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eNews - October 2019

In this eNews
Presidents note
Editors note
Multidisciplinary Management
More than Kegels - A pelvic rehabilitation
Physical Therapy Managment of chronic pelvic pain

Message from the President:

It gives me great pleasure to announce the success of the SAUGA Congress which was held at Department of Obstetrics and Gynaecology at Charlotte Maxeke Johannesburg Academic Hospital between 8-10th Aug 2019. The congress provided delegates with a unique opportunity to interact with international Urogynaecology experts i.e. Professors, Peter Petros, Tomi Mikkoli and Guenter K. Noé. Prof Guenter K. Noé demonstrated live laparoscopic pectopexy, POP repair while Prof Tomi Mikkola elegantly demonstrated Bulkamid peri-urethral injection for SUI. Once in a lifetime opportunity to meet the infamous Peter Papa Petros who detailed the integral theory system during a masterclass. Congratulations and thank you to Prof Andreas Chrysostomou and team!

“Your silence gives consent.” ― Plato

Prof Zeelha Abdool
SAUGA Chairman

Message from the Editor:

Dear Colleagues This newsletter highlights the importance of teamwork in our profession.

The 3 papers presented are important in highlighting this approach which is indispensable in the management of incontinence.

I hope you enjoy this issue – thanks to Hester van Aswegen for her efforts.

Peter de Jong

 


PHYSIOTHERAPY AS PART OF THE MULTIDISCIPLINARY TEAM APPROACH IN THE MANAGEMENT OF PELVIC FLOOR DISORDERS IN SOUTH AFRICA

(compiled by practising physiotherapists)

Multidisciplinary teams convey many benefits to both the patients and the health professionals working on the team. These include improved health outcomes and enhanced satisfaction for patients, and the more efficient use of resources and enhanced job satisfaction for team members. (https://www.health.nsw.gov.au/healthone/Pages/multidisciplinary-team-care.aspx  ).

The general recommendations from recent research (Kathy Davis et al, Hartmann et al, Berghmans et al) is that management of a patient in a comprehensive multidisciplinary setting is more effective and offers many advantages including dynamic links between disciplines, appropriate and timely investigations and referrals, and better coordination of patient-centred care. There is a recent tendency to involve physiotherapists in the multidisciplinary assessment and treatment of pelvic floor disorders. In 2013, the National Institute for Health & Care Excellence (NICE) Urinary Incontinence guideline recommended that a multidisciplinary team (MDT) review should be mandatory before any invasive therapy is offered to all patients with stress urinary incontinence (SUI) & overactive bladder (OAB). In the 2019 update of the NICE guidelines on management of women with urinary incontinence and pelvic organ prolapse, the new recommendations on the organSAUGAtion of specialist services suggested that a multidisciplinary team should include not only consultants with expertise in managing urinary incontinence and/or pelvic organ prolapse, but also a urogynaecology, urology or continence specialist nurse as well as a pelvic floor specialist physiotherapist. The physiotherapy services include a diverse variety of treatment strategies such as behavioural training, education and advice, pain management, myofascial and scar mobilSAUGAtion techniques and pelvic floor rehabilitation tailored to the specific needs of the patient.
Those physiotherapists in South Africa who are part of multidisciplinary teams treating pelvic dysfunctions ( e.g. urinary and anorectal dysfunctions, pelvic pain, pelvic organ prolapse and sexual dysfunction) can confirm the advantages of managing patients in such settings, but unfortunately there is still a huge need for establishing more units at both public hospitals and private settings.
There are a few units where physiotherapy forms part of the multidisciplinary services offered to patients, for instance the Urogynaecology Unit at the University of Pretoria, the colorectal / pelvic floor unit at Wits Donald Gordon Medical Centre, the Tygerberg Hospital Urogynaecology Clinic, the Gynecology / Urology clinic at Groote Schuur and the urogynaecology unit at Pholoso Hospital in Polokwane. There are also other public hospitals where urologists, gynaecologists and colorectal surgeons refer patients to physiotherapy care even if they don’t have access to a multidisciplinary unit, but unfortunately there are many more that doesn’t provide a physiotherapy service at all.
As part of a larger project, Dr Corlia Brandt from the Physiotherapy dept. at the University of the Witwatersrand, is busy developing Pelvic and Women`s Health Clinics in the public sector. These clinics are an interprofessional collaboration between mainly Urogynaecology and Physiotherapy (public and private sector). The aim of these clinics is not only to see patients on an out-patient basis weekly, but also to develop opportunities for clinical placements and research on post-graduate level. The clinics of Urogynaecology and Physiotherapy run on the same day, as to create an optimal learning opportunity for all. It also involves interprofessional discussion sessions once a month, where clinical cases are discussed by Urologists, Urogynaecologists, Dietitians, Psychologists, and Physiotherapists. The pilot project is currently run in Gauteng at the Charlotte Maxeke hospital, whereafter the model will be proposed to other provinces in South Africa to develop these clinics.

The Pelvic and Women’s Health Physiotherapy Group of SA has been involved with postgraduate training of physiotherapist in the field of pelvic and women’s health and more physiotherapists are now qualified to help patients with pelvic dysfunction. These physiotherapists are encouraged to volunteer hours at established multidisciplinary units to improve their own learning experience and also experience the advantages of a multidisciplinary setting. One of the PWHPG’s goals is to host courses for physiotherapists in the other outlying provinces to educate them about the importance of this and to encourage them to become part of multidisciplinary units.
We hope that our collaboration with other medical health professionals in MDT’s will lead to improved service and care to patients and increase job satisfaction for all team members. As Nancy Epstein stated in her review on Multidisciplinary in-hospital teams (2014): “Within hospitals, delivering the best medical/surgical care is a “team sport.”. As physiotherapists we extend the invitation to all doctors in these units to encourage physiotherapists to be an active part of your unit.

REFERENCES:

  1. Berghmans B. Physiotherapy for pelvic pain & female sexual dysfunction: an untapped resource. Int Urogynecol J. 2018 May;29(5):631-638.
  2. Nancy Epstein*. Multidisciplinary in-hospital teams improve patient outcomes: A review; Surg Neurol Int. 2014; 5(Suppl 7)
  3. Kathy Davis;Devinder Kumar;Stuart Stanton .Pelvic Floor Dysfunction: The Need for a Multidisciplinary Team Approach; Journal of Pelvic Medicine and Surgery. 9(1):23-36, JANUARY-FEBRUARY 2003
  4. Balachandran 2015 Balachandran A, Duckett J. What is the role of the multidisciplinary team in the management of urinary incontinence? Int Urogynecol J. 26, 791-3 2015
  5. Urinary incontinence and pelvic organ prolapse in women: management - NICE guideline [NG123]Published date: April 2019 Last updated: June 2019

 


“Kegels alone don’t cure” – a pelvic rehabilitation perspective

By Karen Swanepoel (Women’s Health Physiotherapist)


A Kegel exercise is a voluntary contraction/squeeze of the Levator Ani muscles performed to train the pelvic floor muscle. It has increased muscle tone and strength as its goal. It can be assessed by the Oxford muscle scale used for other skeletal muscles. The reason why not all patients who do Kegels get better is because a “strength-only rehabilitation approach” is not always to the benefit of the patient.

Patients with pelvic floor dysfunction are desperate for help. And unfortunately the internet offers many “one size fits all” and “cure all” approaches, including pelvic stimulators, cell phone applications, magnetic chairs, vaginal rejuvenation therapy- and all claim to improve the strength of the pelvic floor muscles. But is a good pelvic floor contraction enough?

The short answer is no.

As a pelvic floor physiotherapist, I explain pelvic floor muscle rehabilitation to a patient by using a more visible muscle, namely the calf muscle. If a contraction/strength was the only goal for a muscle to be deemed effective, the calf muscle would lose its ability to relax. Walking on the toes is not functional. The biomechanical impact on the knees, pelvis, hips and lumbar spine would be significant. It is not only about contracting a muscle.

The calf muscle needs to contract and relax correctly to enable ambulation. The contraction intensity varies and calves need to contract both concentrically and eccentrically. Otherwise a static position of plantar flexion is all that is achieved and will result in pain and fatigue. The calf muscles respond to proprioceptive input from the whole lower limb. All the above functions are true for the pelvic floor. It is not enough to be able to contract the pelvic floor. And no number of Kegels alone can cure pelvic floor dysfunction.

The field of pelvic floor rehabilitation has thankfully developed extensively from the original “Kegels” of yesteryear. A pelvic floor rehabilitation plan may include:

  • Evaluation of the correct contraction and relaxation of perineal muscles
  • Education of anatomy and how it relates to the present condition
  • Pelvic floor muscle training which includes coordination, control, and incorporating other muscle groups into activities of daily living
  • E-stim, Biofeedback (EMG, RTUS), Electrotherapy
  • Vaginal cones
  • Hypopressive abdominal techniques
  • Urotherapy

Physiotherapists also address co-existing lumbo-pelvic conditions and incorporate the coordinated working of the Abdomino-pelvic synergists in individualised rehabilitation programmes to suit the activity level of the woman.

“Kegels alone” don’t cure pelvic floor dysfunction

The proper assessment of pelvic floor musculature enables the pelvic floor physiotherapist to establish realistic therapeutic goals. Muscle training should be aimed at reaching the objectives. A functional pelvic floor will provide urethral support as well as pelvic organ support not only in a static environment but during activities of daily living. Correct rehabilitation will improve muscle strength, tone, resistance as well as coordination to contract appropriately in response to increased intra-abdominal pressures during activities of daily living. Rehabilitation should be aimed at both slow twitch and fast twitch muscle fibres of the muscle group. The pelvic floor must lengthen and shorten appropriately for each phase of movement in a coordinated fashion. A constantly shortened and contracted pelvic floor prevents defecation, intercourse and increases pelvic pain.

A sufficient supportive resting tone prevents prolapse. A strong and speedy contraction will prevent leakage sudden surges in intra-abdominal pressures. The therapist will progress the pelvic floor training by altering the position of exercise and increasing complexity by increased resistance, adding more muscle groups and functional movements.

Hypertonic pelvic floor muscles cannot contract effectively and require manual techniques to enable relaxation to occur. Patients should be equipped with relaxation exercises, breathing exercises, flexibility drills and awareness to enable them to correctly use the pelvic floor in a relaxed manner during defecation, intercourse and exercise.

The pelvic floor should never be used in isolation and needs to be incorporated into activities of daily living for example: a mother who needs to lift her three-year old or the older lady who carries her shopping bags.

When patients are asked to carry out a voluntary contraction of the pelvic floor about one third do not perform the contraction correctly or they perform a Valsalva
manoeuvre. In individuals with pelvic organ prolapse, this may aggravate the condition. A correctly taught and executed pelvic floor muscle contraction will, in time, hypertrophy the muscles, improve response time, strength and effectiveness of the pelvic floor support and closure functions.

As pelvic floor physiotherapists we strive to rehabilitate a patient holistically, with a variety of techniques depending on the presentation. Referral to a physiotherapist for an evaluation and correct treatment program will benefit the patient more than Kegels ever can.

 


Physical Therapy Management of chronic pelvic pain

By Hester van Aswegen ( BPhysT)


Although chronic pelvic pain (CPP) is defined as pain in the pelvic area, patients also present with urinary, bowel, sexual and gastro-intestinal dysfunction that could be linked to a musculoskeletal origin. These symptoms could include urinary urgency and frequency, difficulty or pain with urinating, burning during or after urination, pain and / or difficulty with bowel movement / constipation and female or male sexual dysfunction (vaginismus / dyspareunia, erectile dysfunction).
The optimal treatment of chronic pelvic pain is based on a biopsychosocial model delivered by a multidisciplinary approach, that should include pain management strategies and pelvic floor rehabilitation to address the musculoskeletal component of pelvic pain. Studies have shown that many patients with CPP have hypertonic or overactive pelvic floor muscles with trigger points, as well as trigger points in surrounding areas like the abdominal wall, obturator internus, gluteals, piriformis and hip adductors. These can refer pain to many areas of the body and contribute significantly to the above symptoms. (see fig 1 and 2)

Trigger points in the various pelvic floor muscles can refer to the perineum , vagina, anus, and adjacent structures like the lower back, sacrococcyeal region or thighs.

Fig 1. http://www.triggerpoints.net/muscle/levator-ani
Fig 2: http://www.triggerpoints.net/muscle/ 

Berghmans (2018) stated that chronic pelvic pain (CPP) is a complex syndrome where pain sensation and intensity often do not correspond with the identified lesion, but are felt elsewhere, leading to musculoskeletal and myofascial disorders and sexual dysfunction (SD). In many of these patients central sensitization is present as well and this complicates the diagnosis and treatment. Frequently, patients experience pelvic pain as psychological distress resulting in physical complaints, leading clinicians to prescribe medication or surgical intervention to alleviate these symptoms, often with insufficient results. Although pelvic floor physiotherapy has its place in the multidisciplinary approach to these problems, it is widely underused - possibly due to the fact that clinicians are unaware of the physiotherapists role.

Before making the diagnosis of myofascial pelvic pain, other potential causes of pain should be ruled out, such as infections, fibroids, and other gastro-intestinal or bladder diseases. Once myofascial pelvic pain is diagnosed, pelvic physical therapy should be considered together with other treatments or medications. ( EAU guidelines 2018)

PhysiotherapyTreatment

Physiotherapists can either treat the pathology of the specific pelvic floor muscles, or more generally treat myofascial pain if it is part of the pelvic pain syndrome.

As central sensitization and myofascial involvement contribute to CPP and the associated pelvic floor dysfunction (PFD), physiotherapists use strategies that address treatment of the myofascial trigger points (MTrPs) as well as behavioural therapy and pain-neuroscience education. This dual approach addresses physiological and psychological components of chronic myofascial pain and aim to improve the way that an individual manages their pain, and “take back control” of their lives.

Information about the patient’s underlying health problem and education is always the starting point of treatment. Education includes explaining anatomy, function and CPP pathophysiology (including how it links to bladder, bowel and sexual dysfunction), involvement of the pelvic floor muscles as well as the link between the emotions / stress / anxiety and physical symptoms. It is essential that patients understand this, as it provides the rationale for the introduction of physical therapy interventions and managing the patient’s condition holistically.

Providing information that is personalised and responsive to the patient’s problems, conveying belief and concern, is a powerful way to allay anxiety and improves adherence to treatment.

Pain management and cognitive coping strategies should include education about how psychological factors, such as pain related fear and anxiety, may affect myofascial pain as well as bladder, bowel and sexual function.

Holistic treatment should also include mindfulness and relaxation techniques to help regulate emotions and stress. Mindful awareness can be cultivated through training in mindful movement, various breathing and relaxation techniques or meditation. This approach has been shown to help with the reduction of chronic pain and management of anxiety as it downregulates the nervous system.

One of the building blocks of mindfulness training as well as re-education of the pelvic floor muscles is a proper breathing technique and a lot of time is spent teaching the essence of breathing and how to incorporate it into a pelvic floor rehabilitation programme. Deep breathing techniques and other pain management strategies, including general and specific respiratory and relaxation exercises, aim to enhance patient’s self-management and self-empowerment skills.

Pelvic floor muscle pain
Treating pelvic floor over-activity and myofascial trigger points should be done by specialised physiotherapists who are trained not only in the musculoskeletal aspects of pain, but also in the psychological mechanisms and the role of the CNS in chronic pain. Because of the overactivity of their muscles, these patients have difficulty in contracting or relaxing their muscles and it is therefore important to teach them how to relax the muscles in order to interrupt the cycle of pain-spasm-pain. The focus of treatment shifts from strengthening to lengthening and the patient must understand that a typical strength training programme (traditional Kegel exercises) might not be indicated as it could actually worsen their symptoms. The physiotherapist will teach them correct activation and movement of their pelvic floor and core muscles depending on the assessment done.

Physical therapist interventions includes a wide range of modalities.

It includes manual therapy to release trigger points, mobilise scars and soft tissue restrictions, nerve gliding, behavioural retraining for the bladder and bowel, as well as a rehabilitation programme to teach correct movement and breathing techniques. When necessary other modalities like biofeedback, tens / electrotherapy, dry needling, joint mobilization, foam rollers and vaginal dilators can be used to assist the patient in achieving their goals..

Rehabilitation include stretching of all relevant muscle groups surrounding the pelvic region, strengthening of the core muscles where weakness is present and ensuring normal pain-free pelvic floor function..


Fig 5. Physical therapist interventions in management of CPP

Chronic pelvic pain is a complex and debilitating problem affecting many patients quality of life negatively. As part of the multidisciplinary team, and because of its holistic and whole-body approach, pelvic physiotherapy can contribute significantly to assessing and treating these patients.

REFERENCES AVAILABLE ON REQUEST.

SAUGA Congress 2019

 

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