coordination Pelvic floor flexibility
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Physical Therapy Treatment Spinal/pelvic alignment Abdominal visceral/fascial releases Ultrasound Ultrasound/estim combo TENS- electrical stimulation to LB, abdomen and pelvic floor Soft tissue mobilization, trigger point releases to trunk, pelvic floor and hip rotators. Scar tissue mobilization Laser therapy Physio Touch SEMG for relaxation Core strengthening
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Muscle Energy Technique for Sacral Torsion
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Visceral Mobilization
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PT Treatment - Ultrasound The ultrasound waves that pass through the skin cause a vibration of the local tissues. Can have a heating effect through a continuous transmission or non-thermal when pulsed. Causes increases in tissue relaxation, local blood flow, and scar tissue breakdown.
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PT Treatment – US/estim combo
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EMSI TENS UNIT
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TENS TREATMENT
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PT Treatment – Low Level Laser The laser helps to achieve a faster rate of healing and pain relief by stimulating normal cellular function for faster repair and inhibiting inflammation and nerve conduction for pain relief.
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PT Treatment – LED for lymphedema LED is used to stimulate lymphatic drainage to reduce edema
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PT Treatment - Physio Touch Physio Touch is an adjunct to manual therapy. Negative pressure pulls skin and fascia away from body creating a fascial traction. Relieves tension in tissue and improves fluid exchange, muscle tone, tissue length and tissue hydration.
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Treatment of Pelvic Floor Dysfunction Pelvic floor muscle re-education Biofeedback Manual SEMG
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Biofeedback Surface electrodes placed perianally or rectal/vaginal probe with computer screen. Manual and verbal feedback from PT For home treatment; iEase Biofeedback with vaginal/rectal probe
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Home Program Devices
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Home Biofeedback
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Pelvic Floor Treatment Home program: Self spinal/pelvic alignment corrections SI belt Self scar tissue mobilization Self external/internal pelvic floor releases Core strengthening Trunk, hip, LE stretches
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Dilator Therapy Used for vaginal or rectal stretching, trigger point releases in cases of pelvic muscle spasm and pain.
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Crystal Wand Vaginal Dilator
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Vaginismus dilator set
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CORE STRENGTHENING
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Physical Therapy Treatment Address all the factors contributing to the patient’s dysfunction Educate and provide home program for symptom management Recommend counseling if history of sexual abuse Handle with care
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Treatment Plan Pelvic floor pain, muscle spasm: Frequency/duration of treatment: 1 to 2 times per week, 8-12 visits x 4-12 weeks. This may vary depending on evaluation Pelvic floor muscle weakness: Frequency / duration of treatment: 2-4 visits x 4-8 weeks. This may vary depending on evaluation.
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How to locate a Pelvic Floor PT Physical therapists that treat pelvic floor dysfunctions Contact us for Michigan PTs ( data base) www.womenshealthapta.org
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How to Refer to PT Requirements for PT prescription: Document Patient Diagnosis MD signature Evaluate and Treat x 3 months Place PT order in MiChart For MD’s and PA’s outside the U of Mi system; Fax prescription to UH OP PT @ 734-936-7016 Fax to our Canton facility @ 734-844-7798 Fax to our Burlington Clinic @ 734-763-3751 Fax to our Northville Clinic @ 248-305-4400 Call UH OP PT @ 734-936-7070, Canton facility @ 734-844-2020, Burlington Clinic @ 734-763-6464 or our Northville clinic @ 248-305-4807 with any questions
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Questions