Pelvic Floor Muscle Dysfunction in COPD Liz Childs Pelvic Floor Physiotherapist Wellington

Outline PFM anatomy / function Relationship PFM and breathing Teaching PFM exercises Lifestyle modifications Effective huff / cough technique Where / when to refer on

Pelvic floor anatomy – female

Pelvic floor anatomy - male

Function PFMs Support pelvic organs Contribute to continence via: closure urethra & anus support bladder neck closure anorectal angle Role in voiding, evacuation Sexual role – arousal, erection, orgasm, ejaculation

PFM – part of the core Functional unit Spinal stability Intra-abdominal pressure Continence Breathing

What happens to the pelvic floor during breathing? Inspiration: diaphragm contracts, flattens, moves caudally  incr IAP  downward pressure exerted on PFM Expiration: Rest / quiet breathing: passive process, elastic recoil lungs, chest wall, muscle relaxation Forced exp: diaphragm and abdominals contract  incr IAP  upward mvt diaph, downward pressure PFM

Inspiration (Talasz et al, 2010)

Forced expiration / cough – no abdominal or PFM co-contraction (Talasz et al, 2010)

Forced expiration – with ab and PFM co-contraction (Talasz et al, 2010) Reduces pressure on pelvic floor

Practice… Huff Cough

PFM dysfunction Urinary incontinence Pelvic organ prolapse Affects 1 in 3 women Increased prevalence in COPD Pelvic organ prolapse Affects 50% women

Stress urinary incontinence – what happens when you cough or sneeze

Urge urinary incontinence Involuntary loss of urine associated with urgency = detrusor contraction (can be related to anxiety)

Urinary incontinence in respiratory disease Degree of urinary incontinence is greater in those with chronic cough due to CF, COPD compared with general population (Button BM, Sherburn M, Chase J, et al 2005) Not many studies done on prevalence of SUI in patients with chronic cough, Evidence for increased prevalence as yet only exists with CF

Evidence PFMT Pelvic floor muscle training should be offered, as first line therapy, to all women with stress, urge or mixed urinary incontinence Level 1 evidence, Grade A recommendation, ICI 2012

Pelvic organ prolapse

Pelvic Organ Prolapse High quality evidence (8RCTs) supporting PFMT Significant improvement in Symptoms Stage ICI 2012 – Level 1A evidence for PFMT

Risk factors for PFM weakness  lifestyle modifications Chronic cough Breathing retraining Sputum clearance techs, cough suppression The “knack” – PFM with cough, huff Support perineum Constipation / straining Fibre, fluid, exercise Bowel routine Defaecation training Obesity Heavy lifting How much is too much? Technique Fatigue Inappropriate exercise Promote pelvic floor safe exercise Cough = main risk factor in SUI

Patients with COPD Chronic coughing  strain pelvic floor Reduced exercise levels weak muscles PFM ,diaphragm, abdominals Evidence: Women with stronger PFMs are able to generate greater pressure in forced expiratory techniques / coughing (Talasz et al, 2010) COPD/ CF patients: PFM training and Estim resulted in improved PFM strength, reduced symptoms (Button et al, 2005) Teach “The Knack” PFM contraction just before huff/cough leads to reduced urine leakage (Miller et al, 1998)

Teaching PFM Exercises Squeeze and Lift As though trying to stop flow of urine or stop passing wind Must feel the release Hold 2-3 sec, increase as able Repeat up to10 times Do this several times a day

Practice…. Pelvic floor training

Recommendations (Guidelines for the Physiotherapy Management of the adult, medical, spontaneously breathing patient. Thorax, 2009) Question patients about their continence status All patients with chronic cough, irrespective of continence status, should be taught to contract their pelvic floor muscles before forced expiration & coughing (The Knack) If problems of leakage are identified, patients should be referred to a physiotherapist specialising in continence

Asking the question Embarrassment / Shame Language to use Patient Language to use Patient / health professional Let people know Continence problems are common Help is available Being dry is normal Continence products

When to refer on Symptoms of incontinence or prolapse Wet pants, frequency, urgency Soiling Bulging at vaginal entrance Heaviness, dragging Suspect overactive pelvic floor Symptoms may include Pain – pelvis, genital Constipation Voiding difficulty

Referral Women’s Health Physiotherapists in most DHB’s Private Pelvic Floor Physiotherapists in many centres NZ Continence Association www.continence.org.nz List of continence service providers

Conclusion PFM dysfunction is under reported Subjects are unlikely to seek help on their own Impact on an individual’s ability and/or willingness to perform certain activities Exercise Airways clearance techniques and lung function manoeuvres Social outings Education in pulmonary rehab groups