Pelvic Floor Muscle Pelvic Floor Muscle Dysfunction in COPDDysfunction in COPD

Liz ChildsPelvic Floor PhysiotherapistWellington

OutlineOutlinePFM anatomy / functionRelationship PFM and breathingTeaching PFM exercisesLifestyle modificationsEffective huff / cough techniqueWhere / when to refer on

Pelvic floor anatomy – Pelvic floor anatomy – female female

Pelvic floor anatomy - Pelvic floor anatomy - malemale

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

PFM – part of the core PFM – part of the core

Functional unit◦Spinal stability

◦Intra-abdominal pressure

◦Continence◦Breathing

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

Inspiration Inspiration (Talasz et al, 2010)(Talasz et al, 2010)

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)

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

Practice… Practice…

Huff

Cough

PFM dysfunctionPFM dysfunctionUrinary incontinence

◦Affects 1 in 3 women◦Increased prevalence in COPD

Pelvic organ prolapse◦Affects 50% women

Stress urinary incontinence – Stress urinary incontinence – what happens when you what happens when you cough or sneezecough or sneeze

Urge urinary incontinenceUrge urinary incontinence

Involuntary loss of urine associated with urgency = detrusor contraction

(can be related to anxiety)

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)

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

Pelvic organ prolapsePelvic organ prolapse

Pelvic Organ ProlapsePelvic Organ ProlapseHigh quality evidence (8RCTs)

supporting PFMTSignificant improvement in

◦Symptoms ◦Stage

ICI 2012 – Level 1A evidence for PFMT

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

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)

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

Practice….Practice….

Pelvic floor training

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

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

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

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

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