Physical Therapy for
Pelvic Floor Dysfunction
Lisa Odabadiian, MPT. RN, BSN
Pelvic Floor Dysfunction Specialist
Women's Urology Center
Beaurnont - Roya! Oak
Where are we at on the
Caffeine Meter Mug ?
Learning Objectives
By the end of this presentation, the course participant v^II
be able to:
• Identify at least 3 patient medica! diagnoses that may
be appropriate referral for pelvic floor physical therapy
• Identify at least 2 pelvic floor physical therapy
diagnoses
• Identify at least 2 pelvic floor physical therapy treatment
techniques
Why am I here?!?
¥
• How can physical therapy can help my problem?
e PFM dysfunction often presents as an
organ problemi
Physician or Nurse Practitioner Visit
• Male or female patient reports pelvic problems
• bladder, bowel and/or genifal problems. SIJ
• Chief complaint
• Health history by chance
• Specific questioning
• Palienls are often reluclant to discuss these
problems because they are too embarrassed.
3/16/2015
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Common Chief Complaints
URINARY:
Frequency, urgency, nocturia, bedwetting
incontinence: vflth cough, laugh, sneeze, oxcfciso,
running, jumping, lifting objects, ADLs, before/after void,
during intercourse
Wears incontinence pads and/or diapers
Straining, retention, difficulty initiating stream, weal<
stream, slov/stream, pain before/dunng/after void
Common Chief Complaints
Bowel: Frequency, urgency, fecal incontinence,
straining, constipation. IBS. pain before/during/after BM
Genital: Painful intercourse, orgasm, tampon insertion,
pelvic exams; PGAD (persistent genital arousal
disorder), feels lil<e "sitting on a ball', something
protrudes through the vagina while straining on toilet
General; Difficulty/Pain v/ith sitting, ADLs, bike riding,
exerdse. household chores, v/ork activities, wearing
jeans, intimacy, caring for self and others
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Risk Factors for Supportive Dysfunction
• Strain with void/BM
• Pregnancy, childbirtii
• Infections
• Surgeries
• Obesity, sedentary
• Improper posture, bodymeciianics
• Chronic constipation
• Chronic cougtiing, vomiting
» Neurological dysfunctions - PNS, ONS
^^^I^Mefippause, aging •.
Risk Factors for Hypertonia Dysfunction
» Pain in lov/ bacl<, SU. pelvis
» Muscle Imbalance, poor core strength/flexitjiiity
• Habitual PFM holding
• PFM clenching - COP, !C, OAS
• Alxiominai adhesions - C-section, Hysterectomy
® Childbirth Injury
» Pelvic surgery
» Pelvic inflammatory conditions - IBS. endometriosis
• Sexual abuse, STDs, UTIs, yeast infections
^MsOefniatplogical conditions ^ lichen sclerpsis/plartu^^^^
Common Medical Diagnoses
• Urinary: Incontinence (SUi/UUI/mixed), OAB, IC.
PBS, cystocele
• Bowel: incontinence, constipation, IBS, coccydynia,
reciocele, levator ani syndrome
• Vaginal/Genital: Pudendal neuralgia, dyspareunia,
vulvodynia, vestibulitis, vaginismus. POP, pregnancy,
post-pregnancy, post-surgicai, post-prostatectomy,
prostatitis
® General: CPP, scar tissue/adhesions, post-surgical
pelvic pain, fibromyalgia
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What is a Pelvic Floor Dysfunction Specialist?
• Licensed ptiysicai therapists + pelvic floor expertise
» Pelvic floor dysfunction evaluation and treatment is
NOT taught in entry level PT programs
Advanced pelvic floor classes v/ith lecture and handson externa! and internal treatment
« Certifications'new*-not mandatoiy
1 time a week for 6 visits
•APTASection on Women's Health
• CAPP ~ Certificate of Achievement in Pelvic PT
* WCS-Women's Health Clinical Specialist,
Pelvic Floor PT Referral
• Suspect patient's pelvic problem is musculoskeletal or
nerve related
728,2 Muscle weakness - SUI, UUI, Fl
728.85 Muscle pain - spasm
729.1 Pelvic floor pain-myofascitis.
myofascial restriction
728.4 Ligament laxity - POP
* 618.8 Organ Prolapse not payable by BOBS
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Pelvic Floor PT Referral
9
* EVALUATE AND TREAT '
9
Manual therapy
9 Therapeutic exercise
• Neuromuscular Re-education
• Self-care
0 Home Program Instruction
Modalities prn (Estim, IPC, US, heat, cold)
Pelvic Floor PT Referral
TiTiical treatment time:
Duration
1 hour sessions
Pelvic floor weakness without pain
Pelvic floor pain
1-2 fimfls a week for 12 visits
Pelvic Floor Muscles
Function: support and control
• Skeletal muscles lining the bony pelvis and surrounding
the urethra, vagina and anus
9 Hammock - Pubic bone to coccyx and between ischial
tuberosities
® 3 PFM layers
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Bony Pelvis
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1st PFM Layer; Female
Ischiocavernosus
Bulbospongiosus
Superficial Transverse Perineal
1st PFM Layer: Female
• Ischiocavernosus: Located under llie pubic rami,
maintains ciitoral erection
• Bulbospongiosus: Surrounds/strengthens vaginai
orifice and constricts urethra to expei last drops of
urine; also maintains ditoral erection
• Superfictal Transverse Perineal: Supports the lower
vagina, introitus, perineum; connects v/ith the ischial
tuberosities
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1st PFM Layer: Male
ischiocavernosus
Bulbospongiosus
Superficial Transverse Perineal
1st PFM Layer: Male
• Bulbospongiousus muscle on lower shaft of penis
• Ischiocavernosus muscle covers crus of penis
« Superficial transverse perineal muscle
2nd PFM Layer: Female
Deep Transverse Perineal muscle. Urethral Sphincter
Compressor Urethra, Sphincter Urethrovaginalis
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Urogenital Triangle; Female
Consists of urogenital diaphragoi and superficial perineal muscles
Urogenital Diaphragm;
Part of tfie continence mechanism
3 PFM: urethrovaginal sphincter, compressor
urelhrae, sphincter urethrae
Superficial Perineal muscles:
Aid in sexual function
3 PFM: bubocavernosus. ischiocavernosos. superficial
transverseperineal
2nd PFM Layer: Male
Deep Transverse Perinea! muscle
Sphincter muscle
2nd PFM Layer: Male
• Deep Transverse Perineal muscle: broader muscle
under the supeificial, between ischial tuberosities
posterior to urethra
• Sphincter muscle of Membranous Urethra:
surrounds the membranous part of the urethra; relaxes
during micturation
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3"* PFM Layer: Female
Pelvic Diaphragm = Levator Ani and Coccygeus
3'^ PFM Layer: Female
Pelvic Diaphragm » Levator AnI and Coccygeus
« Levator/^l
• Pubococcygeus: pubovaginalis and puborecfalis
• Pubovaginal'^ 'vaginal sling" - os pubis to perineal body and
vaginal v/alls
Puborectalis "rectal sling' - pubic bone and obturator
inlernusfascfa to coccyx and rectal walls
• lliococcygeus; pubic ramus and obturator internus fascia
to coccyx
• Coccygeus
• spine of ischium to antenor coccyx and S4
3"^ PFM Layer; Female
Pelvic Diaphragm a Levator AnI + Coccygeus
¦ It.)- ^ ¦
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Levator Ani muscles: Female (superior)
Puborecfaiis, Pubococcygeus, INococcygeus
__
Levator AnI muscles (superior)
Puborectalis, Pubococcygeus, lliococcygeus
• Puborectalis: originates wth the PC muscle from the pubis and .
passes Infsriortyon either side to form a sling around the rectum.
This muscle aeatesUieanwectaiangleia mechanlsfn to keep the
Gi tract closed for lx>rt-el continence.
• Pubococcygeus: Origin at the txjdyof the pubis and goes
posteriofly to Insert along the midline posteriorly to the coccyx. PC
is subdivided based on the association of the structures in the
midline: Pubovaginalis; puboprostaticus: puboanalis
• liiococcygeus: Origin Is the fascia that covers obturator internus
muscle and joins the same muscle on the other side in midline to
form a ligament (raphe) that extends to form anai aperture to the
coccyx-
Pelvic Diaphragm: Levator Ani and Coccygeus
• Coccygeus muscles
• One on either side of the coccyx, triangular and overlie
the sacrospinous ligament.
• Apices attach to tips of ischial spine.
• Bases are attached to the lateral border of the coccyx
and adjacent margins of (he sacrum
• Completes the posterior part of the Pelvic Diaphragm
• Flexes antenorly and stabilizes the SI joint when PFM
. tense
12
Levator AnI Muscles: Female (inferior)
Piiborectalis, Pubocxiccygeus, lliococcygeus
3'^' PFM Layer
Pelvic Diaphragm » Levator Ani and Coccygeus
Deepest layer of striated muscle which elevates the
peMc floor, resists the intra-abdominal pressure, and
maintains closure of the vagina and rectum.
» Largest muscle group in the pelvic floor
® Responsible for most of the PFM fijnction
• Responsible for most of the PFM dysfunction
• PFM fiber ratio is 70% slov/ ^/itch;30% fast twitch
« Pudendal nerve: proprioception and deep pressure
3'" PFM LAYER: Male
Pelvic Diaphragm = Levator Ani muscles
Innervated by S2-S4
3/16/2015
Pelvic Wail IVluscles:
Piriformis and Obturator Internus
Piriformis:
• Origin: Anterior surface of the sacrum behveen anterior
sacral foramina
• Insertion; Medial side of superior border of greater
trochanter of femur
• Innervation: Branches from L5.S1-2
• Action: Lateral rotation of the extended hip, abductor of
the flexed hip
Pelvic Wall Muscles:
Piriformis and Obturator Internus
• Obturator internus:
• Origin: anterolateralwal! of pelvis
• Insertion: medial surface of greater trochanter of femur
• Lateral rotator of extended hip and abductor of flexed hip
• Innervation; Nerve to obturator internus L5, SI
• Maizes a 90 degree bend around the ischium between the
ischial spine and the ischial tuberosity
Levator Ani muscles: Male (superior)
Puborectalis, Ruttccoccygeus, lliococcygeus
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Anal Sphincter
® Most superficial skeletal musde
• Composed of;
• Internal anal sphincter (IAS)-$mooth muscle
• External anal sphincter (EAS) - sketetal muscle
• Fuse superiorly vw'th puborectalis sling of the pelvic
diaphragm muscle
• Function: fecalcontinence
• Innervation: S4 and pudendal nerve (inferior branch)
Related Muscles:
Adductors and Iliopsoas
o Adductors: pubic ramus and ischial tuberosity to femur
• Iliopsoas:
• Psoas minor and major (T12-L5 vertebral bodies and
discs) and iiiacus muscle (medial Uiac fossa)
• Innervated by L2-L4
• "HkJden Prankster" according to Travell and Simons: key
muscle to treat in tumbopelvic dysfunctions
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Nerves of Perineum: Female
Pudendal Nerve:
Inferior Rectal branch, Perineal branch, Dorsal nen'e
Nerves of Perineum
Pudendal Nerve Innervation:
Inferior Rectal branch. Perineal branch. Dorsal nerve
• Inferior rectal branch
• Anal canal, caudal third of reclom, skin around anus
• Muscles: posterior pofUon of external anal sptiincter
• Perineal branch
• Inferiorthirdof vagina and urethra, skin ofscrotum/labla
• Muscles: transverse perineum, bulbospong'osus,
ischiocavernosus. urethral sphincter, anleriorptwiion of EAS
• Dorsal Nerve of clitoris/penis
• Skin of penis/Clitoris
• Muscles: ischiocaverrtosus?, buibospongiosus?
2011 Prendergast and Rummer. Inc., PHRC
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Nerves of Perineum: Male
Pudendal Nerve:
Inferior Rectal branch, Perineal branch. Dorsal nerve
Nerves of Perineum: IVlale
Pudendal Nerve
inferior Recta! branch, Perineal branch. Dorsal nerve
Pudendal Nerve
9 Forms anteriorly to the lower portion of the piriformis
muscle from S2-S4
• Leaves Ihe pelvic cavity via greater sciatic foramen and
enters the gluteal region
• Enters the perineum by passing around the
sacrospfnous ligament
• Exits the pelvic cavity at the lesser sciatic foramen,
then around the penpheral attachment of pelvic floor
then into the penneum
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Pudendal Nerve
Pudendal Nerve
• f.Tixed nerve:
• SOii ssftsciy to perineum, perts, cTloris
• 20%motortoPFM, EASarxlEUS
• SOVs autonorrto
• PN «ily peripheral nerve to have bo^ somatic and aiitonomlc fibersi
• A patent can experience sympatheti: upfegulat'i:^ symptoms wth
pudendal neura.'g'ta due to its autonomic fibers
• Increase heart rate, btood pressure
• Decreasa rroblfy of large Westns
• Widen bfoncWal p3ss^3s
• Constritt bkxjd vass^s
• Popn tfJation
• P&»rect)oo
• PesspVat'on
•, 20it Pfendetgast and Rutnmef, hw.. PHRC
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Fascia
• Soft tissue connective tissue
• Encases organs, muscles, nerves, bones
• Manufactures collagen, a contractile protein
• Contains elastin, a aibber-like
9
•
Avascular, but highly innen/ated
Capable of changing its compensation in response to
sensory input
60-90% water.
—
Fascial Injury
• Fascial injury results in connective tissue restriction
• Dehydration
• Tissue shrinks
• Collagen fibers "cross lint?"
• Decreased tissue riwbiliiy
• Increase in coBagen fiber matrix
19
Pelvic Floor Function:
Supportive, Sphlncteric, Sexual
• Supportive: supports pelvic organs from below against forces of
gravity and increased Intra-abdominal pressure. (Tigamentous
suppwl from above)
• Sphlncteric: doses urethra and rectum for continence during
normal function and at rest. Incontinence is a symptom, from an
impairment.
• Sexual: PFNts provide proprioceptive sensation that contributes to
sexual appreciation. Vagina has very few sensory nerve fbers.
Hypertrophied PFMs provide a smalfer vagina and more friction
against penis during intercourse-> stimulates more nerve endings
(increased pleasure) -> orgasm strong PF contraction
• V/eak PFMs->r» orgasm
• Men: PFMs assist in achieving ar>d maintaining pea% erection
j PFMdysfuncUononenpresentsas an organpwbleml :^
Gelling kiiocked:down:lnslifeils
Getting up and
moving forward
is a choice!
-ZigZi^
intravaginal/lntrarectal Examination
• Power: ability lo contract mm grade 0-5/5
• Lift-supportive function
• Closure-sphincieric function
• PFM bulk-rehab potential/dufation
• Endurance: ability to hold a slow-twitch muscle
contraction and repeat the contraction; quality
• Resting tone between contractions: tone
• CoordinatJon: PFM isolation or accessory m use
• Other Impairments: PF TPs, altered sensation, scars,
adhesions can limit strengthening
¦^ Internal PFM is the gotd standard evaluation:"
3/16/2015
Manual PFM Evaluation
Pelvic Floor Muscle Strength Testing
Muscle
Rracle
:1 yZefO
U^bCriptions
No pa<pab!a cpntrac^ Of squeeze y ;. , , , , ?
2 Trace
Rckef of a contfa<a>on Of squeeze vsith no
.(^piacement or iift
3 i Pw
.Co(ttractior)orscp;ee2epfe5svfeas)Tnrnetrk^feitat. |
,ya[k>uspoinlswttif»^placefr)eritof,iift "i
4 Good
Con If actions or squeeze pfessure afxl Sfi witfi
cbplacemenlof the whc^«f^erfroman, post, and
side waQs of vegina (or rectum)
- J- S ^ StfonflfNo- Contractions or squeeze presswewthfi^ . ; :
rmal
csfcumferencaeompfessJonofwhoietagef displaced
with an inward gnp .. svis
1 UUTV&rcreS3&reS/K^Wa&caPTaM]Ho^He<maaPr - '"'-I
Pelvic Floor Weakness
If my btxJy wre
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litnonafiett'ermwJeL. j
sneeze cr sputtar tHKb/
rny racSaior isAKs , ,
and exhaust
bacKTras.'. -1b|p%
21
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PFM Dysfunction: OAB and Ul
PFM Weakness
• PF^4 cannot adequately
Inhibit the detrusor
• Detrusor > PFM activity
• Early urge signals from
the bladcferare sensed as
amplified "loud'
• If PFM istoov.'eak to
maintain closure pressure
around the urethra during
the urge then
Incontinence occurs.
» PFM Tension
• PFM oannot adequately
inhibitthe detrusor
• PFM tension stretches or
compresses the urethra
• Urethral irritation from
tension can mimic UTI
and cause urgency and
frequency
• Tension can compress
pelvic floor blood vessels
and nerves
PT Intervention for OAB and UUl
Kegel program
Biofeedback
Urge suppression techniques
Bladder retraining
Dietary irritant education
Avoid constipation
Afinimize soft^connective
tissue restricttons
Core strengthening
Stress management
Fecal Continence
Anorectal angle
• betNS-een the rectum and anal
canal
• Normal 80-100degrees
• Puborectalls "slirjg"
• Increase in tone decreases
the angle, closing the "flap
valve mechanism" to maintain
focal continoncc
• V/eakness of pubrectalis
increases the angle allovving
stool from the rectum into the
anal canal and sutksequent
defecation.
22
Fecal Incontinence
Puborecfalis weakness - increases anorectal angle and
disrupts {he "flap valve mechanism"
EAS +/or IAS weakness
Chronic constipation - mega colon
•
Rectocele - impaired sensory input and function
•
Anorectal reflex impaired
•
Colonic transit time too fast
Stool volume/consistency
Cognitive function - can't respond to urge . .
Functional mobility Impaired - slow gait, difficulty .v.
i^dressiiig .
PT Intervention Fecal Incontinence
• Kegel ixogram
• Biofeedback ,i •. j
(
/
• "Holdingon"lechnique " ^ ^ ' 1 v_
• Bowel retfaining v
• Balloon [raining
• Dietary irritant education
¦
» Avoid constipation
• Minlmtzesoffconnective
tissue reslrictlc^s
• Cofe slrengthening }
i-I.^Slfessmanagernsm •
Organ Prolapse Symptoms
Cystocele, Uterine Prolapse. Rectocele
Failing out feeling
Lower abdominal pressure
lAWse as the day progresses
L8P
Post void residual
Constipation
Bristol Stool Type 1 or 2
'Splinling' to perineum or
posteriofvagmal wall for BM
Prostate
• Men have 2 sphincters
+ PFM lo control urine
• Proximal (internal)
sphincter has smooth
muscle in bladder neck,
prostate gland and
prostatic urethra
• Distal (external) end of
prostate is under
voluntary and
J .
invoiunlary control,
Men do not have
M|i5r$:^fflpressor urethrae .
Prostatectomy
• ** *
• Degree of prostate cancer
dictates degree of resection of
surrounding tissues, blood
vessels and nerves. Proximal
sphincter is usually removed.
•
'
1
"r >\l
1 jK-f
'fli
I-}. A
» Typically, only PFMs and distal
sphincter remain to maintain
continence post-prostatectomy.
• Post-prostatectomy incontinence:
• 60% bladder spasm v.ith Ul,
frequency, nocturia
• 35%sphinclerdamagswilhSUI,
v.; • 10%botfi vwthmixediricontinence
J; 1
,|i
pgi
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i .¦K|
1
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PT intervention Post Prostatectomy
• Kegel program
• Biofeedback
• Urge suppression techniques
• Bladder retraining - timed voiding
Dietary yrilant educatton - increase H20
• Avoid constipation
« Minimize soft/connective tissue reslrfctions
" Core strengthening
incontinence fwoduct education • pad iriskie ofdiai ^ <
1
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PFM Strengthening aka Kegels
Effective PFM strengthening program
• Active PFM v/ilhout accessory muscles
• Verbal cueing
• Tactile cueing
• Daily HEP to build strength with minimal fatigue
• Supine 4 sitting standing functional exercises
• Musde function Is position spedfic
• , Train fast and slow hvitch muscle fibers , ,
Most people are unsure if they are
doing a proper Kegel
Common Mistakes
• Butt squeeze
• Thigh squeeze
• Breath hcridirtg
• Doing a few every once in a
while
• Do only la^'ng down
• Kegel Willie voiding
• Buygadgetstodolhewofk
25
PF Dysfunction - Hypertonus
• Increased PF>.) tension/spasm
-> muscirioskaletal pain,
urogenital and'or colorectal
dysfunction
• Pfo!onged pressure on nerves
and blood vessels 4 pa'n
• Can trigger pelvic pa'n, urinary
frequency/urgency,
constipation and dyspareunia. ,
• Tfeatnienl Goat; norma^ze
lone to decrease pa'n and
improve function
Chronic petvic pa'n:
• Pudenda' neuralgia/PGAO
• Vutvodynia'cdtwodynia
• Interstitial cystitis
PF tensk>n mya'g'a
Levator ani syndrcHTie/spasm
Pirifofm^ syndrome
• Va 9 :nis nius/An « mu s
» Coccy^odynla
Inters b'tiaJ cysUt^
Post-sufgrcal pa:n
• Pehac fraclums ,
Pelvic Floor Symploms
\ Trib^cr points
fc
rrcquGncY« Utiicncy,
P^in
V-.:>
Sliortencd
Vp'cak Pelvic Ffoor
Muscles
Incrcastid need to
suppress Urgency/rrcqucncy
SlowKlaxatlon
HesUant Painful Voiding
How Patients Describe Pelvic Pain
9
Sharp
• Prickly
*
Throbbing
» Burning
•
Tender
« Cramping
Aching
» Gnav/ing
Dull
• Pinching
•
Shcwling
• Stretching
Raw
• Stabbing
e
Ripping
• Shards of glass
Chronic Pelvic Pain Syndrome
Prolonged conslan!, strong pain is physlcaly an<3 mentally exhaustVig emotional
and t>ehaviof changes
•Physical symploms
• Pain > 6 morifs
• Usual teaSriets inefTecS-.'s
• Paht3strc»i^lhanwh3lwoiidl»e>pecied
• Cranga tn psSsms
• ConsfpaBon
• Deae3$ed a(f>s'!3
• 'S!c^v mot'on" bsjy rw.emenls'teacttons
• Oecrwsed acSi^ty
•Emotional symptoms: depression and anM'ety
•Behavior changes: stay in bed, miss v.wk. no longer enjojing osoalacOyibes
Chronic Pelvic Pain
4 Main Characteristics:
Problem at site of origin; injury where pain first
started, i.e., Ovarian cysts, UTI, scar tissue
Referred Pain: 2 nerve types to spinal cord
• Visceral; organs
• Somatic: skin, muscles
• CPP: PF^Vabdominalmuscfes/ski^ <-->bladder
• Trigger Points; atxiominal muscle wall tenderness
• Brain: influences emotions and behavior. Depression
the brain allows more pain spinal cord resulting in
.
more
pain..
_
fRPS November 2Q14 \ww4Selvicpa.f. orrj
Chronic Pelvic Pain: Male
Often diagnosed as "Prostatitis"
« Pain
• Lw/back
• Groin
• Tailbone
• Perineal
• Penile/testicular
• Pubic
• Rectal-"sitting on a golf
ball'
• Doring^aftef ejaculation
» Reduced libido
Difficulty sitting
• Urinary symptoms
• Frequency
• Urgency
• Nocturia
• Dysuria
• Deaeased stream
• Hesitancy
• Incompleleemptying
* Anxiety
« Depression
"
3/16/2015
Pelvic Floor Disconnect
• Chronic pelvic pain
• Neurological inhibition: no conscious connection vrtth
PFM
• Unable to contract or relax PFM efficiently
• Hypertonus or PFM spasm is v/eak musculature
• A 'tight" muscle is not a strong muscle
• Muscle has to be the right length to be the right
strength
» Too long = weak muscle contraction
- ® Too short = weak muscle contraction
Other Reasons for Pelvic Pain
» Faultyposture
• Improper body mechanics
• Strenuousactivitiesofdailyliving
• Sedentary lifestyle
• Obesity
• Poor core strength
• Deaeased muscle fle*bitiiy
• LImiledpInlfangeofmotion
• Asymmetries in body altgnment
• Degenerative changes in the musculoskeletal system commonly
:L,;:.tunH)3rspine,hIps ...
28
PT Intervention for Hypertonus
h'oda'iiss fof pa'n relief
• hast cob, uiraso^nd,
n^jrcnT^isiij<3f EKST*.
EUVii, TENS
^.^af^u^ techr^<pj43 to fea^gn tfia
musci/oskelelal 5>'5lerTi
BWe<K3t>3cJ< ($Ef.(G)! to dOiMiIra'fVreias PFM
• Cofv«ctiv9 tiisu« nxiiTiraLion
Serial vaff'nal dSstofs
PostofeitxxJy mecharios
Core strengtfwrtng
' Sofl tissw mobilization
• Scat tisiua motnlizstton
• SWn rc^f'ng
• TrlgQ-sf po!ftt reJcase
• h))t)fasc'al release
Fle»3bi-ty rormaJized
B/eathire.'slfe$s majT^emsril
Conitipalton Sralea'as
HEP
¦ Viscera) mai-t'piSatton
• Cup^uTg massage
• Sicelelalrmtsdesttelcftrig
. * Yoga, RsiH. massage. guW^d
is;: ,, ttr.a'jay. pan'seioa iherapUl,
Serial Vaginal Dilators
Vaginal dilators
• Dyspareunia
• restore vaginal capacity
• Hypertonic PFM
• expand the vagina in
width and depth
9 Vaginismus
• provide elasticily to the
tissues
9 Vestibulodynia
• allow for comfortable
sexual activity.
• Vaginal atrophy
« Vulvar dermatoses
Smooth plastic, lubber, or
glass cylinder-shaped
• Vaginal agenesis
objects that come in a
variety of graduated sizes
« Post-radiation
fei.aod weights.'
adhesions
* Psychogenic ,
?dyspaf^nlal"2-l^j§gg^
Dilator Therapy
Syracuse brand Leio brand
Connective Tissue Restrictions
Symplonis
Impairments
Genital hypersensilivi'ty
Neural inflamfnatjon
Clothing Intolerance
Adi/erse neural tension
Decreased sitting tolerance
Subopllmal muscle function
Itctiing
Pelvic floor dysfunction
Pain
Triggerpoints
Poor tissue Integfity
Colofchanges
Rummer PHRC
Connective Tissue Evaluation for
Pudendai Neuralgia
Gluteal Crease
?01t I'rorjjKKWl <'d f<i trinsfT'I! <C
Scar Tissue IVlobilization
Abdomlnoplasty Scar C Section Scar
3/16/2015
Connective Tissue Mobilization
Skin Rolling Friction Cross-Fiber Friclion
-
—
Connective Tissue Mobilization
Cross-fiber friction and deep transverse friction
Apply directly to the restricted tissue
•Facilitates healthy scar formation
•Mechanical action across tissues causes broadening and separaticm
of fit>ers
Encourages parallel fit>er arrangement and fev-^r cross-connections
that limit movement
•Prevents normal tissues from adhering to the scarred area
"adhesions"
Cupping Massage
Releases sof{ tissue,
scars raotriz-torl
fascia
Vacuui
separation o't Sbtic
N
layers
Enabk
absorp
flow to
Reduc
31
Referred Pain from Trigger Point
sphincter ani, levator ani and coccygeus muscle TrPs
•Refer poorly localized pain
•Coccyx, anal and distal sacral pain
•"Coccygodynia' ailhough the coccyx is usually normal
and nonlender
•Also called 'Levator ani syndrome" since the levator ani
is the muscle TrP causing referred pain to the coccyx
TfaveS JG. Sinic*B DG 1933 U)OfasciaI paii axl djsftncftin; lha pc^ marusJ,
2, WSans i V/&3ns, BsSmaa. p til
Referred Pain from Trigger Point
Referred Pain from Trigger Point
Obturator Internus TrPs
•Vaginal pain
•Anococcygeal region
•Upper portion of posterior thigh
•"Obturator inlernus syndrome" causes rectal pain and a
feeling of fullness in the rectum
Tra.«J JO, Sirnors DG 1933 Mjti'ascy pa'n atJ d>s#UTCtton: the pcanl irnruii,
vol 2, WiSams & V/3-ir6, BaSnore, p ill
Trigger Point Release
Trigger Point Release
Release of muscle tenston by inactivating the trigger points
lt5a{ are causing the taut bands which are responsible few ttie
increased tension
Trigger Point Pressure Release
AppRcation ofslo\^ increasing, non-painful pressure over a
trigger point until a barrier of tissue resistance Is
encountered.
Contact is then maintained until the tissue barrier releases,
and pressure is Increased to reach a new ban-ier to eliminate
the t^ger point tension and tenderness.
rra'.'^ JG, SirTKTsDG 1933M)0?aidaJ pi^aoldy^jiclion; thalr^gsfpcait cnarLEJ,
TOi 1, WEa-ns a WBd«. Ba'&ntf e. p 8
Myofascial Release
• 'Myofascial restrictions that can produce tensile
pressures of approximately 2,000 pounds per square
inch on pain sensitive structures that do not show up in
many of the standard tesls"
• 'Low load (gentle pressure) applied slov/ly v/ill allow a
visojelastic medium (fascia) to elongate"
• "Myofascial Release can restore tJie necessary slack to
the system to take the pressure off of the pudendal
nerve. This helps to eliminate pain and Improve the
ability to sit, engage in intercourse, and maintain
•-y^ntinence."
JOUt' sr. - 1-1 A J 1.1 ' .>11.
3/16/2015
Myofascial Release
Abdominal MFR
Pelvic Floor MFR
Visceral Manipulation
« "Gentle specifically placed manual forces that
encourage normal mobility, tone and inherent tissue
motion of the viscera, their connective tissue and other
areas of the body v/here physiologic motion has been
impaired"
® Inflamed tissues "dry out", become inelastic and lose
their normal motion
« Restore physiologic motion to improve organ function
Visceral Manipulation Anterior Perineum
34
3/16/2015
Visceral Manipulation Anterior Perineum
Anterior perineum interacts closely with the bladder
Defibrose the perineal body by stretching the
superficial perineal, urogenital diaphragm,
bulbocavernosus, ischiocavemosus and superficial
transverse perineal muscles.
Good episiotomy treatment
Directly affects the pudendal nerves
BaiT^JP i»3UfC9vrt(dinsr^a5i:n. ea55*5J Press. Ssatte.pSJ
Pelvic Floor PT Day 1
• Subjective evaluation
• Patient education
• Intake/output/pain iog
• PFM anatomy, function, dysfunctton
• Envifonmentaltfritants
• Propersrtting posture
• Toileting posture; avoid straining!
• Gl strategies for BM qd-qod
• Self massage
• Integrative medicine and other practittoners
• PFM EMG baserme
» Internal PFM assessment possible
i^ulRltlate PF strengthening if no paia'reslficlion efeRed,;
35
3/16/2015
Pelvic Floor Day 2
• Hypotonic PF: SUI, DDI, MUi, Fl, prolapse without
pain or soft/connective tissue restrictions
• PFM not effectivety closing urethra
• PF strengthening wltti Kegels-excellent outcomes!
• HEP Kegels + core strength; progressive positioning
• Biofeedback
• Estim if PF strength <3/5 mm
• If no pain, but have restrictions, before Kegels:
• Biofeedback to downtrain PFM to normalresting tone
• Manual PFM stretching
• Breathing
.Awareness of voftionarPFMctenctiing'
Pelvic Floor Day 2
•
Review cxDmpleted intake/outpul/pain log
•
Orthopedic evaluation
•
External PF myofascial mobility
•
Soft/connective tissue mobility trunk to knees
•
• Assessing for restriclions, tenderness, pain
Plan of care and goals discussed with patient
m
Discharge planning
•
Tfiani
36