The Musculoskeletal
Mystery: Bridging the
Gap Between PT and
Medical Practitioner
Ingrid Harm-Ernandes PT, WCS, BCB-PMD
Duke Medicine
• I have no relevant financial relationships with the
manufacturers of any commercial products and/or
providers of commercial services discussed in this CME
activity.
Women’s Health Physical
Therapy Categories
• Obstetric Care
• Urinary Incontinence
• Fecal Incontinence
• Lymphedema
• Pelvic Pain
Obstetric
• Sacroiliac Dysfunction
• Transitional motion, 1 or both SI joints, pain with
lifting/carrying, buttock and/or SI pain, sudden and
sharp or dull.
• Low back pain
• Mechanical, discogenic, MSK
• Headaches• hormonal, postural, stress
• Carpal Tunnel Syndrome
• Urinary incontinence
• Functional levels severely reduced and
symptoms can remain following pregnancy
Urinary Incontinence
• Stress
• Misconception that it is normal, especially
post menopausal
• Urgency
• MSK issues often contribute or are the
“Driver of the Bus”
• Mixed Incontinence
• OAB with or without incontinence
Fecal/Anal Incontinence
• Fecal incontinence is the involuntary loss of liquid or
solid stool that is a social or hygienic problem
• Anal incontinence is the involuntary loss of flatus, liquid
or solid stool that is a social or hygienic problem
• Types of FI: urgency, passive and fecal seepage
• Estimates presently are that among community dwelling
adults there are FI prevalence rates of 0.4-18%
• Less than 30% discuss with their physician
• Not many studies but some recent studies show positive
response to PT
Lymphedema
• Abnormal swelling due to increased protein rich
edema as a result of mechanical insufficiency
• Occurs when fluid content >30% of normal
volume
• Results in inflammation and fibrosis
• Types
• Primary: dysplasia (decreased lymph
collectors/less functional or absent lymph
collectors)
• Secondary: acquired
Etiology
• Cancer Therapy-radiation or surgery
• Trauma-physical obstruction
• Infection
• Obesity
• Self-induced
• Tumor
• Filariasis-parasitic disease-uncommon
in US
• Surgical procedures
• Cardiac –damage or removal of vessels
Chronic Pelvic Pain
• Pain perceived within the pelvic area lasting more than
3-6 months. Pain can be cyclical or non-cyclical
• Causes are as varied as the symptoms
• There is evidence that a musculoskeletal system disorder
is present in up to 85 % of women with chronic pelvic
pain. Many of these women suffer from dyspareunia
(painful intercourse)
• Montenegro et. Al. , “Physical therapy in the
management of women with chronic pelvic pain.”
Int. J. clinical practice , Feb. 2008
A Sample of Pelvic Pain Referrals
that Physical Therapists Receive
•
•
•
•
•
•
•
Vaginismis
Vulvodynia
Dyspareunia
Vulvar vestibulitis
Dysmenorrhea
Insterstitial Cystitis/PBS
Urgency/Frequency
syndrome
• Pelvic fractures
• Pudendal neuralgia
• Fecal Incontinence
•
•
•
•
•
•
•
•
•
Piriformis syndrome
Sacroilitis
Coccydynia
Proctalgia fugax
Post surgical issues
Adhesions/scar tissue
Levator ani syndrome
Pelvic floor dysfunction
…many, many more
• What is the common link?
• Why is physical therapy so important in
treating these conditions? How do we
treat these patients?
• How do we recognize these issues so we
can direct these patients to the best kind
of treatment?
The Wonderful, Mysterious,
Musculoskeletal System is the Common
Link
 All of these conditions often have a musculoskeletal
component- PF/entire body
 MSK conditions can cause the following issues: Pain
(local or referred) , reduced strength, reduced
flexibility, endurance, decreased function and a sense
of decreased well being.
 The role of either hypertonic or hypotonic PF
musculature is being studied for the effect they have
on pain, function, incontinence and orgasm.
 Rosenbaum, PF involvement in Male and Female Sexual Dysfunction
and the Role of PF rehabilitation treatment. J.Sex Med. 2007
Why is Physical Therapy so perfectly suited
to treat these conditions?
 Pelvic floor muscles respond the same as all other
skeletal muscle – during pregnancy or any other time
 Muscle tension can lead to weakness –UI/CPP
 Muscle spasm, tightness and weakness at the pelvic
floor can lead to pelvic floor pain, dyspareunia,
incontinence and back issues
 Cyclic effect: increased pain, decreased function, fear
avoidance behavior, and protective responses can
contribute to and increase muscle tightness, spasm and
pain.
 WH PT specifically trained to assess the PF
The impact of a hypertonic pelvic floor
on dyspareunia
 Muscle pain causes protective response. The patient
protects the pelvic floor in anticipation of intercourse as a
result of previous pain. Tightening of the pelvic floor
causes reduced ability for penetration and increased pain,
this then encourages the cycle of pain to continue.
 Trigger points develop- both superficially and deep,
internal and external
 Loss of elasticity/Fibrosis of tissue
 Hypersensitivity of pelvic floor creates a pelvic pain cycle
as well
Important muscles to consider
throughout the Pelvic Region
• Pelvic floor muscles. The largest group is known as
the levator ani.
• Hip muscles that are closely connected to the pelvic
floor (obturator internus)
• Abdominal and lower extremity muscles attached
to the pelvis and hips
• MSK changes often do not show up on diagnostic
testing.
External pelvic floor view
• Levator ani
• Sup. Transverse perineal
• Bulbospongiosusguardian
• Ischiocavernosus
• Coccygeus-stress
• Obturator internus
hip pain
• Piriformis
Internal pelvic floor view
• Levator ani
• Puborectalis
• Obturator internus
• Coccygeus
• Sacrotuberous
ligament
• Sacrospinous
ligament
Pelvic muscles
 Iliacus
 Psoas
 Piriformis
 Obturator internus
 Quadratus
lumborum
 Gluteus medius
 Abdominals
(transverse)
How are these structures important in
sexual dysfunction?
 Pelvic floor specific:
 Muscle spasm can result in poor blood supply , poor
nutrition to tissues, increase hypersensitivity of
tissues, decreased strength, decreased tissues
extensibility. Can create burning- not always superficial
tissue that burns.
 Tissue tightness can result in reduced ability for
stretching introitus as well as deeper structures and
increased risk of tearing
 Stress responses can cause increased muscle reaction
 Weak muscles can lead to reduced sexual response
 Vicious cycle for the pelvic floor muscles
Surrounding Muscle Involvement
• Close proximity of hip muscle to pelvic floor
muscles
• Connected to pelvic floor muscles by tendinous
arches
• Difficulty tolerating sexual positions
• Core Structure: 4 muscle groups
• PF foundation
Association of Chronic LBP/SI
Dysfunction and Incontinence
pain.”
78% of women with LBP reported UI.
Eliasson, et al, “Urinary incontinence in women with low back
Compromised postural control of pelvic and respiratory muscles may
contribute to the development of LBP.
Smith, Russel and Hodges,” Disorders in breathing and
continence have a stronger association with back pain than obesity and physical
activity.
It is important to consider pelvic floor muscle dysfunction and training in
a patient with primary complaints in SIJ region pain
Painter, Ogle, Teyhen, “ Lumbopelvic dysfunction and stress
urinary incontinence: a case report applying rehabilitative ultrasound imaging.”
Subjective
“Our Best Tools are our Ears”
What questions can I ask to more efficiently assess if this may be a
CPP(MSK) patient?
• History/Chief complaint – different from findings
(use questionnaire)
• *read between the lines, body language, abuse hx?
• UI /Urologic symptoms
• Pain symptoms (where) –important to be specific
• What causes it, what makes it better
• Gynecological symptoms
• Medications
• Limitations- what is important in pts life
Pelvic Floor Evaluation
 Educate pt regarding PF anatomy with 3D model
 Proceed with one gloved finger
 We do not use speculums
 Describe to the patient what the exam will entail
 Reduces anxiety and enables pt to give PT good feedback
throughout the exam
 Assess skin integrity
 External trigger points
 Internal Trigger points
 Muscle strength/endurance and ability to relax
 Accurate PF exercise prescription
Trigger Points
• TP is defined as a hyperirritable locus within a taut
band of muscle
• Active- refers pain without external stimulation
• Latent – pain occurs upon external stimulation
• Internal and external points can refer pain to
locations far removed from the original TP/tight
muscle
• Positive note: TP release is a very successful
method of reducing tightness, spasm and pain at the
trigger points as well as referral regions.
Examples of Internal Trigger point
referral regions
• Levator Ani - vaginal, vulvar, and buttock regions
• Obturator internus- rectal, posterior thigh and
hips
• Puborectalis- urgency symptoms, bladder and
suprapubic regions
• Coccygeus- coccyx, buttock, LB pain
• Iliopsoas- anterior hip, anterior thigh, LB, lower
abdominal quadrant “ovary pain”
• Piriformis-buttock and posterior thigh
Finding a Trigger Point
• Iliopsoas-Thomas test position for tightness.
• Trigger points are either at the femoral triangle
or deeper in the abdominal region approximately
2 inches medially to the ASIS. (pt in supine , hook
lying, gentle resistance to hip flexion)
• Piriformis-length test by bringing hip into full
external rotation and beyond 90 degrees. Pt will
have difficulty with the motion and report
buttock stretch or pain
• Trigger points located by running fingers
between ischial tuberosity and the PSIS and
palpating approximately half way between. The
area will be tender and hardened.
The Tricky Trigger Point
• TP can complicate assessments and
diagnosis because they are so varied and
occur far from the pain regions
• TP and muscle tension are often not noted on
diagnostic testing
• Be careful of assuming that an issue does not
exist if diagnostic testing doesn’t demonstrate an
issue
Women’s Health Physical Therapy
Why PT and what do we do?
• Thorough evaluation: internal exam, external exam and
complete history of condition
• No internal with OB
•
•
•
•
•
•
Manual soft tissue work
Biofeedback
Behavioral techniques
Exercises
Home Exercise Program
Communication
Manual Techniques
• Trigger point release –internal and external
• Muscle energy release- using the muscles to realign
pelvic asymmetries.
• Strain/counter strain- very gentle method of releasing
muscle tension. Very sensitive CPP patients respond well.
• Myofascial releases- great for reducing stress on muscles
as well as organs. Pain and urgency reduction
• Visceral release- think entrapment
• Manual stretching
• Mobilization of joints-spine and hips
Biofeedback
• Excellent method for teaching relaxation of not only
the pelvic floor but the whole body as well
• “Up training”- strength
• “Down training”-relaxation/release of pelvic floor
tension
• Many pelvic pain patients need both
• Very effective for pelvic pain vulvodynia, vaginismis,
IC
• Libby Edwards, Am Jour of Obst Gyn, 2003
• Bergeron S, Binik Y et al, Pain, 2001
• Glazer HI, Jour of Repro Med,1995
Biofeedback-”Down Training”
• Attempt to achieve average
of 2 microvolts or less
• Look for sluggish
reaction/relaxation
• Demonstrate effectiveness
of verbal cues
• Print out charts
• Perform in sitting, standing
and supine
• External and internal
sensors – allows treatment
of a wide range of patients
including OB
Anal (Balloon)Manometry-FI
•
•
•
•
•
•
Balloon catheter
Syringe
Stop cock
Condom
Lubrication
Pen and paper and extra
set of hands if you have!
• Insertion in rectum
• Pt. in sidelying/pillows
between knees
• Hyposensitive and
Hypersensitive
Therapeutic Exercise
•
•
•
•
•
•
•
•
•
Extremely long list of exercises
Pelvic floor
Stretching
Strengthening/conditioning
Stabilization
Postural
Modified for the OB patient
Move toward function!
Everybody needs a Home Exercise Program
Pelvic Floor Exercises
• Baseline exercise
• Not Just Kegels!! Specific exercises for specific
needs
• Pelvic floor contraction needs to be isolated
• Giving proper cues is essential
• Sip thru a straw, elevator, flower blossom
• No “squeezing”
• Prevent valsalva
• Relaxation of the pelvic floor can be taught at the
same time
• Patients are encouraged to perform throughout the
day
Stablization Exercises
• Focus is on our “natural corset”
• TrA, pelvic floor, and multifidus
• Progress to gluteals, lumbar and LE muscles
• Reduces current and long term pain
• Prevent future injury and set backs
• OB patient
• CPP
• UI
• FI
Behavioral
• Urge and stress strategies
• Diet/fluid intake
• Toileting habits
• Relaxation techniques
• Diaphragmatic breathing
• Body mechanics-OB and UI patients in particular
• SI belt use –OB, CPP
Home Exercise Program
• Extremely important!
• Self stretch
• Dilators
• Relaxation techniques
• Performed daily
• Empowers the patient
• Major goal is independence!
Supportive Literature
• Lamvu and Steege, “ The anatomy and neurophysiology
of pelvic pain” 2006
• Importance of digital exam, muscular components of
pain syndromes, PT as an essential role in treatment of
pelvic issues.
• Rosenbaum, “ Physiotherapy Treatment of Sexual Pain
Disorders” 2005
• Importance of physical therapy in treating CPP
(biofeedback, trigger points, E-stim), and as a part of a
multidisciplinary approach
What to expect
• CPP, UI, FI patients are generally seen every other week. Total
treatment time can be as short as 2 months and as long as 6-9
months. Very chronic pain patient can be 1 year.
• OB patient generally are seen 1 x per week. Can be as short as
2-4 visits or the completion of their pregnancy. Some may
need to return in the post-partum phase.
• Lymph usually need to be seen at least 3 x per week, over a
few weeks time.
• Pt appreciate some explanation of basic pelvic PT. Internal
work, exercise, behavioral techniques, biofeedback,etc.
• Referral can be as simple as “Pelvic PT, evaluate and treat”
• Email/call for details/questions as needed!!
• Collaboration/multidisciplinary approach
Finding a Women’s Health
Physical Therapist
• APTA website: www.apta.org
• Find a PT
• Type in specialty –women’s health
• Patient zip code
• Call, ask questions
• WCS, residency programs
Where are we?
• Main appointment hub- Pts can make appointments in any clinic:
919.684.2445
• Hillsborough: 167 S Churton St.
• Ingrid Harm-Ernandes, Kaye Harris
• 919. 643.4524
• My email: harme004@mc.duke.edu
• Lenox Baker:
• Lisa Massa, Amanda Health, Chris Holladay, Leigh Wilfley, Ashley
Watts, Alexander Hill
• 919.684.0874
• Duke Cancer Center
• Lisa Massa, Amanda Heath, Natalie Sebba, Chris Holladay
• Brier Creek
• Jennifer Maddocks, Amy Pannullo, Natalie Sebba
• 919.206.4868
Pearls of Wisdom
 MSK plays a very strong but hidden role in pelvic health
and issues. PT is perfect fit for these conditions
 Entire core is often involved in pelvic pain conditions
 Trigger points can often mimic other conditions and pain
patterns. Do not assume that they do not have an issue if
diagnostic tests do not return with positive results.
Muscular issues often do not show up on these tests.
 Ask questions-patient often have difficulty discussing
pelvic issues. Questionnaires often help. “Read between
the lines”
 Connect with other practitioners. There are lots of good
resources and specialists out there who can help you with
those tough pelvic cases. You do not have to “go it alone”.
Supportive Literature for Pelvic
Relationships/Motor Control Patterns
• “Motor Control Patterns During an ASLR in PGP Subjects”,
Beals et al. Spine 2009.
• During ASLR PGP subjects demonstrated bracing, increased IAP
and depression of the PF.
• “The Association between PGP and UI in Pregnant Women in
2nd Trimester.” Fitzgerald, et al. Int J of Gyn and Ob. 2012
• An association of PGP and UI and UI and PFM weakness
• “Changes in PF and diaphragm kinematics and respiratory
patterns in subjects with SI pain following a motor learning
intervention.” O’Sullivan, et all, Manual Therapy. 2007
• Positive changes in motor control (learned) were associated with
improvements in pain and reduction in disability .
Studies considering the entire core
and importance of core ability
• “Instructing pelvic floor contraction facilitates transversus
abdominis thickness increase during low- abdominal
hollowing”, Critchley, Phsyiotherapy Int, 2002
• instructing healthy subjects to co-contract PF results in greater
increased thickness during low abdominal hollowing in four point
kneeling.
• “Effect of variations in forced expiration effort on pelvic floor
activation in asymptomatic women”, Kitani, et al, Journal in
WH PT, 2014.
• minimal forced expiration effort resulted in the most consistent
PF cranial-ventral displacement with vaginal squeeze pressure. PF
automatically activates during respiration with greater activation
during expiration than inspiration.
• “ Differential Activity of Regions of the Psoas Major and Quadratus
Lumborum during Submaximal Isometric Trunk Efforts”
• Study of the function of QL and PM during trunk loading. Various
components of each muscle functioned differently during respiration.
Demonstrates potential effect on of these muscles on respiration and
the effect of respiration on these muscles. ENTIRE CORE FUNCTIONS
AS A UNIT
• “Anticipatory postural Activity of the deep trunk muscles differs
between anatomical regions based on their mechanical advantage”,
Park, Tsao, Cresswell and Hodges.
• Findings suggest that the CNS differentially activates individual
regions within complex spine muscles to control the threedimensional forces applied to the spine. The data also point to a
sophisticated control of muscle advantage that appears based on
mechanical advantage. USING THE RIGHT MUSCLES AT THE RIGHT
TIME
Thank you!
Questions?