Pelvic Floor Muscle Dysfunction in COPD

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Pelvic Floor Muscle Dysfunction in COPD

• Liz Childs
• Pelvic Floor Physiotherapist
• Wellington

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Outline

• PFM anatomy / function
• Relationship PFM and breathing
• Teaching PFM exercises
• Lifestyle modifications
• Effective huff / cough technique
• Where / when to refer on

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Pelvic floor anatomy female
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Pelvic floor anatomy - male
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(No Transcript)
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Function PFMs

• Support pelvic organs
• Contribute to continence via
• closure urethra anus
• support bladder neck
• closure anorectal angle
• Role in voiding, evacuation
• Sexual role arousal, erection, orgasm,
  ejaculation

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PFM part of the core

• Functional unit
• Spinal stability
• Intra-abdominal pressure
• Continence
• Breathing

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What happens to the pelvic floor during breathing?

• Inspiration diaphragm contracts, flattens,
  moves caudally ? incr IAP ? downward pressure
  exerted on PFM
• Expiration
• Rest / quiet breathing passive process, elastic
  recoil lungs, chest wall, muscle relaxation
• Forced exp diaphragm and abdominals contract ?
  incr IAP ? upward mvt diaph, downward pressure
  PFM

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Inspiration (Talasz et al, 2010)
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Forced expiration / cough no abdominal or PFM
co-contraction (Talasz et al, 2010)
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Forced expiration with ab and PFM
co-contraction (Talasz et al, 2010)

• Reduces pressure on pelvic floor

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Practice

• Huff
• Cough

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PFM dysfunction

• Urinary incontinence
• Affects 1 in 3 women
• Increased prevalence in COPD
• Pelvic organ prolapse
• Affects 50 women

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Stress urinary incontinence what happens when
you cough or sneeze
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Urge urinary incontinence

• Involuntary loss of urine associated with urgency
  detrusor contraction
• (can be related to anxiety)

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Urinary incontinence in respiratory disease

• Degree of urinary incontinence is greater in
  those with chronic cough due to CF, COPD
  compared with general population (Button BM,
  Sherburn M, Chase J, et al 2005)

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Evidence PFMT

• Pelvic floor muscle training should be offered,
  as first line therapy, to all women with stress,
  urge or mixed urinary incontinence
• Level 1 evidence, Grade A recommendation,
• ICI 2012

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Pelvic organ prolapse

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Pelvic Organ Prolapse

• High quality evidence (8RCTs) supporting PFMT
• Significant improvement in
• Symptoms
• Stage
• ICI 2012 Level 1A evidence for PFMT

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Risk factors for PFM weakness ? lifestyle
modifications

• Chronic cough
• Breathing retraining
• Sputum clearance techs, cough suppression
• The knack PFM with cough, huff
• Support perineum
• Constipation / straining
• Fibre, fluid, exercise
• Bowel routine
• Defaecation training
• Obesity
• Heavy lifting
• How much is too much?
• Technique
• Fatigue
• Inappropriate exercise
• Promote pelvic floor safe exercise

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Patients with COPD

• Chronic coughing ? strain pelvic floor
• Reduced exercise levels? weak muscles
• PFM ,diaphragm, abdominals
• Evidence
• Women with stronger PFMs are able to generate
  greater pressure in forced expiratory techniques
  / coughing
• (Talasz et al, 2010)
• COPD/ CF patients PFM training and Estim
  resulted in improved PFM strength, reduced
  symptoms
• (Button et al, 2005)
• Teach The Knack
• PFM contraction just before huff/cough leads to
  reduced urine leakage
• (Miller et al, 1998)

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Teaching PFM Exercises

• Squeeze and Lift
• As though trying to stop flow of urine or stop
  passing wind
• Must feel the release
• Hold 2-3 sec, increase as able
• Repeat up to10 times
• Do this several times a day

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Practice.

• Pelvic floor training

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Recommendations (Guidelines for the
Physiotherapy Management of the adult, medical,
spontaneously breathing patient. Thorax, 2009)

• Question patients about their continence status
• All patients with chronic cough, irrespective of
  continence status, should be taught to contract
  their pelvic floor muscles before forced
  expiration coughing (The Knack)
• If problems of leakage are identified, patients
  should be referred to a physiotherapist
  specialising in continence

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Asking the question

• Embarrassment / Shame
• Patient
• Language to use
• Patient / health professional
• Let people know
• Continence problems are common
• Help is available
• Being dry is normal
• Continence products

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When to refer on

• Symptoms of incontinence or prolapse
• Wet pants, frequency, urgency
• Soiling
• Bulging at vaginal entrance
• Heaviness, dragging
• Suspect overactive pelvic floor
• Symptoms may include
• Pain pelvis, genital
• Constipation
• Voiding difficulty

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Referral

• Womens Health Physiotherapists in most DHBs
• Private Pelvic Floor Physiotherapists in many
  centres
• NZ Continence Association
• www.continence.org.nz
• List of continence service providers

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Conclusion

• PFM dysfunction is under reported
• Subjects are unlikely to seek help on their own
• Impact on an individuals ability and/or
  willingness to perform certain activities
• Exercise
• Airways clearance techniques and lung function
  manoeuvres
• Social outings
• Education in pulmonary rehab groups