1. MUSCLE TRAINING for PELVIC FLOOR MUSCLE DYSFUNCTIONS MUSCLE DYSFUNCTIONS دکترفریده دهقان منشادی ، عضو هیات علمی گروه فیزیوتراپی دانشکده توانبخشی، دانشگاه علوم پزشکی شهید بهشتی خرداد ماه 1389 1

2. Muscles Inferior to the Pelvic Floor:The Urogenital Diaphragm Muscles inferior to the pelvic floor Stretches between two sides of the pubic arch in the anterior half of the perineum Contains ◦ Deep transverse perineal muscle ◦ External urethral sphincter muscle The ischiocavernosus and bulbospongiosus assist in erection of the penis and clitoris; lie superficial to the urogenital diaphragm 2

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4. The pelvic floor muscles have several functions: Maintain alignment and support of the internal organs. Control of urine flow. Sexual enhancement. Eliminate waste from the rectum. If the pelvic floor is weak, it can contribute to: Fall of the bladder or uterus through the pelvic floor muscles due to lack of support. Urinary/Anal incontinence Limited sexual pleasure during intercourse. Delayed recovery of tissue in the case of an episiotomy 4

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6. Synergic Activation of Trunk & PFM Muscles: Sapsford 2001 Devreese 2004,Smith,Madil 2007 2

7. 7 از آنجا که عضلات کف لگن به عنوان بخشی از سیستم لوکال ثبات دهنده ستون فقرات کمری و تنه مطرح می شوند. از این روی اختلال سایر عضلات لوکال هم برفعالیت تونیک و هم بر زمان بندی فعالیت فازیک انها در طی فعالیتهای عملکردی اثر می گذارد. برای مثال کمر درد حاد با تاثیربر کنترل حرکتی عضله عرضی شکم سبب کاهش حمایت تونیک عضلات کف لگن و بروز اختلالات عملکردی چون بی اختیاری و بیرون زدگی می شود

8. Different Aspects of PFM Function Different Aspects of PFM Function 8

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11. 11 Box 1. Symptoms of pelvic floor dysfunction Lower urinary tract Urinary incontinence Urgency and frequency Slow or intermittent stream and straining Feeling of incomplete emptying Bowel Obstructed defecation Functional constipation Faecal incontinence Rectal/anal prolapse Vagina Pelvic organ prolapse Pain Chronic pelvic pain Pelvic pain syndrome Sexual function Dyspareunia (painful sexual intercourse) Orgasmic dysfunction

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13. Management Theories 1-Theories Which are basis for Surgical interventions: Extrinsic (Delancey 1998, Umek 2002, Kyu-Jung Kim 2001, Delancey 2005, Robert 2006? ) -Integral(P.Petros 1996-2009) The Integral Theory states that PFD symptoms are mainly caused by connective tissue laxity in the vagina or its supporting ligaments 2-Theories Which are basis for conservative Interventions Intrinsic (Kegel since 1948,ICS Approach, European PT, e.g:BØ) Synergy Co-activation of PF & Abdominal Muscles (Aus. PT,e.g: Sapsford since 2001) Hidden self-care or Knack Mechanism (Ashton- Miller,2001,2008) Functional Training(Carriere 2002) 13

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15. 15 Pelvic Floor Muscle Training Strong evidences to suggest that for women with stress, urge and mixed incontinence PFMT is better than no treatment Reasons why PFMT should be an Effective Measure 1-Strengthening PFM ’ S->better support for the urethra under “ stress ” 2- Morphological changes occurring after strength training 3-Trained muscles might be less prone to injury or? Easier to return after damage 4-Previously trained muscle has a greater strength reserve

16. 16 1-Knack Maneuver (Ashton –Miller 1998,2008) Teaching women to tighten their PFM in preparation for a known leakage provoking event (Hidden self-care Mechanism) 2- Pelvic floor strengthening:kegel Exe. Teaching Women to set aside time to contract the PFM as a repetitive exe. For strength development &enhancement of reflex responses.3-Lumbo-Pelvic Stabilization Exs. PFM Contraction during ADL/4-Functional Training 5-Correction of biomechanical/structural deformities Five Steps for PFM Training in PFD Five Steps for PFM Training in PFD

17. KNACK MANEUVER Step One: Pelvic Floor Contraction With the moment of Expected Leakage to Prompt Cough-Related Stress Incontinence 17

18. Theoretical Explanation Active contraction of both Levator Ani & Ext.Urethral Sphincter-> increase both stiffness in urethral Supporters and urethral pressure -> resist urine outflow - 18

19. How to Teach Kegel Correctly!! Verbal descriptions are only 40% effective. Palpate perennial tissues through clothes, should feel tissues move away from finger. Watch patient kegel(give pt. a mirror) Place finger inside patient’s vagina and pt squeeze Sex Exercises when patient is ready to resume sexual activity 19

20. Part ii: Trans Abdominal US Bladder transverse view at rest & PFM Contraction 20

21. 21 Benefits of PFM Training Benefits of PFM Training Exercised muscles recover better from trauma. (deliveries, episiotomies, forceps/vacuum, prolonged second stage of labor, etc.) Decreased swelling and pain in perineum Prevention &treatment of Urinary Incontinence Improved sex life Strong evidences to suggest that for women with stress, urge and mixed incontinence PFMT is better than no treatment (Hay-Smith et al 2001) A study by Wilson et al (1996) showed a reduction in the prevalence of UI postnatally in women who had performed pelvic floor exercises antenatally. The use of PFE’s is the main non-surgical treatment for UI and has been shown to be more than 80% effective.

22. Samples of Some Kegel Exe. Once you have found the correct muscles, and know what it feels like when you tense them, you should do the following exercises. Tense the muscles so you feel a lifting sensation. Hold this lift for as long as you can up to 10 seconds. Don't hold your breath whilst doing this. Relax. You should have a definite feeling of letting go. Wait 10-20 seconds then repeat the ?lift?. You should aim to lift then relax 12 times. Do 5-10 short fast lifts. You should try to spend 5-10 minutes each day on this exercise routine. 22

23. (1)Lying Position 23 (2)Semi-Reclined

24. 24 (3) Sitting Position Kneeling on all fours(4)

25. 25 (5)Standing, leaning forwards from the hips with hands flat on the table(Left) and (6)Upright Standing(Right)

26. Some Points during Kegel Exs. Make sure patient is breathing through contractions of pelvic floor muscles. (Can be difficult post-cesarean) Teach patient about accessory muscles (abdominals, gluteals) Rest hand on patient’s abdominal to make sure they are not contracting those muscles For patient with very weak musculature, you can teach overflow exercises using hip adductor muscles(Controversial) 26

27. Step 3 : Lumbo –Pelvic Stabilization Exs. The pelvic floor muscles are programmed to work with the innermost abdominal muscle, Transverse Abdominis (TrA) as both are part of the core stability mechanism. 27

28. Abdominal Hollowing 28

29. Abdominal hollowing 29

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31. This exercise strengthens your back, hip, and abdomen muscles. Kneeling on hands and knees, place your hands directly under your shoulders and your knees under your hips. Inhale deeply. While slowly exhaling, pull in your abdomen, and tighten your buttocks and pelvic floor muscles. This should curve your spine into a “C.” Relax, keeping your back straight (don't allow it to curve toward the floor). Do this exercise 8 times or to your comfort level. 31

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33. Slowly, while thinking about contracting your stomach muscles (also your pelvic floor muscles), lift one foot off of the floor. Hold for a count of 3 seconds and then alternate the lift to your other leg 33

34. 34 keep your knees straight, hands out to your sides, and lift your hips high into the air. Make sure you are contracting your Pelvic Floor muscles and abdominal muscles. Then, draw the ball back towards you, as far as you can

35. Pelvic Floor Exercises

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37. 37 Step 4

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39. Functional Fitness Exercises… 39

40. Functional Fitness Exercises… 40

41. 41 Step 5

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45. Some Points from our recent Study Assessment of Posture specially in Lumbopelvic region for women with SUI Asking about other PFD & Musculoskeletal pain in LP region Teaching PFM Contraction by different types of Biofeedback Adding TrA Training for SUI Patients Doing PFM exercises in Crook lying pos. specially for SUI women Keeping Neutral Position in LP region while doing PFM exe.,Also we can recommend active PPTilt as an additional exe. For SUI patients 4545

46. 46 Thanks for your Attention