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Sep 15, 2014

Dyssynergic defecation occurs when the pelvic floor muscles (PFM) are not coordinating in a manner that supports healthy bowel movements. Ideally, emptying of the bowels is accompanied by a lengthening, or bearing down of the PFM, and with dyssynergia, the muscles instead shorten. Because a portion of the levator ani muscles slings directly around the anorectal junction (where the rectum meets the anal canal), when the muscles are tight, the "tube" where the fecal material has to pass through narrows, making it difficult to pass stool. If emptying the bowels is difficult, patients will often strain for prolonged periods of time, an unhealthy pattern for the abdominopelvic area, and constipation may occur due to the stool remaining in the colon for prolonged periods of time, where the water is reabsorbed from the stool, becoming harder and more difficult to pass.

 

 

Can patients with this condition be helped by pelvic rehabilitation providers? Absolutely, with correction of muscle use patterns, bowel re-training education, food and fluid recommendations, and pelvic muscle rehabilitation addressed at optimizing the muscle health. Much of the time, patients with this dysfunctional muscle use pattern present with tension and shortening in the pelvic floor muscles, although they may also present with muscle lengthening and weakness.  Surface electromyography (sEMG), a form of biofeedback, has also been utilized and the literature supports sEMG for bowel dysfunctions including dyssnergia. 

 

 

Another technique used by pelvic rehabilitation providers for re-training dyssynergia (also known as non-relaxing puborectalis, or paroxysmal puborectalis, naming the muscle fibers that sling around the rectum) is the use of balloon-assisted training. In this technique, a small, soft balloon is inserted into the rectum and is attached to a large syringe that will inject either water or air into the balloon, causing the balloon to enlarge within the rectum. This training technique allows the patient to provide feedback about sensation of rectal filling including when the patient perceives urges to defecate. The patient can practice expelling the balloon, and in the event of a dyssynergic pattern of pelvic floor muscles, the balloon would not be expelled due to increased muscle tension and shortening of the anorectal area. In this manner, the patient is trained to bring awareness to the anorectal area, and to respond with healthy patterns of defecation. 


Sep 04, 2014

This post was written by H&W instructor Allison Ariail PT, DPT, CLT-LANA, BCB-PMD. Allison will be instructing the Pelvic Floor Level 1 course Boston this October.

 

Allison Ariail

Several weeks ago some of my fellow faculty members and I were discussing the resting tone of the pelvic floor. These days we take it for granted that we know there is constant low-level activity in the pelvic floor and anal sphincter in order to provide continence. However, how did this information come about? I took it upon myself to do some research to find out the beginnings of this knowledge. What I found was interesting and thought I would share.

 

In the late 1940’s and early 1950’s the belief was held that the pelvic floor and external anal sphincters were inactive at rest, like other striated muscle throughout the body. Activity was believed to be initiated by afferent impulses from the rectal ampulla and anal canal. In 1953 Floyd and Walls found activity in the external anal sphincters at rest, even during sleep. In 1962 Parks, Porter, and Melzak published a study examining the pelvic floor muscles and the external anal sphincters using electromyography recordings. They also found activity in these muscles at rest. They hypothesized the activity was maintained by spinal reflex. These researchers looked at the activity in a healthy population, a paraplegic population, and a population that had undergone a rectal excision. When examining the paraplegic population (all subjects had complete SCI injuries above L3), they did identify activity of the pelvic floor at rest.

 


Jul 11, 2014

This post was written by H&W instructor Steve Dischiavi, MPT, DPT, ATC, COMT, CSCS. Dr. Dischiavi will be instructing the course that he wrote on "Biomechanical Assessment of the Hip and Pelvis" in Virginia this August.

 

Dischiavi

In an outpatient sports medicine clinic the traditional model of physical therapy evaluation typically includes the therapist reviewing a patients chart and subjective symptom questionnaire of some sort. Then the therapist will bring the patient to an area to begin a subjective history and then onto a physical exam. After these procedures have been completed the therapist will typically assign a working clinical diagnosis and then begin treatment. In short, I would like to suggest a paradigm shift to this traditional model of thinking. Instead of starting the exam on a table with a static assessment of the structures involved and identifying the pain generator, I suggest the therapist begin with a specific set of movements used as an evaluative tool to identify movement dysfunction within the anatomical system as a whole.

 

All human interactions on earth occur between ground reaction force and gravity, our bodies are mostly just stuck in the middle of this constant battle and typically we succumb to whichever power exposes the weakest link in our biomechanical chains. One of the reasons the biomechanical chains in our bodies are so pliable and vulnerable to constant ground reaction force and gravity acting on them is because we are basically bones or struts suspended in a bag of skin all connected by soft tissue. Suggesting that without skin, fascia, and connective tissue supporting us, we would collapse to the ground in a pile of bones! Ingber (1997), suggested this concept, known as tensegrity, was the “architecture of life.” So in summary, the tensegrity structures are mechanically stable not because of the strength of the individual bones, but because of the way the entire human body distributes and balances mechanical stresses through the use of polyarticular muscle chains called slings. There will be more on slings in the upcoming blogs.

 


Apr 08, 2014

Allison Ariail

 

This post was written by H&W instructor Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD. Allison will be instructing the Rehabilitative Ultrasound course in Seatlte in May.

 

 

In the past decades, evidence has been established showing the importance of the local stabilizing muscles, including the transverse abdominis, the lumbar multifidus, and the pelvic floor muscles on the stability of the pelvic ring and lumbar spine. Many therapists have embraced this knowledge and incorporate a specific stabilization program into their plan of care for patients with dysfunction in the lumbar spine or pelvic ring. This plan of care can be more time consuming for the therapist since we are no longer simply prescribing strengthening exercises to the patient, but instead are using neuromuscular re-education to retrain recruitment patterns and improve motor control. For many patients, learning to activate these muscles can be very difficult and frustrating.   This is where biofeedback comes in.  For years, women’s health therapists have been using biofeedback to retrain the pelvic floor muscles. Biofeedback is the process of bringing unconscious physiological processes to consciousness and gaining control over it. These same principles can be used in retraining the lumbar multifidus and the transverse abdominis, in addition to the pelvic floor. Currently, biofeedback methods used in treating low back pain include rehabilitative ultrasound imaging (RUSI) and the pressure cuff. My preferred method is using RUSI. This tool not only provides biofeedback for the patient but allows for real-time assessment of the muscle activation. Thus, providing the clinician valuable feedback on timing of recruitment and strategy used by the patient that would not be assessed with palpation alone.

 


Feb 24, 2014

Within the evaluation process for pelvic muscle health, a woman is often asked to "bear down" so that the examiner can assess muscle coordination. This maneuver is also utilized during assessment for prolapse or pelvic organ descent. Clinically, the patient's ability to perform a lengthening or bearing down is quite varied, depending upon many factors such as levator plate resting position, strength and coordination, childbearing status, and comfort with the maneuver. What are the implications of not being able to bear down? An interesting study published in 2007 concluded that women, when asked to perform a Valsalva maneuver (a forced expiration against a closed glottis), frequently co-contracted the levator ani muscles. 

 

 

Participants included 50 nulliparous women between 36-38 weeks gestation and they were assessed with translabial 3D/4D ultrasound following emptying of the bladder. In almost half of the subjects, a pelvic floor muscle contraction was noted during the attempted Valsalva. Patients were provided with visual biofeedback to train the levator muscles to avoid a concurrent contraction, and despite the training, 11 of the 50 women were still unable to avoid a co-activation. (Keep in mind that for purposes of assessment, the prolapse would be best imaged or viewed if the levator muscles were not tightening.) For this reason, the study concludes that levator muscle co-activation is a significant confounder of pelvic organ descent. While a contraction of the pelvic floor muscles may be a positive, protective action when thoracic pressure is increased, a woman's degree of prolapse or pelvic organ descent may appear diminished during an examination. The authors of the study conclude that a clinician may have a false-negative finding for prolapse in the presence of strong, intact pubovisceral muscles. 

 

 

 


Nov 25, 2013

 

Urinary incontinence (UI) and erectile dysfunction (ED) are two well-known risks of a prostatectomy surgery. You may be familiar with research completed by Burgio et al. that treated men with one session of preoperative biofeedback training for pelvic muscle strengthening. The authors concluded that a single session of biofeedback and a daily home exercise program "…can hasten the recovery…and decrease the severity of incontinence following radical prostatectomy." While the conclusions of the study were positive, recommendations for preoperative care were difficult to make from one study.

 

A recent publication in The International Journal of Urology added to this body of work. Researchers in Australia retrospectively analyzed the results of 284 subjects operated on by one "high-volume" surgeon. The 152 men in the intervention group received physiotherapy-guided pelvic floor muscle (PFM) training preoperatively while the control group (n = 132) was instructed in pelvic floor muscle exercise by the surgeon alone. The surgeon's recommendations included verbal instructions to complete PFM exercises daily until the surgery. Postoperatively, all subjects were instructed in physiothrapist-guided PFM training. Outcome measures included 24-hour pad weight at 6 weeks and 3 months postoperatively, percentage of patients who were categorized as experiencing severe UI, and patient-reported time to one and zero pad usage daily. 

 

Therapist-guided PFM assessment and training consisted of the following: history and assessment of comorbidities, education in bladder, urethra, and pelvic floor muscle anatomy and function, and instruction in PFM activation in various functional positions. Transabdominal ultrasound was utilized to provide feedback to the patient during training. Technique was corrected so that overactivity in the superficial abdominals was avoided, and so that breath holding was avoided. Home exercise program instruction included completion in 10 contractions of 10 seconds each to be done in supine, in sitting, and in standing. Functional activation of PFM was encouraged such as during lifting, coughing, and squatting. 

 


Nov 08, 2012

At the annual conference of the California Biofeedback Society last week, a new device was described for the treatment of jaw pain. The SleepGuard biofeedback headband can be worn by the user and when the band senses that the jaw is clenched, an alarm will sound to deter the patient from the clenching. It makes sense that a patient can re-train the body to avoid muscle tension with such a device. 

 

So what can we do about the butt grippers? Although some clever and potentially not-so-comfortable ideas come to mind in relation to biofeedback sensors and the pelvis during sleep, how do we educate our patients who tend to clench at night to let go and avoid that morning pain? If you are unfamiliar with the concept of "butt gripping," please check out the work of Diane Lee, from whom I first heard the term. In an article on her website, Diane discusses the concept of gripping with the chest, back, or butt. Chances are, you can think of a patient who fits one of the categories. (Not that any of us have movement dysfunction, but you might have "a friend" who could use some guidance in re-training one of the gripping patterns.)

 

Patients who tend to clench any muscle all night will be creating compression in nearby joints, and the muscles will not be getting proper recovery and rest time during sleep. These patients will often wake with increased pain in the area of tension or muscle guarding. The first step in treating a condition of gripping is awareness: if you have no idea that you are creating tension in a muscle, the re-training of the muscle won't happen. Help your patients understand that a tendency to tighten a muscle group may be a habit brought up by the body guarding a region for various purposes. Consider the patient who has low back pain- tightening or splinting the area with muscle contractions may be a useful strategy early in the injury. Once a patient is aware of the tension that may aggravate a painful area or promote a dysfunctional movement pattern, creating new strategies is critical. Your patients may require soft tissue or joint mobilization, muscle balancing techniques, movement re-training (to include functional patterns or tasks), and general awareness or relaxation techniques. 

 

Let's think of the patient who goes to bed and maintains tension in the gluteals, pelvic floor, or pelvic area. What can she do at bedtime? There may be a few stretches that loosen the muscles, breathing and awareness exercises, general relaxation or meditation activities, or some contract/relax to improve the muscle state. She might also have a self-massage or trigger point technique, complete a self-massage or partner-assisted massage, take a warm bath, or apply some heat or cold to the area of tension. Once in bed, what position does your patient adopt for sleep? Is she in supine with a posterior pelvic tilt, in sidelying with the thighs pressed tightly together? You can help the patient recognize the postures, positions, and patterns of holding that may be worsening the condition. Many patients find that completing some simple pelvic tilts or rocking prior to falling asleep can decrease guarding. 


Jun 05, 2012

Pelvic floor muscle training has been found to be an effective approach for treating fecal incontinence in children following surgical correction for Hirschprung disease. This disease can cause severe constipation or intestinal blockage due to a lack of nerve cells in the large intestine that are responsible for creating contractions in the smooth muscles of the bowels. Most of the time, Hirschprung disease is identified and corrected in infancy, but it can also be treated in childhood and sometimes in the adult patient. There are several different types of "pull-through' surgical procedures that can be used to remove the diseased portion of the large intestine and attach a functioning portion of bowel to the anus. This type of procedure can injure tissues including the internal anal sphincter, creating the issue of fecal leakage or incontinence. 

 

A case series appears in the European Journal of Pediatric Surgery that reports on 24 cases of children who became incontinent following a Soave pull-through procedure for Hirschprung disease. 16 of the children were treated with 2 weeks of biofeedback training in the hospital followed by home program for pelvic muscle exercises, while 8 children served as a control group, receiving no therapy following the surgery. At baseline and at one year follow-up, measures were taken via anorectal manometry for resting anal canal pressure, squeeze pressure, and for rectal sensation. At one year post-surgery, the children in the treatment group were found to have significantly increased resting rectal pressure as well as squeeze pressure. Rates of fecal incontinence were significantly reduced with only 3 of the 16 children reporting occasional soiling after completing the pelvic muscle training.

 

This research is encouraging as biofeedback therapy is a non-invasive, inexpensive option for patients who have already been through a surgical procedure to correct a biological dysfunction. The International Foundation for Functional Gastrointestinal Disorders (www.iffgd.org) has a wonderful website with more information for rehabilitation providers and for patients, and they also have a website designed for kids and teens who have functional gastrointestinal issues. That website can be accessed at www.aboutkidsGI.org


Feb 18, 2012

"Do night lights cause cancer?" is the title of a blog post written by biofeedback expert and PhD psychologist Dr. Erik Peper. Follow the link above and you can decide for yourself if the post is compelling. Researchers in this study published in the Cleveland Clinic Journal of Medicine asks "Does lack of sleep cause diabetes?" Poor sleep quality or not enough hours of sleep are often considered as precursors to health impairments as the body does much of its cellular regeneration and other restorative functions during the sleeping hours. These questions and concerns bring us to the concept of "Sleep Hygiene." 

 

The American Academy of Family Physicians has published this full text article that describes several components of insomnia treatment, including sleep hygiene. Reasons for insomnia may include anxiety, depression, fibromyalgia, sleep apnea, menopause, pain, or restless legs syndrome. Medications that can contribute to lack of sleep include alcohol, nicotine, caffeine, diuretics, beta blockers, and stimulant laxatives. The authors describe sleep hygiene as one part of a cognitive behavioral therapy (CBT) approach to treat insomnia, which can be comprised of 4-8 sessions. Each session may be 60-90 minutes long and topics covered may include behavioral education for stimulus control, sleep restriction, relaxation therapy, and paradoxical intention (trying to stay awake.)

 

The concepts included in sleep hygiene (adapted from the above study) are as follows:

 

  1. Avoid caffeine and nicotine, particularly before bedtime.
  2. Avoid exercise 4 hours prior to bedtime.
  3. Avoid large evening meals.
  4. Avoid taking naps during the day.
  5. Rise and sleep at same times each day (even on weekends!)
  6. Keep a comfortable temperature in bedroom.
  7. Keep the bedroom very dark.
  8. Set aside time to unwind or use relaxation techniques before bed.
Patients may also find concepts in "stimulus control" very useful as patients are instructed to only associate the bedroom with sleep and sexual activity- no television! Some of the relaxation strategies referenced in this study include autogenic training, biofeedback training, imagery training, progressive relaxation and paced respirations. 
The above are all strategies that a pelvic rehabilitation provider can effectively teach to her patient. If your patient's recovery may be limited by pain, medications, anxiety, and the unfortunate sequelae of sleep loss, education in the concepts described here can be practical ways to help the patient affect her sleep. The authors reference a meta-analysis by Perlis et al. (2003) that finds that CBT for general insomnia is comparable to pharmacotherapy, and that CBT for sleep-onset insomnia is superior to pharmacotherapy. It is also pointed out in this article that most patients can self-administer the sleep treatments once instructed. Consider guiding your patients to strategies for improved sleep, with the intention of helping patients to improve the bodies time in restful recovery.

Nov 23, 2011

Research about animated biofeedback and its effects on children who have elimination disorders appears in the December issue of the Journal of Urology. A report by Rueters can be accessed here, the PubMed abstract can be accessed here

 

Dr. Kajbafzadeh of the Tehran University of Medical Sciences in Iran led a study that involved a total of 80 children randomly assigned with 40 subjects in either Group A or Group B. The average age group was 8-9 years with more than 75% of the children being female. Group A received 6-12 sessions of animated biofeedback in addition to behavioral modification while Group B received behavioral modification only. The animated biofeedback used a computer program with images of dolphins or monkeys to get children to activate and relax the pelvic floor muscles. This type of training could then help the children understand how to relax the muscles with emptying the bowels or bladder, and to have active, more healthy muscles in general. Behavioral modification included education in hydration, high fiber diet, and scheduled voiding. At baseline, and at 6 and 12 months, data was collected regarding dysfunctional voiding scores, constipation and fecal soiling episodes/week, and uroflowmetry.

 

The results were very positive, with vesicoureteral reflux resolving in 7 of 9 children. (Vesicoureteral reflux occurs when urine moves from the bladder towards the upper urinary tract instead of flowing out of the urethra. This can create urinary tract infections (UTI), kidney scarring, and in severe cases, kidney failure.) 10 of 14 children did not have a return of UTI within 1 year from the start of the study. Bladder capacity and voided volume did not significantly change. The authors report that PVR (post-void residual, or how much urine is left in the bladder after voiding) improved as did urine flow. Within 12 months after treatment, children who reported fecal soiling at baseline were symptom-free, and 17 of 25 who had constipation were symptom-free. The control group also had improvements in symptoms but these were not as significant as in the group receiving animated biofeedback therapy. 

 

If you have a biofeedback unit (for surface EMG, or sEMG, one type of biofeedback) and know how to use it, you can apply this wonderful skill in the care of children who need your help. Many of the computer programs do have animations included in the software. If you would like to learn more about treating children who have bowel and bladder dysfunction, the Institute offers a course in pediatric pelvic rehabilitation with faculty member Dawn Sandalcidi. The next course is scheduled in May in Texas. Click here to see more information about the class.


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Bowel Pathology and Function - Torrance, CA
Nov 08, 2014 - Nov 09, 2014
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Menopause: A Rehabilitation Approach - Orlando, FL
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