Pelvic Floor Physical Therapy And How It Relates To The Outpatient Clinic

 

“What in the world does a Pelvic Floor Physical Therapist do?” is a popular question asked by patients, doctors, and fellow colleagues. A Pelvic Health or Urogynecological Physical Therapist formerly known as a “Women’s Health Therapist” has the specialized training to treat numerous diagnoses such as, but not limited to:

Childbearing Years:
    Pregnancy and Post Partum
Urinary Dysfunction:
    Incontinence- Stress, urge, or overactive bladder
    Voiding Difficulties (slow or intermittent stream, straining, feeling of incomplete emptying)
    Cystocele
Bowel Dysfunction:
    Fecal or gas incontinence
    Obstructed Defecation
    Functional Constipation
    Rectocele or rectal/anal prolapse
Vaginal Symptoms:
    Pelvic organ prolapse
    Vaginismus
Sexual Function:
    Orgasmic dysfunction
    Dyspareunia in women
    Erectile and Ejaculatory dysfunction in men
Pelvic Pain Conditions:
    Pelvic Floor Tension Myalgia
    Levator Ani Syndrome
    Dyspareunia
    Vulvodynia
    Vulvar Vestibulitis
    Interstitial Cystitis/Painful Bladder Syndrome
    Pudendal Neuropathy and Neuralgia
    Male Chronic Pelvic Pain or Prostatitis
    Male pre & post prostatectomy
Musculoskeletal:
    SI Joint Dysfunction
    Coccyx or Tailbone Pain
    Pubic Pain
    Lumbosacral Strain
    Fibromylagia
    Improvement of Musculoskeletal Function/Abdominal Wall Tone
    Symphysis Pubis Dysfunction
    Low Back, Hip, Pelvis problems that have not responded to previous P.T.

The focus of my practice is musculoskeletal evaluation and treatment for orthopedic, lumbopelvic, obstetric, gynecologic, urologic, and colorectal conditions. I utilize manual therapy, therapeutic exercises, movement re-education/motor planning drills, connective tissue massage, and myofascial release treatments. Observation of function and movement as it relates to the patient’s condition is an essential component of my treatment as well. Today, I would like to share with the readers the intimate relationship the pelvic floor (PF) and orthopedics have in restoring function. First, allow me to begin with a brief overview of the anatomy and role of the PF.

The PF consists of three layers of superficial and deep muscles that encompass and support the pelvis and it’s adjacent structures. Layer 1 includes superficial transverse perineal, bulbocavernosus, and ischiocavernosis. Layer 2, also known as the Urogenital Diaphragm is made up of sphincter urethra, sphincter urethrovaginalis, compressor urethra, and deep transverse perineal. This layer has a fascial connection with the transverse abdominis. Layer 3, the Pelvic Diaphragm, lifts the pelvic floor and consists of the levator ani, pubococcygeus, puborectalis, and the illiococcygeus. Layer 3 connects to a thickened band of fascia formed by the obturator internus (OI) called the arcus tendinous levator ani (ATLA), which attaches at the ischial spine and the posterior pubic symphysis. When external rotation occurs, the OI pulls on the ATLA. Layer 3 uses type I tonic muscle fibers for support (70%) and type 2 phasic muscle fibers for forceful contractions and closure (30%). The PF muscles and their surrounding tissues are innervated by the following nerves: Pudendal Nerve, Levator Ani Nerve, Ilioinguinal Nerve, Genitofemoral Nerve, Perineal Nerve, Inferior Rectal Nerve, Posterior Femoral Cutaneous Nerve, Coccygeal Nerve, and Sacral Nerves. (1)

There are five roles of the PF muscles, which can be remembered by the “5 S’s”. Sphincter control: closes the openings of the urethra, vagina, and rectum and maintains urinary and fecal continence. Stability: assists in stability of sacroiliac joint (SIJ), pubic symphysis, sacrococcygeal, lumbopelvic and hip joint and is critical in enabling effective load transfer from the lower extremities to the pelvis and spine. Sexual function: orgasm, blood flow, and mobility. Support: for the pelvic organs against gravity and intra-abdominal pressure; tone for the vaginal and rectal walls. Sump Pump: a venous and lymphatic pump for the pelvis to prevent congestion.(1)

After being refreshed on the anatomy and function of the PF muscles one might ask how this potentially relates to an Outpatient Orthopedic Therapist. Below are statistics in conjunction with educational information pertaining to the relationship of the PF and the surrounding structures, as well as, when to screen for a potential referral to a Pelvic Health Therapist. My goal is for Pelvic Health Therapists and Orthopedic Therapists to work hand-in-hand to continually provide the utmost in care for our patients.

During my experience treating the PF I have come to realize the subjective complaints of pain vary drastically. Patient’s have reported pain that lingers in the right flank, pain that wraps from ASIS to the top of the iliac crest and even into the SIJ region, pain that radiates down the anterior thigh that can present unilaterally or bilaterally, pain that simulates “sciatica”, coccyx pain, sacral pain, hip and groin pain. Working manually on the PF has reproduced each of these complaints at some point in my experience. The take home message is if you have been treating your patient and they hit a plateau, don’t forget the “floor” in your treatment.

Hypertonicity of the PF affects SIJ stability.(2) The PF contributes to lowering of the vertical SIJ shear forces, increasing SIJ compression and hence increasing SIJ stability.(3) Counternutation of the sacrum occurs when PF tension is high which stiffens the SIJ, whereas multifidi contribute to nutation of the sacrum and segmental spinal control.(11b) Thus, these two work together as part of “core” stability.  In 2007 Bedova supported the theory that PF muscles alter pelvic and hip alignment with 14 female subjects who had MRI- functional stimulation to unilateral PF. The muscle stimulation resulted in femoral head, innominate and coccyx displacement.(5) Force closure of the SIJ occurs when the muscles acting across the SIJ and pubic symphysis such as back extensors, latisimus dorsi, and hip external rotators, PF muscles, abdominal muscles and hip adductors provide stabilizing force. (11a)

It is reported that 64-72% of patient’s with hip dysfunction also experience pelvic floor dysfunction (PFD).(1) Evaluation of the PF and hip components is key to improving PFD. Hip lateral rotators attach to the bony pelvis and ligamentous structures of the pelvis. Increased hip adduction and internal rotation (IR) results in OI lengthening and PF pain ultimately displaying symptoms such as posterior lateral hip pain, sciatica due to piriformis shortening, lateral thigh pain, pain in weight bearing, activities in standing or with prolonged sitting, dyspareunia, pudendal neuralgia, and urgency/frequency. Shirley Sahrmann’s hip diagnosis reports that too much femoral adduction or adduction with IR during function can cause a physical stress on the pudendal nerves. It also tightens fascially the pelvic diaphragm and can lead to PF hypertonus. Addressing tone in the hip can alleviate PF pain and even incontinence.(6)

On the contrary, if the lateral hip rotators are shortened, they may apply compressive forces on the multiple branches of the pudendal nerve. Shortening of the OI and piriformis can also cause “the sciatic nerve sandwich”. An OI trigger point mimics piriformis syndrome. This trigger point refers to the anococcygeal region with spillover pattern to the posterior thigh.  The patient will report symptoms such as fullness in the rectum, pain referred to the ipsilateral thigh, or coccyx pain.(7)  If piriformis syndrome treatment has hit a plateau, releasing the OI can alleviate sciatic nerve symptoms.  According to Prather 2009 hip disorders result in movement impairments that create a muscle imbalance leading to nerve irritation and finally pelvic pain.(8) Overuse of the deep hip rotators and ischiococcygeus result in anterior displacement of the femoral head resulting in anterior impingement, groin pain, and SIJ pain.(9) Chicken or the egg…has your patient’s hip dysfunction created PFD or does your patient have PFD that has lead to hip dysfunction?  Impaired movement patterns of the lumbar spine and hip regions cause physical stress across the pelvic girdle structures resulting in pain and mobility impairments.(10,11) Sacral nutation occurs with lumbar extension and sacral counter nutation occurs with lumbar flexion. PFM tension increases counter nutation of the sacrum.(11a)

The adductor muscles play a large role in pelvic function as well. Aside from having attachment points at the abdominal fascia that can be limited with any type of abdominal scar adhesions the adductor muscle trigger points refer pain in to the urogenital region (layer2) and increases urgency and frequency.(7) Shortened adductors cause anterior rotation of pelvis, counternutation of sacrum, compression/shearing of the symphysis pubis, and decompression of the SIJ.(1)

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Stress urinary (SUI) and urge incontinence (UUI) are complications that most believe “come with old age” or occur “because I have had babies”. Although SUI and UUI are common in both of these populations please note one does not have to live with incontinence. A Pelvic Health Therapist can help these situations. Second, these are not the only populations that deal with SUI and UUI. Statistics show that both types of incontinence rate high among competitive female athletes ages 18-25, enough to alter activities around voiding habits.(14a) It is reported that 52% of female athletes experience urine loss during sport or activities.(14b) If you are treating young female athletes in your clinic screening for any incontinence issues is necessary prior to implementing abdominal exercise. If the athlete has incontinence their PF is weak, abdominal exercises and increasing intra-abdominal pressure will jam their pelvic organs down with each contraction. This repetitive jamming will lengthen their PF ultimately making them weaker and exacerbating their problem. Screening even your young athletic population is vital for success in overall health while in rehab. Increased intra-abdominal pressure that occurs with incorrect abdominal work is not the only factor that can increase the risk of incontinence. A BMI >30, chronic cough, asthma, smoking, repetitive lifting, chronic constipation, straining, and high impact exercise are all possible contributing factors to incontinence.(14)    

Numerous postural changes occur with a growing fetus. Greater than 50% of pregnant women with low back pain also had PFD, with increased activity in PF muscles. In all cases, low back pain was present prior to complaints of PFD.(14) It is stated that 41-83% of post-partum women 2-3 months are identified to have sexual dysfunction and 92% of post-partum women who are incontinent at 12 wks will still be at 5 years unless treated.(12) Please educate your pregnant patients on the potential issues of PFD and incontinence. As a healthcare provider often times initiating the conversation will open the door for the patient to feel comfortable discussing otherwise embarrassing issues. If you are uncomfortable asking the questions you can always add them to your initial intake form. If you need to refer out to a Pelvic Health Therapist, please do so. We will work as an extension of you.

Kegels, Kegels, Kegels…..First, if a patient has any kind of pelvic pain they should NOT be doing kegels. Shortening an already hypertonic muscle will only exacerbate issues. Secondly, 50% of women are unable to accurately identify PF muscles with one-time verbal and written instructions. Compensatory patterns are accessory muscle activation of gluteus maximus, hip adductors, and abdominals; breath holding; bearing down.(4) Just as there is a protocol for Achilles tendinopathy rehab there is a protocol that must be followed for PF muscle strengthening (aka: Kegels). Kegels are only assigned to appropriate patients. Screening for any kind of pelvic pain is imperative prior to assigning Kegels.

Statistics show that structural changes in the spine can affect the pelvic floor region as well. It is stated that those with kyphosis have a 1.3 increased risk of incontinence and pelvic organ prolapse for each degree of kyphosis.(1, 4)

I hope that after reading this blog you are more aware about what a Pelvic Health Therapist truly does and how we can be an extension to your practice. I am honored to write a blog on TheStudentPhysicalTherapist.com and have the chance to share my passion with others. Thank you James, Chris, and Brian, for having me.

~Breann Suddock, PT, DPT

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I am an Arizona Native who pursued my undergraduate degree from Creighton University and Northern Arizona University while playing D1 soccer at both schools. In 2002 I received my Bachelor’s of Science in Community Health Education from Northern Arizona University. I obtained my certification as a Certified Strength and Conditioning Specialist in 2005 and worked closely with club soccer teams and high school soccer teams throughout the valley. I worked in an outpatient physical therapy clinic for four years followed by three years in sales and marketing for a local radiology company before I decided to seek out PT school. I received my DPT from A.T. Still University in 2013 and currently work for Rehab Plus Sports Rehabilitation in Scottsdale where I am blessed to treat the orthopedic population as well as pelvic health patients.

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Reaction:

As an orthopaedic physical therapist, I have encountered numerous patients that required assessment and treatment by a pelvic floor therapist. Whether it's in conjunction with my treatments or ends up being in lieu of my orthopaedic treatment treatments, pelvic floor physical therapy has played a significant role in quite a few of my patients' plans of care. Due to the ability of pelvic floor dysfunction to mimic pain patterns of orthopaedic conditions, it is essential that we are aware of any potential involvement. It can be difficult to always obtain the necessary subjective information when screening for pelvic floor dysfunction, due to the sensitivity of the topic. We should be especially alert when our patients are not progressing as expected. This can be due to the involvement of the pelvic floor. Working in a hospital-based outpatient orthopaedic setting, I have been fortunate to have regular access to a pelvic floor physical therapist. I feel like every other week I am either consulting with her or referring another patient to her for assessment. I have even had patients' pain completely resolve with that treatment alone after referral. I know I will miss having regular access to this valuable asset in my next position.

References:
1. Pelvic Floor Function, Dysfunction and Treatment- Advanced PF3. Herman & Wallace Inc. Pelvic
Rehabilitation Institute. 2010-2013.

2. Kathe Wallace, PT, BCB-PMD. Women’s Health Summit. 2014. 1-32.

3. Pel. 2008.

4. Vickers D, Davila GW. Kegel exercises and biofeedback. In: Davila GW, Ghoniem GM, Wexner SD, eds.
Pelvic Floor Dysfunction: A Multidisciplinary Approach. London: Springer-Verlag; 2006.

5. Bedova. 2007.

6. Sahrmann, Shirley PT, PhD. Hip Diagnosis. Communication with T. Spitznagle.

7. Travel and Simons. Myofascial Pain and Dysfunction. 1992.

8. Prather. 2009.

9. Women’s Health Summit 2014.
    a. Diane Lee lecture: (Gilleard and Brown 1996)
    b. Diane Lee lecture: (Spitznagle et al. 2007)

10. Spitznagle, T. Pelvic Girdle Pain (PGP): Movement Systems Theory. 2006.

11. Spitznagle, Theresa “Tracy” M. PT, DPT,MHS, WCS. 2013. Movement Systems Approach to Musculoskeletal Pelvic Pain. a. The Pelvic Girdle. Diane Lee 2000, pg 53.
    a. Pool-Goudzwaard. 2004

12. Vicierup et al. 2000.

13. Australian Journal of Physiotherapy 52: 11-16

14. PF1: Pelvic Floor Muscle Disorders. Section on Women’s Health 2011.
    a. Dockter M. Kolstad AM, Martin KA, Schiwal LJ. Prevalence of Urinary Incontinence: A
     comparitive study of collegiate female athletes and non-athletic controls. JWHPT. 2007; 31:12-17.
    b. Nygaard IE, et al. Urinary Incontinence in elite, nulliparous athletes. Obstet Gynecol. 1994; 84:183-187.