By Rhonda Kotarinos, PT, DPT
In this week’s post, guest author and pelvic floor expert Rhonda Kotarinos shares a controversy from the 2016 International Pelvic Pain Society conference.
In October I had the privilege of presenting at the International Pelvic Pain Society’s annual meeting. During one of the presentations, a discussion ensued regarding the term contracture. The discussion was centered on whether or not the pelvic floor could ever be in a state of contracture. Given the confusion that was evident during this discussion, I thought a review of the muscle physiology associated with skeletal muscle contracture would be useful to our membership.
First, one should review the definition of contracture. Central to the definition is that a muscle or group of muscles remains in a persistent state of shortening to the point that complete range of motion of the muscle is limited and is resistant to stretching.1 Kendall et al defines a contracture as a marked decrease in muscle length where the range of motion in the direction of elongation of the muscle is markedly limited.2 Of course there are neuromuscular and ischemic pathological conditions where contractures can develop. Contractures associated with pathological conditions are usually considered irreversible.
An additional skeletal muscle phenomenon is the length-tension curve of muscle. The maximal force generated by a muscle contraction is when the muscle is at some midpoint in its range of motion. A muscle that is too short or too long will have a decreased force generation. Therefore, a muscle in a state of contracture will be weak when assessed for strength.
Given the definitions above, can the pelvic floor be in a state of contracture? The pelvic floor, with its supportive function, is considered a postural muscle composed of predominately slow twitch muscle fibers. Slow twitch muscle fibers trigger more easily and are capable of sustained contraction therefore are more inclined to become shortened and tight.3 Even though there are fast twitch muscle fibers within the pelvic floor muscles it is possible that they can be transformed from fast twitch to slow twitch. The neural impulse transmitted by the nerve conditions the fiber type.4 A contracture develops slowly but is maintained by constant continued neural stimulation.5 Postural muscles are known to shorten in response to stress.6 With pain or a constant sense of urinary urge, there is psychological stress but there is also the physical response of protective guarding. Guarding is the additional recruitment of the pelvic floor in response to pain or to inhibit urge. Initially there will be active shortening, but it will lead to a shortening of the muscle(s) without any electrical activity.7
Therefore, it appears that the pelvic floor should respond as any other skeletal muscle in the body, and is capable of developing a reversible contracture. The next question to answer is how best to evaluate the pelvic floor for contracture – is it short and weak or long and weak?
References:
- Salter R B, Textbook of Disorders and Injuries of the Musculoskeletal System. Philadelphia, Lippincott Williams &Wilkins. 1999.
- Kendall F P, McCreary E K, Provance P G. Muscles Testing and Function. Baltimore. Williams and Wilkins Inc. 1993.
- Waddell G. The Back Pain Revolution. Churchill Livingston, Edinburgh. 1998.
- Buller A. Interactions between motor neurons and muscles. Journal of Physiology (London) 150:417-439.
- Graham H. Muscles and Their Neural Control. New York, John Wiley & Sons. 1983.
- Chaitow L. Muscle Energy Techniques. Edinburgh, Churchill Livingstone, 2006.
- An Exploratory and Analytical Survey of Therapeutic Exercise, Northwestern University Special Therapeutic Exercise Project. Am J Phys Med. 1967:46;1.
About Rhonda:
Dr. Rhonda Kotarinos received her Bachelor of Science degree in Physical Therapy from the University of Illinois, Chicago in 1974. She began her professional career as a staff physical therapist in a hospital acute care physical therapy department. Her clinical experience grew to include responsibilities in hospital administration, eventually becoming the director of a physical therapy department. In 1980, she went into private practice where she remains today. In 1989, Rhonda completed her Masters of Science in Physical Therapy from Northwestern University with a specialization in Obstetrics and Gynecology. She served the American Physical Therapy Association as President of the Section on Women’s Health for 7 years. This experience heightened her interest in pelvic floor dysfunction, where she currently concentrates her clinical, educational and research responsibilities. Rhonda lectures and publishes internationally, and is an active member of the American Urogynecologic Society, American College of Obstetricians and Gynecologists, The International Association for the Study of Pain, The American Pain Society, International Myopain Society, International Continence Society and the International Pelvic Pain Society. Rhonda has also completed the Trigger Point Dry Needling course at Andrews University.
FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.
Comments
Nice article. This is why assessment for Pelvic Floor must include a full postural and emotional history assessment also. Altered pelvic angles alone cause short tight and long weak attachments and emotional history is key to reversing levels of stress and altered breath which impacts the ph and makes body think under constant attack.
We must take a global approach to healing Pelvic Floor muscle weaknesses if we want to get the best outcome for the patient.
Great post Rhonda and just in time for the start of my book review “The Overactive Pelvic Floor”. This 12 week session will review each chapter with additional discussions. That book has 3 very good chapters on evaluation of the overactive PFM and incudes both instrument and digital techniques with some validated scales. I agree with your thoughts and think it is very important for PTs to understand both the contractile and non contractile components of the very complex muscle. Love to keep the discussion going.