© Springer International Publishing Switzerland 2016
Anna Padoa and Talli Y. Rosenbaum (eds.)The Overactive Pelvic Floor10.1007/978-3-319-22150-2_1616. A Classical Physical Therapy Approach to the Overactive Pelvic Floor
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Beyond Basics Physical Therapy, LLC, 110 E 42nd Street Suite #1504, New York, NY 10017, USA
Keywords
Pelvic floor muscle overactive dysfunctionPelvic floor physical therapyPelvic painPelvic tension myalgiaPelvic floor muscle retrainingMyofascial trigger point releaseCore mobility and stabilityBiofeedback16.1 Introduction
Pelvic floor (PF) muscle dysfunction is a global term that incorporates malfunctioning of the musculoskeletal and neuromuscular systems . While the process for determining its underlying cause can be complex, the dysfunction is often a result of a structural malalignment of the skeletal system [1–3], of hyperactivity or hypoactivity of a muscle or muscle group, or of restrictions in the tissues and fascia [4–8]. One may suffer from both overactive and underactive pelvic floor dysfunction, and it is essential to address both for this complex presentation. For instance, a postpartum female may present with stress incontinence related to an underactive or weak pelvic floor condition, as well as dyspareunia, related to overactive pubococcygeus and transverse perineal muscles. In order to address the weakness without causing further muscle shortening, the pelvic floor muscles require lengthening to function at an optimal position, before they are strengthened with pelvic floor exercises. Such traumas as a slip and fall, childbirth, infections, and poor posture can contribute to these structural changes and muscle imbalances.
Pelvic floor muscles assist with voluntary sphincter control of the bladder and bowel and with sexual performance and function. They provide support for pelvic organs and assist with lumbopelvic stability and mobility. It is estimated that 80 % of pelvic floor muscle fibers are Type I slow-twitch skeletal fibers; 20 % are Type II fast-twitch skeletal fibers. As a result, symptoms of bladder, bowel, and/or sexual dysfunction often accompany PF dysfunction. Pain in the pelvic and abdominal regions, in the back and lower extremities, and in the genital area as well as central sensitization are often correlating findings of PF dysfunction. These symptoms can start as early as childhood and present up until the elder years.
In recent years, there has been an increase in research, specifically regarding treatment techniques [9–19]. It has been described that pelvic floor physical therapy can be an integral and extremely effective treatment for the musculoskeletal causes of functional pelvic pain [20–24]. In this chapter we will review manual therapies, reeducation for both the bladder and bowel, neuromuscular reeducation, posture/body mechanics, therapeutic exercise, and modalities including biofeedback, low-level laser therapy (LLLT) , ultrasound, electric stimulation, transcutaneous electrical nerve stimulation (TENS) , and heat and cold therapy. This list by no means represents all the treatments available nor does it reflect the research in its entirety.
It should be noted that to successfully treat pelvic floor dysfunction, it is essential to treat the body as a whole and to address all the biopsychosocial conditions contributing to the patient’s pelvic pain. A treatment plan must be constantly monitored by the therapist, and the patient’s progress consistently re-evaluated in order to advance the treatment plan [25] and modify it as warranted.
16.2 Manual Therapy Techniques
Myofascial release
Myofascial trigger point release
Connective tissue manipulation
Scar mobilization
Neural mobilization
Visceral manipulation
Joint mobilization
16.2.1 Myofascial Release
It is estimated that a myofascial dysfunction afflicts as many as 23 % of women with chronic pelvic pain (CPP ) [26]. Myofascial Release (MFR) , a holistic therapeutic approach to manual therapy, was developed by John Barnes as part of a comprehensive approach to the evaluation and treatment of the myofascial system [27]. As the term implies, the main tissue to target for release in the myofascial system is the fascia, described by Barnes as “a tough connective tissue which spreads throughout the body in a three dimensional web from head to foot without interruption.” The fascia surrounds all structures in the body including muscles, nerves, vessels, and bones. MFR is reported to be an excellent technique for releasing such restrictions as trigger points, muscle tightness, and dysfunctions in soft tissue that may cause pain and limit motion in all parts of the body [28].
In the MFR process , the therapist evaluates, identifies, and treats fascial restrictions. Such restrictions may be caused by trauma, musculoskeletal conditions, repetitive stress syndrome, or poor posture. The gentle, hands-on techniques the MFR therapist applies to the whole body can bring about positive structural changes, increasing range of motion (ROM) , reducing pain, and augmenting fascial mobility [28].
Barnes’ approach teaches the therapist to evaluate the fascial system through visual analysis of the human frame’s three-dimensional space, by palpating the tissue texture and various fascial layers, and by observing the symmetry, rate, quality, and intensity of strength of craniosacral rhythm.
Craniosacral rhythm is the use of light touch to perform delicate mobilization of the cranial bones and sacrum. This subtle hands-on treatment facilitates the release of connective tissue tightness surrounding the brain and spinal cord, or the Central Nervous System (CNS). This light touch can help to create balance within the CNS, by inhibiting the Sympathetic Nervous System (flight or flight response), and activating the Parasympathetic Nervous System (rest and digest), it reduces stress within the body, decreases pain, and promotes normal function. In addition to assessing the craniosacral rhythm, it is important to have the treating therapist “observe the vasomotor response and their location after a particular fascial restriction has been released. This provides instantaneous and very accurate information enabling the therapist to proceed intelligently and logically from one treatment to the next” [27].
MFR at first releases the elastic component of the fascia; at some later point, the collagenous barrier will be engaged. This barrier cannot be forced. The therapist maintains gentle pressure for some 90 to 120-plus seconds, and as the collagenous barrier releases, the therapist follows the motion of the tissue until all the barriers are released [28].
16.2.2 Myofascial Trigger Point Release
Travell and Simons define a trigger point as a highly irritable spot in a palpable taut band in the muscle or the fascia [8]; according to Travell, a true trigger point is a restriction that has a clear and consistent referral pattern [7, 8]. When pressure is applied, pain or tenderness is often provoked along with the possibility of autonomic nervous system involvement . The autonomic nervous system plays a role in the regulation of internal organs. Sweating, vasoconstrictions, vasodilation, and cutis anserine are possible responses to trigger points linked to the autonomic nervous system. McPartland and Simons reported the ANS may indirectly exacerbate myofascial trigger points formation via viscerosomatic reflexes [29].
Muscles containing trigger points are characteristically shortened and present with decreased ROM, hyperactivity, incoordination, and substitution patterns [4, 5, 30]. Muscles with trigger points present must expend greater effort than muscles without trigger points to produce the same effects ; this may cause changes in surrounding muscles, and it may also disorder the proprioceptive, nociceptive, and autonomic functions of the affected region [31].
It is well documented that trigger points may produce pelvic pain; these trigger points can be found in the levator ani muscle group, obturator internus, coccygeus, abdominals, gluteals, adductors, iliotibial band, tensor fascia latae quadricep, piriformis, quadratus lumborum, paraspinals, and hamstrings [8].
Trigger points in the posterior pelvic region result in symptoms in the rectum, anus, coccyx, and sacrum. Trigger points in the anterior portion may result in more urogenital pain and symptoms. Dyspareunia and bladder and bowel dysfunction can be the result of pelvic floor trigger points and can present with sharp, dull, aching symptoms both deep and superficial [4, 5, 8, 30, 32–34].
Yet trigger points may often go unrecognized. For this reason, it is essential that a skilled practitioner actively palpate the tissue in order to find and treat the restriction. Once identified, the trigger point muscles may be eased and lengthened through stretching and/or with such proprioceptive neuromuscular facilitations, as contract relax, reciprocal inhibition, and active release techniques [5, 13].
Research has found that myofascial trigger point release can achieve up to an 83 % improvement in symptoms; it can lessen the overactivity of the pelvic floor musculature , which in turn can reduce neurogenic bladder inflammation and decrease CNS sensitization [33]. A research study by Fitzgerald et al. concluded that a group of women with interstitial cystitis/painful bladder symptoms responded with significantly higher improvement to myofascial physical therapy, achieving an overall improvement in symptoms, than to global therapeutic massage [18]. Success has also been achieved in the treatment of pelvic pain and bladder, bowel, and sexual dysfunction through the use of many of these manual therapy techniques [5, 7, 13, 18, 31, 32].
16.2.3 Connective Tissue Manipulation
Connective tissue manipulation is the movement of one layer of skin over the other—skin rolling—in order to release tension in the tissue, thereby augmenting the ROM of the joint and restoring neurodynamics [7]. The manipulation creates the sensation of a sharp scratch or of a nail digging at the skin. The more restricted the tissue, the sharper the sensation, and the patient may complain of feeling bruised [24]. Connective tissue manipulation improves circulation to areas with decreased blood flow and pelvic congestion. When tension is released, blood flow to the area increases, flushing toxins from that region. This also improves mobility in the surrounding structures [32]. The therapist will note any changes to the skin texture, color, temperature, and elasticity [24].
16.2.4 Scar Tissue Mobilization
Any restrictions throughout the trunk, pelvic floor, sacral, and lower extremity regions that could be causing restrictions and overactivity contributing to the patient’s pain should be addressed through scar mobilization. For abdomino-pelvic floor disorders, it is essential to address both the superficial scars that are visible—i.e., from Caesarian sections, episiotomies, and any abdominal surgeries—and those not visible but formed internally either by a surgical procedure or by such conditions as endometriosis. Some studies suggest releasing the scar with each physical therapy treatment until normal flexibility returns and there is no more adherence to deeper tissues [4].
16.2.5 Neural Mobilization
The theory behind neural mobilization is that in improving axonal transportation, nerve conduction velocity is increased [28]. Manual neural mobilization restores altered neurodynamics by balancing the relative movement of neural tissue and surrounding mechanical interfaces, thus reducing intrinsic pressure and optimizing physiological functions [35]. Treatment is indicated if there are signs of pain due to increased resistance of the tissues and reproduction of symptoms [7]. The therapist will use various techniques to palpate and reduce restrictions in any tissue and musculature that could be restricting the nerve. In addition, neural glides can help free restrictions of the nerve.
16.2.6 Visceral Manipulation
Just as the skeletal system needs to be in proper alignment to maintain homeostasis, so do the viscera. Adhesions, abnormal tone, or displacement may result in a disharmonious movement between internal organs, and this disharmony may in turn lead to chronic irritation and pain. As Carriere and Feldt write, “The viscera of the pelvic floor needs to be very flexible to adapt to the daily filling of the bladder and rectum and to the monthly changes in the endometrium” [36].
Visceral manipulation uses gentle palpation and manual therapy to evaluate and correct the imbalances, returning the organs to their appropriate position and stimulating arterial and venous blood supply so that the organs return to optimal functioning [36]. Please refer to Chap. 21 for more information on visceral manipulation.
16.2.7 Joint Mobilizations
Joint mobilization is a manual therapy intervention, a type of passive movement of a skeletal joint. When applied to the spine, it is known as spinal mobilization. In a patient with pelvic pain, a structural deviation within the skeletal system can often be resolved with these techniques , which decrease muscle guarding, lengthen the tissue surrounding a joint, and affect neuromuscular influences on muscle activity and increased proprioceptive awareness [28].
16.3 Neuromuscular Reeducation
As per O’Sullivan and Schmitz, PNF, which is one of the many techniques of neuromuscular reeducation, focuses primarily on the facilitation of total patterns of movement and posture; this promotes learning—reeducation—in synergistic muscle groups. Pelvic floor muscle weakness, incoordination, adaptive shortening, joint immobility, and alterations in muscle tone may lead to impaired patterns of posture and movement. By applying PNF techniques to the pelvic floor and surrounding structures, those muscles and structures may be strengthened, lengthened, and coordinated [37].
These techniques include contract-relax to promote relaxation at a point of limited ROM [37] and strain-counterstrain, a form of passive positional release designed to release connective tissue restrictions. In this latter technique, the tissue is initially moved in the direction of ease that shortens the affective structure. According to Jones and Randall, “The purpose of movement toward shortening is to relax aberrant reflexes that produce the muscle spasm forcing immediate reduction of tone to normal levels. This allows the joints influenced by the now relaxed muscle to function optimally increasing its ROM and easing muscle pain. Strain and counterstrain is an effective but extremely gentle technique because its action for treatment moves the patient’s body away from the painful, restricted directions of motion ” [38].
16.4 Pelvic Floor Muscle Retraining
Pelvic floor muscle retraining requires developing or improving motor control for bladder, bowel, and sexual function and to ameliorate pelvic pain [39, 40]. Patients diagnosed with CPP , dyspareunia , or any urgency-frequency dysfunction often present with overactive pelvic floor muscles [30]. Pelvic floor muscle overactivity may also be the result of holding patterns, which, over time, can result in shortened muscle fibers, restricted connective tissues, and/or contracted sarcomeres [4].
Behavioral therapy needs to be integrated into the treatment approach in order to break the cycle of dysfunction and pain. Education and training must focus on proper motor control— that is, on relaxing the pelvic floor muscles in voiding and intercourse rather than contracting or tensing the muscles out of fear of pain. Such training entails “learning” the difference between contracting, elongating, and relaxing the pelvic floor through verbal cueing and such other forms of cueing as biofeedback. The techniques for this retraining follow principles of the operant learning model and of cognitive behavioral therapy [41, 42]. In addition, it may be helpful to do any or several of the following behavioral modifications before or after any painful activity, including sexual activity: scheduled voiding, urge control, posture re-training, and pelvic floor muscle relaxation and massage. Such modifications have been shown to be extremely effective in pelvic floor rehabilitation [43, 44].
Various forms of “home remedies ” have also been shown to be effective and can be applied by the patient. Stress management, relaxation breathing, pelvic floor muscle relaxation, relaxing time with a walk, hot bath, yoga, and meditation are all examples of behavioral or lifestyle modifications that can help with physiological quieting [43]. Two particularly effective techniques are the use of a dilator, or internal massage device, to help eliminate myofascial trigger points and to further elongate the shortened pelvic floor muscles [41, 44], and passive stretching of the tissues at the vaginal introitus [45].
16.5 Bladder and Bowel Reeducation
Pelvic floor muscles need to be relaxed during urination and defecation, which is why regulating bladder and bowel function is an essential component of the treatment of pelvic pain. For those diagnosed with chronic overactive pelvic floor muscles, getting those muscles to relax and lengthen is often a multi-step process that can be helped by both manual therapies and reeducation techniques. For example, proper positioning is key when voiding. Leaning forward and slightly extending the spine decreases the anorectal angle facilitating bowel movement. Depending on the height of the toilet, it may be necessary to place a stool under the patient’s feet to allow for optimal positioning [9]. In addition, taking time on the toilet and allowing oneself time to relax can help avoid the straining that can put a lot of adverse tension on the pelvic floor muscles. Manual therapies, as well as such techniques as imagery, deep breathing, and biofeedback, may all assist in the reeducation of the muscles to address post-void dribble, bladder and bowel frequency, urgency, retention, and hesitancy [43, 46]. Here are some key techniques and tips for addressing these issues.
Related posts:
Overactive Pelvic Floor: Gastrointestinal Morbidities
Female Voiding Dysfunction
The Pelvic Floor and Male Sexual Function
Female Genital Pain and Penetration Disorders
A Tale of Two Pain States: The Integrative Physical Therapy Approach to the Overactive Pelvic Floor
Complementary and Alternative Therapies for the Overactive Pelvic Floor
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