Pelvic PT Flashcards
What is the canister model?
Interplay of trunk structures to assist in load transfer while meeting movement objectives, ensuring safety to structures, supporting organs, all while maintaining optimal respiration.
Top of the canister is diaphragm - bottom is the pelvic floor.
What are the supporting muscles of the canister
Glute med/max
Hamstrings
quadratus lumborum
Thoracolumbar fascia
Hip Adduction
What is the role of the pelvic floor muscles
- Support the pelvic organs
- Sphincters
- Aids in sexual appreciation/function
- Provides stability to SIJoints
- Possible aids in lymphatic drainage
- Posture and breathing.
What are the muscles in first layer of pelvic floor
- Superficial transverse perineal
- Bulbospongiosus (bulbocavernosus)
- Ischiocavernosus
- External anal sphincter
What muscles are in the second layer of pelvic floor
Deep transverse perineal
External urethral sphincter
Sphincter urethrovaginalis - in females
Compressor urethra - in females
What muscles are in third layer of pelvic floor
- Levator Ani
- Pubococcygeus
- Puborectalis
- Pubovaginalis - in females
- Iliococcygeus.
What do we ask in history during PF PT eval
Chief complaint
Surgeries
OBGYN history
Last pelvic/prostate exam
Medications
Bowel and bladder history
What bladder habits do we want to know
Urine stream
Emptying
Frequency at night time and during day
Urge
Volume
Fluid intake
Stop test
Position
What urinary and fecal incontinence symptoms should we ask
Leakage and number of episodes, how much
Form of protection
Symptom aggravators
looking for red flags item that point to neural involvement and cauda equina
What are the neuromuscular controls of the pelvic floor exam we look for
- Relationship b/w TA, Multifidis, and pelvic floor muscles
- Not simply a co-contraction
- Also need to coordinate continence, breathing, and spinal stability.
Describe co-contraction between TA and PF muscles
Hallowing with pelvic floor muscle contraction improved TA thickness by >15%
Describe co-contraction between TA and Multifidis muscles
Two types of abdominal contraction (draw in and brace) both improve lumbar Multifidis activation.
Describe co-contraction between diaphragm and PF muscles
PFM relax on inhalation and contract along with TA with exhalation
Describe co-contraction between Diaphragm and lumbar Multifidis muscles
Diaphragm training may increase thickness of lumbar multifidis and TA
What are the considerations of MSK exam/screening for stability of SIJ
- Force closure
- Form closure
- Any asymmetries
What are the special tests you can use for load transfer assessment
- Stork test
- Active straight leg test
psychometrics of tests improve with cluster, tests are poor individually
What is the stork test
Typical movement during single limb stance — posterior rotation innominate relative to sacrum on stance side (as weight is shifted onto the stance side)
+ve test — anterior rotating innominate.
What is the active straight leg raise
- Supine with both legs fully extended - raise single limb about 5-20 cm - repeat on contra side.
+ve test — pain or heaviness
Differential diagnosis/MSK considerations for the LE during exam
- Hamstring and sacrotuberous ligament
- Adductor magnus trigger point can be described as diffuse/internal pelvic pain
- THA/hip function — possible effects to PF function
- Piriformis Syndrome and obturator Internus
- Labral tears and hip impingement.
What are the external/visual perineal componentes of the PT exam
- Skin integrity
- Scar
- Contraction response
- Bear down response
- External palpation of musculature (clock thing)
What are the internal pelvic exam componentes of the PT exam
- Go in through vagina or rectal canal. Can access the 3 layer palpation
- During palpation - assessing tone, trigger points, tender or painful points.
- Assessing relaxation after contraction
Describe MMT of pelvic floor muscles
ONLY AT 3RD LAYER OF PFM
Grading contractions on a scale of 0-5
0 - zero no palpable contraction/squeeze
1 - trace flicker or pulsation of contraction
2 - poor squeeze pressure asymmetrical or felt at various points (NO LIFT/DISPLACEMENT)
3 - fiar Squeeze pressure/contraction and LIFT or displacement
4 - good Squeeze pressure/contraction and LIFT or displacement from anterior, posterior, and side walls
5 - strong Full circumference of finger compressed, displaced with an inward pull.
— can also grade endurance
What does SEMG biofeedback eval do
- Indicator of skeletal muscle recruitment
- Surface or Internal electrodes used
- Evaluates endurance and quick contractions.
What are some examples of male and female pelvic dysfunctions
- Urinary incontinence
- Fecal incontinence
- Pelvic pain
- Sexual dysfunction
- Voiding dysfunction and constipation
What are examples of female only pelvic dysfunction
- Prolapses - pelvic relaxation
- Dyspareunia - pain with intercourse
- Vulvodynia
- Vaginismus
What are examples of male only pelvic dysfunctions
Prostadynia
Prostatitis
Considerations of pelvic muscle function
- Healthy pelvic floor muscle should be able to fully contract, relax, and bulge
- Contractions are subtle and difficult to feel and difficult to judge the quality of contraction.
What is the overview of PT treatment for pelvic floor dysfunction
- Exercise/Neuromuscular re-education - balancing musculature, strengthening, flexibility, coordination
- Manual therapy
- Education — on normal function of bowel and bladder
- Bowel and bladder retraining.
Things that can happen with an under active PF
- Urinary Incontinence
- Stress urinary incontinence
- Fecal incontinence
- Sexual dysfunction
What is stress urinary incontinence?
- Involuntary loss of urine with physical exertion - like a cough, sneeze, physical activity.
- Common but not normal and NOT A NATURAL RESULT OF AGING.
What is fecal incontinence
- Involuntary loss of fecal matter or flatus
- Often a result from injury during childbirth
What is sexual dysfunction and how does it relate to underactive PFM
Weak PFM contribute to decrease orgasm in men and women.
- Potentially contribute to erectile dysfunction
- Stronger muscles = more blood flow
- Contributes also to decrease contact with partner/device.
What PT treatment can help with underactive PFM
- Strengthening/Neuromuscular re-education
(Metals, endurance and quick contractions, vaginal weights, functional activities, biofeedback)
Recommendations for PFM strengthening
During strengthening period — 6 weeks with 24 contractions/day
During maintenance period — 10 contractions/day
What conditions are associated with an overactive PF
- Urinary frequency
- Urge incontinence
- Urinary retention
- Pelvic pain
- Constipation
- Pudendal neuralgia
- Dyspareunia
- Vaginismus
- Trigger points in PFM
What is difference between urge incontinence and stress incontinence
Stress — involuntary loss BECAUSE OF PHYSICAL EXERTION
Urge — leakage due to BLADDER MUSCLES THAT CONTRACT INAPPROPRIATELY
patients can also have mixed - stress and urge incontinence
What is urinary retention
Lack of ability to pee or fully empty bladder
POST void residual
What falls under pelvic pain
Anything with -dynia ending
Define constipation
2 or less bowel movements per week
Without laxitives — staring, feel incomplete empty thing, hard stools
What is Dyspareunia
Pain with sex
What is Vaginismus
Spasm of muscles surrounding the vagina
Patient cant tolerate vaginal penetration — so tampons, sex, pelvic exams
What are trigger points in PF
Can happen in any layer of pelvic floor muscles
Anterior PF TrigPts — refer pain to genital structures
Posterior PF TrigPts — pt’s may say they are uncertain of symptom location either hip back or tailbone area
What happens when PFM are shortened
Healthy muscles need to be able to fully contract or relax so if it’s short needed it can’t generate tension and may “appear” weak.
Strengthening when they are already short may cause more hypertonicity and delay progress.
What PT treatment can help with over active PFM
Connective tissue, scar tissue, visceral mobilizations
Myofascial release
Lengthening tissues
Intervaginal or inter rectal TrigPts/myofascial release
Relaxation of PFM
How do you promote relaxation of PFM
- Diaphragmatic breathing
- Biofeedback
- Sub max contract/relax
- Visualization
- Train bulging
What topics can we educate and retrain patients on
- Bowel health
- Pelvic Floor Anal Spincter function
- Bladder health
What do we teach with bowel health
- Regular evacuation — usually 20-30 minutes after eating
- Soft, formed consistency and easily passed
- Fiber intake = 25-30g/day
- Fluid intake = 6-8 glasses/day
- go when you get the urge!! No straining should only take a few minutes
- Exercise
- bowel massage — follow path of Large Intestine
What does continence require
Contraction of puborectalis
Maintenance of anorectal angle
Normal rectal sensation
Contraction of sphincter
What does defication require
Relaxation of puborectalis
Straightening of anorectal angle
Relaxation of sphincter
What do we teach with bladder health
- Average bladder holds 2 cups of urine before it needs to be emptied
- Normal to pee 5-7 times in 24 hour period and normal to pee 0-1 time at night
- Urge is a signal felt as bladder stretches
- GOOD Bladder habits include - no straining, full emptying, go at least every 4-5 hours, and don’t go “just in case”
- Maintain good fluid intake and avoid caffeine, alcohol, artificial sweeteners
- Use bladder diary
