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

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

3. Pelvic floor anatomy – female

4. Pelvic floor anatomy - male

6. 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

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

8. 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

9. Inspiration (Talasz et al, 2010)

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

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

12. Practice…
Huff Cough

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

14. Stress urinary incontinence – what happens when you cough or sneeze

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

16. 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

17. 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

18. Pelvic organ prolapse

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

20. 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

21. 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)

22. 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

23. Practice….
Pelvic floor training

24. 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

25. 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

26. 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

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

28. 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