by clicking here. - St Augustines Moreland

4/10/2012
(c) Debbie Callif, OT, BCB-PMD 2012
CLINICAL UPDATE ON PELVIC
FLOOR REHABILITATION
Debbie Callif, OT, BCB-PMD
[email protected]
Urinary Dysfunction

Incontinence
Stress
OAB/urge
Mixed

Frequency

Urgency

Retention

Painful Bladder Syndrome
http://www.ucurology.org/images/moreImages/bioFeedback.jpg
(c) Debbie Callif, OT, BCB-PMD 2012
Does Pelvic Floor Muscle Training
Really Help?





Fourteen trials involving 836 women
Women who did pelvic floor muscle training (PFMT) were more likely to report :
Cured or improved
Better continence specific quality of life
Experienced fewer incontinence episodes per day
Less leakage on pad test
Stress urinary incontinence required longer duration of training vs urge urinary
incontinence
Women with stress urinary incontinence best outcome if participate in PFMT
program for at least three months
Recommended PFMT should be 1st line conservative treatment in stress, urge and
mixed incontinence
Cochrane Database Syst Rev. 2010 Jan 20;(1):CD005654.
(c) Debbie Callif, OT, BCB-PMD 2012
Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women.
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4/10/2012
Which is best: Medications or
Behavioral Treatment?



Each treatment intervention is efficacious
Decision based on the patient's severity of symptoms, tolerability, compliance and
satisfaction with the treatment
Combination of behavioral therapy and OAB drug intervention:
Best patient satisfaction and perceived improvement
Reduction of bladder symptoms
Most practical and cost effective for optimal management of patients with OAB
Adv Urol. 2009:345324. Epub 2009 Dec 15.
Behavioral intervention versus pharmacotherapy or their combinations in the management of overactive bladder dysfunction
(c) Debbie Callif, OT, BCB-PMD 2012
Acupuncture

12 major meridians in traditional Chinese medicine (TMC) that correspond to organ systems

Bladder imbalances can stem from the lungs, heart, spleen, bladder, kidneys or liver

Kidneys’ energy, or “qi” plays a role in urinary continence

Chinese concepts of “yin” and “yang”
Bladder’s yin function affects urge incontinence
Kidney yin affects stress incontinence
Kidney yang associated with nocturia and ED
http://www.bladderhealthawareness.org/2011/06/acupuncture-and-chinese-herbs-for-overactive-bladder/
(c) Debbie Callif, OT, BCB-PMD 2012
Can Rushing to the Bathroom Cause
Fractures?





>6,000 community dwelling women completed questionnaire
25% of women had weekly or more frequent urge incontinence, 19% stress
incontinence, 12% mixed incontinence
Weekly or more frequent urge incontinence was associated with an increased risk of
falls and fractures in older women
Urinary frequency, nocturia, and rushing to the bathroom to avoid urge incontinent
episodes most likely increase the risk of falling, which then results in fractures
Early diagnosis and appropriate treatment of urge incontinence may decrease the
risk of fracture.
J Am Geriatr Soc. 2000 Jul;48(7):721-5.
Urinary incontinence: does it increase risk for falls and fractures? Study of Osteoporotic Fractures Research Group.
(c) Debbie Callif, OT, BCB-PMD 2012
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Risk for Falls


Urge urinary incontinence associated with a
modest increase in falls
Falls prevention programs need to include an
assessment of incontinence
Aust J Physiother. 2009;55(2):89-95. Urinary incontinence is associated with an increase in falls: a systematic review.
(c) Debbie Callif, OT, BCB-PMD 2012
Not Just a Kegel

Isolate out pelvic floor muscles

C
Co-contract
t t

Use during functional activities
(c) Debbie Callif, OT, BCB-PMD 2012
Stop Trying to Isolate the Pelvic Floor
Muscles

Muscles that enhance pelvic floor muscle
contractions:
v
abdominis
Transverse
Adductors
Obturator internus
Multifidus
(c) Debbie Callif, OT, BCB-PMD 2012
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4/10/2012
Muscles That Help Intensify Pelvic Floor
Muscle Contractions
(c) Debbie Callif, OT, BCB-PMD 2012
Urinary Stress Incontinence

Stem Cell Therapy:
Animal models-promising
1st human trial in Australia
(c) Debbie Callif, OT, BCB-PMD 2012
Erectile Dysfunction and Biofeedback

55 men > 20 years old
ED >/= 6 months

Biofeedback pelvic floor muscle exercises and lifestyle changes or lifestyle changes only

Control group that did not respond after 3 months were treated

All men given home exercises for 3 more months

Results:
After 3 months the biofeedback group erectile function was significantly improved
Control group significantly improved 3 months later
After 6 months 40% regained normal erectile function, 35.5% improved, 24.5% failed to improve
BJU Int. 2005 Sep;96(4):595-7.
Pelvic floor exercises for erectile dysfunction.
(c) Debbie Callif, OT, BCB-PMD 2012
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4/10/2012
Vacuum Erection Device Rehabilitation


Negative pressure to increase blood inflow to penis
After radical prostatectomy:
Facilitates tiss
tissue
e ooxygenation
genation
Reduces cavernosal fibrosis
Increases likelihood of preserving penile function
Yuan J, Hoang AN, Romero CA, Lin H, Dai Y, Wang r. Int J Impot Res. 2010 Apr 22
www.google.com/imgres?q=vacuum+erection+devi
ce&um=1&hl=en&client=firefox-
(c) Debbie Callif, OT, BCB-PMD 2012
Vacuum Erectile Device
141 sexually active men underwent radical
prostatectomy
 Mean age 68
 1 year later 113 (80%) still sexually active
 5 years later (mean age 73) 62% remained
sexually active
71% had natural erections for intercourse without
assistance
29% sexually inactive- 40% loss of interest

(c) Debbie Callif, OT, BCB-PMD 2012
More Is Not Always Better

Dr. Berman-100’s

V i lC
Vaginal
Cones
(c) Debbie Callif, OT, BCB-PMD 2012
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Dietary


Prelief: OTC food acid reducer
Reduces urinary urgency and bladder pain
Superior to IC/PBS interventions (surgery, bladder installations, oral therapies)
www.prelief.com
800-994-4711
Natural Touch Kaffree Roma
Multigrain beverage with chicory
Similar taste to coffee without caffeine or tannic acids
Urologu (Jan. 2008: Vol.17, 62-22)
(c) Debbie Callif, OT, BCB-PMD 2012
Bowel Dysfunction

Incontinence

Urgency

Frequency

Constipation

Diarrhea

IBS
(c) Debbie Callif, OT, BCB-PMD 2012
Fecal Incontinence



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Community living adults frequency:
6% of those < 40
15% in older women
10% + in older men
Nursing home residents frequency:
46 % prevalence
Minor fecal incontinence (staining underclothes or losing less than 2
tsp. of stool):
7% of adults
Irritable bowel syndrome (IBS):
30% frequent loose stools
20% fecal incontinence
(c) Debbie Callif, OT, BCB-PMD 2012
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4/10/2012
Pediatric Bowel Dysfunction



Constipation or encopresis complaints comprise
10-25% of pediatric gastroenterologist visits
Irritable bowel syndrome
s ndrome (IBS)
(IBS):
17% of high school students
8% of middle school students
Functional GI disorders occur in 10% of the pediatric
population
(c) Debbie Callif, OT, BCB-PMD 2012
Pediatric Bowel Dysfunction Treatment

Biofeedback assisted pelvic floor muscle exercises

Proper breathing techniques

Proper positioning

Fiber intake children ages 3-10 years: Age +5 gms of dietary fiber/day

Fluid intake: six to eight 8 ounces of fluid/day

Abdominal, back and hip exercises
(c) Debbie Callif, OT, BCB-PMD 2012
Diet and Bowel Function

Konsyl

Natural Calm
http://www.vulvodynia.com.au/articles/images/wh_2_f1.gif
(c) Debbie Callif, OT, BCB-PMD 2012
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4/10/2012
Probiotics

Live microorganisms similar to those found in the
intestines

Beneficial bacteria

Store in the refrigerator
(c) Debbie Callif, OT, BCB-PMD 2012
Probiotics


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RCTs with at least 1 week of treatment comparing probiotics
with placebo or no treatment in adults with IBS
Studies had to provide improvement in abdominal pain or
global IBS symptoms as an outcome
19 RCTs (18 papers) in 1650 patients with IBS were
identified.
Probiotics were statistically significantly
(c) Debbie Callif, OT, BCB-PMD 2012
Probiotics

Florajen3
Lactobacillus acidophilus (7.5 billion cells)
Bifidobacterium lactis (bifidum) strain Bb-12 (6 billion cells)
Bifid b
Bifidobacterium
i llongum (1
(1.5
5 billi
billion cells)
ll )

Align
Bifantis (Bifidobacterium infantis 35624 (1 billion cells)
http://www.florajen.com
http://www.aligngi.com
(c) Debbie Callif, OT, BCB-PMD 2012
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4/10/2012
Prebiotic

Rebuilds intestinal flora

FOS- Fructooligosaccharides
(c) Debbie Callif, OT, BCB-PMD 2012
New FDA Treatments for Fecal
Incontinence


Solesta
Failure of conservative therapy
Biocompatible bulking agent
j
into submucosal layer
y of anal canal
Injected
42.7% reduction in fecal incontinence in 3 months
InterStim
Sacral nerve stimulation
Used for bladder dysfunction
(c) Debbie Callif, OT, BCB-PMD 2012
Chronic Pelvic Pain


Pain > 6 months
Pain is stronger than expected from previous surgery, injury
or present condition

Difficulty sleeping or sleeping too much

Decreased appetite

Decreased activity level
(c) Debbie Callif, OT, BCB-PMD 2012
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4/10/2012
Chronic Pelvic Pain

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One of the most common medical conditions in women
25% of women with CPP will spend 2-3 days in
bed/month
90% have dyspareunia
Almost 50% will feel sad or depressed at one time due
to CPP
(c) Debbie Callif, OT, BCB-PMD 2012
Chronic Pelvic Pain


Chronic Pelvic Pain Syndrome
Men: Prostatitis
Women: Vulvodynia
y
Vulvar Vestibulitis
Vaginismus
Dyspareunia
Painful Bladder Syndrome
http://www.vulvodynia.com/dia_vv_ab10_files/image004.jpg
(c) Debbie Callif, OT, BCB-PMD 2012
Chronic Pelvic Pain
It is not all in your head!

Physical

Psychological

Behavioral
(c) Debbie Callif, OT, BCB-PMD 2012
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Chronic Pelvic Pain



Muscle tension
Changes in connective tissue, skin, nerve function
and blood supply
Can affect bowel, bladder, genitals, pelvis, hips,
back, abdomen, legs
(c) Debbie Callif, OT, BCB-PMD 2012
Chronic Pelvic Pain Treatments


Biofeedback relaxation exercises
Biofeedback assisted pelvic floor eccentric
lengthening exercise

Manual therapy

Cognitive behavioral therapy
(c) Debbie Callif, OT, BCB-PMD 2012
Chronic Pelvic Pain Treatments

Aloe Vera capsules
Desert Harvest 6 capsules/day=3,600 mg Aloe Vera concentrate for 3
months
Improvement in pelvic pain, frequency of urination, pressure and nocturia
www.desertharvest.com
800-222-3901

Neogyn
Cutaneous lysate cream for provoked vestibulodynia
Apply to vulva twice daily for 3 months
Effective in reducing erythema of the vestibule and pain with intercourse
www.neogyn.us
rologu (Jan. 2008: Vol.17, 62-22)
http://www.rehabpub.com/features/112005/4a.jpg
(c) Debbie Callif, OT, BCB-PMD 2012
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Chronic Pelvic Pain
Vitamin E oil

I t vaginally/rectally
Intra
i ll / t ll

Topically
(c) Debbie Callif, OT, BCB-PMD 2012
Pelvic Organ Descent



Cystocele, rectocele or uterine prolapse
Pelvic organ descent pulls on sacrum and can lead
to sacroiliac and lumbosacral dysfunctional
alignment
g
Treatment:
Positioning
sEMG activation of pelvic floor muscles
Core exercises
(c) Debbie Callif, OT, BCB-PMD 2012
Resources
International Foundation for Functional Gastrointestinal
Disorders:
www.iffgd.org
 International Pelvic Pain Society: www.pelvicpain.org
 National Association for Continence:
www.nafc.org
www.bladderhealthawareness.org

Images from google images unless otherwise noted.
(c) Debbie Callif, OT, BCB-PMD 2012
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