The Role of Physical Therapy and Manual Therapy in Treating Pelvic Floor Dysfunction

"Beyond all doubt the use of the human hand, as a method of reducing human suffering, is the oldest remedy known to man; historically no date can be given for its adoption." (1) John Mennell, M.D. (Highly noted practitioner in the Field of Orthopedic Medicine)

The pelvic floor is a diamond shaped area identified by the pubic bone, the sit bones (ischial tuberosity) and the tail bone (coccyx). The muscles of the pelvic floor form a sling or hammock-like structure and have many diverse functions. They support the abdominal contents (such as bladder, rectum and uterus) and play a major role in maintaining urinary and fecal continence. They also play a role in sexual function- gaining and maintaining penile erection and providing muscle tone to enhance sensation.

Pelvic pain and dysfunction manifests as a Myofascial Pain Syndrome, in which abnormal muscular tension persists. Chronic Pelvic Pain Syndrome (CPPS) in both men and women has been implied throughout the literature to be a hypertonus (high muscle tone) or overuse injury. The state of chronic constriction of pelvic floor muscles creates pain referring trigger points, reduced blood flow, and an inhospitable environment for the nerves, blood vessels and structures (such as digestive and reproductive organs), throughout the pelvic basin. Many cases of CPPS may begin with repeated tightening of the pelvic floor muscles. The initial trigger may be a major stressor such as pregnancy and childbirth, an accident, injury or trauma of any kind or several minor stressors including postural and repeated daily movements.

Anxiety is also considered to be a stressor consistent with increased muscular constriction. Our fast paced society contributes to this malady making longer work hours and less leisure time a norm. Numerous studies have shown that stress and anxiety impairs the healing of wounds, and results in increased inflammation. (2). Poor nutritional habits become contributing factors consistent with an overall decline in good self care.

All of the therapists at Hands on Physical Therapy have received advanced training in techniques specifically for pelvic floor dysfunction ( PFD )or chronic pelvic pain syndrome ( CPPS). PFD or CPPS include rectal, genital, or abdominal pain. These kinds of conditions can also include urinary frequency, urgency, incontinence and sexual pain and dysfunction. Physical Therapists are uniquely qualified to treat pelvic floor dysfunction with conservative management techniques such as manual therapy, pelvic floor strengthening, biofeedback, and bladder retraining. Physical Therapy assessment for PFD/CPPS consists of a thorough evaluation of external pelvic floor trigger points, internal pelvic floor muscles, and identification of any postural and structural asymmetries as a contributing factor. Therapy may be external, as in muscle training or strengthening. It may also be internal using manual therapy techniques to directly affect the pelvic floor muscles, spine and supporting musculature.

The Orthopaedics Section of the American Physical Therapy Association (APTA) offered the following position:

"Manipulative techniques by licensed physical therapists in evaluation and treatment of individuals with musculoskeletal dysfunction has always been an integral component within the scope of practice." "Manipulation implies a variety of manual techniques which is not exclusive to any specific profession."

Internal techniques, most notably Myofascial Release, are applied directly to the pelvic floor musculature. Symptoms are reduced as muscle tone normalizes. Detailed description of fascia and Myofascial Release are prevalent throughout the literature. John F. Barnes, PT, has trained well over 50,000 therapists in the Myofascial Release approach (www.myofascialrelease.com). According to John Barnes, PT, fascia is a tough connective tissue which spreads throughout the body in a 3 dimensional web from head to foot without interruption including the pelvic floor. It wraps around all of the pelvic organs, blood vessels, nerves, ducts, and surrounding musculature.

Fascial restrictions within the pelvic floor can adversely affect all of the pelvic organs, and the adjacent muscular and osseous connections (for example lumbar spine, sacroiliac joints). Shortened fascia will develop cross-links or adhesions which decreases its ability to glide resulting in restriction within the musculoskeletal system as well as limited organ motility.

Some common diagnosis associated with CPPS and PFD are as follows:

In Men:

Prostatitis

In women:
Vulvodynia (vulvar vestibulitis)

In Men and Women:
Interstitial cystitis

Levator ani syndrome

Pudendal nerve entrapment

Sexual dysfunction- dyspareunia

Erectile Dysfunction (ED)

Incontinence

Pelvic pain

Irritable Bowel Syndrome (IBS)

Other related areas where manual therapy can help are related to female infertility due to adhesions within the pelvic floor. Medical literature notes that mechanical dysfunction (primarily adhesions) is the cause of 40 is idiopathic or unexplained.

Although awareness of the male and female pelvic floor has improved over the years, it is still very common to consider these areas private and difficult to talk about even with your health care providers. Sometimes, symptoms like urinary incontinence and sexual dysfunctions are dismissed as aging or normal aches and pains that have to be tolerated.

Hands on Physical Therapy provides a specialized approach that addresses whole body acute and chronic pain patterns. Their staff has extensive training in manual therapy techniques which are utilized for treating structural and soft tissue imbalances within the body. If you would like to learn more about their cutting edge techniques, you may visit them online at Handsonpt.net