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Pelvic Floor Therapy -Biofeedback and more

Conservative treatment for Pelvic Floor Disorders

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What is Biofeedback?Biofeedback is a technique in which people are trained to improve their health by learning to control certain internal bodily processes that normally occur involuntarily, such as muscle tension (i.e.: pelvic floor muscle tone) via the use of a computer screen portraying the activity of the pelvic muscles.

Urostym – Biofeedback and More Laborie Medical Technologies

Purpose, Characteristics, Function

Purpose1. Aide in identification of target muscles2. Use conscious awareness to properly work muscle

to void or stool. 3. Learn relaxation in those with retention,

constipation4. Requires desire and motivation for improvement of

life over time and with effort.5. With Uroflowmetry, addresses voiding dysfunctions

by allowing the patient to view their muscle use during voiding.

Patient Requirements1. Cognitive awareness2. Able to participate3. Understands the need to do homework4. Aware this is not a ‘quick fix’5. At least partial innervation of Pelvic Floor

Muscle6. Motivated to change7. Engaging and knowledgeable Therapist

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Review of anatomy –as relating to the pelvic floor

The pelvic floor supports the bladder, and helps to maintain

continence.

During voiding, the pelvic floor must relax and allow the

free flow of fluid


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Pelvic Floor MusclesSlow Twitch Muscles fibers (Type 1 muscle fibers) Predominant muscle fiber in the pelvic floor; physiologically suited to provide sustained pelvic muscle tone over prolonged periods of time. Comprise about 70% of pelvic floor musculature.

Fast Twitch Muscle fibers (Type 2 muscle fibers) Comprise about 30% of the pelvic floor muscle fibers, physiologically designed to provide rapid contraction needed to increase sphincter tone when there is a sudden increase in abdominal pressure, as seen with stress incontinence.


Pelvic Floor Musculature

Three layersSuperficial layer: the perineum

Intermediate Layer: the uro-genital diaphragm

Deep Layer: the pelvic diaphragm

Superficial layer

Paired ishiocavernosis and bulbospongiosis muscles

Superficial transverse muscle

External anal sphincter – placement of surface electrodes

Intermediate Layer

- External urinary sphincter

- Deep transversus muscle

Deep layerPaired:

1. Pubovaginalis muscles2. Puborectalis muscles3. Pubococcygeus muscles4. Iliococcygeus muscle-these 4 make up the Levator Ani Group5. Ishiococcygeus muscles

Innervation of Pelvic Floor

Pudendal nerve

S2, 3, 4

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Types of pelvic floor dysfunctionStress incontinence – the loss of continence during exertion : cough, laugh, exercise

Urge incontinence – the loss of continence due to a sudden overwhelming need to void (or evacuate)

Dysfunctional voiding – a learned behavior where the pelvic floor does not relax to allow completion of voiding or bowel movement.


Abbreviated pelvic floor examExternal EvaluationSkin condition and hygieneSensation: should feel same sensation to touch and pressure on both sides of midlineVisibility of pelvic floor contraction:

Central perineal tendon should move in a superior and an anterior directionContraction should be limited to pelvic floor musculature only

Compensation during pelvic floor contraction

Pt often contract adductors (close legs), gluteii (buttock) muscles, or overuse the abdominal muscles in an attempt to do a pelvic floor contraction

Pt typically compensate if they have decreased proprioception (muscle awareness), if they have decreased strength or if they are in pain

Pelvic floor Exam cont’d.Internal Evaluation – digital examMuscle tone

What the muscle is like at restVerify by testing the resistance to passive stretchGrade as: low, normal, or highMuscle contractilityGrade from 0 to 5 (Oxford Scale) or -1 if inversion of perineal command

Oxford scale of muscle contractility

0 No contraction1 Trace2 Perceptible contraction3 Good contraction, can’t sustain resistance4 Can sustain moderate resistance5 Can sustain max resistance

Pelvic Floor ExercisesStrength

Speed

Endurance

Functional applications

The KnackTight perineal closure

An active mechanism used to compensate for a functional deficiency (conscious control)

Objective is to develop a conditioned reflex

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Who could benefit from PFR?

Patients who suffer from:Urinary incontinence (stress/urge/mixed)Urinary retentionChronic pelvic pain (prostatitis, vaginismus, etc)Chronic constipationFecal incontinence Sexual disordersDysfunctional voidingPost-prostatectomy, post-partum


Purpose, Characteristics, Function

Purpose1. Aide in identification of target muscles2. Use conscious awareness to properly work muscle

to void or stool. 3. Learn relaxation in those with retention,

constipation4. Requires desire and motivation for improvement of

life over time and with effort.5. With Uroflowmetry, addresses voiding dysfunctions

by allowing the patient to view their muscle use during voiding.

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How does biofeedback help?

•It is patient controlled – empowering through conscious awareness, to take charge of their pelvic floor issues.• It offers an option for those who do not want surgery or medication•It does not prevent or complicate future surgery•It may be used in combination Rx


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Biofeedback

Terminology

is the “old term” for pelvic floor re-education or rehabilitation, more to the point, biofeedback is one aspect of Pelvic Floor Therapy

Electrical stimulation is the delivery of electrical current to stimulate muscle contraction, another option in Pelvic Floor TherapyPelvic Floor Therapy includes the above options along with: bowel and bladder management, fluid and nutrition awareness, posturing, anatomy and physiology of pelvic floor and elimination, positive affirmations and breathing.


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Biofeedback for PFRHow to measure muscle tension?

For pelvic floor training, electromyography (EMG), measures actual muscle tension and relaxation (muscular electrical activity)

Manometry (pressure), a technique that monitors pressure change related to the muscle. Or the actual strength and weakness of the muscle with an internal probe.

Urostym – Biofeedback and More Laborie Medical Technologies August

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Biofeedback for PFRmonitor PF EMG activity through vaginal/anal probe or surface electrode patches.monitor PF pressure through vaginal/anal manometry probe.monitor abdominal muscles EMG through surface electrode patches.Only surface electrodes (EMG) are on children


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Treatment follows accurate diagnosis of urinary / fecal dysfunction

Urodynamic studies pinpoint the cause of the symptoms

A trial of Pelvic Floor exercises may be done –the patient receives verbal instructions to strengthen the muscles by contracting the pelvic floor –often unsuccessful because patients are not able to correctly perform the exercises, or the pelvic floor is just too weak to contract:

Often these exercises are taught by instructing the patient to stop and start the urinary stream during voiding

Modern physicians discourage this now, since it is interfering with the natural voiding function, and can lead to bad habits


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The advantage of pelvic floor re-education in a clinical setting

The clinician and the patient are able to visualize the muscle activity

confirms they are contracting the proper muscle groupThe clinician becomes a personal trainer and provides positive reinforcementProgress can be monitoredA Session is terminated if patient shows fatigue and recruits abdominal musclesImprovement is often reported after 3 sessions!


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Typical treatment programs

First, the diagnosisNext, begin pelvic floor re-education sessions

Most often, done once weekly for a period of 6-8 weeksFollow up to assess success and reinforce proper techniqueHomework of exercises performed 3 to 4 times daily along with bowel and bladder management, improved fluid intake, and possibly bladder retraining.


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Success?

It has been found that the success rate is 75-85% -either complete “cure” or improvementWithin one year, the symptoms will return if exercises are discontinued

This is a lifelong commitment for the patient – the monitored training is just the beginningSome may return for a ‘tune up’ 6 mo to a year later!


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UrostymProvides monitoring of both pelvic floor and abdominal muscles

This confirms that only the right muscles are used

Tracks improvement

Provides electrical stimulation (when appropriate) to help strengthen muscles even before the patient can contract the muscles voluntarily


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Cautions/ correct useInternal probes are only used with adultsElectrical Stimulation is never used with childrenInternal probes are contraindicated whenever it is not appropriate – such as the presence of open wounds, or when placing an internal probe is painful or extremely distasteful to the patient, hemorrhoids

But remember that internal probes allow treatment to be more specific (by being physically closer ) to the levator ani muscle


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The contraindications for Electrical Stimulation (ES)

Persons with the following conditions should not use electrical stimulation: 1. Complete denervation of the pelvic floor 2. Dementia 3. Demand cardiac (heart) pacemaker 4. Unstable or serious cardiac arrhythmia 5. Pregnancy or planning/attempting pregnancy 6. Broken/irritated peri-anal skin 7. Rectal bleeding 8. Active infection (UTI/vaginal) 9. Unstable seizure disorder 10.Swollen, painful hemorrhoids


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Electrical stimulation as part of pelvic floor rehabilitation

Electrical current is administered through the EMG vaginal or anal probe, or through surface electrode patches.

Manometry probes (pressure) are not be used for electrical Stimulation


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Understanding Current

Pulsed ,bi-phasic current: Particles move in one direction, according to their charge, fall briefly to zero, and then reverse direction.

Current Amplitude:Amplitude is the intensity of the current ( measured in micro-volts)


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Understanding Current

Current Frequency:The number of pulses that are generated per

unit of time (seconds). (measured in Hz)Band width:

The duration of each pulse (measured in microseconds)


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Current for PFRLower Hz 10 to 12 are used for pelvic pain

20 Hz is usually used for Urgency/Frequency and Urge Incontinence.

Higher Hz 50 to 100 are used for Stress incontinence.

Hz 200 are used for urinary retention


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What happens during PFR?EMG or pressure probe (vaginal /anal) is inserted Note: An EMG probe can monitor muscle tension (electrical activity) and can administer ES. A pressure probe can only monitor change in pressure

Surface electrodes are placed on the abdominals to monitor EMG activity in this areaThe information gathered is fed to a computer screen, and the therapist then leads the person in exercisesThrough trial and error, participants learn to identify and control their pelvic floor muscles


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Pediatric ApplicationsBiofeedback performed with surface electrode patches only –no probesNO electrical stimulationOften combined with Uroflowmetry to diagnose voiding dysfunction: patient arrives with full bladder, patches positioned perianally and abdominally and uroflometry is performedThe goal to allow complete bladder emptying through relaxation of the pelvic muscles


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Female Probe Placement


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Male Probe Placement


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Animation for Uroflow


44 Urostym – Biofeedback and More Laborie Medical Technologies

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Monkey Game


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Alien shoots down Asteroids!


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Continence Therapy SummaryPelvic Floor Therapy includes a multitude of

approaches:1. Electrical Stimulation2. Biofeedback, Manometry3. Uroflowmetry4. Bladder and bowel training5. Behavior modification6. Posturing7. Positive affirmations to build confidence and

empowerment


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Pelvic Floor Therapy: The means to helping Patients

to takeCONTROL!


Date post:	24-Mar-2018
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