MUSCLE TRAININGMUSCLE TRAINING

for PELVIC FLOORPELVIC FLOOR MUSCLE DYSFUNCTIONSMUSCLE DYSFUNCTIONS

منشادی دهقان ،دکترفریدهگروه علمی هیات فیزیوتراپیعضو

توانبخشی ، دانشکدهبهشتی شهید پزشکی علوم دانشگاه

ماه 1389 خرداد

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Muscles Inferior to the Pelvic Floor:The Urogenital DiaphragmMuscles Inferior to the Pelvic Floor:The Urogenital Diaphragm

Muscles inferior to the pelvic floorStretches between two sides of

the pubic arch in the anterior half of the perineum

Contains◦Deep transverse perineal muscle

◦External urethral sphincter muscleThe ischiocavernosus and

bulbospongiosus assist in erection of the penis and clitoris; lie superficial to the urogenital diaphragm

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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 incontinenceLimited sexual pleasure during intercourse.

Delayed recovery of tissue in the case of an episiotomy

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

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از از بخشی عنوان به لگن کف عضالت که آنجاکمری فقرات ستون دهنده ثبات لوکال سیستم

. اختالل روی این از شوند می مطرح تنه وهم و تونیک برفعالیت هم لوکال عضالت سایر

طی در انها فازیک فعالیت بندی زمان بر . مثال برای گذارد می اثر عملکردی فعالیتهای

عضله حرکتی کنترل تاثیربر با حاد درد کمرتونیک حمایت کاهش سبب شکم عرضی

عملکردی اختالالت بروز و لگن کف عضالتشود می زدگی بیرون و اختیاری بی چون

Different Aspects of PFM Different Aspects of PFM FunctionFunction

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Box 1. Symptoms of pelvic floor dysfunctionLower urinary tractUrinary incontinenceUrgency and frequencySlow or intermittent stream and strainingFeeling of incomplete emptyingBowelObstructed defecationFunctional constipationFaecal incontinenceRectal/anal prolapseVaginaPelvic organ prolapsePainChronic pelvic painPelvic pain syndromeSexual functionDyspareunia (painful sexual intercourse)Orgasmic dysfunction

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PFMT

Neo-Control

Electrical Stimulation

Behavioral Therapy

Biofeedback

Lifestyle

PT ApproachesFor PFD

Management TheoriesManagement 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)

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Pelvic Floor Pelvic Floor Muscle TrainingMuscle TrainingStrong 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

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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 Training5-Correction of biomechanical/structural

deformities

Five Steps for PFM Training in PFDFive Steps for PFM Training in PFD

KNACK MANEUVERKNACK MANEUVER

Step One:

Pelvic Floor Contraction With the moment of Expected Leakage to

Prompt Cough-Related Stress Incontinence

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Theoretical Explanation

Active contraction of both Levator Ani & Ext.Urethral Sphincter->

increase both stiffness in urethral Supporters and urethral pressure

>-resist urine outflow

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How to Teach Kegel CorrectlyHow 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 squeezeSex Exercises when patient

is ready to resume sexual activity19

PartPartii: ii: TransTrans Abdominal US Abdominal US

Bladder transverseBladder transverseview at rest &view at rest & PFM Contraction PFM Contraction

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Benefits of PFM TrainingBenefits of PFM TrainingExercised 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 lifeStrong 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.

Samples of Some Kegel ExeSamples 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.

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(1)Lying Position

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(2)Semi-Reclined

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((33 ) )Sitting PositionSitting Position Kneeling on all Kneeling on all fours(4fours(4))

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((55))Standing, leaning forwards from the hips with Standing, leaning forwards from the hips with hands flat on the table(Left) andhands flat on the table(Left) and

(6)Upright Standing(Right)(6)Upright Standing(Right)

Some Points during Kegel ExsSome 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 musclesFor patient with very weak musculature, you can teach overflow exercises using hip adductor muscles(Controversial) 26

Step 3 : Step 3 : Lumbo –PelvicLumbo –Pelvic Stabilization Exs 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.

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Abdominal HollowingAbdominal Hollowing28

Abdominal hollowingAbdominal hollowing 29

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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.

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

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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

Pelvic Floor ExercisesPelvic Floor Exercises

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Functional Fitness ExercisesFunctional Fitness Exercises……

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Functional Fitness ExercisesFunctional Fitness Exercises……

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Step 5

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Some Points from our recent StudySome Points from our recent StudyAssessment of Posture specially in Lumbopelvic region for women with SUIAsking about other PFD & Musculoskeletal pain in LP regionTeaching PFM Contraction by different types of BiofeedbackAdding TrA Training for SUI PatientsDoing PFM exercises in Crook lying pos. specially for SUI womenKeeping Neutral Position in LP region while doing PFM exe.,Also we can recommend active PPTilt as an additional exe. For SUI patients •4

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Thanks for your

Attention