© Springer International Publishing Switzerland 2016
Diego Riva and Gianfranco Minini (eds.)Childbirth-Related Pelvic Floor Dysfunction10.1007/978-3-319-18197-4_1313. Principles and Methods of Physiotherapy After Delivery
(1)
UOC di Medicina Riabilitativa, Centro di Riabilitazione “Villa Beretta” dell’Ospedale Valduce, Costa Masnaga (Lc), Italy
13.1 Introduction
According to a number of epidemiological studies, one of the most socially devastating sequels of vaginal delivery is pelvic floor muscle’s damage [1]. It can cause pelvic organ prolapse with loss of bladder and bowel control, making life very hard to manage and painful: child-care, walking, sitting, sleeping, and human relationships may become problematic [2, 3]. The conservative treatment is universally considered as the first line intervention, and the British National Institute for Health and Clinical Excellence (NICE) with the International Continence Society (ICS) recommend it as the first step [4–7]. As a matter of fact, a damaged pelvic floor can be improved through re-education exercises [9], and after them, approximately 65 % of women will improve, with 30–50 % ending up to surgery [8, 10, 11].
Principles of physiotherapy include a combination of different approaches:
To teach how to overcome difficulties in movement using a combination of educational methods
To stimulate sensory and motor pathways by encouraging normal movement patterns in order to normalize or restore the muscle and regain the motor control
To improve muscle strength, endurance, and function through task-specific treatments, and restore normal motor function
All of the above points are intended to improve short- and long-term motivation and adherence to the health-enhancing behavior.
13.2 The Physiology
The pelvic floor is an interrelated system of organs, muscles, nerves, and connective tissue working synergistically as a dynamic system in balanced tension: its denervation, and the consequent muscle dysfunctions, can result in loss of the pelvic support organ, which can be followed by genital prolapse and urinary and/or fecal incontinence.
In order to plan the re-education program, the pelvic floor dysfunction should be analyzed on three levels of scientific background.
13.2.1 Motor Control
The central governance of the bladder provides a good example of the interplay network between the cortical motor system, the autonomic, and the somatic nervous system with the modulatory effects of the pudendal nerve. The functional magnetic resonance can identify the cerebral zones where bladder filling and voiding are regulated: reductions in the activation of the insula, of the right frontal operculum and of the anterior cingulate cortex suggest that treatment with EMG – biofeedback or pelvic floor muscle training (PFMT) or contraction-exercises [12–13] can change the emotional behavior related to micturition. The central nervous system coordinates and controls all the structures involved in opening and closing of urethra and anus as a switch mechanism. The anterior portion of the pubococcygeus muscle is a precise motor sensitive feedback zone that controls the tension in the vaginal membrane. Proportionate tensions are essential to maintain continence at rest because motor units of pelvic floor muscles are continuously activated (except during voiding or defecation), and their action increases with bladder or bowel activation. Defects, such as urinary stress incontinence and pelvic organ prolapse, have been associated with EMG alterations that may represent either loss of motor units or failure of central activation [14]. Recently, signs of dysfunction in the neural control (such as changes in the activation patterns) have been reported between the pubococcygeus [15], the levator ani, and the urethral sphincter [16].
Every sensory information from the pelvic region is relevant for the neural motor control of the pelvic floor muscles (PFM) and for the decision to activate the motor pattern. Lesions of fibers innervating the external anal sphincter are frequent (2–19 %) during childbirth and are caused either by spontaneous laceration or by episiotomy and can cause reduction in the contraction of the pubovisceral portion of the levator ani and in the external anal sphincter [17, 18].
13.2.2 Postural Balance
Posture is the result of multiple and complex processes that involve all the parts of the body and its relationship with the environment. The interactions among the different anatomic districts occur at different levels and are influenced by different starting conditions; alterations of imbalances produce a structural and physiological re-organization of the anatomic structures in order to improve the dynamic posture. A good posture requires an orchestrate recruitment of the muscles of the whole system, which is limited by respiratory, pelvic, diaphragmatic, abdominal, and multifidus muscles. The peritoneum and perineum support comes from their connection to the pelvis and to the endopelvic fascia which is a unique network of connective tissue able to strength the muscle and its tendon insertions and to accommodate the viscera’s cohabitation. It is well established that transversus abdominis plays a crucial role in optimal function of the lumbopelvic region; fascial tension is thought as the mechanism by which this muscle contributes to intersegmental and intrapelvic stiffness. Diastasis rectus abdominis (DRA) has the potential to disrupt this mechanism and is a common post-delivery occurrence [19].
13.2.3 Sphincter Capacity
Incontinence disorders, caused by pudendal nerve injuries, involve the urethral hypermotility, its external sphincter, the mucosal sealing effect, and the striated muscle activity. Urethra has three normal positions: resting closure, closure during effort and opening during micturition; and each state is the result of muscles forces whose contraction is required to open or close the sphincter. There are three directional muscle forces zone: upper (pubococcygeus and elevator plate) that stretches the organs forward or backward, middle (longitudinal muscle of the anus) which closes the bladder neck during effort and opens it during micturition and lower (perineal membrane) for stabilization of the distal parts of the urethra. Muscle’s slow-twitch fibers maintain the urethral closure during effort, while the fast-twitch fibers are recruited to close the system further. After vaginal delivery, changes occur in muscle function: the urethral reaction, the simultaneous passive transmission of the abdominal pressure to the urethra and the “guarding reflex” are compromised and that is critical; furthermore, coughing increases the pelvic floor muscle’s activity and induces an important decrease of the bladder neck’s mobility, with its stabilization. “Squeezing” of the pelvic diaphragm is a movement explained only by the voluntary contraction of the puborectalis muscle and this is radically different from what is observed during coughing and straining. Levator ani, puborectalis, and anal sphincter muscles provide the majority of control for anal continence and they are constantly active. The puborectalis muscle works independently of the three directional forces, maintains the “anorectal” angle, facilitates continence, and has to be relaxed to allow defecation.
13.3 Clinical Pictures
Disorders that can be treated by physiotherapy:
Sensory–motor disorders or neuroaprassia is the reduction of the sensitive perception and of the muscle activation (often on one side) due to the surface damage of the pudendal S2–S4 roots; alterations of muscle’s morphology and asymmetric contractions can also be observed.
Micturition dysfunction is generally related to laxity of the external urethral ligament and to disorders of the low urinary tract (LUT). These symptoms can be stress or urge incontinence, when coughing, straining, or even at rest; they can also be associated with altered emptying, voiding hesitancy, interrupted stream, raised residual urine volume, nicturia, and discomfort.
Postural disorders are sensory–motor changes in pelvic, spinal, and respiratory functions related to biomechanical problems of the sacral and lumbar spine and of the muscle’s area innervated by the S2–S4 roots. Trunk flexion, upper limb asymmetric or obturator internus, psoas, and piriformis shortening can be observed. Some muscles of the pelvic girdle may compensate for limitations of the pelvic floor in neutralizing the intra-abdominal pressure rises, by stiffening the sacroiliac joint, allowing backward rotation of the sacrum, and stabilizing the spine. Example of maladaptive movement patterns and poor stabilizing may be seen as abdominal bulging and breathing holding; excessive internal/external oblique activation with posterior pelvic tilt and flexor thoracolumbar attitude, excessive erector spinae activation with anterior pelvic tilt and thoracolumbar extension.
Anorectal dysfunction is the inability to evacuate or to contain the rectal contents. It can be due to reduction of muscle thickness, loss of innervations, and motor disorders (of the levator plate, the longitudinal muscles, the anus, the puborectalis muscles, and the external anal sphincter).
Pelvic and perineal pain, is due to laxity of the uterosacral ligaments and/or to spasm of the obturator muscle. It is a condition marked by dragging abdominal pain (often on one side), low sacral backache, aching or cramping pain in the vaginal and rectal area or in the coccyx and in the tailbone; symptoms can often be triggered or exacerbated by sitting, defecation, or by other motor activities stretching the pelvic floor. These symptoms are more frequent in case of dystocia or macrosomia. This picture, in the absence of neurological disease, is defined as overactive pelvic floor (OAPF) and is characterized by ischemic mucosa, sustained muscles contraction and forceful closure of the urethral sphincter.
Pudendal neuralgia is defined as a neuropathic pain in one or more of the areas innervated by the pudendal nerve or by one of its branches: rectum, anus, urethra, perineum and the genital area (clitoris, mons pubis, vulva, lower third of the vagina, and labia).
Typically, the perineal discomfort can evolve in chronic pelvic pain (CPP) which is not modified by standing or lying down, and can be exacerbated by sitting and is associated with sciatica and low back pain.
Sexual dysfunction is lack of orgasm or feeling of “strange sensation” or loss of sexual desire. This condition is characterized by excessive activity of pubovisceral muscles that cause pain; the muscles become taut, short, and spasmodic with a modified activation pattern. These symptoms are often associated with the OAPF (overactive pelvic floor).
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