In the second installment of this three part series: Caring for the complex patient, we will review the patient’s presentation and discuss the treatment techniques employed and how documentation using bestPT supported the treatment.
The patient was a 34 year old female referred to physical therapy (PT) by her obstetrician-gynecologist (OB-GYN) for evaluation of pelvic organ prolapse (POP). The patient presented to physical therapy para 2 grava 2 (P2G2) indicating 2 pregnancies and 2 live births. On the day of evaluation she was 5.5 weeks post vaginal birth after cesarean (VBAC) of her second child. Her primary concern was a feeling of heaviness and a sense that her organs were falling out, especially during standing and lifting tasks. Her physician had not yet performed a complete six week post-delivery examination, though this appointment was scheduled for three days after physical therapy evaluation.
The patient reported neither pain nor unintentional loss of urine (incontinence), though she felt weak throughout the abdominals and pelvic floor. Pertinent past medical history consisted of cesarean section 11/19/12 (almost two years prior to PT evaluation date) with subsequent hematoma at the surgical site which resolved with use of an abdominal binder. She is otherwise a very healthy woman with no comorbidities. The patient lived at home with her husband and two children, works as a physician assistant specializing in hospital based gastroenterology which requires prolonged standing during procedures and patient rounds. She is an avid runner and aerobics instructor. Her primary goal was to be able to safely lift each of her children without the sense of heaviness in the pelvis. Secondary goals were to return to running and teaching aerobics classes which are her primary sources of recreation and stress reduction.
Physical therapy examination revealed abdominal strength to be 3+/5 on the Kendall scale. The Pelvic Floor Impact Questionaire (PFIQ-7) was utilized as standardized outcome tool. This patient received a score total of 0 on the bladder and rectum subsets, and a score of 19 on the pelvis subset for a total score of 19 on the scale. Internal examination and musculoskeletal physical therapy differential diagnosis included pelvic floor dysfunction resulting in prolapse, and increased abdominal pressure due to visceral adhesions from previous c-section.
The first priority of intervention was patient education to avoid bearing down and valsalva maneuvers. Discussion on the day of evaluation included contracting the pelvic floor prior to lifting her toddler or infant, safe lifting spinal mechanics, and breathing technique to avoid abdominal bulging or bearing down. Avoidance of constipation was discussed, though this was not an issue for this patient, nor was weight management. The patient was issued a copy of the American Physical Therapy Association’s postpartum health awareness information brochure to provide further education regarding postpartum back and pelvic pain, pelvic floor muscle care, post partum fatigue, posture, and cesarean scar management.
Following the internal pelvic exam, the patient was given a pelvic floor strengthening program. Given that the role of connective tissue in providing support to the pelvic floor has gained significant emphasis in the literature, it is understood that if the patient does not benefit from a pelvic floor strengthening program than other means of intervention may be warranted. The rationale for intensive strengthening of the pelvic floor muscle to treat POP is that strength training will build up the structural support of the pelvis by elevating the levator plate to a higher resting point, and maintain this position through hypertrophy and improved stiffness of the pelvic floor muscles.
As no single or absolute protocol has been reported to be the absolute gold standard in the literature, pelvic floor muscle (PFM) training was dosed based upon compilation of evidence in the literature, and patient response. Initially the patient was given a program of 80-100 kegels per day, with 4 sets of 10 being 5 second hold, and 4 sets of 10 being 15 second hold to address speed and endurance of the muscles. These numbers were calculated based upon her muscle test scoring durng initial evaluation. Due to her busy schedule and PFM strength of 4/5, she was advised that these could be performed in various positions, including supine hooklying, sitting, and standing. She was educated to gently draw in the abdominals during PFM contraction as transverse abdominis co-contraction has been demonstrated to enhance activation of the pelvic floor.
Progression of PFM exercise and lumbo-pelvic stability exercises were increased each visit as the patient became stronger. Progressions included diaphragmic breathing pattern with pelvic floor muscle contractions, sidelying clams while performing a PFM and transverse abdominis contraction, and quadruped PFM with transverse abdominis contraction. This exercise was progressed by adding an opposite upper and lower extremity lift (commonly referred to by physical therapists as a bird dog). Pelvic brace with cough was added to address co-ordination and timing of PFM contraction prior to increased intra-abdominal force.
Planks in the forward and side position were introduced at the fourth visit with instructions to contract the pelvic floor muscles and transverse abdominis. At this point, the patient was able to sustain this contraction and sense lift of the pelvic floor for approximately 20 seconds. Sit to stand with kegel and small range squats were added as well. At this point in treatment the patient reported that she was already feeling much better, noting a 50% improvement in overall symptoms during activities of daily living.
Manual therapy consisted of myofascial release (MFR) and scar mobilization, and was performed on the first several appointments to address restriction and adhesion from herÂ cesarean scar. The scar was mobilized in all planes by applying gentle pressure to the scar itself and moving it in the caudal-cephalad, medial-lateral, and rotational planes. Myofascial release of the surrounding tissue was performed similarly. Tissue restriction was assessed to be restricted in all planes both above and below the scar.
Treatment consisted of applying gentle pressure downward with the patient positioned comfortably in supine-hooklying with a bolster under the knees. The theory behind MFR is that the pressure will stimulate increased blood flow and subsequent heat production, enhance lymphatic draining, and provide proprioceptive input into the tissue addressed. Treatment technique of this nature can be direct, wherein the tissue is mobilized in the direction of restriction, or indirect wherein the tissue is mobilized away from the direction of restriction, similar to sliding a stuck dresser drawer backwards in attempts to gain a smooth slide outwards.
Both direct and indirect techniques were utilized on this patient due to the fact that she tolerated both quite well. Once pressure was established and direction of restriction determined, which was both superior and inferior to the Pfannenstiel’s incision, and on the left of the incision, gentle pressure was held until a giving way sensation was felt. The patient was educated in self scar massage technique and advised to perform daily. Additionally, strain-counter-strain (SCS) technique was utilized to release tight and shortened iliopsoas muscles bilaterally.
Muscle energy technique (MET) was utilized in order to re-establish symmetry to the sacroiliac joints of the pelvis. The pubic shotgun technique was utilized prior to torsion MET to draw the left anterior innominate posteriorly and thus level with the right. The patient responded extremely well to treatment. The final installation of this three part series will discuss her outcomes and provide insight to other possible treatment techniques for this patient population.
-Amanda Olson, DPT