Pelvic Injuries Rehabilitation
Pelvic floor muscle training is often recommended to women with Stage 1 and 2 vaginal prolapse. PFMT involves a concentrated exercise regimen of 6-12 weeks lead by either a physical therapist, nurse practitioner, or other appropriate staff member which involves instructing the patient in the correct methods to isolate and contract the muscles of the pelvic floor. While PFMT will not reverse anatomic derangements it may alleviate many of the symptoms of pelvic organ prolapse including urinary/fecal urgency, frequency, and incontinence. Multiple observational studies have indicated subjective relief for patients treated with pelvic floor muscle training. PMFR/ES therapy or pessary if pt are having quality of life effects but either does not want or to delay surgery, is not a good candidate for surgery, failed surgery or wish to have more children. Treatment with Pelvic Muscle Floor Rehabilitation and Electrical stimulation (PMFR/ES) The pelvic floor musculature provides support to maintain the position and function of the pelvic organs. When weakened, it loses its ability to adequately support these structures. In addition, sphincters that surround the urethra and anus also lose strength and tone, and may not close tight enough to prevent leakage, particularly with activities that increase intra abdominal pressure. Pelvic floor muscle rehabilitation is targeted towards the levator ani which consists of the pubococcygeus, the puborectalis, the ileococcygeus and the coccygeus muscles. Strengthening of these muscle groups are an integral part of PFMR/ES.
The muscle fiber type is determined by the nerve fiber supplying it. Slow twitch striated muscle fibers (tonic, type 1) sustain activity, whereas fast twitch striated muscle fibers (phasic, type 2) are involved in bursts of activity. In asymptomatic women, the PFM are approximately 30% fast fibers and 70% slow fibers. A muscle contraction must be:
- Greater than that of its ordinary everyday activity in order to increase in force.
- Longer-lasting to increase the endurance capability.
Electrical stimulation is typically used in PFMR to stimulate the pelvic nerves to enhance the contractile response. Electrical stimulation works via the model of neuromodulation which remodels the neuronal reflex loop by stimulating afferent nerve fibers of the pudendal nerve that influence this reflex loop. By this method of inhibiting bladder reflex contraction and using high intensity stimulus for short duration (15 Mins), the bladder spasm reduces or the detrusor muscles is" clamed". Electrical stimulation has also shown to strengthen the pelvic muscle and structural support of the urethra and the bladder neck. Thus we hypothesize that combined therapy with pelvic floor muscle rehabilitation and electrical stimulation should provide patients with an optimal combination for improving urinary incontinence symptoms. , a digital vaginal exam will be used to help the provider determine degree of muscle levator ani strength and this will be recorded and graded as below:
Scale Grade Description
| None | 0 | No discernible muscle contraction, pressure and/or displacement of examiner's finger. |
| Flicker | 1/5 | Trace but instant contraction <1 second, very slight compression of examiner's finger. |
| Weak | 2/5 | Weak contraction or pressure with or without elevation/lifting of examiner’s finger, held for >1 second but <3 seconds. |
| Moderate | 3/5 | Moderate contraction or compression of examiner’s finger with or without elevation/lifting of finger, held for at least 4-6 seconds, repeated 3 times. |
| Firm | 4/5 | Firm contraction with good compression of examiner’s finger with elevation/lifting of finger toward the pubic bone, held for at least 7-9 seconds, repeated 4-5 times. |
| Strong | 5/5 | Unmistakably strong contraction and grip of examiner’s finger with posterior elevation/lifting of finger, held for at least 10 seconds, repeated 4-5 times. |
The exercise program will consist of squeezing and holding the levator ani muscle contraction. The average mm/Hg pressure generated and the maximal time in seconds for maintaining a contraction for each patient will be determined at baseline and recorded as the baseline contractile strength and time. The goal for these intervals will be to hold each contraction for 10 seconds and then to relax the muscle for 10 seconds. However, in patients who are unable to hold the contraction for 10 seconds at baseline, the study will be performed using their baseline contractile time in seconds. Patient will perform squeeze, hold relax repetitions until fatigue of the muscle is noted (fatigue is defined as not being able to hold the contraction for the baseline time in seconds or a drop from the peak contraction strength). Once a patient’s muscle begins to fatigue, they will be instructed to perform 2 additional repetitions for their home therapy11. This exercises program will be use to developed strength and endurance (Kegel Maneuvers), under visual video computerized observation and instruction by the provider with a Prometheus pelvic floor muscle rehab unit. The patient maximum pelvic muscle strength contraction for the endurance exercise will be measured, in mmHG.
The patient will either be able or not able to contract the muscle when instructed. The patient will either be able or not able to relax muscles when instructed. An appropriate or inappropriate response will be obtained. The contractions will be graded as nonexistent / weak / moderate I strong and the average will be measured in mmHG of duration, for the endurance exercise. Patient physically performing the directed instruction of squeezing the pelvic muscle floor, and relaxing will be measured in seconds with the number of repetitions recorded.
The patient will be encouraged through detailed and explicit instruction and direction by the Provider of how to perform and improve the pelvic muscle floor function. Fast twitch exercises will be done to decrease urinary urges and prevent leakage. With this exercise the fast twitch or short muscle fibers are being strengthened. Patient will either be able or not able to perform muscle contraction.
The patient maximum pelvic muscle strength contraction for Fast twitch exercise will be measured, in mmHG. . The average strength of the fast twitch contraction will be measured and tested in mmHG for the short muscle fiber will either be weak/moderate/strong amplitude.
The next portion consists of the electrical stimulation. Vaginal probe will kept in vagina and electrical stimulation will be initiated for SUI patients 50 Hz will be used for 15 minutes, with pulse of 5 second on and 5 seconds off and 12.5 Hz for UUI and OAB/DI patients. The stimulation regimen will be used alternating 50Hz and 12.5Hz every other week for MUI... The Electrical Stimulation Level is measured in uv/ma. Patient will be asked on their toleration of the stimulation. Electrical stimulation will be maintained during therapy based on the patient’s tolerance of the stimulation. Evaluation of this procedure will be determined from muscle fatigued noted from the decrease in the length of her contraction. Management of the patient will be to instruct her to continue a new prescribed exercise at home. For Home therapy pt will be prescribes exercises repetitions based on their endurance and muscle fatigue. All patients will need to do exercises 3 times per day 7 day per week in a sitting, standing and lying position.