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Nov 04, 2013

Can patients successfully perform a pelvic muscle contraction following verbal instruction? This question was asked by Bump and colleagues in the often-cited research article published in 1991. Urethral pressure profiles were assessed in forty-seven women at rest and during a pelvic muscle contraction following brief, standardized verbal instruction. In the article, the authors found that nearly half of the women performed with "an ideal effort" leading to urethral closure without a Valsalva effort. 25% of the women, unfortunately, demonstrated an effort at muscular contraction that could promote incontinence. The authors' conclusion is that simple verbal or written instruction is not the best approach for a patient engaging in a pelvic floor muscle training program.

 

The limitations of the above study (small number of subjects, arbitrary definition of "effective Kegel," and inability to predict patient outcomes based on urethral profile) are made very clear throughout the article, yet how do we see this apply to our patient population? How often do we complete a perineal observation during an examination and identify that the patient is not generating any perineal movement, demonstrating a bearing down maneuver rather than a shortening, protective contraction, or creating such force through the abdomen that even a well-contracted pelvic floor would struggle against the strain from above? The value of the Bump study reminds us that not all patients respond positively to verbal or written instruction only. 

 

What about men? A recent study aimed to assess the ability of 52 healthy men (mean age of 22.6 years with a standard deviation of 4.42 years) to complete a pelvic muscle contraction in standing or crook lying following brief, standardized instruction. Real-time transabdominal ultrasound was used to measure bladder base elevation. 6 participants were unable to contract the pelvic floor muscles in either position, 17 were unable to contract the muscles in crook lying, and 14 could not contract the muscles in standing. While many of the men we instruct in pelvic muscle rehabilitation strategies are significantly older than the men in this study, the major point matches that of the Bump article: it is not safe to assume that a patient (even a young, healthy patient) can contract the pelvic floor muscles following verbal instruction. The authors suggest that transabdominal ultrasound may be a useful clinical tool for measuring bladder base elevation and therefore pelvic muscle activity. 

 

To be fair, more people in general need to be educated about the pelvic floor muscles; we can likely agree that the lack of awareness and discussion about the roles the PFM play in daily life leads to persisting dysfunction. There are people within the population who can activate the pelvic muscles appropriately with verbal instruction, and for this portion of the population, verbal or written instruction may be better than no instruction. Group education in community or institutional settings may benefit patients who are unwilling, unable or uninterested in acquiring a referral to a pelvic rehab provider. But for the group of patients who is either not contracting the muscles or bearing down rather than lifting, the consequences of doing pelvic muscle strengthening incorrectly may be significant. Do we need to change how we are instructing the patient verbally? Should we offer assessment of pelvic muscle contraction ability in varied positions? Must we include other functional applications of the coordinating muscles such as the respiratory diaphragm? At this time, there is not one answer. If we can ask the questions, read the research, and participate in our own way to the research, or at a minimum, apply these questions to clinical care, we may find the best answer for each individual patient. 


Jun 28, 2013

Although exercise is critical for pregnant women (just as it is for everyone), few receive the appropriate amount of exercise.  This may seem intuitive, but physical symptoms of pregnancy often are a barrier to physical activity for women.

 

A recent Research Report article published in The Journal of Women's Health - Physical Therapy, titled “The Impact of Symptom Type and Frequency on Activity Level During Pregnancy,” studying the daily records of physical activity for “sedentary women with a history of preeclampsia,” discusses how maternal weight and gestational age affect activity levels.  For example, women who are already over-weight have lower activity levels during pregnancy.  Similarly, the further along the baby is, the less likely the mother is to be physically active.  Women, after week 28, have the greatest reduction in physical activity.

 

This is problematic because a healthy mom is crucial for both the health of the mother and the health of the baby.  Furthermore, symptoms like fatigue and backache decrease among more active moms.  Gestational diabetes and cardiovascular disease are less likely among active moms as well.  Over-exercise can be detrimental as well; however, the numbers of women over-exercising during pregnancy is negligible compared to the majority, who are under-active during pregnancy.  Often, these physiological problems persist after pregnancy.

 

Therefore, the challenge for therapists is to find a way to educate their pregnant patients about the importance of physical activity during pregnancy as well as give them advice on how to implement an active lifestyle within their daily routine. H&W recently expanded our courses on pregnant, peripartum, and postpartum patient care to help therapists when they treat these patients.  Check out the following events on the horizon in the coming months:


May 13, 2011

In a study from the Center for Aging at the University of Alabama, Birmingham and the Birmingham/Atlanta Veterans Affairs Geriatric Research, Education, and Clinical Center, researchers determine that physical therapy, bladder control strategies, and biofeedback significantly reduced the incidence of urinary incontinence in post-radical prostatectomy males when compared to a control group.

Check out the abstract of the study here.


Apr 19, 2011

On April 18th, a group of German and Italian researchers published this article on the impact of episiotomy on pelvic floor dysfunction. The paper found that "Episiotomy appears to be a protective factor for women's wellness. Women who had episiotomy and who experienced perineal symptoms have a better psycho-physical health status in the 12.79 months follow-up."

Available for download is a 15 page PDF of "Impact of episiotomy on pelvic floor disorders and their influence on women's wellness after the sixth month postpartum: a retrospective study". The PDF contains research highlights (including Abstract, Background, Methods, Results and Conclusion)


Upcoming Continuing Education Courses

Bowel Pathology and Function - Torrance, CA
Nov 08, 2014 - Nov 09, 2014
Location: HealthCare Partners - Torrance

Pelvic Floor Level 1 - San Diego, CA (SOLD OUT)
Nov 14, 2014 - Nov 16, 2014
Location: FunctionSmart Physical Therapy

Mindfulness- Based Biopsychosocial Approach to Chronic Pain - Seattle, WA
Nov 15, 2014 - Nov 16, 2014
Location: Swedish Hospital - Cherry Hill Campus

Yoga as Medicine for Pregnancy - New York, NY
Nov 16, 2014 - Nov 17, 2014
Location: Touro College

Pelvic Floor Level 2B - St. Louis, MO (SOLD OUT)
Dec 05, 2014 - Dec 07, 2014
Location: Washington University School of Medicine

Pelvic Floor Level 1 - Omaha, NE (SOLD OUT!)
Dec 05, 2014 - Dec 07, 2014
Location: Methodist Physicians Clinic

Pelvic Floor Level 3 - Derby, CT
Dec 12, 2014 - Dec 14, 2014
Location: Griffin Hospital

Pelvic Floor Level 1 - Oakland, CA (SOLD OUT)
Jan 09, 2015 - Jan 11, 2015
Location: Samuel Merritt University

Care of the Postpartum Patient - Santa Barbara, CA
Jan 10, 2015 - Jan 11, 2015
Location: Human Performace Center

Sexual Medicine for Men and Women - Houston, TX
Jan 23, 2015 - Jan 25, 2015
Location: Women's Hospital of Texas

Pelvic Floor Level 1 - Maywood, IL
Jan 23, 2015 - Jan 25, 2015
Location: Loyola University Stritch School of Medicine

Sacroiliac Joint Evaluation and Treatment - Seattle, WA
Jan 24, 2015 - Jan 25, 2015
Location: Pacific Medical Center

Menopause: A Rehabilitation Approach - Orlando, FL
Feb 21, 2015 - Feb 22, 2015
Location: Florida Hospital Sports Medicine and Rehabilitation

Breast Oncology - Phoenix, AZ
Feb 21, 2015 - Feb 22, 2015
Location: Spooner Physical Therapy

Care of the Pregnant Patient - Seattle, WA
Mar 07, 2015 - Mar 08, 2015
Location: Pacific Medical Center