Abstract
Pelvic floor muscle spasm is one of the most common reason for pelvic pain, and it often coexists with other pelvic pain conditions. Oral muscle relaxants do not seem to be helpful in these patients and vaginal suppositories seem to relax muscles much better. A combination of diazepam 5 milligrams placed vaginally, baclofen 4 milligrams, and ketamine 15 milligrams used before bedtime works well on pelvic muscle spasm. The mainstay of treatment of pelvic floor muscle spasm is pelvic floor physical therapy. It is best done by Women’s Health physical therapists who are specifically trained in pelvic floor dysfunction. Patients who fail physical therapy may be candidates for injections of botulinum toxin into pelvic floor muscles.
Editor’s Introduction
Pelvic floor muscle spasm is one of the most common reasons for pelvic pain, and it often coexists with other pelvic pain conditions. Oral muscle relaxants do not seem to be helpful in these patients and vaginal suppositories seem to relax muscles much better. A combination of diazepam 5 milligrams placed vaginally, baclofen 4 milligrams, and ketamine 15 milligrams used before bedtime works well on pelvic muscle spasm. The mainstay of treatment of pelvic floor muscle spasm is pelvic floor physical therapy. It is best done by Women’s Health physical therapists who are specifically trained in pelvic floor dysfunction. Patients who fail physical therapy may be candidates for injections of botulinum toxin into pelvic floor muscles.
Treatment Planning and Goal Setting
The treatment of pelvic pain has notoriously been difficult due to the likelihood for multisystem involvement; interconnected symptoms; and lack of evidence demonstrating a clear benefit of one treatment, intervention, or technique over another. As discussed in Chapter 5, it is clear that often a patient’s pain can be reproduced or aggravated by testing intrapelvic and extrapelvic structures. Deciding how to prioritize the multiple impairments and patient complaints can be challenging; however, it is necessary for successful treatment. The clinician must be able to tease apart the primary drivers causing the patient’s symptoms: an organ or organ system, biomechanical deficiency, or pathological process.
There are various interventions including procedures, medications, and manual techniques that can be implemented to help address the patient’s pain with specificity once the primary driver of the pain is identified. This chapter focuses on conservative treatments that can be utilized including referral to pelvic health physical therapy and education/techniques the primary clinician can provide if referral to physical therapy is difficult because of the location of the patient and lack of available referral sources.
To guide clinicians in their treatment and plan of care development, it is helpful to apply the definition of evidence-based medicine proposed by Sackett and Haynes, which is the “conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” [1]. This involves integrating the best available current evidence, which in the case of pelvic pain is still evolving, with clinical expertise. As of now, there are no clear conservative techniques or treatment approaches that have been found to be superior therefore the clinician’s proficiency and judgment they have acquired through clinical practice is heavily relied upon. Increased expertise in a clinical area is reflected in more effective and efficient diagnosis and in the integration of the individual patient’s values and preferences that shape how the patient experiences and conceptualizes her pain symptoms. Within the context that the patient creates, it is important for the clinician to provide options to allow the patient to choose her preferred treatment that will help her progress toward her stated goals [2].
Utilizing this definition helps to not only identify the driver of the pain but also assists in the treatment planning process. When reflective critical thinking and expertise are integrated with a thorough assessment, the primary impairment, or driver, is often identified and an initial treatment plan can develop [2]. It is important to note that the primary driver of the pain may not always be a painful tissue and focusing treatment solely on the painful tissue may not yield successful results. Other systems, structures, or biomechanical habits may be dysfunctional and impaired but pain free and could be the underlying driver(s) that is/are causing pain in other systems or tissues due to excessive stress or overuse. To create a holistic picture of the patient’s pain as well as develop a successful treatment plan, it may be these nonpainful structures or systems that need to be addressed in addition to the painful sources.
Identifying what tissue or structure hurts does not explain why it is hurting or why the patient is in pain. Often the question of why a structure is painful can and should be answered through a collaborative effort. It is often not possible for a clinician consulting in a medical setting to be able to take the time required to glean the necessary information from subjective interviewing; objective assessment of all integrated components to the patient’s pain; as well as deciphering and discussing the patient’s individual pain experience, goals, psychological status, and impacts to her functional abilities and daily life. Referral to collaborative and complementary providers is often necessary and recommended to help create a whole picture of the patient and her pain symptoms. This next section will specifically focus on what the pelvic health physical therapist is able to provide as a referral source to the clinician including an overview of treatment techniques often utilized in the pelvic pain population.
Faubion et al. suggest that referral to physical therapy early on in the patient’s treatment planning should be a “cornerstone of management” for patients with pelvic pain [3]. Physical therapy is a profession grounded in a theoretical and scientific base with the goal to help individuals restore, maintain, and develop optimal physical functioning to allow for enhanced quality of life [4]. The focus in not just on the physical impairments of the body structures and functions but also on how those impairments impact a person’s ability to participate in her activities of daily living and in her community and environment at large. This whole person approach is based on the concept developed by the International Classification of Functioning, Disability and Health (ICF), which is a World Health Organization approved system designed to classify heath and health-related states. The ICF is a biopsychosocial model of disability that conceptualizes a patient’s level of functioning as a dynamic interaction between their health conditions, how that impacts her ability to function at the individual and society level, and how environmental factors affect her experience [4].
Physical therapists are experts in the assessment of the musculoskeletal system and how dysfunctions and impairments within this system can impact or be impacted by other bodily systems, pathologies, and injuries. Pelvic health physical therapists have additional knowledge and specific skill sets to be able to assess and treat musculoskeletal impairments of the pelvic floor and integrate how that relates to and impacts the larger body system and person. The role of the pelvic health physical therapist in the treatment of pelvic floor dysfunction is to work in concert with other medical professions such as urologists, urogynecologists, colorectal specialists, as well as psychologists, nutritionists, and integrative medicine doctors to help develop and implement an overarching individualized treatment plan. As discussed in Chapter 5, pelvic health physical therapists evaluate the structure and function of the pelvic girdle and address conditions or impairments noted through numerous hands-on and other modality techniques that will be described further in the next section. The development of goals and treatment planning is a collaborative process between the therapist and the patient, integrating the patient’s conceptualization of their symptoms as described earlier to allow for the most optimal outcomes possible [4].
Through detailed evaluation and assessment of the patient with pelvic pain, the therapist is able to determine the primary driver(s) of the symptoms and treatment planning is then based on this information within the context of the patient’s specific goals. It is typically difficult, if not impossible, to determine at times which dysfunction may have appeared first. The pain could be originating from pelvic floor muscle dysfunction in the form of overactivity that over time has led to dysfunctional voiding and painful bladder symptoms. Alternatively, visceral dysfunctions, although not directly related to muscular involvement, may over time cause guarding within the pelvic floor and eventually pain due to chronic holding patterns. The viscera and pelvic floor muscles may both be considered the drivers of the continued pain and both must be treated simultaneously to reach optimal interventional success. One can see how pelvic pain can begin as a singular issue or complaint that, if not addressed properly or due to chronicity of symptoms, can spread out to include other systems. The patient with an initial visceral issue such as irritable bowel syndrome (IBS), due to episodic and chronic pain the abdomen, may develop pelvic floor tension and overactivity from increased frequency of bowel movements eventually leading to pain during bowel movements and increased tissue tension in the extrapelvic muscles including within the abdomen and lower extremities. The patient may develop postural deviations and poor mechanics during activity, causing shortening in the hip flexors, abdominals, and diaphragm, which further limits trunk movement and perpetuates further cranial movement of the pain into the shoulders, jaw, and neck, causing headaches and further impaired function and activity participation [5]. Decreased participation and withdrawal from activity can impact the patient’s mental status, leading to depression and further social isolation. At this point, the pain becomes a cycle with each system and area setting off the other, impacting the patient’s ability to cope and the clinician’s ability to effectively treat the pain. This type of patient presentation is not uncommon in the chronic pelvic pain world, and deciding where to start in terms of treatment is challenging; however, it is important to focus on what the potential initial drivers to the pain may have been including the visceral dysfunction of IBS and pelvic floor tension in this example. Working our way from the “central” pain driver can help to impact the more “peripheral” issues that are likely due to compensatory strategies the patient has developed in response to the pain.
In the process of establishing a treatment plan, the clinician must determine patient-identified goals and how to show incremental progress toward the desired outcomes. Patients are encouraged to describe their lifestyle and activities that they wish to resume and the therapist can work on creating measurable goals for each of the impairments and domains that are affected by the patients current conditions.
It is important to describe to the patients that the progress expected may be slow and may have some challenges as the body responds to the demands placed on the system to encourage adaptation and recovery. This means they may experience flare ups from overuse or fatigue as they try to establish how much they can do an activity or an exercise before they have maxed out the resources for their current tolerance.
The clinician should include goal setting, which involves not only increases in activity tolerance but recovery from activities as well. For a woman who may experience postcoital pain, her goal may include reducing the soreness and discomfort from 12 hours to 1 hour after sexual activity.
Keeping daily pain intensity journals is not usually recommended except to establish a pattern of the nature of the pain experience. It is the clinician’s role to maintain records of activity-specific limitations and pain levels so that when reassessing a patient, it can be referenced to demonstrate progress or persistent disability.
Physical Impairment–Based Interventions
Interventions discussed in this section are considered conservative in nature and are targeted mainly at pelvic floor, abdominal wall, and hip musculature dysfunctions. These interventions are not used in isolation. One area of the musculoskeletal system may require a reduction of activation; another may require increased stability and strength. Patients with pelvic pain may be found to have overactivity at the puborectalis leading to dyspareunia symptoms, particularly during initial penetration; however, they also demonstrate true pelvic floor weakness and a lack of tenderness to palpation within deeper pelvic floor muscles as is sometimes the case with women who are postpartum reporting incontinence, low back pain, and dyspareunia. As there are overlapping symptoms, overlapping treatments are commonly implemented. In fact, a patient may need to begin with strategies to relax and lengthen the pelvic floor and then progressing to strengthening the intra- and extrapelvic muscles within the context of training the postural, respiratory, and biomechanical systems through facilitation techniques and education.
As discussed previously, pelvic floor overactivity can be the primary driver or a response to the patient’s pain symptoms. Pelvic floor muscles that are overactive can be functionally short, meaning there is no length change to the muscles; however, the patient may consciously or subconsciously be clenching. Functionally short pelvic floor muscles will demonstrate elevated resting tone when assessed using surface electromyographic (SEMG) biofeedback. Alternatively, patients with pelvic floor overactivity may also demonstrate structurally short muscles. In this scenario, there is a length change of the muscles and therefore no elevated muscle activity is required to maintain the muscles in this shortened position, as they have become “fixed” into this position. During SEMG biofeedback, there would be no elevation in resting tone; however, on palpation trigger points reproducing pain would likely be present and the tissue quality of the muscles would appear taut. In addition to the intervention described earlier, these patients likely benefit from an increased frequency of manual stretching and use of dilators or other internal release devices depending on what areas of the pelvic floor are demonstrating this dysfunction. Interventions to address overactivity may include manual techniques, therapeutic exercise, dilators, modalities, relaxation training, and patient education. These various techniques will be further discussed in the following sections.
The goal with patients with overactive pelvic floor muscles is to relax the pelvic floor muscles through bringing awareness to the clenching pattern, optimizing breath and postural patterns that could contribute to the holding of the pelvic floor muscles and relaxation techniques introduced to the intrapelvic as well as extrapelvic girdle muscles. Another goal with these patients is to lengthen the muscle to an appropriate resting state – ready for its tasks.
Interventions for Overactive Pelvic Floor Muscles
Manual Therapies
Manual therapy can encompass a multitude of techniques that are typically employed by the pelvic health physical therapist when focusing on pelvic floor overactivity. Indications for manual treatment may include pain with pelvic floor contraction, taut bands or trigger points identified within the pelvic floor, and presence of restricted movement of the fascia overlying the muscle fibers.
It was found in one study that myofascial trigger point release led to resolution or significant [6] improvement in symptoms in 83% of cases, lessening the overactivity of the pelvic floor musculature, and in turn decreasing bladder inflammation and central sensitization [7]. Manual release techniques provided by pelvic health physical therapy have shown success in the treatment of bowel and bladder dysfunction, pelvic pain, and sexual dysfunction [7–10]. It is important to consider that although release of the trigger point can be beneficial, the presence of trigger points is likely perpetuated by other factors that could include postural malalignments, biomechanical dysfunctions, and asymmetries or poor movement patterns and habits. Addressing these factors is necessary to be able to resolve completely the symptoms caused by the trigger points. Thiele’s massage is a classic manual intervention for relieving pain and trigger points in the levator ani and coccygeus muscle groups. This technique emphasizes a stroking motion along the overactive pelvic floor muscle from origin to insertion with periodic sustained holds when active trigger points are identified [11].
The prevalence of myofascial dysfunction in women with interstitial cystitis/bladder pain syndrome (IC/BPS) reported has varied from 14% to 23% to as high as 78% [12]. Restrictions in the fascia can be due to trauma, posture, musculoskeletal conditions, or inflammation. Myofascial release is a manual therapeutic approach developed by John Barnes that targets the fascia [13]. Myofascial release has been found to significantly improve pelvic pain related to urological dysfunctions compared to global therapeutic massage [9]. Release to the myofascial system involves a gentle, hands-on approach that can be applied throughout the entire body, helping to improve posture, range of motion, and pain reduction [14]. Once the therapist determines where the fascial restrictions lie, gentle pressure is applied in in the direction of the restriction focusing first on the elastic component of the fascia progressing to the collagenous barrier. This may involve maintenance of pressure for up to 120 seconds. As the barrier is released, the therapist follows the motion of the tissue until all barriers are released [13].
Visceral mobilization was developed in the 1970s by Jean-Pierre Barral, a French osteopath and physical therapist. This technique assists in aligning and balancing various functional and structural imbalances throughout bodily systems including the musculoskeletal, nervous, urogenital, digestive, lymphatic, and vascular. Within a healthy system working optimally, all of these interrelated components move with fluidity. Impairments or adhesions restricting the motion dynamics between internal organs, fascia, and ligaments can lead to chronic pain and irritation. Adhesions and strains in this connective tissue can be due to surgery, illness, injury, or habitual postures. The approach aims to evaluate and treat structural relationships between the viscera and their fascial or ligamentous attachments to the musculoskeletal system through a hands-on, gentle technique. The target system are the organs that are suspected to be causing or contributing to the dysfunction and pain based on patient report. Once dysfunction is identified, specific placement of the hands is meant to encourage optimal mobility of the viscera and its connective tissue. The goal is to improve the functioning of the individual organ, the system, and environment within which the organ is situated by facilitating the return of the organ to its appropriate position, thereby stimulating blood flow and optimal functioning and alignment to the area. The state and ability of the visceral organs to move freely can affect the musculoskeletal system in turn, such as in the example of recurrent infections within the urogenital viscera or injury contributing to symptoms such as pelvic floor muscle dysfunction due to sustained holding patterns and tension. The reverse can also be true: the pelvic floor muscles can create enough tension chronically leading to irritation and decreased mobility within the surrounding viscera. Both scenarios may, and likely will, produce similar patient reported symptoms such as urinary frequency, hesitancy, and dysuria leading the clinician to think this could be precipitated by a urinary tract infection when it fact it could also be pelvic floor tension that is creating or mimicking an infectious process [15].
Connective tissue manipulation is considered distinct from massage therapy in its technique as well as effects it has on the body. It is characterized by the movement and distortion of the connective and subcutaneous tissues with the goal being to release tension in the tissue and improve range of motion of the adjacent joints and neurodynamics. It is based on the principles that dysfunction of an internal organ is revealed in the increased tone of superficial muscles and disruption in the subcutaneous tissues. Typically the dysfunction is distributed in the dermatomes corresponding to the innervation of the affected organ, signaling where treatment should be targeted. Altered blood flow within the deep tissues or pain suppression is seen as the therapeutic benefit. In comparison to myofascial and visceral release techniques, the pressure exerted during connective tissue manipulation is firm, such as in the example of skin rolling creating a sensation felt as an uncomfortable scratching or cutting. Local effects include release of histamine, local swelling, and arterial dilatation increasing blood flow to the region and facilitating resolution of subacute or chronic inflammation, thereby reducing pain by removing noxigenic chemicals from the tissues. The more general effects are also thought to be due to increased blood flow and stimulation to distance sites from the treatment area through stimulation of the autonomic nervous system, and more specifically, the parasympathetic nervous system [16].
Other manual therapy techniques can be utilized in this patient population to target overactivity in the pelvic floor in the form of neuromuscular reeducation activities to lengthen and coordinate the muscles of the pelvic floor. These techniques include contract–relax to promote relaxation at a point of limited range of motion with isometric contractions of the tensed muscle for 5–8 seconds followed by voluntary relaxation and movement into the newly acquired range of motion. Strain–counterstrain is a form of passive positional release that involves moving the dysfunctional tissue into a shortened position to allow for a reduction of tone [17].
Therapeutic Modalities/Devices
Vaginal dilators can be used a source of treatment to help address myofascial trigger points and to further elongate the shortened pelvic floor as well as a mechanism to allow for the patient to perform self-release as part of a home exercise program. Vaginal dilators are available in a variety of materials including silicone and plastic with and without handles to allow for improved ergonomics of the hand and wrist during release. The vaginal dilators provide a stretch to the vaginal muscles and tissue either at the vaginal entrance or for deeper release into the pelvic floor muscles if angled in that direction. Graded sizes are provided if the target tissue is at the vaginal introitus or second layer of the pelvic floor. The patient is encouraged to assume a comfortable, relaxed position when using the dilators to allow for optimal effect with the use of lubricants for improved ease of insertion and comfort [18]. Benefits of dilator use include restoration of soft tissue elasticity, improved relaxation and awareness of the pelvic floor muscles, desensitization of the vaginal tissue, and improved mobility of scars in the introital and perineal area [19]. Patients may benefit from concurrent use of topical creams to improve comfort and aid relaxation during release. Although vaginal dilators can be used to perform patient self-release into deeper pelvic floor muscles, internal release devices are also available that have curved shapes more conducive for releasing soft tissue into the vaginal side walls. The use of vaginal dilators and release devices has been noted to be successful in the treatment of pelvic pain syndromes including dyspareunia, however, in conjunction with physical therapy treatments to allow for education in proper use, graded progression, and relaxation techniques [20].
The use of SEMG biofeedback devices can be particularly useful in improving the patient’s awareness of the pelvic floor muscles. SEMG biofeedback can be facilitated through internal vaginal or rectal probes or external electrode sensors placed on either side of the anal opening. SEMG biofeedback is not a measure of muscle strength; instead it records the voltage sum of muscle action potentials, giving feedback on muscle events. The use of biofeedback to improve overactive pelvic floor muscles is to facilitate “downtraining” or relaxation of the muscles. Patients may be overrecruiting pelvic floor muscles at rest, when experiencing stressors, or when performing basic mobility tasks such as transitioning from sit to stand. Using the SEMG biofeedback during functional activities, whether actual or simulated, can be a beneficial tool to allow patients to understand and become aware of how their pelvic floor muscles are responding to numerous activities. Various relaxation positions or techniques can be taught and practiced during the use of SEMG biofeedback and this will help the patient and therapist to determine what the pelvic floor muscles respond optimally to, thus developing a more individualized home program [5]. Relaxation of the pelvic floor muscles is an important skill not only in a relaxed supine position but also in various positions and during various activities, as this better corresponds with real life for the patient and allows the training to be more adaptable and pertinent. SEMG biofeedback should not be considered a treatment on its own but rather used in conjunction with other therapeutic techniques such as manual therapies [21].
Other modalities that have various levels of research as treatment for patients with pelvic pain due to overactivity in the pelvic floor muscles include ultrasound and transcutaneous electrical nerve stimulation (TENS). Ultrasound utilizes high-frequency sound waves applied through a wand or probe to the skin to penetrate deep tissue and produce deep warmth, decreased tension, and increased blood flow. Nonthermal settings aim to help promote healing and reduce inflammation within the target muscle [5]. Ultrasound has been used on perineal episiotomy scars as well as extrapelvic muscles that may be contributing to increased pelvic floor tension. Studies have shown women receiving therapeutic ultrasound versus placebo for treatment of acute and persistent perineal pain are more likely to report improvement in symptoms; however, no statistically significant differences have been shown and further research is warranted [22]. TENS is a frequently used modality in the management of musculoskeletal pain and is gaining evidence for its use in the pelvic pain population. This noninvasive and nonpharmacological method of pain relief has also been successful in the treatment of dysmenorrhea, labor pain, and overactive pelvic floor disorders with various placements of electrodes including bracketing the lumbar and sacral spine, along pudendal nerve dermatomes, and in suprapubic areas [5, 23, 24].
Mind–Body Techniques
Many patients with pelvic pain resulting from pelvic floor muscle overactivity will note an increase in symptoms related to increasing stress levels. Women with chronic pelvic pain have been found to have higher levels of hypervigilance, catastrophizing, and anxiety [25]. A large aspect of pelvic floor muscle overactivity retraining is devoted to education about this connection to allow patients to become aware of how their mental states are affecting their physical states as well as teaching the patients tools and methods they can utilize to help manage this connection.
Relaxation techniques have been found to be beneficial in this patient population. Peters et al. report in a clinical cohort of 87 women with IC/BPS that 25% reported relief with the use of relaxation techniques alone [26]. There are various techniques that can be utilized in the therapeutic setting to assist in relaxation. Autogenic training focuses on the physical sensation the patient experiences including her breathing and heartbeat with other psychosomatic cues such a describing a feeling of warmth throughout the patient’s body or into the painful area. Guided imagery is the use of storytelling or descriptions that may be calming or have a positive connotation for the patient to replace negative associations or images. Progressive relaxation has the patient focus on contracting and relaxing each muscle group, working in a pattern throughout the body and typically combined with guided imagery and breathing. The benefits of relaxation training in chronic pain include a decrease in pain intensity, anxiety, depression, and fatigue; an increase in balance, mobility, and coordination; improved coping strategies; and a decrease in medication usage and healthcare costs [27, 28]. These techniques are often beneficial to utilize in conjunction with physical and hands-on techniques that are traditionally employed by physical therapists. It is important to note that collaboration and referral to trained psychologists and counselors is beneficial and often necessary to continue to help the patient develop various stress management strategies that will impact their pain.
Modifications to a patient’s breathing mechanics are another crucial aspect to relaxation training with benefits not only for the nervous system but also on the biomechanical movement of the pelvic floor. Deep breathing has been shown to have a calming effect on the central nervous system, with various recommendations for specifics of inhale and exhale timing employed [29]. The respiratory diaphragm is also known to synchronize with the pelvic floor, and optimal diaphragm descent during inhale helps the pelvic floor to descend properly as well. This synchronization can be used to the patient’s advantage throughout the day or during activities when increased pelvic floor tension is noted, as she can be taught to perform an optimal inhalation that includes diaphragmatic descent, lateral lower rib excursion, minimal movement into the upper chest, and excursion of the abdomen and, in turn, relaxation of the pelvic floor muscles [30, 31].
Interventions for Underactive Pelvic Floor Muscles
Although not typically the most common finding in patients with pelvic pain, there are instances in which pelvic floor muscle hypoactivity or weakness may be present and contributing to the dysfunction and impairments a patient is describing. As discussed in Chapter 5, pelvic floor muscles that are weak do not typically produce pain on palpation, have increased extensibility, and may be present with concurrent patient complaints or issues such as prolapse, pelvic girdle pain, and incontinence. Patients may also demonstrate a combination of pelvic floor overactivity as well as hypoactivity; for example, a postpartum patient may report pain with intercourse on initial penetration and urinary leakage that on assessment demonstrates pain and taut muscle tissue at the vaginal entrance and on deeper palpation increased extensibility without pain reproduction. A patient presenting with these symptoms may be provided verbal instruction to perform Kegel or pelvic floor contraction exercises for a prescribed number of repetitions per day. On return to the clinic, this same patient, having been diligent about performing upwards of 50 pelvic floor contractions per day, will likely report increased pain in the pelvic floor and during intercourse. Patients such as in this example require an individualized treatment plan, likely involving first a decrease in the pelvic floor tension and a “downtraining” approach that can be progressed to pelvic floor strengthening once demonstration of improved pelvic floor awareness and ability to relax the pelvic floor has been shown.
As with any other musculoskeletal dysfunction or impairment throughout the rest of the body, muscular tone first needs to be normalized to then progress into stability and strengthening exercises so as not to exacerbate and flare symptoms. This is not different in the pelvic floor. Patients with pelvic floor overactivity will also require pelvic floor strengthening to create optimal stability through the pelvic girdle, synchronization and support during functional movements, and improvement or maintenance of pelvic floor function; however, it has to be timed appropriately within the rehabilitation journey once the patient is able to demonstrate proper awareness and controlled relaxation of her pelvic floor.
The goal of rehabilitation of underactive floor muscles is to restore the activation capacity and build dynamic muscular ability by focusing not just on the strength of a single contraction but also the endurance, coordination, and quick response of the muscle in various positions and during various challenges.
Therapeutic Modalities/Devices
In opposition to downtraining of the pelvic floor muscles, uptraining is the focus when wanting to retrain or strengthen into the pelvic floor. This involves pelvic floor muscle contraction, commonly known as Kegels. Verbal instruction in the performance of a pelvic floor contraction is often not sufficient, with research showing more than 50% of women performing contractions incorrectly after verbal instruction alone and 25% actually straining when asked to contract, therefore likely worsening their symptoms [32]. Repeated verbal instruction in conjunction with internal palpation and SEMG biofeedback can help to assess the accuracy of movement within the pelvic floor to ensure the patient is performing the correct maneuver. Depending on the significance of weakness present or inability of the patient to contract the pelvic floor, training into synergistic muscles including the hip adductors, gluteals, and low abdominals may be warranted in the initial phases of training to help produce pelvic floor muscle movement. Voluntary activity of the abdominal muscles has been shown to result in increased pelvic floor muscle activity, and this can be used to the patient and therapist’s advantage when starting an exercise program [33]. As the patient continues to progress with her strength, accessory use of the synergistic pelvic girdle muscles will be encouraged to decrease with the goal for the patient to be able to produce an isolated pelvic floor muscle contraction.
Pelvic floor muscle training has been shown to be more effective than training with vaginal weighted cones alone when focusing on increased pelvic floor muscle strength as well as reduced urinary leakage. Treatment with weighted cones typically consists of holding the cone for 15–20 minutes, which may result in decreased blood flow to the area and therefore decreased O2 consumption, muscle fatigue, and pain, promoting possible recruitment of compensatory muscles such as the abdominals and gluteals instead of a true pelvic floor contraction. Using the vaginal weighted cones in conjunction with pelvic floor muscle training may be more beneficial if the patient is advised to contract the pelvic floor around the cones in various positions for a number of repetitions at intervals throughout the day [34].
Similar to promoting relaxation of the overactive pelvic floor in various positions and situations, it is important as part of the individualized treatment program developed between the patient and therapist to progress strengthening exercises within a functional context. Patients are not static; therefore static training of muscles is not functional and will not produce the intended benefits. After initial training of how to accurately contract the pelvic floor, the therapist will guide patients through a graded program taking into consideration the effects of gravity, postures, body mechanics, and movements required for performance and participation in patient-desired activities.
The addition of SEMG biofeedback to a pelvic floor training program has not been found to be overwhelmingly beneficial. A review by Herderschee et al. of 24 randomized controlled trials comparing pelvic floor muscle training with and without biofeedback concluded the use of SEMG biofeedback may provide additional benefit however most available studies currently have small sample sizes and the largest two randomized controlled trials showed no additional benefit [35]. Studies that demonstrate the most improvement related to short-term cure rates of symptoms in patient with pelvic floor muscle weakness report thorough individual instruction by a physical therapist, training with SEMG biofeedback or electrical stimulation and close follow-up every 1–2 weeks [36]. In women with stress urinary incontinence or mixed incontinence, most randomized controlled trials have failed to show an additional effect or benefit of SEMG biofeedback to the training protocol for stress incontinence [4]. However, the use of SEMG biofeedback may be a helpful adjunct to other therapeutic techniques to increase patient awareness of her pelvic floor during various assessment and strengthening activities.
Electrical stimulation is another modality that is traditionally used to supplement a typical musculoskeletal strengthening program; however, there have not been robust studies to demonstrate the efficacy of electrical stimulation for pelvic floor muscle strengthening, as many studies have small numbers and poor methodological quality. Electrical stimulation can be applied to the pelvic floor through external electrodes or internal devices with the goal to stimulate the motor fibers of the pudendal nerve and a contraction of the pelvic floor muscles. When comparing electrical stimulation to pelvic floor muscle training, voluntary pelvic floor muscle contraction increases urethral pressure significantly more than electrical stimulation[37]. Conclusive evidence is lacking; however, pelvic floor muscle training seems to be more effective than electrical stimulation in women with stress urinary incontinence and there does not seem to be an extra benefit with the addition of electrical stimulation to pelvic floor muscle training.
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