No longer a background player in physical therapy practice, the prospects seem bright for this growing discipline.
By Christine L. King, PT, DPT
Over the past few years, a plethora of new research has emerged related to pelvic floor dysfunction (PFD) and physical therapy intervention. This research is helping validate what women’s health physical therapists have been utilizing in their practices since the specialty area of women’s health was first introduced in 1951. As new generations of women are becoming more vocal about PFD and their desire for solutions, the field of women’s health physical therapy has grown exponentially. Today’s practitioners should have a full grasp of this discipline, and this article will help therapists understand what women’s health is, the best evidence-based practice for this discipline, and the outcomes that can be expected following treatment.
Women’s health physical therapy is a specialty field that focuses on the management of pelvic floor specific diagnoses.1 Because these diagnoses generally affect women more than men, the terms pelvic floor specialist and women’s health specialist are more or less interchangeable, but it should be noted that PFD can and does affect many men.1 It is a common misconception to assume “women’s health physical therapy” automatically implies urinary incontinence. While urinary (and fecal) incontinence does make up a large percentage of the diagnoses treated by a women’s health clinician, it is important to consider other diagnoses as well. These diagnoses include, but are in no way limited to: stress urinary incontinence, urge urinary incontinence, mixed incontinence, fecal incontinence, dyspareunia (painful intercourse), constipation, pelvic organ prolapse, vaginismus, vulvodynia, coccydynia, pudendal nerve entrapment, and interstitial cystitis.1 The term PFD is an umbrella term for symptoms that arise from some dysfunction within the pelvic musculature.
It is also necessary to consider the pelvic floor and its role in sacroiliac joint (SIJ) dysfunction, hip pain, and lumbar pain. In particular, a significant association between chronic back pain and stress urinary incontinence has been found.2 To understand this connection, we must consider the location and function of the pelvic floor. The pelvic floor muscles (PFM) are a group of muscles arranged like a sling at the base of the pelvis. Their purpose is to maintain sphincter control of bowel and bladder continence, support the pelvic organs by keeping them within the pelvic cavity, maintain sexual function (including arousal and climax), and assist with providing lumbar and hip stability. The PFMs are comprised of the superficial urogenital diaphragm (bulbocavernosus, ischiocavernosus, and superficial transverse perineal), the deep urogenital diaphragm (sphincter urethrae, compressor urethrae, and deep transverse perineal), the levator ani (pubococcygeus and iliococcygeus), coccygeus, obturator internus, and piriformis muscles. Due to various sacral, coccygeal, ischial, ilial, and pubic attachments of the pelvic floor, a unilateral rotation or upslip of the innominate bone as is often seen clinically with SIJ dysfunction would cause spasm within certain PFMs and would place other PFMs in a lengthened position. The levator ani has been shown to co-contract with the transverse abdominis, making the pelvic floor an important lumbar stabilizer.2 The obturator internus, a hip external rotator, is considered a part of the pelvic floor and often pelvic floor dysfunction is seen secondarily in patients with hip pathology such as femoral acetabular impingement (FAI) and labral tears.
CAUSES OF DYSFUNCTION
There are many sources of pelvic floor dysfunction. One possibility is damage to the pelvic floor that occurs during childbirth, with tearing of the musculature on one or both sides of the pelvic floor. There is also the possibility of needing an episiotomy with resulting scar tissue. A literature review done by Bortolini et al in 2010 found that vaginal childbirth delivery is the main etiological event for PFD.3 Repetitive falls on the coccyx (as is the case with many former gymnasts, figure skaters, and cheerleaders), or even one traumatic fall, can cause spasm in the pelvic floor muscles due to their coccygeal attachments. Sarcopenia, or the degenerative loss of muscle fibers during the normal aging process, can affect the PFM and cause progressive weakening of the musculature over time. Other causes of PFD can include trauma following sexual abuse or a bad pelvic examination. The condition can be secondary to urogynecologic or gastrointestinal conditions such as interstitial cystitis or irritable bowel syndrome. Lastly, PFD can have an unknown etiology and can be simply one piece of a greater lumbopelvic or core dysfunction.
There are multiple types of PFD. An individual can have a hypotonic pelvic floor, meaning the muscles have a low resting tone, or are functionally long. A person also may have a hypertonic pelvic floor, meaning the muscles have a high resting tone, or are functionally short. It is also possible to have mixed tone within the pelvic floor musculature—meaning there is an asymmetry of tone with one side being “short and strong” and the other side being “long and weak.” This can be the case following vaginal delivery childbirth, with scar tissue causing hypertonicity on one side, which creates a pull on the other side and causes a lengthened hypotonicity. Mixed tone such as this often causes dyssynergia, or lack of muscle coordination. This will result in insufficient contraction or relaxation of the pelvic floor and can lead to a variety of symptoms including urinary or fecal incontinence, painful intercourse, coccydynia, lumbar or sacroiliac pain, pudendal nerve entrapment, or pelvic pain.
SEE THE BIG PICTURE
As mentioned earlier, lumbar, SIJ, and hip pain and dysfunction often go hand-in-hand with PFD. Because of this, it is important women’s health practitioners have a solid foundation of orthopedic and musculoskeletal knowledge. Likewise, it is important to be able to tease out pelvic pain secondary to PFD versus groin pain secondary to FAI or hip labral tear. It is also important to consider the rest of the core and its role in PFD. The core is meant to function like a house: the roof of the house is the diaphragm, the abdominals, erector spinae, obliques, and intercostals are the sides, front, and back of the house, and the bottom of the house is the pelvic floor. The musculature needs to be both pliable enough to move with changes in intra-abdominal pressure, and strong enough to withstand the pressure without allowing the external sphincters to open. For the house to stand strong, each piece must do its part. It is quite common to see levator ani weakness with underlying lumbar pain, or vice versa.2 It is also common to see SIJ dysfunction with PFD, especially in the case of asymmetric pelvic floor tone. If a therapist becomes pigeonholed into treating only pelvic floor-related diagnoses, they will often miss these other big pieces of the puzzle that are vital in restoring function.
EVALUATION AND TREATMENT
Given the broad scope of what women’s health physical therapy can encompass, the question remains: How are these conditions managed with physical therapy, and what does current research say about effective treatments? As is the case with any field of physical therapy, it is important to address all contributing factors to the dysfunction, and not chase symptoms. A thorough subjective evaluation should be done to identify any comorbidities and aggravating and easing factors, and to identify the patient’s goals for treatment. During the objective portion of the examination, the lumbar spine, SIJ, and hip should all be screened as contributing factors to symptoms and for possible underlying dysfunction. Direct palpation of the pelvic floor muscle, via a single gloved digit inserted vaginally by the therapist, is the best way to assess for hyper- or hypotone with the PFMs. During the internal portion of the exam, the therapist also can assess for scar tissue or poor mobility of an episiotomy scar, and can conduct a formal strength assessment via manual muscle test (MMT) of the pelvic floor. While assessing strength, it is important to also assess endurance, quick contraction ability, and coordination of the muscle (ie, smooth contraction and relaxation).1
In cases of hypotonicity, there is not always a significant need for internal soft tissue mobilization (STM) to the pelvic floor but rather there is a need for neuromuscular re-education of these muscles. Often patients have been performing what they thought was a “Kegel,” but they are overrecruiting their hip adductors, gluteals, or abdominals and not producing a pure levator ani contraction. Verbal and tactile cueing is often required for this, and some practitioners like to use electromyography (EMG) for biofeedback. These patients often report issues with urinary or fecal incontinence, pelvic heaviness (prolapse), and lumbar or pelvic pain. Research shows that a 3-month program of pelvic floor exercises instructed by a physical therapist is the most effective way to improve stress urinary incontinence.4 Traditional core strengthening exercises may be used as well for overall core conditioning to improve urinary incontinence,5 and some patients do very well with Pilates-based training, which emphasizes a neutral spine and stable pelvis. Hip abduction strength has been shown to be 12% weaker in women with stress urinary incontinence,6 making the gluteus medius/minimus an important muscle group to consider in addition to the transverse abdominis and rectus abdominis.
In the case of hypertonicity, internal STM directly on the specific PFMs that are involved is often the best way to decrease spasm. Practitioners commonly use sustained pressure on the muscle until they feel the muscle relax and blood flow return to the tissue. Neuromuscular re-education (manual or EMG) can be used with these patients to “downtrain” the muscles, or to teach the patient how to achieve normal resting tone. It is best to hold off on abdominal exercises until the practitioner feels the patient has a good understanding of levator ani versus abdominal contraction to avoid accidental “uptraining” of the pelvic floor. Research has emerged that shows more than 85% of patients with interstitial cystitis have one or more myofascial trigger points within the pelvic floor, and more than 65% have multiple myofascial trigger points within the pelvic floor.7 The study concludes that evidence shows a connection between pelvic floor muscle pain and interstitial cystitis.7 The pelvic floor also has myofascial connections with the hip adductors, gluteals, hamstrings, and lower abdominal fascia. For this reason, it may be appropriate to perform skin rolling or other forms of myofascial release (MFR) on these muscle groups in the case of global PFM spasm, as is often seen in cases of interstitial cystitis, dyspareunia, vulvodynia, vestibulitis, or coccygeal trauma. A stretching regimen keeping the lumbar, hip, and shoulder ROM within normal limits is also indicated with these patients at times, and yoga may be an appropriate maintenance tool in these cases.
In cases of mixed tone, or asymmetry of tone within the pelvic floor, there likely will be some combination of both strengthening exercises—as with hypotonia—and direct manual techniques to improve muscle extensibility—as with hypertonia. It is important for the practitioner to determine where the asymmetry is and which side requires STM/MFR. Any SIJ or hip dysfunction should be addressed at this time as well. Often neuromuscular re-education for symmetrical recruitment and relaxation of the pelvic floor is helpful in treating these conditions.
Allied health professionals can be helpful team members in adjunct to physical therapy for management of these issues. Acupuncture, massage therapy, yoga/Pilates, and guided imagery can all dovetail nicely with a physical therapy program for symptom management.
WHEN TO REFER
In states with direct access, it is important to understand when to refer out if a patient has not yet consulted with a physician. If an active infection is suspected, this is obviously grounds for immediate referral. If any type of coccygeal trauma is suspected, it may be necessary to refer out for imaging to rule out a fracture. If a patient is exhibiting signs and symptoms of interstitial cystitis that has not been formally diagnosed, referral to a urogynecologist is necessary as there are several helpful pharmacological interventions they can prescribe. The hip, lumbar spine, and SIJ should be screened for major pathology and referred out to a specialist if there is suspicion of hip labral tear or FAI, fracture, lumbar herniated nucleus pulposus, cauda equina syndrome, etc. The basic rules of screening should be followed, and it is always safe to refer out if the therapist cannot reproduce the patient’s pain or if the patient exhibits signs/symptoms of systemic pathology. In patients complaining of pelvic pain without a current normal pap smear or pelvic exam, referral to a gynecologist is warranted. There are many possible reproductive causes of pain such as endometriosis, pelvic inflammatory disease, follicular cysts, or dysmenorrhea that may be contributing to their symptoms and can be managed by their gynecologist.
Women’s health physical therapy is an exciting and fast-growing field, with new research emerging continuously. This new research is helping to validate what women’s health physical therapists have been doing in their practices for some time. A study by Dusi et al in 2012 found that physical therapy intervention significantly improves pelvic symptoms and health-related quality of life among women who have a primary diagnosis of urinary incontinence,8 but that piece of evidence is something women’s health practitioners have observed in their practice for many years prior to 2012. As new generations of women become more vocal about pelvic floor dysfunction, it is important that all practitioners—not only women’s health specialists—be comfortable asking questions to ascertain whether a patient may be a good candidate for a women’s health evaluation.
We are in an exciting time in the field of women’s health, where research is finally catching up to clinical practice and the demand for treatment. As the field continues to grow, it is important that practitioners keep up with evidence-based practice and continue to expand their skill set to provide the best possible care. RM
Christine L. King, PT, DPT, is Director of the Women’s Health Program at Mariners Physical Therapy, an outpatient private practice in Santa Ana, Calif. King received her DPT from Chapman University, Orange, Calif. She practices a hybrid of orthopedic manual therapy and women’s health physical therapy. For more information, contact RehabEditor@nullallied360.com