4/10/2012 (c) Debbie Callif, OT, BCB-PMD 2012 CLINICAL UPDATE ON PELVIC FLOOR REHABILITATION Debbie Callif, OT, BCB-PMD [email protected] Urinary Dysfunction  Incontinence Stress OAB/urge Mixed  Frequency  Urgency  Retention  Painful Bladder Syndrome http://www.ucurology.org/images/moreImages/bioFeedback.jpg (c) Debbie Callif, OT, BCB-PMD 2012 Does Pelvic Floor Muscle Training Really Help?      Fourteen trials involving 836 women Women who did pelvic floor muscle training (PFMT) were more likely to report : Cured or improved Better continence specific quality of life Experienced fewer incontinence episodes per day Less leakage on pad test Stress urinary incontinence required longer duration of training vs urge urinary incontinence Women with stress urinary incontinence best outcome if participate in PFMT program for at least three months Recommended PFMT should be 1st line conservative treatment in stress, urge and mixed incontinence Cochrane Database Syst Rev. 2010 Jan 20;(1):CD005654. (c) Debbie Callif, OT, BCB-PMD 2012 Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. 1 4/10/2012 Which is best: Medications or Behavioral Treatment?    Each treatment intervention is efficacious Decision based on the patient's severity of symptoms, tolerability, compliance and satisfaction with the treatment Combination of behavioral therapy and OAB drug intervention: Best patient satisfaction and perceived improvement Reduction of bladder symptoms Most practical and cost effective for optimal management of patients with OAB Adv Urol. 2009:345324. Epub 2009 Dec 15. Behavioral intervention versus pharmacotherapy or their combinations in the management of overactive bladder dysfunction (c) Debbie Callif, OT, BCB-PMD 2012 Acupuncture  12 major meridians in traditional Chinese medicine (TMC) that correspond to organ systems  Bladder imbalances can stem from the lungs, heart, spleen, bladder, kidneys or liver  Kidneys’ energy, or “qi” plays a role in urinary continence  Chinese concepts of “yin” and “yang” Bladder’s yin function affects urge incontinence Kidney yin affects stress incontinence Kidney yang associated with nocturia and ED http://www.bladderhealthawareness.org/2011/06/acupuncture-and-chinese-herbs-for-overactive-bladder/ (c) Debbie Callif, OT, BCB-PMD 2012 Can Rushing to the Bathroom Cause Fractures?      >6,000 community dwelling women completed questionnaire 25% of women had weekly or more frequent urge incontinence, 19% stress incontinence, 12% mixed incontinence Weekly or more frequent urge incontinence was associated with an increased risk of falls and fractures in older women Urinary frequency, nocturia, and rushing to the bathroom to avoid urge incontinent episodes most likely increase the risk of falling, which then results in fractures Early diagnosis and appropriate treatment of urge incontinence may decrease the risk of fracture. J Am Geriatr Soc. 2000 Jul;48(7):721-5. Urinary incontinence: does it increase risk for falls and fractures? Study of Osteoporotic Fractures Research Group. (c) Debbie Callif, OT, BCB-PMD 2012 2 4/10/2012 Risk for Falls   Urge urinary incontinence associated with a modest increase in falls Falls prevention programs need to include an assessment of incontinence Aust J Physiother. 2009;55(2):89-95. Urinary incontinence is associated with an increase in falls: a systematic review. (c) Debbie Callif, OT, BCB-PMD 2012 Not Just a Kegel  Isolate out pelvic floor muscles  C Co-contract t t  Use during functional activities (c) Debbie Callif, OT, BCB-PMD 2012 Stop Trying to Isolate the Pelvic Floor Muscles  Muscles that enhance pelvic floor muscle contractions: v abdominis Transverse Adductors Obturator internus Multifidus (c) Debbie Callif, OT, BCB-PMD 2012 3 4/10/2012 Muscles That Help Intensify Pelvic Floor Muscle Contractions (c) Debbie Callif, OT, BCB-PMD 2012 Urinary Stress Incontinence  Stem Cell Therapy: Animal models-promising 1st human trial in Australia (c) Debbie Callif, OT, BCB-PMD 2012 Erectile Dysfunction and Biofeedback  55 men > 20 years old ED >/= 6 months  Biofeedback pelvic floor muscle exercises and lifestyle changes or lifestyle changes only  Control group that did not respond after 3 months were treated  All men given home exercises for 3 more months  Results: After 3 months the biofeedback group erectile function was significantly improved Control group significantly improved 3 months later After 6 months 40% regained normal erectile function, 35.5% improved, 24.5% failed to improve BJU Int. 2005 Sep;96(4):595-7. Pelvic floor exercises for erectile dysfunction. (c) Debbie Callif, OT, BCB-PMD 2012 4 4/10/2012 Vacuum Erection Device Rehabilitation   Negative pressure to increase blood inflow to penis After radical prostatectomy: Facilitates tiss tissue e ooxygenation genation Reduces cavernosal fibrosis Increases likelihood of preserving penile function Yuan J, Hoang AN, Romero CA, Lin H, Dai Y, Wang r. Int J Impot Res. 2010 Apr 22 www.google.com/imgres?q=vacuum+erection+devi ce&um=1&hl=en&client=firefox- (c) Debbie Callif, OT, BCB-PMD 2012 Vacuum Erectile Device 141 sexually active men underwent radical prostatectomy  Mean age 68  1 year later 113 (80%) still sexually active  5 years later (mean age 73) 62% remained sexually active 71% had natural erections for intercourse without assistance 29% sexually inactive- 40% loss of interest  (c) Debbie Callif, OT, BCB-PMD 2012 More Is Not Always Better  Dr. Berman-100’s  V i lC Vaginal Cones (c) Debbie Callif, OT, BCB-PMD 2012 5 4/10/2012 Dietary   Prelief: OTC food acid reducer Reduces urinary urgency and bladder pain Superior to IC/PBS interventions (surgery, bladder installations, oral therapies) www.prelief.com 800-994-4711 Natural Touch Kaffree Roma Multigrain beverage with chicory Similar taste to coffee without caffeine or tannic acids Urologu (Jan. 2008: Vol.17, 62-22) (c) Debbie Callif, OT, BCB-PMD 2012 Bowel Dysfunction  Incontinence  Urgency  Frequency  Constipation  Diarrhea  IBS (c) Debbie Callif, OT, BCB-PMD 2012 Fecal Incontinence     Community living adults frequency: 6% of those < 40 15% in older women 10% + in older men Nursing home residents frequency: 46 % prevalence Minor fecal incontinence (staining underclothes or losing less than 2 tsp. of stool): 7% of adults Irritable bowel syndrome (IBS): 30% frequent loose stools 20% fecal incontinence (c) Debbie Callif, OT, BCB-PMD 2012 6 4/10/2012 Pediatric Bowel Dysfunction    Constipation or encopresis complaints comprise 10-25% of pediatric gastroenterologist visits Irritable bowel syndrome s ndrome (IBS) (IBS): 17% of high school students 8% of middle school students Functional GI disorders occur in 10% of the pediatric population (c) Debbie Callif, OT, BCB-PMD 2012 Pediatric Bowel Dysfunction Treatment  Biofeedback assisted pelvic floor muscle exercises  Proper breathing techniques  Proper positioning  Fiber intake children ages 3-10 years: Age +5 gms of dietary fiber/day  Fluid intake: six to eight 8 ounces of fluid/day  Abdominal, back and hip exercises (c) Debbie Callif, OT, BCB-PMD 2012 Diet and Bowel Function  Konsyl  Natural Calm http://www.vulvodynia.com.au/articles/images/wh_2_f1.gif (c) Debbie Callif, OT, BCB-PMD 2012 7 4/10/2012 Probiotics  Live microorganisms similar to those found in the intestines  Beneficial bacteria  Store in the refrigerator (c) Debbie Callif, OT, BCB-PMD 2012 Probiotics     RCTs with at least 1 week of treatment comparing probiotics with placebo or no treatment in adults with IBS Studies had to provide improvement in abdominal pain or global IBS symptoms as an outcome 19 RCTs (18 papers) in 1650 patients with IBS were identified. Probiotics were statistically significantly (c) Debbie Callif, OT, BCB-PMD 2012 Probiotics  Florajen3 Lactobacillus acidophilus (7.5 billion cells) Bifidobacterium lactis (bifidum) strain Bb-12 (6 billion cells) Bifid b Bifidobacterium i llongum (1 (1.5 5 billi billion cells) ll )  Align Bifantis (Bifidobacterium infantis 35624 (1 billion cells) http://www.florajen.com http://www.aligngi.com (c) Debbie Callif, OT, BCB-PMD 2012 8 4/10/2012 Prebiotic  Rebuilds intestinal flora  FOS- Fructooligosaccharides (c) Debbie Callif, OT, BCB-PMD 2012 New FDA Treatments for Fecal Incontinence   Solesta Failure of conservative therapy Biocompatible bulking agent j into submucosal layer y of anal canal Injected 42.7% reduction in fecal incontinence in 3 months InterStim Sacral nerve stimulation Used for bladder dysfunction (c) Debbie Callif, OT, BCB-PMD 2012 Chronic Pelvic Pain   Pain > 6 months Pain is stronger than expected from previous surgery, injury or present condition  Difficulty sleeping or sleeping too much  Decreased appetite  Decreased activity level (c) Debbie Callif, OT, BCB-PMD 2012 9 4/10/2012 Chronic Pelvic Pain     One of the most common medical conditions in women 25% of women with CPP will spend 2-3 days in bed/month 90% have dyspareunia Almost 50% will feel sad or depressed at one time due to CPP (c) Debbie Callif, OT, BCB-PMD 2012 Chronic Pelvic Pain   Chronic Pelvic Pain Syndrome Men: Prostatitis Women: Vulvodynia y Vulvar Vestibulitis Vaginismus Dyspareunia Painful Bladder Syndrome http://www.vulvodynia.com/dia_vv_ab10_files/image004.jpg (c) Debbie Callif, OT, BCB-PMD 2012 Chronic Pelvic Pain It is not all in your head!  Physical  Psychological  Behavioral (c) Debbie Callif, OT, BCB-PMD 2012 10 4/10/2012 Chronic Pelvic Pain    Muscle tension Changes in connective tissue, skin, nerve function and blood supply Can affect bowel, bladder, genitals, pelvis, hips, back, abdomen, legs (c) Debbie Callif, OT, BCB-PMD 2012 Chronic Pelvic Pain Treatments   Biofeedback relaxation exercises Biofeedback assisted pelvic floor eccentric lengthening exercise  Manual therapy  Cognitive behavioral therapy (c) Debbie Callif, OT, BCB-PMD 2012 Chronic Pelvic Pain Treatments  Aloe Vera capsules Desert Harvest 6 capsules/day=3,600 mg Aloe Vera concentrate for 3 months Improvement in pelvic pain, frequency of urination, pressure and nocturia www.desertharvest.com 800-222-3901  Neogyn Cutaneous lysate cream for provoked vestibulodynia Apply to vulva twice daily for 3 months Effective in reducing erythema of the vestibule and pain with intercourse www.neogyn.us rologu (Jan. 2008: Vol.17, 62-22) http://www.rehabpub.com/features/112005/4a.jpg (c) Debbie Callif, OT, BCB-PMD 2012 11 4/10/2012 Chronic Pelvic Pain Vitamin E oil  I t vaginally/rectally Intra i ll / t ll  Topically (c) Debbie Callif, OT, BCB-PMD 2012 Pelvic Organ Descent    Cystocele, rectocele or uterine prolapse Pelvic organ descent pulls on sacrum and can lead to sacroiliac and lumbosacral dysfunctional alignment g Treatment: Positioning sEMG activation of pelvic floor muscles Core exercises (c) Debbie Callif, OT, BCB-PMD 2012 Resources International Foundation for Functional Gastrointestinal Disorders: www.iffgd.org  International Pelvic Pain Society: www.pelvicpain.org  National Association for Continence: www.nafc.org www.bladderhealthawareness.org  Images from google images unless otherwise noted. 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