From a Physical Therapy Perspective
By Christine Ladyga MS, PT
The process of urination and defecation are interrelated and very complex. Physical therapists are an integral member of the evaluation and treatment team when certain problems are evident in regard to continence. They are able to evaluate and treat multiple issues within the dysfunction of these systems.
Physical therapists and assistants are experts in musculoskeletal and neurologic symptoms. Nerves involved in these systems are sympathetic, parasympathetic, as well as sensory and motor nerves from various spinal roots. Muscle tissue is both smooth and striated. And the primary bony structure is the pelvis with joints, ligaments and multiple muscle attachments.
Using Primary Skills in Specialized Ways
Physical therapists with specialized training and understanding of the urinary and colorectal systems are best prepared for intensive individual evaluation and treatment. However, the primary skills utilized are common to all physical therapists and PT assistants. Since the evaluation process is a physical therapy evaluation, many aspects are standard practice. With little additional information, therapists can uncover complaints or problems related to the pelvic floor. The primary purpose of this information on evaluation is to provide insight into pelvic floor dysfunction, allowing non-specializing therapists and assistants to be of assistance to clients with methods already familiar to them, and improve their recognition of the need for expertise in these problems.
Pelvic floor dysfunction can be due to a variety of diagnoses. However, the primary complaints are pain or inability to voluntarily control urination or defecation. The problem may be initiating, sustaining or stopping these functions.
Evaluation begins with a medical history. This includes gathering information regarding medications, surgery, a description of pain symptoms and past treatments. Additionally, details regarding obstetrical and gynecological history, urinary tract health, and bladder and bowel habits assist in determining the correct treatment approach. The client's perception of the impact this problem has on daily life includes changes in activities and/or relationships due to the particular problem, and frequently feeling alone and isolated since the problem is not readily discussed. A patient's normal physical activity level is also used to determine individual approach.
There is no precise order to the other aspects of the evaluation process and many are standard physical therapy practice. A postural assessment is necessary; focuses are on thoracic mobility, pelvic alignment, pelvic stabilization and sitting positions. Breathing excursion and rate are noted, indicating a client's ability to deep breathe and relax.
Neurological screen and muscle assessment are done dependent on the primary complaints, with more detail in the areas related to the pelvis. Abdominal strength is graded. Hip range of motion and strength are assessed and imbalances or problems noted.
Gait is screened with pelvic motion of primary concern. Functional activities are also assessed including changing position and lifting. Often, instruction in body mechanics with use of muscle bracing is most beneficial to reducing pressure on the pelvic floor and perineum, thus reducing incontinence and/or prolapse of pelvic organs.
Trigger point assessment will assist to indicate muscular areas that may be contributing to the pelvic floor problems. The abdomen, hip adductors, external rotators of the hip, coccyx, sacral and low back points are usually of prime concern. These muscles, as well as the muscles of the pelvic floor, all use the pelvis as origin or insertion of fibers. Their health and ability to function optimally affect the pelvic floor muscle function.
The perineum is observed. This observation includes skin condition and scars. Adhesion or tenderness of an episiotomy or surgical scar can be treated similarly to other scars. The evaluation of color, tenderness and mobility will determine the preferred approach. The sensation is assessed through touch, using an external technique called the pelvic clock. The top of the clock face covers the urogenital triangle from the pubic symphysis to the peroneal body and the bottom half the anal triangle. Each position on the clock face corresponds to a specific muscle in the pelvic floor muscle group. The assessment provides the therapist with feedback related to sensation, tenderness and muscle bulk. There are also specialized tests indicating position changes in the pelvic organs and weakness in the function of the muscles.
The manual muscle test is done internally. Again, palpation skills are utilized to assess sensation, muscle bulk, coccyx position and tone of the walls. Then the pelvic floor muscle is graded for strength. The scale is 0-5, with "fair" or grade 3 indicating ability to work against gravity. The muscle is graded on both the left and right side. The client's ability to hold a contraction is timed in seconds, and the possible repetitions prior to fatigue are noted. Then the number of quick contractions are rated indicating phasic ability. During these contractions there is an observation of use of accessory muscles, breathing pattern with contractions, response speed and ability to relax.
Use of Modalities
Biofeedback, a surface EMG assessment of the pelvic floor muscle function, gives a specific baseline at initiation of treatment and a clear visualization of the muscle activity to both the therapist in designing treatment and the client in the function of the pelvic floor muscle. The electrodes used may be external or internal depending on the client's preference, and contraindications for either type.
Both types of electrodes are used by only one individual client. Most clinics have policies that expect the client to keep the electrode and bring it to the next session rather than store it at the clinic.
The position of the client should be noted to assure proper comparison with reassessment. The evaluation may vary from therapist to therapist but should include a resting baseline, a specific number of quick flick contractions, and hold or endurance contractions. Optional tests may be done related to the chief complaints. For example, a reading during a functional activity that usually causes leakage may show lack of awareness of proper use of the muscle group.
In one particular case a functional test became the primary treatment. The client arrived in the summer, complaining about incontinence when getting up from a low beach chair. She was able to tolerate occasional leakage at other times, but now in a bathing suit did not want to wear an absorbant product. She made it clear she was not giving up the low beach chair. Her muscle grade on evaluation was functionally adequate. Observation visually and using biofeedback during her transition from a low chair, showed a technique that included valsalva and minimal use of the pelvic floor. Instruction and one additional visit was all that was needed to solve a functional problem.
Another issue is the personal aspect of the presenting problems and the evaluation process. Most physical therapists use a Consent to Treat form that includes an explanation of the internal manual muscle test. It specifically addresses the client's right to refuse or stop the evaluation at any time. It is also essential that each evaluating therapist continually observes the comfort level of the client. Observation is ongoing during the evaluation and later treatments with particular attention to behaviors indicating disassociation, prompting a discontinuation of the session. Many physical therapists also offer to have another person present, either related to the client or another employee.
The evaluation process is similar to all physical therapy evaluations and is the primary determinant of subsequent treatment approaches. Treatment sessions frequently begin at the evaluation visit. The initial education offered during the gathering of information often changes the way clients approach their problem. It is the first step to identifying a cause that is controlled by the clients and that they may participate in changing. The option of behavioral approaches to bladder, bowel and pelvic pain treatment through physical therapy should be available to all clients.
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Wallace, K. (April 1994). Female pelvic floor functions, dysfunctions, and behavioral approaches to treatment. Clinics in Sports Medicine, 13(12).
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Christine Ladyga, Norwich, CT, practices in long-term care and at four outpatient locations developing women's health programs, mentoring, and consulting in women's health. Professional memberships include Women's Health Section of APTA, Pelvic Pain Society, International Foundation for Functional Gastrointestinal Disorders, and National Vulvodynia Association.