Physical Therapy for Pelvic Floor Dysfunction
Wendy Baltꢀzer Fox, PT, DPT GCS
Although the field of physical therapy to bowel and bladder incontinence, pel- ies, as well as the expectations or goals of began during the polio epidemic, the vic pain or pressure, and back pain. sub-discipline of Women’s Health Physithe patient, will guide the plan of care.
A review of all medications is necessary.
For example, diuretic use by the patient needs to be considered in the behavioral cal Therapy1 is only approximately 30 years old. Until recently, specialized training in women’s health for physical
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VALUATION OF ELVIC LOOR
USCLE ISORDERS
When a patient is referred to physi- management of urinary incontinence,
MDtherapists was available only on a post- cal therapy, the typical management pro- particularly in timing activities and overgraduate level. The American Physical cess includes examination, evaluation, all outcome expectations. A review of all
Association sanctioned Board certifica- diagnosis of impairments, and determi- laboratory and diagnostic testing (e.g. tion2 for the first time in 2009. Those nation of prognosis and interventional urodynamics, cystoscopy, defecogram, who pass the exam will be deemed to plan of care.4 Impairments may include MRI) are important as well as bowel, have professional expertise in the man- weakness, pain, decreased range of mo- bladder, nutrition and hydration diaries. agement of urinary incontinence, pelvic tion, and functional limitations. Inter- The patient’s medical history, as well as pain, pregnancy-related pain, lymphe- ventions may include therapeutic exer- current medical status, are required to dema that occurs following surgery for cises5 for strengthening, education of understand the connection of pre-existbreast cancer, and pelvic pain.3
Pelvic floor muscle dysfunction or back and electrical stimulation. chronic pelvic pain are not normal con- A physical therapist will complete a a course of management rather than a behavioral changes, orthotices, biofeed- ing conditions and outcome. An underlying neurological condition may dictate sequences of the aging process. For ex- thorough examination before designing resolution of the urinary concern. A ample, vaginismus may occur in the teen an interventional plan. Patient history patient’s perception of her general health; years when girls attempt to use tampons will include general demographics in- psychological issues including anxiety, and/or during their initial gynecological cluding primary language and race/ depression, impaired memory; and habexamination. Pregnancy may be accom- ethnicity so that there is no language bar- its including smoking and exercise all are panied by bowel and/or bladder prob- rier that can impede treatment6 and all considered in forming a physical therapy lems as hormonal changes result in sup- verbal and written instruction will be plan of care. port dysfunction or muscle weakness. appropriate for the patient. An under-
Following history and systems re-
These changes may also occur along the standing of ethnic beliefs and traditions view, additional PT tests and measureaging continuum as a consequence of may alter the treatment approach and ments are completed. These may indecreased muscle use and decreased ac- dictate the education component. In clude assessment of the pelvic floor8 with tivity levels. This article will discuss the some cultures, discussion of female pel- external observation for anomalies, skin physical therapy management of women vic anatomy is limited, even taboo,. The integrity, palpation for tender points or who present with pelvic floor dysfunction patient’s occupation may indicate the trigger points, pain location, neurologior pelvic pain. need for behavioral modifications. For cal tests, strength grading by manual
There are two main findings during example, jobs that require prolonged muscle test of superficial and deep a physical therapy examination for standing or sitting require postural muscles. Examination also includes the women with pelvic floor muscle disor- awareness, particularly with patients with evaluation of endurance, relaxation, and ders: supportive dysfunction and chronic pelvic pain. Functional status, contraction speed of the pelvic muscles. hypertonus dysfunction. Supportive dys- activity level, ability and willingness to Surface electromyography (EMG) is functions occur as a result of the loss of participate and to be compliant are im- used to assess the muscle tone. The nerve, muscle, ligament, or fascial integ- portant to note when setting patient patient’s breathing pattern at rest and rity of the pelvic floor muscles resulting goals. An elder’s living environment7 may during activity would be observed. in weakness and laxity. Weak supportive be a cause of incontinence if functional Breathing dysfunction is commonly seen dysfunctions could be caused by injury mobility or the need for an assistive de- with pelvic floor dysfunction; the inincurred during childbearing or gyneco- vice such as a walker impedes toileting. creased intra-abdominal pressure and logic surgery, chronic constipation, Impaired mobility, combined with uri- straining contribute to the pelvic floor chronic coughing, obesity, or hormonal nary urgency and frequency, are safety dysfunction. More tests9 may include changes. A hypertonus dysfunction can concerns. A bedside commode at night musculoskeletal assessment of posture, cause symptoms of pain in the abdomi- can enhance safety and promote conti- spinal flexibility, abdominal and back nal area, back, or vulvar region. Patients nence. may report burning, itching, dyspareustrength/stability, as well as assessment
Determination of variables such as of lower extremity strength, range of nia, urinary urgency and leakage, or con- the onset of the current condition, what motion and length. A relatively new stipation. Interestingly, both supportive prompted the patient to seek medical technique, real time ultrasound, is used and hypertonus dysfunction contribute consultation, past interventions or surger- to observe muscle function during ac-
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MEDICINE HEALTH/RHODE ISLAND
M. Butterworth-Heineman, 2004; 348.
8. Laycock J. Clinical evaluation of the pelvic floor.
Pelvic Floor Re-education, Principles and Practice, ed. Stanton S. Springer- Verlang, London;1994:42-8.
9. Prendagast SA, Weiss JM. Screening for musculoskeletal causes of pelvic pain.
Clin Obstet Gynecol 2003; 46:773-82.
10. Whitaker J. Ultrasound Images for Rehabilitation of the Lumbopelvic Region. Churchill- Livingston,
London, 2007. tivities, as well as a means to provide biofeedback as a treatment.10 As examination progresses, identification of addi- sessment of a woman with pelvic floor tional impairments would require refer- muscle dysfunction or pain complaints ral to other medical practitioners. The and has briefly described the intervenphysical therapy plan of care will outline tions used to treat women with these con-
S
UMMARY
This article has summarized the asa specific physical therapy diagnosis. cerns. The American Physical Therapy
Association explains: : “As a woman in today’s world, you enjoy a life of many choices. The choices we make will deter-
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REATMENT OF ELVIC LOOR
USCLE ISORDERS
Direct interventions prescribed by mine the way we use our body through
MD
11. Kegel AH. Progressive resistance exercise in the functional restoration of the physical therapists are evidence-based and the decades. A physical therapist will be include the following elements: coordi- there for you as you progress through all nation of care, communication and docu- stages of your life.” mentation, patient education and direct intervention. The primary intervention prescribed by physical therapists has alperineal muscles. Am J Obstet Gynecol 1948;
56:238-49.
12. Burgio KL. Influence of behavior modification on overactive bladder. Urol 2002, 60; 72-7.
13. Weis JM. Pelvic floor myofascial trigger points. J
Urol 2001;166: 2226-31.
14. Bok K,TalsethT, Holme I. Single blind, randomized controlled trial ofpelvic floor exercises, electrical stimulation, vaginal cones, and no treatment in the management of genuine stress incontinence in women. Brit Med J 1999; 318: 487-93.
ACKNOWLEDGEMENT :
I wish to thank Dr. Nancy Rich for ways been therapeutic exercise.11 These her assistance in the preparation of this arinclude core strengthening of abdomi- ticle, Nancy C. Rich, Ph.D.,PT, FACSM, nal muscles, postural and pelvic floor Editor-in-Chief, Journal ofWomen’s Health muscles. Breathing and relaxation exer- Physical Therapy, Bridgton (Maine) Hoscises are typical key components for ev- pital Physical Therapy, and Director of ery patient. Relaxation involves the qui- Women’s Health, Bader PhysicalTherapy, eting of the autonomic nervous system Norway, Maine
Wendy Baltzer Fox, PT, DPT GCS, is a Physical Therapist and Board-certified Geriatric Clinical Specialist, Women and Infants Hospital. and includes visualization,12 soft tissue mobilization, heat modalities and positioning. Scar management (abdominal or perineal) includes soft tissue mobilization, application of heat or cold, and therapeutic ultrasound. Manual therapy techniques include myofascial release, trigger point release, soft tissue mobilization and massage.13 Active stretching and specific tissue stretching may be completed with vaginal dilators.
Methods of strengthening may include electrical stimulation, muscle reeducation using biofeedback techniques, or instruction in the use of vaginal weights.14 Biofeedback involves the use of external or internal sensors that record levels of muscle activity that are displayed on a computer as the patient performs exercises. This visual technique can provide motivational support as it increases the awareness of correct muscle contractions in various positions. Electrical stimulation is used to correct incoordination. In the treatment of overactive bladder electrical stimulation is used to inhibit and decrease unstable detrusor contractions.
Electrical stimulation is contraindicated for patients for whom there is urinary retention or post void residual volume 200 cc. Electrical stimulation is also contraindicated for women during pregnancy and may not be effective with patients who are obese.
R
EFERENCES
1. Section of Women’s Health, American Physical
Therapy Association; SOWH, APTA.
Disclosure of Financial Interests
The author has no financial interests to disclose.
2. American Board of PhysicalTherapy Specializa-
tion, ABPTS;
3. Description of Specialty Practice, ABPTS,
4. American PhysicalTherapy Association. Guide to
PhysicalTherapy Practice. Laycock J. Pelvic muscle exercises.Urol 1994;14:136-40.
ORRESPONDENCE
C:
Wendy Baltzer Fox, PT, DPT GCS
Women and Infants Hospital
101 Dudley Street
6. Sangi-Haphpeykar H, Mozayeni P, et al. SUI, counseling, and practice of pelvic floor exercises Providence, RI 02905 in postpartum low-income Hispanic women. Int
Urogynecol J Pelvic Floor Dysfunct. 2008;19:361-
5. Epub 2007 Aug 15.
Phone: 401-453-7560 e-mail:wfox@wihri.org
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