89th annual postgraduate convention | llu homecoming
TRANSCRIPT
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
Pelvic Floor Dysfunction:
The Role of Physical Therapy
Sarah Sydnor, PT, CAPP, WCS
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
PT’s are Movement Specialists
Mobility StrengthMovement
Coordination
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
“Down There”
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
”4 Components to Core Strength”
Resource
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
Stress Urinary Incontinence Case
Mobility StrengthMovement
Coordination
NO DEFICITS 4/5 MMT in SUPINE
NO KNACK
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY This Photo by Unknown Author is licensed under CC BY
This Photo by Unknown Author is licensed under CC BY
Urinary Incontinence
Fecal Incontinence
Pelvic Organ Prolapse
MSK Dysfunct.
Perinatal
4th Trimester
Scar Tissue
Constipation
Sexual Dysfunct.
Erectile Dysfunct.
Vaginismus
Vestibulodynia
PGAD (persistent genital arousal
disorder)
Pudendal Neuralgia
Bladder Dysfunct.
PBS (painful bladder syndrome)
Proctalgia Fugax
Neurogenic Bladder
Pelvic Floor Dyssynergia
Endometriosis
Dysmenorrhea
Pediatrics
Pelvic Floor Tension
UTI’s (urinary tract infections)
IC (interstitial cystitis)
LBP, hip pain
Sciatica, piriformis
Diastasis
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
Pelvic Organ Prolapse Case
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
• I
It’s NOT normal to leak urine after labor and delivery
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
Case Study
Prostatectomy?
Inguinal Hernia Repair?
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
AVOID constipation as if it IS COVID!
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
• I
Pain with sex is NOT NORMAL
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
Pudendal Nerve
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY This Photo by Unknown Author is licensed under CC BY
This Photo by Unknown Author is licensed under CC BY
Urinary Incontinence
Fecal Incontinence
POP
MSK Dysfunct.
Perinatal
4th Trimester
Scar Tissue
Constipation
Sexual Dysfunct.
Erectile Dysfunct.
Vaginismus
Vestibulodynia
PGAD (persistent genital arousal
disorder)
Pudendal Neuralgia
Bladder Dysfunct.
UTI’s, IC, PBS
Proctalgia Fugax
Neurogenic Bladder
Pelvic Floor Dyssynergia
Endometriosis
Dysmenorrhea
Pediatrics
Pelvic Floor Tension
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
Pelvic Floor Tension
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
LISTEN FIRST
TREAT SECOND
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
Tough Conversations
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
PT Treatment•Questions•PT Orthopedic MSK assessment •Pelvic Floor Assessment•Exercises•Lifestyle Recommendations•Education•Pelvic Floor Electrical Stimulation•Pelvic Floor Biofeedback •Manual Therapy Treatment
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
Kegels:“Squeeze as if
stopping urine”
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
PT Treatment•Questions•PT Orthopedic MSK assessment •Pelvic Floor Assessment•Exercises•Lifestyle Recommendations• Interdisciplinary Recommendations
•Education•Pelvic Floor Electrical Stimulation•Pelvic Floor Biofeedback •Manual Therapy Treatment
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
Expectations…
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
PT Treatment•Questions•PT Orthopedic MSK assessment •Pelvic Floor Assessment•Exercises•Lifestyle Recommendations• Interdisciplinary Recommendations
•Education•Pelvic Floor Electrical Stimulation•Pelvic Floor Biofeedback •Manual Therapy Treatment
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
Onlinelibrary.wiley.com
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
Find a Pelvic Floor Physical Therapist
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
Aren’t the symptoms just all
in their head?
Is this ALL in my head?
FALSE… SO False
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
Case Study Problem List
•Vaginal burning symptoms for 30 years•Dysuria•Bladder Pain•Constipation•Vaginal Atrophy•Nocturia – 5 times per night•Urinary Leaking•2-4 cups of decaf coffee/green tea per day
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
Findings
•Highly respected professional career •Beautiful posture (abdomen tightly draw in ALL the time)•Flomax•Urodynamic Study (slow flow time, detrusor underactivity, increased electrical activity in the abdominal muscles)
•MRI defecography – Grade 2 rectocele, defecation required maximum strain
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
PT Treatment
Visit 1Initiated the PT evaluation and education
Visit 2External orthopedic MSK assessment FINDINGS
Maximum mobility deficits RIGHT OBTURATOR FORAMENModerate fascial restrictions LEFT BLADDER
TreatmentGENTLE myofascial release suprapubic region and RIGHT OBTURATOR FORAMENLIFESTYLE counseling: adequate fluids, wean off caffeine, notice and avoid
irritating foods
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
PT Treatment continuedVisit 3Pt. Subjective: After last visit, “I had no pain for 5 days, the first time in 30 yrs.” AND, “I sat in my car and cried due to memories of forced abortions when I was young, I didn’t realize I had residual anger.”
Treatment
-The majority of the treatment session was spent LISTENING-RECOMMENDATION for possible counseling/trauma therapy (she was very
receptive)-Diaphragmatic breathing exercises, body awareness, relaxation strategies,
POSTURE training (HEP)-Gentle manual therapy
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
PT Treatment continuedVisit 4Pt. Subjective: “4/10 vaginal burning.”
Treatment-PFM relaxation exercises-Diaphragmatic breathing-NO MANUAL TREATMENT PERFORMED
Treatment Outcome*Patient left with 0/10 pain*Patient did the work with minimal (<25%) verbal coaching*Patient with increased confidence in her own ability to manage her symptoms
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
PT Treatment continuedVisit 5• Pt. Subjective: “I’m drinking just under a cup of coffee per day.” (previously 2-4 cups)
“I’m doing the breathing exercises.”
“Last week I had a night were I voided only 1 time and last night I voided 2 times.”
“I feel much better because I’m getting sleep. My energy is much better and I’m doing more.”
“I just went to the bathroom and have 0/10 burning right now, I’m consistently not having burning with voiding.”
“I have spikes of pain to 8/10 and I do think it has to do with stress and if I breathe it takes the pain away.”
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
PT Treatment continuedVisit 5
Treatment
Started Submax KEGELS with overcompensation noted in the hips with internal rotation, glut recruitment, and lower abdominal recruitment.
Patient Affect
Laughing and Joking
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
Summary
It’s NOT all in their head
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
References
Hunter C, Dave N, Diwan S, Deer T. Neuromodulation of pelvic visceral pain: review of the literature and case series of potential novel targets for treatment. Pain Practice. 2013;13(1):3-17.
Urquhart D, Hodges P, Allen T, Story I. Abdominal muscle recruitment during a range of voluntary exercises. Man Ther. 2005;10(2):144-53.
Braekken, I, Majida M, Engh M, Bo K. Can pelvic floor muscle training reverse pelvic organ prolapse and reduce prolapse symptoms? An assessor-blinded, randomized, controlled trial. Am J Obstet Gynecol. 2010;203(2):170.
Hagen, S, Stark D. Conservative prevention and management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2011;7(12):CD003882. doi: 10.1002/14651858.CD003882
Wallace S, et al. Pelvic floor physical therapy in the treatment of pelvic floor dysfunction in women. Curr Opin Obstet Gynecol. 2019;31(6):485-493.
The American College of Obstetricians and Gynecologists Communications Office. ACOG redesigns postpartum care. http://www.acog.org. Published April 23, 2018. Accessed February 17, 2021.
Wasserman J, Copeland M, Upp M, Abraham K. Effects of soft tissue mobilization techniques on adhesion-related pain and function in the abdomen: A systematic review. J Bodyw Mov Ther. 2019;23(2):262-269.
Maldonado PA, Chin K, Garcia AA, Corton MM. Anatomic variations of pudendal nerve within pelvis and pudendal canal: clinical applications. Am J Obstet Gynecol. 2015;213(5):727
Montoya TI, Calver L, Carrick KS, Prats J, Corton MM. Anatomic relationships of the pudendal nerve branches. Am J Obstet Gynecol. 2011;205(5):504
89TH ANNUAL POSTGRADUATE CONVENTION | LLU HOMECOMING
ALUMNI ASSOCIATION, SCHOOL OF MEDICINE OF LOMA LINDA UNIVERSITY
Ackerman A, Lee U, Jellison F, Tan N, Patel M, Raman S, Rodriguez L. MRI suggests increased tonicity of the levator ani in women with interstitial cystitis/bladder pain syndrome. Int Urogynecol J. 2016;27(1):77-83. doi: 10.1007/s00192-015-2794-6.
Agarwal S, Chapron C, Giudice L, et al. Clinical diagnosis of endometriosis: a call to action. American Journal of Obstetrics and Gynecology. 2019;220(4):354.e1-354.e12. Shafrir A, Farland L, Shah D, Harris H, Kvaskoff M, Zondervan K, et al. Risk for and consequences of endometriosis: A critical epidemiologic review. Best Pract Res Clin Obstet Gynaecol. 2018;51:1-15. Pugsley Z, Ballard K. Management of endometriosis in general practice: the pathway to diagnosis: Br J Gen Pract. 2007;57(539):470-476. Kiesel L, Sourouni M. Diagnosis of endometriosis in the 21st century. Climacteric. 2019;22(3):296-302. Velde J, Everaerd W. The relationship between involuntary pelvic floor muscle activity, muscle awareness and experienced threat in women with and without vaginismus. Behav Res Ther. 2001;39(4):395-408.
Damon H, Guye O, Seigneurin A, et al. Prevalence of anal incontinence in adults and impact on quality of life. Gastroenterol Clin Biol. 2006;30(1):37-43. Miskin C. A Purposeful Ride. APTA Magazine. 2020-2021;11(12):60-64.
Some images taken from the World Wide Web