Women’s Health Topics in Physical Therapy Holly Bommersbach PT, MPT Angela Avalos PT, MPT

Objectives Identify types of pelvic pain and dysfunction, potential causes, and physical therapy approaches Discuss types of bladder and bowel dysfunctions and physical therapy approaches Discuss the effects of pregnancy and delivery on the body and physical therapy approaches

Pelvic Pain and Dysfunction

Pelvic Pain and Dysfunction Pain which occurs in the perineal and/or anal areas Pain in the lower abdomen, low back and/or pelvic girdle Pain may often affect other areas, making defecation and/or penetration painful or can cause bowel/bladder urgency/frequency

Pelvic Pain and Dysfunction Study of 5000 US women 18-50 years old found 1 in 7 affected by chronic pelvic pain (CPP) Of 500 employed women with CPP, over half reported lost time from work or reduced work productivity Estimated medical costs of outpatient visits for CPP in US population of women aged 18-50 years at $881 million/year

Pelvic Pain and Dysfunction Musculoskeletal dysfunctions often contribute to the signs/symptoms of CPP and in many cases are the primary factor Physical Therapists can specialize to be skilled in the evaluation and treatment of pelvic floor musculoskeletal dysfunctions and are often successful in treating/managing CPP

Frequently Seen Pelvic Pain Diagnoses Endometrial adhesions or nodules on pelvic ligaments Referred from the low back or spine Pelvic trigger points Fibromyalgia Abdominal or perineal scar adhesions Pelvic floor dysfunction Levator ani syndrome Pelvic relaxation Pelvic fractures Coccydynia Vulvodynia Vaginismus- pelvic floor tension, myalgia and hypertonus Vulvar vestibulitis syndrome Injury sustained during sexual assault Results of childbirth, vaginal or cesarean section Pelvis alignment Pudendal nerve entrapment

Dysfunction Terminology Tone: resistance to displacement of the pelvic floor muscles at rest “Spring System” Normotonus Hypertonus Hypotonus “Spring System”- role is to counterbalance the weight effect of the pelvic and abdominal organs Normotonus: muscle tension is adequate to counterbalance forces working on it Normal PF muscles can voluntarily and involutarily contract and relax Hypertonus: increased PF m. tone More or less continuous state of contraction And impaired contraction due to m. fatigue

Dysfunction Terminology Overactive Pelvic Floor Muscles do not relax and may even contract when relaxation is needed such as when urinating or having a BM

Dysfunction Terminology Underactive Pelvic Floor Unable to voluntarily contract when this is appropriate

Dysfunction Terminology: Nonfunctioning Pelvic Floor Muscles- Pelvic floor muscles with no action palpable

Dysfunction Terminology Short Pelvic Floor Usually without increased muscle activity Doesn’t respond to palpation with normal spring Muscles feel like “firm shelves and violin strings” Display trigger points (points of marked tenderness) Relaxation difficult; slow, if at all Weakness due to shortened length of muscle

Treatment Trigger point release, vaginal dilators, manual therapy Therapeutic US, heat, cold, electrical stimulation Stretching, strengthening, stabilization, relaxation, muscle energy techniques, behavioral activities, progressive exercise program

Pelvic Floor Pain Treatment Planning

Case studies

Bowel and Bladder Dysfunctions

Bowel and Bladder Dysfunctions: Urinary Incontinence Voiding Dysfunction Bowel Incontinence Constipation

Urinary Incontinence (UI)- “Bladder Leakage” Condition in which involuntary loss of urine is a social or hygienic problem UI is not a disease process UI is a symptom or a sign UI is NOT a natural part of aging

Attitudes Toward Incontinence Most people do not understand treatment options Studies show an average of 7-9 years for someone to seek treatment Social Isolation may occur Quality of life affected

Impact of Incontinence Affects 13 million people of all ages Women are twice as likely as men to be incontinent As many as 30% of men and women over the age of 60 living at home experience some bladder control problems Cost estimated at 10+ billion annually

Causes of Incontinence Overactive bladder muscles Weakness of muscles that support and hold the bladder in place Weakness of the urethral sphincter and muscles Blocked urethra- enlarged prostate Hormone imbalance in women Neurologic disorders and immobility

Common Types of Incontinence Stress Incontinence Urge Incontinence Mixed Incontinence Overflow Incontinence Functional Incontinence

Stress Incontinence Involuntary loss of urine during physical exertion Laughing Lifting Coughing Sneezing Running Jumping Dancing

Urge Incontinence Involuntary loss of urine with a strong need/urge to go to the bathroom Can’t get to the bathroom quickly enough Frequent urination Strong link to diet: caffeine, artificial sweeteners, acidic fruits/vegetables/juices

Mixed Incontinence A combination of both stress and urge incontinence (present together)

Overflow Incontinence The involuntary loss of urine from an overfull bladder, often in the absence of any urge to urinate

Functional Incontinence A form of incontinence in which a person is usually aware of the need to urinate, but for one or more physical or mental reasons, they are unable to get to a bathroom. The loss of urine can vary from small amount of leakage to full emptying of bladder

Treatment for Incontinence Behavioral techniques/Physical Therapy Surgical Techniques Pharmacological treatment

Physical Therapy Treatment 3-4 visits over 2 month time frame Focus: May use strengthening, relaxation, and/or muscle coordination exercises Dietary changes Behavioral techniques Patient education

Voiding Dysfunction Voiding dysfunction- a broad term used to describe conditions where there is poor coordination between the bladder muscles and the urethra which results in incomplete relaxation or over-activity of the pelvic floor muscles

Physical Therapy Treatment focus: Bladder training Pelvic floor relaxation Biofeedback Manual therapy Vaginal scar massage, if indicated Internal self-mobilization/massage (with/without dilator)

Bowel Incontinence Urge Incontinence: Being unable to resist the urge to defecate, which comes on so suddenly that person is unable to make it to the toilet on time Passive Incontinence: Bowel leakage in which person is unaware of the need to pass stool *may be accompanied by diarrhea, constipation, gas, and/or bloating

Causes Muscle damage Nerve damage Constipation Diarrhea Loss of storage capacity in the rectum Surgery Rectal prolapse Rectocele

Physical Therapy Treatment Patient Education Muscle Relaxation (biofeedback) Strengthening PF muscle control/awareness/coordination Manual therapy Pain relief modalities Home exercise program: dependent upon what is indicated

Constipation Defined as the difficult passage and infrequent (fewer than 3) bowel movements per week, straining during bowel movements more than 25% of the time, and/or the feeling of incomplete evacuation

Causes Limited fluid intake Laxative abuse Imbalanced diet (too much sugar and animal fat) Medications Neurological diseases

Physical Therapy Treatment Discussion re: diet and exercise Increasing physical activity Addressing musculoskeletal concerns: muscle coordination Instruction in proper toileting techniques Designing and instruction in toileting schedule/training

Case studies

Physical Therapy in Obstetrics

Physical Therapists provide: Treatment for musculoskeletal pain Exercise ideas and guidelines Post-partum care for Mom

Effects of Pregnancy Hormonal Respiratory changes Tissue Laxity Variable Blood sugar-gestational diabetes Increased fat storage Decreased gastric motility Respiratory changes Diaphragm rises, ribs spread Decreased efficiency of breathing Decreased space for brachial plexus

Effects of Pregnancy Musculoskeletal Posture Increasing body weight Strain on joints Weakness from stretched muscles  More susceptible to injury

Physical Therapy Approaches Exercise for Gestational Diabetes Postural aches and pains Stretch Strengthen Enhance blood flow Enhance muscle relaxation Emotional boost Post-partum care

Areas of Exercise Emphasis Back Pain relief-stretching, postural correction Strengthening for trunk stability Pelvic girdle alignment Belly Abdominal muscles weaken as they stretch Strengthening core for overall stability

Areas of Exercise Emphasis Bottom Muscles weaken due to: Hormonal changes Weight of baby Stress of delivery Strength pelvic floor to : Avoid and/or treat urinary or fecal incontinence Treat pelvic pain issues Cardiovascular fitness Weight loss Increase stamina for the physical challenges to motherhood

More Post-partum issues Diastasis Rectus Linear separation of the abdominal wall (rectus abdominus) to accommodate the growing fetus If separation is excessive it may lead to abdominal and back pain. Mom may need to avoid certain exercises and activities and perform specialized exercises to help knit these muscles back together.

Post-partum Issues Pelvic Floor Pain/Inflammation after delivery Pelvic Floor Therapeutic Ultrasound C-section Scarring May be painful or hypersensitive Adjacent tissues/muscle may become adherent causing pain/dysfunction and require manipulation to break up scar tissue and release adhesions Symphysis Pubis Separation 25% of women have 7-9 mm separation between 7-9 months pregnancy May separate up to 12 mm May remain painful after delivery

Case studies

References: Herman, H., Wallace, K. The Prometheus Group, course notes: Female Pelvic Floor: Function, Dysfunction, and Treatment Level 1, October 2006 Tanner, H., Downey, P. Herman and Wallace Inc. Pelvic Rehabilitation Institute, course notes: Intermediate Pelvic Floor 2A: Pelvic Floor Function, Dysfunction, and Treatment, July 2012 Hampton, E., Vande Vagte, J. Herman and Wallace Inc, Pelvic Rehabilitation Institute, course notes: Pelvic Floor Function, Dysfunction, and Treatment- Intermediate PF 2B, Nov 2010 Stephenson, R., O’Connor, L. Obstetrics and Gynecological Care in Physical Therapy, 2000 Pirie, A., Herman, H. How to Raise Children Without Breaking Your Back, 1995 Herman, H. The Prometheus Group, course notes: Pregnancy and Postpartum: Clinical Highlights, June 2004