If patient can’t maintain re-positioning…

Breathing

• Are they diaphragmatically breathing?
• Quality of respiration?
• Symmetry of respiration?
• Decreased diaphragmatic motion, increased descent of pelvic floor, altered breathing patterns associated with pelvic pain.
• Diaphragmatic and TA muscle activity reduced with hypercapnea.
• Pelvic floor depression associated with breath holding/Valsalva maneuver.

Abdominals

• Can they isolate IO / TA?
• Symmetrical or Asymmetical?

• Palpate approximately 2 cm medial and inferior to ASIS.
• Slowly & gently draw in your abdominals away from your fingers.
• Sub maximal contraction.
• Change positions (supine, side lying).
• Monitor for substitutions.
• Is IO / TA activity sustained with breathing?

• Can they maintain IO / TA contraction with upright static & dynamic control?

Pelvic Floor

• Can they isolate their pelvic floor muscles?
• Can they actively contract and relax the pelvic floor?
• Do they feel an up & in contraction?
• Are they substituting (glute squeeze, breath holding, adductor squeeze, bearing down)?
• Is there symmetry?
• Is there appropriate motor planning?
• Voluntary contraction of the abdominal muscles stimulates pelvic floor contraction.
• TA and IO recruited during all pelvic floor muscle contractions.
• Relaxed abdominals resulted in only 25% of maximum pelvic floor contraction.
• Women with stress incontinence have increased OE activity (increased OE increases IAP).
• Back pain more common in women with incontinence , increased probability of LBP if have symptoms of incontinence.
• Pelvic floor muscles are part of preprogrammed response to postural adjustment.
• Decreased pelvic floor strength, endurance and thickness noted in women with incontinence.
• Increased pelvic floor activity with postural perturbations noted with women with incontinence.
• Pelvic floor tonic activity at rest, with cough automatic phasic response, in women incontinence unsustained tonic pattern with asymmetrical recruitment.
• Timing deficit of muscle recruitment lost with women with incontinence.
• Higher resting tone of pelvic floor with dysfunction, need to teach down training.
• High resting tone does not always mean a strong pelvic floor.
• The pelvic floor needs to relearn how to function within a neutral pelvis.
• Feel the pelvic floor contract and relax.
• Reported cure rate of pelvic for urinary incontinence ranges between 44-69%.
• 30% of contractions are performed incorrectly; 50% of contraction are strong enough to increase urethral pressure.
• Pelvic floor muscle activity alone does not predict UI, activity related to UI needs to be considered.
• Isolated contraction of pelvic floor produces greatest displacement of pelvic floor.

Hypermobility - But Still Have Symptoms

• Is there global hypermobility?
• There is a high correlation of pelvic dysfunction with a reduction in tissue collegan concentration.

Referral

• Has there been trauma?  Consider referral early on if patient not progressing appropriately.
• Patient can reposition but they still have symptoms- are they able to relax their pelvic floor?
• Is there psyco-social issues?

Referral To

• If symptoms have not subsided consider referral to OB GYN/Urologists/Primary MD
• PT with pelvic floor specific training (biofeedback, internal evaluation, condition specific integration)
• Podiatry (correlation of foot flexibility and SUI)
• Dentist
• Neuro - Optometrist