An Ostrich’s View of the Pelvic Floor
Transcript of An Ostrich’s View of the Pelvic Floor
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An Ostrich’s View of the Pelvic Floor
Jane DixonClinical Specialist Physiotherapist
Fitzwilliam HospitalPeterborough
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Learning outcomes
�Overview of anatomy� Up to date assessment techniques� Thoughts around treatment options� Documentation� Ability to challenge your own practice
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Anatomy
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Superficial layer
� External anal sphincter� Superficial transverse perineal muscle� Ischiocavernosus� Bulbocavernosus (bulbospongeosus)
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Pelvic diaphragm(deep layer)
� Pubovisceral muscle� Pubococcygeus� Pubovaginalis� Puborectalis
� Iliococcygeus� Levator plate� Ischiococcygeus
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Ligaments
� Anterior longitudinal ligament� Iliolumbar ligament� Sacroiliac ligament� Sacrotuberous ligament� Sacrospinous ligament� Anterior sacrococcygeal ligaments� Inferior (arcuate) pubic ligament� Pubovesical ligament� Sacrouterine ligament� Cardinal ligament� Etc.
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Fascia
� Arcus tendineus fascia pelvis� Important in continence mechanism
� Endopelvic fascia� Surrounds vagina� Attaches laterally to ATFP� Thought to act as connection between bladder
neck and urethra to ATFP� Umbilical prevesical fascia� Transversalis fascia� Vesicocervical fascia� Superior fascia of pelvic diaphragm� Iliac fascia
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Fascia
� Uterine fascia� Rectal fascia� Vaginorectal fascia� Obturator internus fascia� Presacral fascia� Pubocervical fascia� Piriformis fascia
� Thoracolumbar fascia
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Lateral aspect of female pelvis
Uterus Uterus
Uterus
Uterus
Bladder
BladderBladder
Bladder
Rectum
Rectum
Rectum
Vagina
VaginaVagina
Vagina
Rectum
Uterine prolapse
Enterocele
Cystocele
Rectocele
Rectocele
Normal view
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Continence and the continence mechanism
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Continence mechanism
� Proximal urethra moves downwards and backwards
� Stretch resistance (stiffness) of pelvic floor muscles counteracts force
� Proximal urethra compressed against endopelvic fascia, vagina and levator ani
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From De Lancey 1994From De Lancey 1994
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Tools of the trade …..
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Improved assessment techniques
�What do I test?� How do I palpate?�What do I feel?� Am I right in my assumptions?�What else can I do to support my
findings?� How do I record my findings?
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What do I test?
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Grant’s Atlas of Anatomy 1999
Dermatomes
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Myotomes
�Quadriceps - L3� Tibialis anterior - L4� Extensor hallucis longus - L5� Toe extensors - L5 & S1�Calf - S1 & 2� Toe flexors - S2� Puborectalis - S2, 3, & 4� EAS - S2, 3 & 4
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Reflexes
� Knee jerk - L3� Ankle jerk - S1 & S2� Plantarflexor - S2� EAS - S4
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How do I palpate?
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Palpation
� Horizontal plane of palpation
� Vertical plane of palpation
� But the pelvis is a ‘bowl’
�Which muscles are being palpated?
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Palpation
� Horizontal plane�Coccyx� Posterior vaginal wall� Rectum and contents� Pubovisceralis�Pubococcygeus�Puborectalis portion
� Levator ani� iliococcygeus
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Palpation
� Vertical plane� Pubic bone� Urethra�Anterior vaginal wall� Pubovisceralis�Pubovaginalis portion
� Pubococcygeus, anterior fibres
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What do I feel?
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What do I feel?
� Resting tone� Muscle bulk� Scarring� Elasticity of vaginal walls� Painful points� Quality of activation / relaxation� Timing on command� Asymmetry� Sensory pick up� Loaded bowel� Etc
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© Weiss 2001
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Am I right in my assumptions?
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Transversus Abdominis
Internal oblique
External oblique
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Before squeeze
After squeeze
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How do we record our findings?
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Grading
� Modified Oxford Scale (Laycock 2002)� 0 - no discernible contraction� 1 - flicker of movement or pulsation under
examining finger� 2 - weak contraction without lift or squeeze� 3 - moderate contraction, lift of posterior wall and
squeeze on finger� 4 - good contraction, elevation of posterior wall
against resistance� 5 - strong contraction against strong resistance
If we test muscle action against gravity is our recording mechanism the same?
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Oxford classification
� 0 = No contraction� 1 = Flicker of
contraction� 2 = Weak. Small
movement with gravity counterbalanced
� 3 = Fair. Movement against gravity
� 4 = Good. Movement against gravity and some resistance
� 5 = Normal
� 0 = No contraction� 1 = Weak� 2 = Good� 3 = Strong
ICS classification
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Documentation
�How do you record your findings when palpating in two planes?�Should we use the simplified ICS
scoring?�Should we be thinking gravity
eliminated and resisted?�How do you record specificity of
muscle action?� It’s just not that easy after all!
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New assessment formsPalpation / Action Findings Key
Inferior Aspect
Superior Aspect – Anterior Component Superior Aspect – Posterior Component
Lateral Aspect – Right Lateral Aspect – Left © Jane Dixon
� Trigger points
Decreased muscle bulk
Bulbospongiosus
Perineal body
Transverse perinei
Action of bulbospongiosus and transverse perinei / tension of perineal body
0 / � / ��
V
V
R
R
Pubococcygeus
Puborectalis
Piriformis
Obturator Internus Obturator Internus
ATLA
Scarring
R R
Movement Analysis
Key
Accurate closure Posterior compartment only Bilateral bulbospongiosus Right bulbospongiosus only Left bulbospongiosus only Anterior compartment only
Movement beginning posteriorly but with vector force along vaginal length
� Valsalva Grade of movt: 0 = nil 1 = weak 2 = good 3 = strong
© Jane Dixon
(L)
(R)
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Improved assessments
� P performance� E endurance� R repetition� F fast� E elevation� C co-contraction� T timing
� S strength / stability / speed
� U urethral closure� B bladder neck
mobility� T tone / timing
(accuracy / control)� L left / right symmetry� E endurance at sub-
max level
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Thank you