pelvic floor muscle dysfunction in copd liz childs pelvic floor physiotherapist wellington
TRANSCRIPT
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Pelvic Floor Muscle Pelvic Floor Muscle Dysfunction in COPDDysfunction in COPD
Liz ChildsPelvic Floor PhysiotherapistWellington
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OutlineOutlinePFM anatomy / functionRelationship PFM and breathingTeaching PFM exercisesLifestyle modificationsEffective huff / cough techniqueWhere / when to refer on
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Pelvic floor anatomy – Pelvic floor anatomy – female female
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Pelvic floor anatomy - Pelvic floor anatomy - malemale
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Function PFMsFunction PFMsSupport pelvic organsContribute to continence via:
◦ closure urethra & anus◦ support bladder neck ◦ closure anorectal angle
Role in voiding, evacuationSexual role – arousal, erection, orgasm,
ejaculation
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PFM – part of the core PFM – part of the core
Functional unit◦Spinal stability
◦Intra-abdominal pressure
◦Continence◦Breathing
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What happens to the pelvic What happens to the pelvic floor during breathing?floor during breathing?Inspiration: diaphragm contracts,
flattens, moves caudally incr IAP downward pressure exerted on PFM
Expiration: ◦Rest / quiet breathing: passive
process, elastic recoil lungs, chest wall, muscle relaxation
◦Forced exp: diaphragm and abdominals contract incr IAP upward mvt diaph, downward pressure PFM
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Inspiration Inspiration (Talasz et al, 2010)(Talasz et al, 2010)
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Forced expiration / cough – Forced expiration / cough – no abdominal or PFM co-no abdominal or PFM co-contraction contraction (Talasz et al, 2010)(Talasz et al, 2010)
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Forced expiration – with ab Forced expiration – with ab and PFM co-contraction and PFM co-contraction (Talasz et al, (Talasz et al,
2010)2010)
Reduces pressure on pelvic floor
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Practice… Practice…
Huff
Cough
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PFM dysfunctionPFM dysfunctionUrinary incontinence
◦Affects 1 in 3 women◦Increased prevalence in COPD
Pelvic organ prolapse◦Affects 50% women
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Stress urinary incontinence – Stress urinary incontinence – what happens when you what happens when you cough or sneezecough or sneeze
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Urge urinary incontinenceUrge urinary incontinence
Involuntary loss of urine associated with urgency = detrusor contraction
(can be related to anxiety)
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Urinary incontinence in Urinary incontinence in respiratory diseaserespiratory disease
Degree of urinary incontinence is greater in those with chronic cough due to CF, COPD compared with general population (Button BM, Sherburn M, Chase J, et al 2005)
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Evidence PFMTEvidence PFMTPelvic floor muscle training should be
offered, as first line therapy, to all women with stress, urge or mixed urinary incontinence
Level 1 evidence, Grade A recommendation,
ICI 2012
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Pelvic organ prolapsePelvic organ prolapse
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Pelvic Organ ProlapsePelvic Organ ProlapseHigh quality evidence (8RCTs)
supporting PFMTSignificant improvement in
◦Symptoms ◦Stage
ICI 2012 – Level 1A evidence for PFMT
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Risk factors for PFM Risk factors for PFM weakness weakness lifestyle lifestyle modificationsmodifications Chronic cough
◦ Breathing retraining◦ Sputum clearance techs, cough suppression◦ The “knack” – PFM with cough, huff◦ Support perineum
Constipation / straining ◦ Fibre, fluid, exercise ◦ Bowel routine◦ Defaecation training
Obesity Heavy lifting
◦ How much is too much?◦ Technique
Fatigue Inappropriate exercise
◦ Promote pelvic floor safe exercise
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Patients with COPDPatients with COPD
Chronic coughing strain pelvic floor Reduced exercise levels weak muscles
◦ PFM ,diaphragm, abdominals Evidence:
◦ Women with stronger PFMs are able to generate greater pressure in forced expiratory techniques / coughing
(Talasz et al, 2010)
◦ COPD/ CF patients: PFM training and Estim resulted in improved PFM strength, reduced symptoms (Button et al, 2005)
◦ Teach “The Knack”PFM contraction just before huff/cough leads to reduced urine leakage (Miller et al, 1998)
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Teaching PFM ExercisesTeaching PFM ExercisesSqueeze and Lift
◦As though trying to stop flow of urine or stop passing wind
Must feel the release Hold 2-3 sec, increase as ableRepeat up to10 timesDo this several times a day
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Practice….Practice….
Pelvic floor training
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Recommendations Recommendations (Guidelines for the Physiotherapy Management of the adult, medical, (Guidelines for the Physiotherapy Management of the adult, medical, spontaneously breathing patient. Thorax, 2009)spontaneously breathing patient. Thorax, 2009)
Question patients about their continence status
All patients with chronic cough, irrespective of continence status, should be taught to contract their pelvic floor muscles before forced expiration & coughing (The Knack)
If problems of leakage are identified, patients should be referred to a physiotherapist specialising in continence
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Asking the questionAsking the questionEmbarrassment / Shame
◦Patient Language to use
◦Patient / health professionalLet people know
◦Continence problems are common◦Help is available◦Being dry is normal◦Continence products
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When to refer onWhen to refer onSymptoms of incontinence or
prolapse Wet pants, frequency, urgency Soiling Bulging at vaginal entrance Heaviness, dragging
Suspect overactive pelvic floor◦Symptoms may include
Pain – pelvis, genital Constipation Voiding difficulty
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ReferralReferralWomen’s Health Physiotherapists in
most DHB’s Private Pelvic Floor Physiotherapists
in many centres
◦ NZ Continence Association
www.continence.org.nz
List of continence service providers
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ConclusionConclusionPFM dysfunction is under reportedSubjects are unlikely to seek help on
their ownImpact on an individual’s ability
and/or willingness to perform certain activities
Exercise Airways clearance techniques and lung
function manoeuvres Social outings
Education in pulmonary rehab groups