18.4: Treatment

Behavioural modifications

1. Fluid/diet management; diaries are of great use as behaviour sensitisers.
2. Education and counselling are of particular importance in identifying triggers and breaking psychological sensitisers.
3. Bladder training using the PF as an inhibitor of detrusor activity helps to decrease urge incontinence, control urgency, delay voiding, increase bladder capacity and decrease nocturia. Often, in that order!
4. Defaecatory technique teaching correct positioning and pressure transmission can alleviate the signs and symptoms of obstructed defaecation.
5. Disability management; although the aim is a clean dry subject, there will be times when management of disability is the best short-term solution; this includes the use of pads and occlusive devices in sports women.

Table \(\PageIndex{1}\): QOL scale

QOL	Delighted	Pleased	Satisfied	Fence sitting	Dissatisfied	Unhappy	Terrible
Score	0	1	2	3	4	5	6

PF Muscle Rehab

Physiotherapists specialise in muscle function and rehabilitation. PF rehab follows very similar guidelines to general muscle rehab, relying on the same physiological responses of exercise and overload (without fatigue) to cause muscle hypertrophy. All aspects of muscle function need to addressed. Furthermore, the specific function of that particular component needs to be considered e.g. fast twitch work of the compressae urethrae. The PF, working as it does as a low load support (bladder inhibition, support of pelvic viscera, support of rectum during defaecation) and a high load resistor (fast twitch activity with rapid changes in pressure/speed), needs to be rehabilitated through a variety of diverse functions. A balance needs to be found between power and endurance training. Pure technique needs to be offset against functional outcome and skill acquisition. The PF muscles, like the fascial muscles, control a number of openings, through a range of activites, for a variety of functional outcomes. The challenge with the PF lies in sensory motor integration. Virtually all other muscle rehab can be mediated by some form of feedback, usually visual. The PF and its actions cannot be seen or mediated. Biofeedback remains an invaluable tool for the PF specialist physio.

Re-ed breathing

All rehab should begin with basic body awareness and breathing. Some form of automatic speech e.g. counting is often beneficial as it mediates the breath whilst giving auditory feedback.

Re-ed PF

In the 1940s Kegel described a basic contraction of the PF musculature. To date, aspects such as stablility and ease of activation are as important as strength and endurance. Despite enjoying a certain popularity (notoriety?) in the media (women’s magazines), many medical staff remain dubious about the benefits of specific rehab for the PF. Whilst there is increasing emphasis on ante and post natal care and education, many women are not being advised that there is something that they can do before medication or surgery need to be explored. A basic rehab program would progress as follows:

Table \(\PageIndex{2}\): Rehabilitation of Muscles

Rehab	Outcome
Assessment	Baseline
Active exercise	Muscle conditioning
Skill training	Functional
Recruitment of muscle and reflexes	Patterning for automatic function
Sensory awareness	Improved efficiency
Biofeedback, preferably EMG	Enhanced awareness
Neuromuscular stimulation	Enhanced awareness and function

Not all subjects will require the full scope of rehab.

Re-ed abdopelvic synergy

Research in the field of orthopaedic manual therapy (OMT) is increasingly showing coupled relationships between the PF and abdominal muscles. This research is ongoing. At a glance:

Table \(\PageIndex{3}\): Abdominopelvic Partners

Abdonimal Muscle	Pelvic Floor
Transversus Abdominis (TA)	Pubococcygeus (PC) & anterior PF
Obliques	Levator ani
Rectur Abdominis (RA)	Puborectalis

These muscle pairings allow for different types of spinal load (low load, rotation, high load) to be distributed evenly through the pelvis.

Rehab any objective deficits Biofeedback, a useful tool in any rehab setting, is invaluable in rehabilitation of the PF due to the lack of other forms of sensory feedback. If the deficit includes a marked motor component (<Gr3 Modified Oxford Scale) then some form of artificial stimulation may be indicated.

Rehab whole body A strong PF that cannot contract at precisely the right time is insufficient for daily life. The stresses, strains and pressures of individual subjects need to be assessed. Gyrokinesis, Pilates, Yoga and Tai Chi (amongst others) offer exercise within functional limits. In particular, an excellent PF may still be insufficient for the rigours of long distance road running, and certain jumping activities.

Home Exercise Programme (HEP)

A combination of PFEs, core work and sports specific training will achieve a certain level of skill acquisition. A maintenance programme is invaluable. Many women choose to include PF work to improve their current sporting function or to enhance another form of exercise.

Biofeedback

In cases of poor sensation and proprioception, biofeedback serves as an external mediator of internal function, allowing the subject to create ‘movement memories’. The age old ‘jade egg’ has morphed into today’s weighted vaginal cone. Of major significance is the conical end, which stretches the introitus as it descends with increased IAP, hence cueing a PF contraction.

Pressure biofeedback and some of the simple EMG options offer real time imaging. Many EMG options allow for viewing on a workout session via recorded imaging.