Supported in part by Arkansas Blue Cross and Blue Shield and the Office of the Arkansas Drug Director and in partnership with the Arkansas Academy of Family Physicians (AAFP), the Arkansas Medical Society (AMS), the Arkansas State Medical Board (ASMB), the Arkansas Department of Health (ADH) and its Division of Substance Misuse and Injury Prevention (Prescription Drug Monitoring Program—PDMP) Continuing Education Credit: TEXT: 501-406-0076 Event ID: 32358-30782

Faculty Disclosure of Financial Relationships: Leah Tobey, PT, DPT, cert D.N. has no financial relationships to discuss.

How to join our poll questions: Open a new text Text “To”: the number 22333 In the message line, type LEAHTOBEY999 (not case sensitive)

Objectives Identify common conditions treated by physical therapist, certified in pelvic floor rehabilitation Understand the patient’s perspective of pelvic floor physical therapy Understand the two types of kegel exercises for up-training & the importance of down-training for pelvic pain

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Pelvic floor physical therapy (PFPT) Dispelling rumors & creating understanding What is it? Why should I know? Effective & beneficial treatment Considered conservative management Patient empowerment Crucial for patient quality of life & confidence beyond our office doors Similar to controlling HTN with medication, pelvic floor therapy can better manage a person’s myofascial pain or weakness/UI. Creating understanding: Many patients are initially hesitant when this type of therapy is brought up as part of the treatment plan.

Misperceptions Incontinence is a natural part of aging Incontinence after childbirth is normal Nothing can be done to change incontinence Walking up to urinate every night is normal It is normal for intercourse to be painful 2014 Cochrane Review found high quality evidence to support pelvic floor muscle training as the 1st line treatment for stress & mixed UI in women. Credit to Island Optimal Health & Performance PT group

PFPT Pelvic floor PTs provide evidence-based physical therapy interventions while promoting lifelong musculoskeletal health. Treatment emphasis is placed on patient education, therapeutic exercise, home exercise and symptom management. Our goal is to restore function and return our patients back to social, home and leisure activities.

Pelvic Floor Functions Pelvic Floor Dysfunction RFs: Support of organs Sphincteric *Maintain continence Sexual Sump-pump *Helps move Lymphatic & venous fluid

Pelvic Rehab PT Services (PFPT) Common Conditions Pelvic floor muscle weakness UI, FI, POP PPUI: Post-prostatectomy urinary incontinence Pelvic pain CPPS: Chronic pelvic pain syndrome “chronic prostatitis” IC: Interstitial cystitis/Painful Bladder Syndrome (PBS) PN: Pudendal Neuralgia Coccydynia Dyssynergia Constipation/IBS-C

Pelvic Floor Muscle Weakness UI or FI: Stress Urge Mixed Pelvic organ Prolapse: Cystocele Rectocele

PFM Weakness: Subjective reports “I’ve tried those ‘Kegels’ and they don’t work for me!” 44 y/o WF s/p bladder sling/ TVT “My surgeon gave me a handout on these exercises but I don’t know if I’m doing them right.” 68 y/o AAM s/p prostatectomy

To Kegel or not to Kegel? Type of Kegel Purpose Quick flicks (Type 2) For urgency delay, nocturia, bladder retraining Endurance holds (Type 1) Main-bulk of pelvic floor Most important for long-term training strengthening 4-6 sets of 10 second holds per day (initial) *Not appropriate for Down-Training *Must first relax PFM (pelvic floor muscles)

Technique is KEY Top 8 exercise mistakes Using the wrong muscles Incorrect form *breath holding No variety Following the wrong routine Not measuring progress Forgetting to relax Not being consistency Giving up before seeing results

Pelvic Floor Rehab …what to expect Services for men and women Evaluation and internal/external Examination Orthopedic evaluation Bowel and bladder evaluation & retraining Dietary & food considerations (related to constipation, IE)

The Journal of Sexual Medicine Table 2.  Manual muscle testing grading scale No response 1 Flicker 2 Weak contraction 3 Moderate contraction, some degree of lift 4 Good contraction, against some resistance 5 Normal muscle contraction, strong squeeze, and lift *Currently there is no standardized method of grading PFM tone but this guide is the most commonly used. There is however, reported high reliability and diagnostic agreement among PTs in diagnosing pelvic floor pathology. Reissing ED, et al. Vaginal spasm, pain, and behavior: An empirical investigation of the diagnosis of vaginismus.

PFPT for pain Pelvic Pain Sometimes this pain is mistaken for other conditions or missed entirely. Important to diagnose the initial cause of the pain Secondary problems as well, to get the best results. “Myofascial pelvic pain in women may be the underlying cause of chronic pelvic pain in 14% to 23% of cases and up to 78% of cases of interstitial cystitis, which is a type of otherwise unexplained bladder pain.” 2012 article in the Journal of Obstetric, Gynecologic & Neonatal Nursing June 2019 Vanderbilt University, Women’s Health Department: My Southern Health.

Commonly treated pain diagnoses IC/PBS: Interstitial cystitis/Painful bladder syndrome CPP: Chronic pelvic pain Constipation PN: Pudendal neuralgia EDS: Ehler’s Danlos Syndrome Important for pelvic floor therapist to teach patient how to relax his/her pelvic floor. Down-training Imagery Reduce stress Diaphragmatic breathing

Pelvic floor anatomy review Urogenital triangle: Layer 1 & 2 Colorectal triangle: Layer 3

The pelvis is a complicated place

Neuromodulation for Pelvic Pain

Neuromodulation for Pelvic Pain Recent advancements in neuromodulation have lead to the use of spinal cord stimulation for the treatment of severe pelvic pain. Multiple Case Reports/Case Series have demonstrated benefit with the use of Dorsal Root Ganglion Stimulation for Pelvic Pain Two randomized, multicenter studies are currently on-going to examine efficacy of this treatment

Dorsal Root Ganglion Stimulation for Pelvic Pain Treatment. Current Described Technique: Placement on Bilateral L1 and S2 nerve roots. Treats neuropathic or post surgical pain from Ilioinguinal, Iliohypogastric, Genitofemoral, and Pudendal Nerve distributions.

Barriers? Compliancy PFPT Provider availability Study about compliancy of pts in treatment for CPP Frustrating Similar to OUD, SUD/Addiction PFPT Provider availability List of statewide providers can be available to you on our website. Most all patients need 2-3 PT sessions 8-12 sessions are suggested for optimal outcomes

PFPT What does all this mean? PTs routinely use education, manual therapy, and exercise to manage pelvic pain conditions (Alappattu, M. Journal of Women’s Health PT: April/June 2019-Volune 43-Issue 2 p 82-88). Physio/PT, similar to CBT therapist can be a helpful team-member to include in complicated patient cases.

PFPT Study 17 countries with just <1K PT responses. >80% PTs used Education, Exercise, Manual therapy for patient with PP Differences/Challenges/Future research: Geographical differences in patterns of use-specific manual therapy and exercise interventions. Differences were also noted on the basis of the levels of advanced post professional training Most common interventions considered effective *but not used frequently were: CBT Dry needling Acupuncture Topical medications Internal pelvic manual therapy techniques

Special thanks to: Dr. Lori Mize, board-certified WH specialist & instructor at UCA. Dr. Goree

Discussion Continuing Education Credit: TEXT: 501-406-0076 Event ID: 32358-30782

Questions about the Topic Continuing Education Credit: TEXT: 501-406-0076 Event ID: 32358-30782