PELVIC FLOOR

PHYSICAL THERAPY

Colleen Sandro, MS, PT, COMT, BCIA-PMD

Objectives
 Understand Physical Therapy evaluation
and treatment for pelvic floor dysfunction

 Become familiar with Physical Therapy

outcomes for pelvic floor patients
Pelvic Floor Physical Therapy
 Incontinence
 Urge and stress incontinence
 Urinary and fecal incontinence

 Pelvic Organ Prolapse

 Pelvic Pain
 Voiding Dysfunction
 Constipation
 Hesitancy, incomplete voiding
Pregnancy and Post Partum PT
 Pregnancy related musculoskeletal
problems
 Back pain
 Pubic pain
 Sciatic/Radicular pain

 Post partum musculoskeletal problems

 Diastasisrecti
 Incontinence
Normal Pelvic Floor Function
 Support for pelvic organs
 Sphincter closure for continence
 Sexual function
 Spine and pelvis stabilization
 Resting tone for urination
 Descent for stool evacuation
 Categories
Pelvic Floor Dysfunction
 Low Tone or Weak

 Uncoordinated

 High Tone or Pain

 Pelvic Floor Weakness
Symptoms/Diagnoses
 Incontinence

 Pelvic Organ Prolapse

 Back Pain
 Physical Therapy
For the Low Tone or Weak Patient

 Increase muscle recruitment and strength for

support
 Improve sphincter closure pressure for
continence
 Improve reflex inhibition of bladder to control
urgency
 Core strength for support and stability
 Uncoordinated Pelvic Floor
Symptoms/Diagnoses
 Constipation

 Hesitancy/Incomplete Voiding

 Pelvic Floor Dyssynergia

Pelvic Floor Pain/High Tone
Diagnoses
 Pelvic Pain  Endometriosis
 Back Pain  Prostatitis
 Coccydynia  Interstitial Cystitis
 Dyspareunia  Irritable Bowel
 Pudendal neuralgia Syndrome
 Non-relaxing pelvic
floor
 Levator ani syndrome
 Tension myalgia of
pelvic floor
Pelvic Floor Pain/High Tone
Symptoms/Diagnoses
 Vulvar Pain Syndromes
 Vulvodynia (burning, itching, redness)
 Vestibulitis (pain to touch - vestibule)
 Vaginismus (muscle spasm/hypertonus)
 Vulvar Vestibulitis Syndrome/Vestibulodynia
 Rosenbaum, J Sex Med 207; 4:4-13, Pelvic Floor
Involvement in Male and Female Sexual Dysfunction and
the Role of Pelvic Floor Rehabilitation and Treatment: A
Literature Review
Body Systems Involved With
Pelvic Pain
 Urologic
 Gynecologic
 Urogynecologic
 Gastrointestinal
 Neurologic
 Psychological
 Vascular
 Lymphatic
 Endocrine
 Musculoskeletal
(Prendergast, S, Weiss, J, 2003)
Incidence of Pelvic Floor
Involvement in Chronic Pelvic Pain
 90% of women with vestibulodynia
demonstrated pelvic floor pathology (Reissing,
2005)
 50% of patients with chronic pelvic pain have
pelvic floor muscle spasms or dysfunction
(Jensen 2011)
 34% of 200 women had diagnosis of tenderness
of pelvic floor muscles as a primary cause of
chronic pelvic pain (Montenegro, 2010)
 22% of patients with chronic pelvic pain had
tenderness of levator ani (pelvic floor muscle),
(Tu, et al, 2006)
 Physical Therapy
For the High Tone or Pain Patient

 Improve muscle resting tone

 Improve tissue mobility
 Restore joint and muscle balance
Pelvic Floor Physical Therapy
Evaluation
 Physical Therapy Evaluation
 History/Intake
 Pelvic Floor Exam (external/internal)
 Screening Exam
 Thoracic-lumbar-sacral/lower extremities

 Patient Education
 Pelvic floor exam
 Pelvis and pelvic floor anatomy
Physical Therapy Evaluation
 Muscle
 Ligament
 Joint
 Nerve
 Connective tissue
 Fascia
 Scar Tissue
Physical Therapy Evaluation
 Posture/Movement Patterns/Walking
 Mobility (joint glide) – spine/pelvis/hips
 Soft tissue assessment (tenderness/tone)
 Lower extremity flexibility
 Hip assessment
 Abdominal assessment
 External pelvic floor muscle exam
 Internal pelvic floor muscle exam
 Biofeedback/Electromyography (EMG)
External Pelvic Muscle Exam
“Pelvic Clock”
Internal Pelvic Floor Muscle Exam
 Symmetry
 Endurance Contraction
 Repeated Quick Contractions
 Ability to Isolate
 Ability to Relax
 Muscle Thickness
 Tenderness
 Tone
 Lift
 Closure
 Pelvic Floor Muscle Exam

0= No contraction
1= Flicker
2= Weak Contraction/Closure; No Lift
3= Moderate Squeeze/Closure with Lift
4= Good Squeeze with Lift and Endurance
5= Strong Squeeze with Lift and Deflection of
Examiner’s Finger
Laycock--modified Oxford Grading System
Is more lift better?
 “Is lifting through a larger distance a
measure of greater pelvic floor force, or
might it indicate a stretched or ruptured
fascia within which the pelvic floor can lift
a greater distance?”
 Bo, Sherburn, Phys Ther 2005
 Pelvic Floor Recruitment
 >30% of women are unable to effectively recruit their
pelvic floor muscles at the initial evaluation
 Common substitution patterns include contraction of:
gluteal, hip adductors, abdominals, breath holding
(Bo, K. and Sherburn, M, 2005)
 49% not able to contract pelvic floor in a way that
increased urethral closure pressure
(Bump et al, Am J Obs Gynecol, 1991)
 Transversus Abdominis and
Pelvic Floor Muscle
“A strong PFM contraction resulted in strong and
simultaneous recruitment of transversus
abdominis and internal oblique. . . “ (Neuman, P
and Gill, V.)
“Pelvic floor muscle alone demonstrated
significantly higher elevation displacement than
transversus abdominis or pelvic floor plus
transversus abdominis” (transabdominal
ultrasound measurement)
Physical Therapy
Treatment
 What To Expect
Physical Therapy Treatment

 6-12 sessions
 1-2x/week
 45 minutes duration

 Private setting

 Insurance coverage
 Physical Therapy Treatment
Incontinence
 Pelvic Floor Muscle Recruitment
and Strengthening

 Biofeedback Training
 Electrical Stimulation
 Weighted vaginal cones
 Biofeedback
Electromyography (sEMG)

http://www.theprogrp.com/therapists/PROMETHE.PDF
Pelvic Floor Biofeedback
Endurance Holds
Pelvic Floor Biofeedback
Quick Contractions
 Electric Stimulation

 Muscle Recruitment (50 Hz)

 Bladder Inhibition (12 Hz)

www.theprogrp.com/therapists/PROMETHE.PDF
Vaginal Weight Training
Pelvic Floor Muscle Training & SUI
Hypothesis of Mechanisms
 Aim & Rationale PFM strength training
 Build structural support of pelvis
 Elevate levator plate to permanently higher position
 Enhance hypertrophy and stiffness of pelvic floor
muscle and connective tissue
 Facilitate more effective automatic motor unit firing
(neural adaptation)
 Prevent descent during increases of abdominal
pressure
 Bo, Kari, Int Urogyn J, 2004
Skeletal Muscle
Exercise Prescription

 Effective muscle strength training in skeletal

muscles, exercise scientists recommend:
 Three sets of 8-12
 Slow velocity
 Close to maximum contractions
 2-4 days/week (several studies concluded higher
dosage PFM training effective for Incontinence)
 May take 5 months to achieve results
 American College of Sports Medicine Position Stand 1998
Pelvic Floor Muscle
Exercise Prescription
 Daily
 Endurance Contractions
3 sets of 10
 close to maximum contractions
 hold 6-8 seconds

 Quick contractions
 3-6 months to maximize pelvic floor
strength
 (Bo, Mokved, Fjortoft, Obstetrics & Gynecology, 2002)
Pelvic Floor Muscle Training
Exercise Prescription
 Individualize
 Proper Technique
 Endurance
contractions
 Support
 stiffness

 Quick contractions
 Coordination

 Pre contractions
 Urge Control
Pelvic Floor Pre-Contraction
 Contract before cough
 Reduced urine leakage
 98.2% with medium cough
 73.3% with deep cough
 Miller et al, 1996, J Am Geriatr Soc 46:870-874,
1998
Pelvic Floor Pre-Contraction
 Vesical neck mobility
 5.4 mm without voluntary contraction
 2.9 mm with voluntary contraction

 Conclusion: pelvic floor voluntary

contraction stabilizes the bladder neck
during increases of abdominal pressure
 Bo, Kari, Int Urogy J 2004
 Behavioral Training
Voiding Diary
 Voiding interval
 Amount Voided
 Fluid Intake/Food
 Cause of Leakage
 Amount of Leakage
 Padding
 Urgency
 Stool type/frequency
 Behavioral Training
Urinary Urge Control
 Patient Education

 Waves of Urges

 Pelvic Floor Muscle Contractions

 Distraction Techniques
Behavioral Training
Foods that can contribute to urinary
urgency/frequency/leakage

 Caffeinated beverages
 Alcoholic beverages
 Artificial sweeteners
 Highly spiced foods
 Tomato based products
 Citrus and fruit juice
Behavioral Retraining
Foods that can cause bowel irritability
 Milk or milk products  Citrus fruit/juice
 Fried or greasy foods  Eggs
 Tomato based foods  Salads
 Artificial sweeteners  alcohol
 Caffeinated
beverages
 Chocolate
Behavioral Training
Fecal Incontinence and Urgency
 “Holding On” Technique
 On toilet
 In bathroom
 Gradually increase time and distance from
toilet
Outcomes
Pelvic Floor Muscle Training
& Urinary Incontinence

 Effective treatment for Stress and Mixed

Urinary Incontinence
 Recognized as first line of treatment
 Cure and improvement rates 56%-70%
 Cure (<=2 g leakage on pad tests) 44-49%
 Cochrane Review, 2010
Outcomes Fecal Incontinence
Pelvic Floor Muscle Training

 “A systematic review found sufficient

evidence for the efficacy of biofeedback
and/or electric stimulation combined in
treating fecal incontinence”
 Vonthein, et al, Int J Colorectal Dis, 2013.
 Joanna Briggs Institute Best Practice Recommendations
Do I have to do this forever?

Outcomes Long Term

Pelvic Floor Muscle Training & SUI

 Exercise science has shown less effort

needed to maintain than to build muscle
strength
 Intensity of contraction important
 2x/week sufficient to maintain strength
 Outcomes Long term
Pelvic Floor Muscle Training & SUI
 Maintenance PFM exercise program
(1 or 4 times/week)
 6 month follow up
 Urodynamic Stress Urinary Incontinence
 60.7% prior to intervention
 42.8% after intervention
 35% at 6 month follow up (not statistically significant)
 Post intervention status was sustained for all
outcomes in both groups
 Borello-France, et al, Phys Ther, 2008
Physical Therapy Treatment
Pelvic Organ Prolapse
 Pelvic floor strengthening with biofeedback
 Positioning
 Inverted lying
 Body mechanics
 Lifting
 Bed mobility
 Avoidance of
breath holding
Outcomes Prolapse
Pelvic Floor Muscle Training
 330 experimental group; 324 control group
 Rate of worsening of genital prolapse
 72.2% in control group
 27.3% experimental group

 Pelvic floor muscle exercise effective to prevent

worsening in women with severe genital
prolapse
 Not significantly different with mild prolapse
 Piya-Ant, et al, J Med Assoc Thai, 2003
Outcomes Prolapse
Pelvic Floor Muscle Training (PFMT)
 PFMT Stages l and ll pelvic organ prolapse
 47 women
 Randomized controlled trial
 Blinded pelvic organ prolapse quantification
 Questionnaire
 Symptom severity
 Quality of life
 Improved prolapse stage 45% vs 0%
 Subjective improvement 63% vs 24%

 Data support trial of PFMT for prolapse

Hagen et al, Intl Urogyn J, 2009
Physical Therapy Treatment
for Pelvic Pain

(Needle Tower
by Kenneth
Snelson, 1968)
Pelvic Pain Treatment
 Manual Techniques
 Soft tissue techniques
 Joint mobilization
 Therapeutic Exercise
 Abdominal bracing/Gluteal strengthening
 Lower extremity flexibility
 Neural Mobilization
 Pelvic Floor Biofeedback
 Relaxation Training
 Therapeutic ultrasound (deep heat)
 Education
Structure vs Function
 Functional Therapy
 To maximize the body’s flexibility, endurance,
strength
 Structural Therapy
 To remove barriers to movement and improve
the patient’s potential to function
Functional Therapy
 Strength
 Stretching/ROM
 Mobility Exercises
 Postural Training
 ADL
 Balance Training
 Endurance Training
 Cardiovascular
Structural Therapy
 Joint Mobilization
 Connective Tissue Mobilization
 Strain-Counter strain
 Muscle Energy Technique
 Lymphatic Drainage
 Neural Mobilization
 Craniosacral Therapy
 Myofascial Release
 Visceral Mobilization
The nature of the barrier determines which manual
technique should be used.
(D’Ambrogio/Horton)
 Barrier-Technique
 Articular=muscle energy, joint mobilization
 Muscular=SCS, ischemic compression
 Fascial superficial=conn tissue mob/MFR
 Fascial deep=visceral mob/fascial release
 Fascial deepest=craniosacral therapy
 Lymphatic=lymphatic drainage
 Neural=neural mobilization
Muscular
 Strain Counter strain (Jones Technique)
 Slacken tissue
 Trigger Point release
 Compress tissue
 Thiele's massage
 Lengthen tissue
Soft Tissue Techniques
 Urogenital Triangle
 Sup Transv Perineal Ms
 Bulbocavernosus
 Ishiocavernosus

 Anal Triangle
 EAS

 Urogenital Diaphragm
 Sphincter urethra
 Pelvic Diaphragm
 Levator ani (pubococcygeus/puborectalis/iliococcyg)
 Ishiococcygeus

 Obturator Internus
Soft Tissue Techniques
Superficial Layer

(
Soft Tissue Techniques – Superficial Layer
Weiss, Jerome, Pelvic Floor Myofascial Trigger Points: Manual
Therapy for Interstitial Cystitis and the Urgency-Frequency Syndrome
2011
Soft Tissue Techniques – Middle Layer
Weiss, Jerome, Pelvic Floor Myofascial Trigger Points: Manual
Therapy for Interstitial Cystitis and the Urgency-Frequency Syndrome
2011
Soft Tissue Techniques – Deep Layer
Obturator Internus
Weiss, Jerome, Pelvic Floor Myofascial Trigger Points: Manual Therapy for
Interstitial Cystitis and the Urgency-Frequency Syndrome, 2011
Fascia
 Superficial layer
 Connective Tissue Mobilization/Skin Rolling
Fascia
Deep layer
Visceral mobilization/Fascia release
(Ramona Horton, PT)
Premise of Visceral Mobilization
 Organs are required to expand, displace,
glide and rotate with the normal
requirements of digestion, elimination and
somatic activities
 Any restriction, fixation or adhesion to
another structure implies structural
impairment of that organ and tissues
Neural Dynamics of Fascial
Plasticity
 CNS-Activation of fascial mechanoreceptors
cause a change in muscle tone mainly through
resetting of the gamma motor system, not as
much on the alpha
 ANS-Activation of fascial mechanoreceptors
lowers sympathetic activity resulting in plasma
extravasation, activation of the anterior lobe of
the hypothalamus and altering the tone of the
intrafascial smooth muscle cells
Fascia
 With visceral mobilization/fascial release,
a change is not brought about through the
force applied, but through the stimulation
of mechanoreceptors contained within the
fascia
Fascial Release
sigmoid colon for treatment of mechanical
constipation
(Ramona Horton, PT)
Fascial release
Urogenital Triangle (Ramona Horton, PT)
Fascial Release
Obturator Foramen (Ramona Horton, PT)
 Related Muscles

Diaphragm Quadratus Lumborum

Psoas - Iliacus Lumbar Paraspinal
Abdominal Multifidus
Adductor Gluteal
Hamstring
Internal and External Trigger
Points and typical referral
patterns
“A Headache in the Pelvis”
David Wise, Ph. D
Rodney Anderson, MD

maherrehabilitationinstitute.com/wst_page17.html
Flexibility Exercises
.
Flexibility Exercises
Pelvis ROM- Coordination
Nerve Flossing
Sciatic Nerve Pudendal Nerve
Diaphragm Breathing
Outcomes - Manual Therapy
 52 Subjects (45 women/ 7 men)
 10 Interstitial Cystitis
 42 urgency-frequency syndrome

 Conducted over 5 years (1995-2000)

 Results
 83% (35/42) mod to complete resolution (Urg-Freq)
 70% (7/10) mod to marked improvement (IC)
 Conclusion
 Pelvic floor manual therapy effective
reducing pelvic floor hyper tonus
reducing symptoms urgency-frequency-IC
(Weiss, J, 2001)
Outcomes –
Myofascial Physical Therapy
(FitzGerald, et al 2009)

 48 subjects (23 men/24 women)

 Patients: chronic prostatitis/chronic pelvic pain
syndrome or interstitial cystitis/painful bladder
syndrome
 2 groups
 MyofascialPhysical Therapy or
 Global Therapeutic Massage

 10 treatments (1x/week)
Outcomes –
Myofascial Physical Therapy
(FitzGerald, et al 2009)

 57% Myofascial Physical Therapy

 Statistically significant
 21% Global Therapeutic Massage

 Findings indicate a beneficial effect from

myofascial Physical Therapy
Outcomes – Pelvic Floor Massage
(M.L.L.S., Montenegro, 2010)

 6 women with chronic pelvic pain

 Treatment
 Pelvicfloor massage technique, 5 minutes
 1x/week, 4 visits

 Results 1st visit 1month f/u

 Tenderness Score 3 0-1
 Visual Analog Scale 8.1 1.5
 McGill Pain Scale 34 16.6
  Ultrasound (external)
Modalities
 Electric Stimulation
 80-200 Hz Pain
 Internal or external
sensors

theprogp.com
Pelvic Floor Biofeedback
common findings in patients with pain
 Elevated baseline/resting tone
 Poor awareness of contraction
 Slow return to baseline after contraction
 Low peak of contraction
 Decreased endurance
Pelvic Floor Biofeedback (sEMG)
patients with high tone muscles have
poor ability to relax and contract

Bernstein,AM, 1992
Pelvic Floor Biofeedback
treatment for patients with pelvic pain

 Down-training” to decrease electrical

output of hypertonic pelvic floor muscle
 Relaxation Training with Biofeedback
 Visualization
 Diaphragm breathing
 Relaxation techniques
Biofeedback with Vaginal Dilator
Training

Syracusemedicalintropkg.jpg
Outcomes – Biofeedback
 Glazer et al, Treatment of Vulvar Vestibulitis
Syndrome with Electromyographic Biofeedback
of Pelvic Floor Musculature. J Reprod Med April
40 (4) 283-90, 1995.

 33 subjects
 16 weeks home biofeedback pelvic floor
 Instruction and re-evaluations with
physical therapist for correct technique
Outcomes - Biofeedback
 83% Self reported improvement
 78% patients resumed intercourse (22/28)
 50% “cure rate”
 68% reduction in resting tone
 95.4% improvement in muscle contraction

 Results maintained at 6 months

Dysfunction related to
Constipation
 Non-relaxing PFM/Rectal hypersensitivity
 Mega Colon/Rectal hyposensitivity
 Slow transit constipation
 Paradoxical pelvic floor contraction
 Behavioral patterns/bowel habits
 Prolapse/laxity
Physical Therapy Treatment
Constipation
 Healthy bowel habits
 Toilet positioning
 Dietary factors
 Manual techniques
 Biofeedback
 Sensation training
 Diaphragm breathing
Healthy Bowel Habits
Bowel Diary
 Eat breakfast
 Eat regularly timed and portioned meals
 Drink warm fluid in the morning
 Fiber recommendation and examples
 Fluid recommendation
 Exercise/Activity
Toilet Position and Mechanics
 Feet supported
 Stool under feet
 Legs apart
 Exhale
 Expand abdomen
Manual Techniques
Slow Transit Constipation
 External Colon
Massage
(Abdominal
massage)
 Soft tissue
techniques
 Anterior abdomen
 Fascia, muscle
 Pelvic floor
Rectal Sensation Training
 Decrease sensitivity protocol

 Increase sensitivity protocol

 mega colon
Pregnancy Related
Musculoskeletal Diagnoses
 Lumbo-sacral pain
 Radicular pain
 SIJ dysfunction
 Pubic symphysis dysfunction
 Upper back pain

 Prevalence pregnancy related LBP or

Pelvic Girdle Pain 24-90%
Pregnancy PT Treatment
 Education
 Body mechanics
 Manual techniques
 Soft tissue techniques
 Therapeutic exercise
Pregnancy PT Outcomes
 Systematic Review of Physical Therapists
Treatment of Lumbopelvic Pain During
Pregnancy.
 22 articles RCT, 1992-2013
 Treatment
 Exercisetherapy
 Education
 Manual therapy
Pregnancy PT Outcomes
 Conclusion
 Positiveeffect on pain, disability, sick leave
 Evidence based recommendations can be
made for the use of exercise therapy for the
treatment of lumbo-pelvic pain during
pregnancy
 July 2014, Journal of Orthopedic & Sports Physical
Therapy
Post Partum Physical Therapy

 Diastasis recti
 Pubic symphysis dysfunction
 SIJ dysfunction

 Pelvic pain/dyspareunia
 Incontinence
Post Partum
Diastasis Recti Rehabilitation
Per Diane Lee in The Pelvic Girdle:
 We do not yet have studies indicating the best
rehabilitation approach for a diastasis recti abdominis
(DRA)
 If forces transmitted through the diastasis recti
abdominis can provide stability in the thoracolumbar
spine and pelvis, patient may recover function despite
DRA
 . . .the goal is not to close the diastasis but rather to
generate tension through it.
Post Partum Diastasis Recti
Rehabilitation
 Abdominal exercise progression
 What to do
 What to avoid

 Kinesiotape
 Education in body mechanics to minimize
increase of intra-abdominal pressure
Rectus Abdominis Training
Recommended abdominal exercises
OhioHealth Locations
Pelvic Floor Physical Therapy
 Doctors Hospital
 Dublin Health Center
 Eastside Health Center
 Grady Memorial Hospital
 Powell Rehabilitation
 Riverside Methodist Hospital
 Southwest Health Center
 Upper Arlington
 Westerville Medical Center
Contact Information
 Colleen Sandro, MS, PT, COMT, BCIA-PMDB
OhioHealth Neighborhood Care

(614) 791-1733
Colleen.Sandro@Ohiohealth.com