Physical Therapy and Pelvic Floor Dysfunction

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By Susan C. Clinton PT, MHS, OCS, WCS

For 30 years, physical therapists (PTs) have treated women and men with pelvic floor weakness or spasm.   PTs apply their broad knowledge of anatomy, physiology, evidence based clinical assessment and interventions to enhance pelvic floor health.  Post graduate programs such as American Physical Therapy Association (APTA) credentialed residency programs and certified education programs exist to expand the depth of clinical practice to include the pelvic floor both in isolation and in conjunction with other comorbidities such as low back pain (LBP).

General PT practice serves to develop, maintain or restore movement.  The pelvic floor muscles (PFM) do not create large movement patterns, but work in synergy with other muscles to stabilize the trunk and pelvis during movement.  Muscle or soft tissue dysfunction may lead to symptoms such as incontinence or pain during movement and may lead to a change in movement patterns and/or result in lack of movement altogether.1,2   PFM dysfunction became the primary focus of the manifestation of pelvic organ prolapse and incontinence in 1991.3  Many researchers suggested that PFM dysfunction may lead to the development of urinary and fecal incontinence, pelvic organ prolapse, sensory and emptying abnormalities of the lower urinary tract, defecatory dysfunction, sexual dysfunction and chronic pelvic pain syndromes. PFM dysfunction is not a normal consequence of aging and is noted throughout the life span from young children to the geriatric client.  Pelvic floor dysfunction etiologies are classified as predisposing, inciting, promoting and decompensatory.

The predisposing factors include genetic, neurological, anatomical, collagen, muscular, cultural and environmental.  Examples of inciting factors are childbirth, nerve damage, tissue disruption and radiation.  Factors that are responsible for the promotion of dysfunction are occupation, constipation, obesity, surgery, lung disease, smoking, menstrual cycle, infection etc.  Decompensation occurs with ageing, debility, and disease.4  PFM are continuously under postural strain throughout the lifespan and may require regular intervention and training to stay healthy.

Physical Therapy initial evaluation includes a thorough history, physical examination, diagnosis of impairments, determination of prognosis and interventional plan of care.5  The pelvic floor muscles are addressed specifically with a vaginal and/or rectal examination for determination of muscle tone, strength and coordination.  The presence or absence of trigger points, tender points, scar tissue, flexibility, tissue integrity, muscle spasms and pain are identified as specific impairments.6   The PFM function for adequate trunk stabilization and control within the movement system is also part of the examination.  PT treatment techniques address specific patient goals, provide education regarding PFM dysfunction, lifestyle adaptations, manual techniques and PFM retraining.  Treatment modalities can include electrical muscle stimulation and biofeedback training to promote downtraining of overactive muscles or strengthening of underactive muscles.  Emphasis is also placed on managing orthopedic dysfunctions that accompany PFM dysfunction.

Physical therapy is an obvious and essential component of the treatment of pelvic floor health in reducing the symptoms of pain and incontinence.  The American Physical Therapy Association elegantly explains:  “Our clients can enjoy a life of many choices. The choices we make will determine the way we use our body through the decades. A physical therapist will be there for them as they progress through all stages of their life.”7

Acknowledgements:  I would like to thank Dr. Susan E. George for her assistance in preparation of this article.  Susan E. George PT, MS, DPT, OCS, WCS, Director of the WomensRehab and Men’s Health Physical Therapy program at UPMC Centers for Rehab Services in Pittsburgh, PA.

References:

1.  Bo K, Maehlum S, Oseid S, Larsen S.  Prevalence of stress urinary incontinence among physically active and sedentary physical therapy students.  Scan J Sports Sci  1989;11(3):113-116.

2.  Nygaard I, DeLancey JOL, Armsdorf L, et al.  Exercise and incontinence.  Obstet Gyn  1990;75:848-851.

3.  Wall L, DeLancey J.  The politics of prolapsed:  a revision approach to disorders of the pelvic floor in women.  Perspectives Bio Med  1991;34(4):486-496.

4.  Bump RC, Norton PA.  Epidemiology and natural istory of pelvic floor dysfunction.  Obstet Gyn Clinics North America  1998;25(4):723-746.

5.  American Physical Therapy Association. Guide to Physical Therapy Practice, 2nd ed.  Phys Ther  2001;81:9-744.

6.  Laycock J. Clinical evaluation of the pelvic floor. Pelvic Floor Re-education, Principles and Practice,

ed. Stanton S. Springer- Verlang, London;1994:42-8.

7.  American Physical Therapy Association.  www.apta.org

Susan C. Clinton PT, MHS, OCS, WCS is a board certified physical therapist in orthopedics and women’s health.  She is the director of the UPMC Centers for Rehab Services WomensRehab Physical Therapy Residency Program. If you should have any questions regarding Pelvic Floor Rehabilitation please contact Susan at 412-269-7062.