Pelvic Floor Therapy Biofeedback and more Conservative treatment for Pelvic Floor Disorders What is Biofeedback? Biofeedback is a technique in which people are trained to improve their health by learning to control certain internal bodily processes that normally occur involuntarily, such as muscle tension (i.e.: pelvic floor muscle tone) via the use of a computer screen portraying the activity of the pelvic muscles. ` 2 Urostym – Biofeedback and More Laborie Medical Technologies Purpose, Characteristics, Function ` 1. 2. 3. 4. 5. Purpose Aide in identification of target muscles Use conscious awareness to properly work muscle to void or stool. Learn relaxation in those with retention, constipation Requires desire and motivation for improvement of life over time and with effort. With Uroflowmetry, addresses voiding dysfunctions by allowing the patient to view their muscle use during voiding. Patient Requirements 1. 2. 3. 4. 5. 6. 7. 4 Cognitive awareness Able to participate Understands the need to do homework Aware this is not a ‘quick fix’ At least partial innervation of Pelvic Floor Muscle Motivated to change Engaging and knowledgeable Therapist Review of anatomy – as relating to the pelvic floor The pelvic floor supports the bladder, and helps to maintain continence. During voiding, the pelvic floor must relax and allow the free flow of fluid 5 Urostym – Biofeedback and More Laborie Medical Technologies Pelvic Floor Muscles ` Slow Twitch Muscles fibers (Type 1 muscle fibers) Predominant muscle fiber in the pelvic floor; physiologically suited to provide sustained pelvic muscle tone over prolonged periods of time. Comprise about 70% of pelvic floor musculature. ` Fast Twitch Muscle fibers (Type 2 muscle fibers) Comprise about 30% of the pelvic floor muscle fibers, physiologically designed to provide rapid contraction needed to increase sphincter tone when there is a sudden increase in abdominal pressure, as seen with stress incontinence. 6 Urostym – Biofeedback and More Laborie Medical Technologies Pelvic Floor Musculature ` Three layers ` Superficial layer: the perineum ` Intermediate Layer: the uro-genital diaphragm ` Deep Layer: the pelvic diaphragm Superficial layer Paired ishiocavernosis and bulbospongiosis muscles Superficial transverse muscle External anal sphincter – placement of surface electrodes Intermediate Layer - External urinary sphincter - Deep transversus muscle Deep layer Paired: 1. Pubovaginalis muscles 2. Puborectalis muscles 3. Pubococcygeus muscles 4. Iliococcygeus muscle -these 4 make up the Levator Ani Group 5. Ishiococcygeus muscles y Innervation of Pelvic Floor ` Pudendal nerve ` S2, 3, 4 Types of pelvic floor dysfunction ` Stress incontinence – the loss of continence during exertion : cough, laugh, exercise ` Urge incontinence – the loss of continence due to a sudden overwhelming need to void (or evacuate) ` Dysfunctional voiding – a learned behavior where the pelvic floor does not relax to allow completion of voiding or bowel movement. 14 Urostym – Biofeedback and More Laborie Medical Technologies Abbreviated pelvic floor exam ` External Evaluation Skin condition and hygiene Sensation: should feel same sensation to touch and pressure on both sides of midline Visibility of pelvic floor contraction: Central perineal tendon should move in a superior and an anterior direction Contraction should be limited to pelvic floor musculature only Compensation during pelvic floor contraction Pt often contract adductors (close legs), gluteii (buttock) muscles, or overuse the abdominal muscles in an attempt to do a pelvic floor contraction Pt typically compensate if they have decreased proprioception (muscle awareness), if they have decreased strength or if they are in pain Pelvic floor Exam cont’d. ` Internal Evaluation – digital exam Muscle tone What the muscle is like at rest Verify by testing the resistance to passive stretch Grade as: low, normal, or high Muscle contractility Grade from 0 to 5 (Oxford Scale) or -1 if inversion of perineal command Oxford scale of muscle contractility 0 1 2 3 4 5 No contraction Trace Perceptible contraction Good contraction, can’t sustain resistance Can sustain moderate resistance Can sustain max resistance Pelvic Floor Exercises ` Strength ` Speed ` Endurance ` Functional applications The Knack ` Tight perineal closure ` An active mechanism used to compensate for a functional deficiency (conscious control) ` Objective is to develop a conditioned reflex Who could benefit from PFR? Patients who suffer from: ` Urinary incontinence (stress/urge/mixed) ` Urinary retention ` Chronic pelvic pain (prostatitis, vaginismus, etc) ` Chronic constipation ` Fecal incontinence ` Sexual disorders ` Dysfunctional voiding ` Post-prostatectomy, post-partum 22 Urostym – Biofeedback and More Laborie Medical Technologies Purpose, Characteristics, Function ` 1. 2. 3. 4. 5. Purpose Aide in identification of target muscles Use conscious awareness to properly work muscle to void or stool. Learn relaxation in those with retention, constipation Requires desire and motivation for improvement of life over time and with effort. With Uroflowmetry, addresses voiding dysfunctions by allowing the patient to view their muscle use during voiding. How does biofeedback help? •It is patient controlled – empowering through conscious awareness, to take charge of their pelvic floor issues. • It offers an option for those who do not want surgery or medication •It does not prevent or complicate future surgery •It may be used in combination Rx 24 Urostym – Biofeedback and More Laborie Medical Technologies Terminology ` ` ` Biofeedback is the “old term” for pelvic floor reeducation or rehabilitation, more to the point, biofeedback is one aspect of Pelvic Floor Therapy Electrical stimulation is the delivery of electrical current to stimulate muscle contraction, another option in Pelvic Floor Therapy Pelvic Floor Therapy includes the above options along with: bowel and bladder management, fluid and nutrition awareness, posturing, anatomy and physiology of pelvic floor and elimination, positive affirmations and breathing. 25 Urostym – Biofeedback and More Laborie Medical Technologies Biofeedback for PFR How to measure muscle tension? ` For pelvic floor training, electromyography (EMG), measures actual muscle tension and relaxation (muscular electrical activity) ` Manometry (pressure), a technique that monitors pressure change related to the muscle. Or the actual strength and weakness of the muscle with an internal probe. 26 Urostym – Biofeedback and More Laborie Medical Technologies August Biofeedback for PFR ` ` ` ` monitor PF EMG activity through vaginal/anal probe or surface electrode patches. monitor PF pressure through vaginal/anal manometry probe. monitor abdominal muscles EMG through surface electrode patches. Only surface electrodes (EMG) are on children 27 Urostym – Biofeedback and More Laborie Medical Technologies Treatment follows accurate diagnosis of urinary / fecal dysfunction ` Urodynamic studies pinpoint the cause of the symptoms ` A trial of Pelvic Floor exercises may be done –the patient receives verbal instructions to strengthen the muscles by contracting the pelvic floor –often unsuccessful because patients are not able to correctly perform the exercises, or the pelvic floor is just too weak to contract: ` Often these exercises are taught by instructing the patient to stop and start the urinary stream during voiding ` 28 Modern physicians discourage this now, since it is interfering with the natural voiding function, and can lead to bad habits Urostym – Biofeedback and More Laborie Medical Technologies The advantage of pelvic floor re-education in a clinical setting ` The clinician and the patient are able to visualize the muscle activity ` ` ` ` ` confirms they are contracting the proper muscle group The clinician becomes a personal trainer and provides positive reinforcement Progress can be monitored A Session is terminated if patient shows fatigue and recruits abdominal muscles Improvement is often reported after 3 sessions! 29 Urostym – Biofeedback and More Laborie Medical Technologies Typical treatment programs ` ` First, the diagnosis Next, begin pelvic floor re-education sessions ` ` ` Most often, done once weekly for a period of 6-8 weeks Follow up to assess success and reinforce proper technique Homework of exercises performed 3 to 4 times daily along with bowel and bladder management, improved fluid intake, and possibly bladder retraining. 30 Urostym – Biofeedback and More Laborie Medical Technologies Success? ` ` It has been found that the success rate is 75-85% either complete “cure” or improvement Within one year, the symptoms will return if exercises are discontinued ` ` 31 This is a lifelong commitment for the patient – the monitored training is just the beginning Some may return for a ‘tune up’ 6 mo to a year later! Urostym – Biofeedback and More Laborie Medical Technologies Urostym ` Provides monitoring of both pelvic floor and abdominal muscles ` This confirms that only the right muscles are used ` Tracks improvement ` Provides electrical stimulation (when appropriate) to help strengthen muscles even before the patient can contract the muscles voluntarily 32 Urostym – Biofeedback and More Laborie Medical Technologies Cautions/ correct use ` ` ` Internal probes are only used with adults Electrical Stimulation is never used with children Internal probes are contraindicated whenever it is not appropriate – such as the presence of open wounds, or when placing an internal probe is painful or extremely distasteful to the patient, hemorrhoids ` 33 But remember that internal probes allow treatment to be more specific (by being physically closer ) to the levator ani muscle Urostym – Biofeedback and More Laborie Medical Technologies The contraindications for Electrical Stimulation (ES) ` Persons with the following conditions should not use electrical stimulation: Complete denervation of the pelvic floor 2. Dementia 3. Demand cardiac (heart) pacemaker 4. Unstable or serious cardiac arrhythmia 5. Pregnancy or planning/attempting pregnancy 6. Broken/irritated peri-anal skin 7. Rectal bleeding 8. Active infection (UTI/vaginal) 9. Unstable seizure disorder 10. Swollen, painful hemorrhoids 1. 34 Urostym – Biofeedback and More Laborie Medical Technologies Electrical stimulation as part of pelvic floor rehabilitation ` Electrical current is administered through the EMG vaginal or anal probe, or through surface electrode patches. ` Manometry probes (pressure) are not be used for electrical Stimulation 35 Urostym – Biofeedback and More Laborie Medical Technologies Understanding Current Pulsed ,bi-phasic current: Particles move in one direction, according to their charge, fall briefly to zero, and then reverse direction. Current Amplitude: Amplitude is the intensity of the current ( measured in micro-volts) 36 Urostym – Biofeedback and More Laborie Medical Technologies Understanding Current Current Frequency: The number of pulses that are generated per unit of time (seconds). (measured in Hz) Band width: The duration of each pulse (measured in microseconds) 37 Urostym – Biofeedback and More Laborie Medical Technologies Current for PFR ` Lower Hz 10 to 12 are used for pelvic pain ` 20 Hz is usually used for Urgency/Frequency and Urge Incontinence. ` Higher Hz 50 to 100 are used for Stress incontinence. ` Hz 200 are used for urinary retention 38 Urostym – Biofeedback and More Laborie Medical Technologies What happens during PFR? ` EMG or pressure probe (vaginal /anal) is inserted Note: An EMG probe can monitor muscle tension (electrical activity) and can administer ES. A pressure probe can only monitor change in pressure ` ` ` Surface electrodes are placed on the abdominals to monitor EMG activity in this area The information gathered is fed to a computer screen, and the therapist then leads the person in exercises Through trial and error, participants learn to identify and control their pelvic floor muscles 39 Urostym – Biofeedback and More Laborie Medical Technologies Pediatric Applications ` ` ` ` Biofeedback performed with surface electrode patches only –no probes NO electrical stimulation Often combined with Uroflowmetry to diagnose voiding dysfunction: patient arrives with full bladder, patches positioned perianally and abdominally and uroflometry is performed The goal to allow complete bladder emptying through relaxation of the pelvic muscles 40 Urostym – Biofeedback and More Laborie Medical Technologies Female Probe Placement 41 Urostym – Biofeedback and More Laborie Medical Technologies Male Probe Placement 42 Urostym – Biofeedback and More Laborie Medical Technologies Animation for Uroflow 43 Urostym – Biofeedback and More Laborie Medical Technologies 44 Urostym – Biofeedback and More Laborie Medical Technologies Monkey Game 45 Urostym – Biofeedback and More Laborie Medical Technologies Alien shoots down Asteroids! 46 Urostym – Biofeedback and More Laborie Medical Technologies Continence Therapy Summary Pelvic Floor Therapy includes a multitude of approaches: 1. 2. 3. 4. 5. 6. 7. 47 Electrical Stimulation Biofeedback, Manometry Uroflowmetry Bladder and bowel training Behavior modification Posturing Positive affirmations to build confidence and empowerment Urostym – Biofeedback and More Laborie Medical Technologies Pelvic Floor Therapy: The means to helping Patients to take CONTROL! 48 Urostym – Biofeedback and More Laborie Medical Technologies