Therapeutic methods for functional pelvic floor rehabilitation - N° 1

THE FRENCH EXPERIENCE OF PELVIC FLOOR REHABILITATION WITH BFB AND FES THERAPEUTIC METHODS FOR PELVIC FLOOR FUNCTIONAL REHABILITATION 

Partie N° 1

Introduction: objectives & methods for rehabilitation

Rehabilitation of the pelvic floor dysfunction was started at the end of the 70’s by some French therapists of whom the first was Alain Bouncier.

Intra vaginal & anal stimulation increase urethral pressure profile by activating nerves to the striated pelvic floor and para-urethral muscles. It has been demonstrated that the pathways involved are similar in both humans and animals although the influence of the sympathetic nerves on the bladder may be less important. The smooth muscle component contributes also to a good urethral pressure profile.

Pelvic floor rehabilitation aims to restore proper function of the perineal musculature through pelvic muscle education and/or re-education.

Patients need to learn and practice pelvic floor exercises in clinic with the therapist and to follow up at home.

One also uses behavioural techniques for bladder or faecal control as well as for pelvic floor blocking while standing.

Rehabilitation is therefore used to treat lower urinary tract and terminal bowel dysfunction using physical therapy for the pelvic floor.

Factors limiting rehabilitation

Some factors limiting successful rehabilitation.

1- Body weight is an important factor influencing results because of the pressure generated downwards by viscera - chronic coughing is another - and also poor posture.

2- Motivation for re-education is one of the most important factors. Without strong  motivation it is more difficult to obtain a good result.

3- Testing of the pelvic floor muscle; the first evaluation before starting a re-education plan can predict good results or not.

4- Chronic coughing because of the pressure downwards.

5- Women doing physical fitness training such as aerobics, body building, tennis and hard footing, is evidently a limiting factor.

6- Finally urodynamic data depending on the degree of sphincter damage, striated insufficiency, bladder dysfunction, and so on, may help us to define the limits to rehabilitation.

Appraisal of perineal risk

Before starting rehabilitation one has determine whether any perineal risk exists, For example:

1- family history

2- Childbirth: parity, dystocia, too quick a delivery of both large and small babies.

3- pelvic floor examination : tight vulva, narrow vagina, thin fibrous nucleus, thin levator ani, short ano-vulvar distance, straight muscle diaphragm, fat infiltrated pelvic floor, tissues made fragile by vulva-vaginal inflammation, hypertonic pelvic floor with levator ani spasms and reflex contractions, ischio-pubeous branches abnormally parted

4- physical and daily living factors

5- history of urogynaecological surgery

Objective of physiotherapy

Physiotherapy has to restore perineal function by re-educating the pelvic floor musculature: manual techniques, biofeedback and electric stimulation, postural gymnastics.

Physiotherapy has to restore bladder control using bladder training techniques.

Physiotherapy has to guide and advise patients on incontinence aids, precautions and at sometimes social change.

Female pelvic floor disorders Physiotherapy (Ph)

What are lower urinary tract abnormalities improved by physiotherapy techniques?

1- genuine stress incontinence

2- urge incontinence

3- mixed incontinence

4- nocturnal enuresis

5- voiding difficulty

6- retention

7- weak pelvic floor function

8- PF pain in dyspareunia

Who can benefit from Ph

1- post-natal period for women

2- patients with pelvic floor dysfunction desiring another pregnancy

3- patients who prefer to delay surgery

4- patients with moderate discomfort

5- patients with failed surgery

PELVIC FLOOR REEDUCATION...

Pelvic floor re-education must not be confused with gymnastics. It is not only a simple repetitive movement to reinforce a muscle.

Treating the whole pelvic area

Before re-educating the pelvic floor one has to keep 4 steps in mind :

1- The quality of the levator ani muscles: it is really important to block the pelvic floor when straining.

2- The importance of the integrity of internal pudendal nerves, erector & hypogastric nerves, perineal nerves, ensuring the right reflex mechanism to control pelvic floor musculature.

3- The importance of the inter-relationship between perineal nerve damage and pelvic floor control.

4- Childbirth & the effect on the pelvic floor knowing the relaxation action of the pelvic floor musculature.

One understands consequently that a multidisciplinary approach can lead to a complete understanding of pelvic floor dysfunction.

Some epidemiological studies demonstrate a higher prevalence of PF dysfunction in younger women. However we also know that urinary incontinence is not the only pelvic floor disorder. We know that faecal incontinence is a problem affecting predominately but not only elderly people. Middle-aged and even younger patients need treatment. We know too that chronic constipation is a common female disorder.

Last but not least, pelvic organ prolapse is a common pelvic floor dysfunction.

Reeducation of pelvic floor musculature

Usually we have to follow four stages:

1- informative : information about PF physiology & anatomy

2- Awareness of pelvic floor muscles: finding out whether front, middle and rear PF voluntary contraction is present with or without synergy.

3- Strengthening of pelvic floor muscles: by exercises and neuro-muscular electrostimulation.

4- Reflex pelvic floor contraction: with teaching perineal blockage before stress.

About reflex PFM contraction; the patient must be made aware of constant contraction of the pelvic floor during daily activities e.g. upright position, movements, lifting, carrying a load, and so on...

About perineal blockage before stress; the patient must be taught that pelvic floor muscles must be contracted before the abdominal pressure rises e.g. coughing, sneezing, running & sport. To control PF blocking with stress one uses EMG biofeedback in standing up position with a special probe inside the vagina.

To understand the visceral mechanism and the importance of perineal blockage, one has to remember that the vertebra should not deform and that the diaphragm undergoes only slight variations.

Conservative treatment

First of all conservative treatment we have to keep in mind that:

1- Women need to be informed that physiotherapy is available, and that symptoms can be alleviated if not eradicated.

2- Physicians & doctors should be encouraged to question patients about bladder, bowel habits and any sexual problem, and to practice regular examinations to detect early signs of pelvic symptoms needing rehabilitation.

3- Patients have to be advised to undergo pelvic floor rehabilitation.

Reeducational techniques

To rehabilitate the pelvic floor muscles one has at our disposal:

 improved Kegel’s exercise programme

 therapeutic gynaecological exercises

 functional neuro-muscular electric stimulation

 biofeedback therapy

 behaviour therapy

Management techniques

1°) - manual & instrumental pelvic floor function evaluation.

2°)- manual, postural & pelvic floor muscles exercises

3°) – NMS -neuro-muscular electric stimulation & BFB - biofeedback training.

Stimulation: we apply stimulation therapy in the clinic, hospital, and for homecare, we use programmable home units with daily or long term stimulation.

Using biofeedback training we have standard EMG & pressure BFB in office and apply pressure BFB at home. 

1- Manual & instrumental PF evaluation

Unskilled work on muscles of the vaginal sidewall (puboccygeous, ilio and ischio-coccygeous) may be difficult because of the anatomy - the direction and the insertion of these muscles. Therefore any therapist who wants to provide complete and successful therapy must first learn to feel the vaginal muscles and to be able to evaluate them against a proper functional anatomy.

The PF contraction evaluation must evidently be the most complete and perfect possible with verbal orders. That means that the patient has to understand what we are asking for. Any functional disorder may reveal a bad body message, such as antagonist or agonist synergies, a reverse perineal order...

The therapist should not be satisfied by only a simple and total pubo-coccygeous and pubo-rectalis contraction. This is usually the case when giving a grade for the test. The therapist should also evaluate each part of the pelvic floor muscle branches, front, rignt, and left, looking for any hidden tears, any muscle ruptures or any P.C. asymmetry.

The manual appraisal of the P.F.M. therefore allows the establishment of a subjective measures for:
    External vaginal muscle capacity for closing
    Vaginal and central nucleous fibrous tonicity
    Fatigability with repetitive contractions
    Rapid contraction capability
    Duration of the contraction
    Synergies - agonist & antagonist

Then an objective instrumental evaluation - EMG & pressure - of the reflex and volontary contraction, will be correlated to the manual evaluation.

This allows for management of progress in future. 

2- Manual, postural & Therapeutic gynaecological exercises

Exercises against manual contra-resistance, daily voluntary contractions, reinforce PF musculature improved by Kegel’s exercises.

Postural exercises may help to reinforce the pelvic floor muscles by avoiding excessive downwards pressure.

Manual exercises are simple and easy:

Technique 1: The index finger is used easily and can evaluate the quality of the pubo-coccygeus on right then on the left, at the same time one applies a pressure (contra resistance) on the muscle asking the patient for a voluntary contraction.

Technique 2: For the bulbo-spongious muscle one proceeds by introducing the index and middle fingers into the vaginal opening (vulval entrance), palm downwards, then part the fingers asking the patient for a contraction, opposing a resistance when closing the vulva. It can help the imagination by asking the patient pretend she has two sliding doors to close.

Technique 3: for an antero-posterior position, one introduces the index and middle fingers into the vaginal opening (vulva), the middle finger in contact with puborectalis and the index with the external inferior part of the urethra, under the urethral opening. Therapist parts the fingers and the patient is asked for a contraction opposing the resistance of the fingers. Urethral sensitivity may give the patient a better feeling of her contraction.

Technique 4: The appraisal of the puborectalis is easier and therefore more effective. It is better to operate with the therapist’s inch upon the muscle, the palm face of the hand and the other fingers palming the sacrum, the patient relaxing herself on. This muscle can then be worked usefully, in concentric, eccentric therefore in pliometric (one after the other successively) and lateral right and left.

Postural exercises have different objectives:

a) To keep the spinal column stretched - maximum distance head/coccyx - whatever the position

b) To make its efforts while expiring upwards without preliminary inspiration.

c) To begin to expire by an increasing pelvic floor activity, maintained and increased during the effort

d) To begin the contraction by transverse, then oblique, eventually the rights, from bottom upwards to climb up pelvic visceras

e) To never push down to the bottom, let the coasts/diaphragm going down in the efforts and during the exercises

f) Not to shorten the rights, not to let them either too much lengthen (Lordosa camber)

g) Appraisal of the rights into isometric contraction

This technique is usually used at the end of the re-habilitation program allowing the patient to control the reflex and the voluntary PF blocking when moving, coughing, and squeezing, etc...  This has  limited success with older women.

Kegel exercises:

They are well-known and we have to remember to exercise tonic and phasic contraction muscles, numerous times in the day-life.

A pelvic floor exercise programme may include:

daily Kegel exercises

pelvic floor exercises with vaginal cones

Technique 1 –exercises must be simple and easy to perform at home and in the daily life :

Ø      one contraction hold for 5 seconds

Ø      5 quick contractions

Ø      10 second rest

Ø      This must be done 10 times X 3 times a day

Technique 2 – when the patient is able to exercise easily we may double the exercise time:

Ø      one contraction hold for 10 seconds

Ø      10 quick contractions

Ø      20 second rest

Ø      this must be done 10 times X 3 times a day

Ø      then 6 times a day

Voir suite N° 2

André Mamberti-Dias

MK spécialisé en périnéologie

Marseille - France

Email : amd5@orange.fr

www://info-perinee.over-blog.com

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