Phys of Activity Final

what is the clinical value of palpating the pelvic floor internally?

-evaluating for trigger points and resting tone

-bony alignment

-flexibility

Internal urinary sphincter

smooth muscle at the juncture of the bladder and urethra; relaxes as the bladder fills to allow urine into the urethra

External urinary sphincter

skeletal muscle; must be relaxed consciously to void urine

Internal anal sphincter

smooth muscle, involuntary (under autonomic control)

External anal sphincter

skeletal muscle, voluntary

what is the role of the prostate?

Creating fluid to transfer sperm

what is the impact of an enlarged prostate/prostate removal?

-when it is enlarged it can block urine flow

-when it is removed, internal urinary sphincter is also removed which can lead to incontinence

neurologic control of a bowel movement

-sympathetic fibers (preganglionic fibers T10-L2) are in charge of storage

-parasympathetic fibers (preganglionic fibers S2-S4) are in charge of actual defecation

fecal incontinence

recurrent uncontrolled passage of fecal material for at least one month, in an individual with a developmental age of at least 4 years old

anal incontinence

involuntary loss of flatus, solid, liquid feces or mucus. Definitions can include consistency of stool and frequency of occurrence

what are some components that play a role in anal continence

stool consistency, rectum/sigmoid peristalsis, rectum capacity/compliance, pelvic floor function, anorectal sensitivity, anal sphincter function (EAS and IAS)

common causes of constipation

poor fiber intake, poor fluid intake, inactivity, medications, metabolic or endocrine disorders, neuropathic disorders, pelvic floor hypertonicity

what is paradoxical puborectalis contraction

muscles are contracting instead of reflexively relaxing

what does paradoxical contraction of the anal sphincter or levator ani cause?

obstructed defecation or constipation

what is the anorectal angle in sitting?

90-120 degrees

what is the importance of the anorectal angle with pooping?

must increase anorectal angle at least 20 degrees to open anal canal...squatty potty creates the ideal angle for defecation

causes of acute pelvic pain

infection, trauma, iatrogenic or neurologic involvement

chronic pelvic pain

persistent or recurrent pain in the lower abdomen or pelvis lasting at least 3-6 months

coccygodynia

pain in and around the coccyx

-most common MOI is external or internal trauma followed by prolonged sitting (birth)

-men with BMI over 29 are pre-disposed

vulvodynia

a syndrome of unknown cause that is characterized by chronic burning, pain during sexual intercourse, itching, or stinging irritation of the vulva

vaginismus

involuntary contractions of the perineal muscles

-painful, difficult vaginal penetration

-classified as primary (never had painfree penetration) or secondary (new pain with penetration)

dyspareunia

females=painful vaginal penetration (primary vs secondary and superficial vs deep)

males=pain in genitals or pelvic region during or after sex

interstitial cystitis

recurrent pelvic pain, pressure, or discomfort in the bladder or pelvic region and urinary frequency and urgency

-non-ulcerative is most common

Prostatitis

inflammation of the prostate gland that may cause discomfort in the rectal and suprapubic region (50% of men will experience this)

-Category 3=non bacterial and PT focus is on reducing hypertonicity

pudendal neuralgia presentation

sensory=lower butt, perineum, area around rectum/anus, vulva, labia, clitoris, scrotum, penis

other symptoms=urinary frequency/urgency, sx can mimic interstitial cystitis, painful ejaculation, persistent sexual arousal

anatomy of the pudendal nerve

-arises from sacral nerve roots 2,3,4

-mixed nerve, 50% sensory, 30% autonomic, 20% motor

areas of entrapment for the pudendal nerve

between sacrospinous and sacrotuberous ligaments, alcock's canal, penile branch at change in directions

pelvic floor symptoms

muscle spasm, itching, burning, tightness, pain at the vaginal canal or deep within the vagina, cramping or throbbing in the pelvis, pain worsens as the day goes on (with prolonged sitting)

functional impairments of pelvic floor symptoms

limitations in functional mobility, limitations with prolonged sitting/standing, sexual dysfunction, bladder and bowel emptying disorder

main points of treatment for urinary incontinence

education on anatomy, reinforce dietary management, bladder training, neuromuscular re-education, EMG/biofeedback

main points for treatment for bowel issues

education on anatomy, reinforce dietary management (increase fiber), bowel training, pelvic floor strength 1-2 times per week

main points for treatment for pelvic organ prolapse

dietary modifications to avoid constipation, toileting strategies to minimize strain, pelvic floor strengthening, valsalva avoidance, postural education, lumbopelvic stabilization

pelvic floor therapy treatment goals

keep it functional and relate it back to what they are avoiding (social activities, exercise, sex, etc), consider sleep cycle, hygiene, include self management (pain, bladder and bowel routine, dietary mods)

eating disorder definition

mental illnesses clinically diagnosed by meeting criteria characterised by abnormal eating behaviors

disordered eating definition

abnormal eating behaviors including restrictive eating, compulsive eating or irregular or inflexible eating patterns, excessive exercising beyond assigned training to compensate for dietary intake, and use of purgatives. the behaviors do not meet the clinical criteria for an eating disorder

anorexia nervosa definition

an eating disorder characterized by marked self-induced weight loss accompanied by an intense fer of fatness

bulimia nervosa definition

an eating disorder marked by an unrealistic appraisal of body weight and or shape that is manifested altering bingeing and purging behavior

anorexia athletica definition

an eating disorder occuring primarily in young femal athletes that is characterized by a food intake less than that required to support the training regimen and by body weight no more than 95% normal

eating disorder risk factors

dieting at an early age, unsupervised sieting, lack of acceptance of pubertal changes, early sport-specific training, a large increase in training volume accompanied by a significant weight loss, traumatic events, personality, coaching behavior and perceived or real pressure from coaches, weight regulations in some sports

female athlete triad

disordered eating. menstrual dysfunction. skeletal demineralization

primary amenorrhea

age 15 and no period

secondary amenorrhea

had period and it went away

oligomenorrhea

infrequent menstrual cycle

relative energy deficiency in sports (REDs)

a syndrome of impaired physiological and or psychological function experienced by female and male athletes that is caused by exposure to problematic LEA

REDs outcomes include...

decreases in energy metabolism, reproductive function, MSK health, immunity, glycogen synthesis and CV and hematological health. all can individually and synergistically lead to impaired wellbeing

Physiology of REDs

changes in metabolic substrate (glucose, fatty acids, ketones). changes in metabolic hormones (insulin, cortisol, insulin like growth factor, grehlin, leptin, tyrosine)

screening for REDs

we are step 1. we can screen and refer if needed. we are not diagnosing

detrusor

smooth muscle of the bladder

internal sphincter

sm under ANS control (closed with sympathetic, relaxed with parasympathetic)

external sphincter

skm under voluntary control

Afferent A delta fibers (pelvic floor)

located in sm (detrusor), function is responding to touch and pressure, role detecting bladder fullness and wall tension

Afferent C fibers (pelvic floor)

located in mucosa, nociceptive function

fibers in charge of sensing bladder fullness and stretch

A delta and C fibers

layers of bladder wall

-urothelium = most interior, sends impulses to C and A delta fibers, at rest its 5-7 layers thick but when max filled and stretched it can be 1 layer thick

-extracellular = mast cells and NO/ATP

-detrusor muscle

should we pee at first urge?

no, but don't want to chronically wait, constant overfilling can lead to flaccid bladder.

review bladder storage and voiding

bet

urinary incontinence

most common type of bladder dysfunction. overwhelming urge to pee causing leakage, leak with things like caughing or laughing

urinary frequency

Type of bladder dysfunction. going pee often with or without urgency

urinary retention

Type of bladder dysfunction. cant pee even when trying

neurogenic bladder

Type of bladder dysfunction. detrusor not working so its flaccid or its spastic and elevated tone.

painful bladder syndrome

unclear cause, hurts to pee

overactive bladder

similar to spastic bladder (neurogenic bladder) but they neurologically are intact

muscles of the superficial layer of pelvic floor (layer 1), innervation and function

ischiocavernosus, bulbocavernosus, superficial transverse perineal, external anal sphincter. S2-4 innervation. controls bowel function and sexual function

muscles of the urinary continence layer of pelvic floor (layer 2),

external urethral sphincter, sphincter urethrovaginalis, compressor urethrae, deep transverse perineal, deep perineal pouch. muscles embedded in CT

muscles of the deep layer of pelvic floor (layer 3), and function

levator ani (pubococcygeus, pubovaginalis, puborectalis), coccygeus. important for stability and defecation, 30% fast twitch (cough/sneeze), 70% slow twitch.

5 S's of pelvic floor muscle function

support (keep things in place), sphincteric, sexual, stability (of pelvis and spine), sump pump (remove blood after sex)

what is pelvic floor muscular dysfunction

pain within soft tissue, incontinence, pelvic pain, pelvic organ prolapse, pelvic girdle pain

difference in types of prolapse... Rectocele, cystocele, urethrocele, enterocele

rectocele = movement of rectum

cystocele = movement of bladder

urethrocele = urethra opening bulging

enterocele = descent of intestines

symptoms of pelvic organ prolapse

pelvic heaviness, bulging, dragging, pressure, something falling out. visual tissue bulging out, difficulty with bowel/bladder function. LBP worsening throughout day, pain w prolonged standing, relived by laying down

estrogen peaks in menstrual cycle

peaks just before ovulation (day 13-14), has second smaller peak during luteal phase (later in cycle)

luteinizing hormone peaks in menstrual cycle

peaks during ovulation (day 14-16)

progesterone peak in menstrual cycle

released during luteal phase (day 18-28)

follicular stimulating hormone peaks in menstrual cycle

remains low and peaks during ovulation (day 14-16)

T/F peak of hormones in female menstrual cycle is different for everyone and can change between cycles

True

influence of menstrual cycle phases on neuromuscular performance/MSK health

no current evidence to support generalized phase based rec's. symptomatic approach best

Female sex hormones during pregnancy

HCG significantly increases immediately after fertilization. until birth estrogen and progesterone gradually increase significantly

menopause diagnosis

no period for 12 months, symptoms can occur 10 years before

things affecting menopause

weight of individual, when they start their period, age entering menopause, hormone replacement therapy

people who may be harmed by hormone replacement therapy

high risk = known CV issue, emoblism, stroke, clotting disorder, breast cancer.

some risk/caution = diabetes, smoking, uncontrolled HTN, obesity

influence of menopause on ex/neuromuscular performance/MSK health

increased endothelial dysfunction during menopause transition (inc risk of CVD), dec bf during LE ex that worsens w progressive menopausal stages, vasomotor sx associated with CVD (hot flashes and night sweats also), exaggerated ex pressor response compared to premenopausal females (elevated BP response to compensate for lower CO)

influence of ex on health after menopause

improve lipid status this improving endothelial function, improves metabolic health, improve VO2 max, improve ability to burn fat during aerobic ex

physiological changes during pregnancy

inc RR, inc blood plasma voolume by 50-60%, changes in renin-angiotensin system, inc thyroid hormones and ACTH from pituitary, dec or no change in bp until 3rd trimester when in inc, hypercoagulative state, greater dilation of veins, 20% inc in O2 consumption, inc tidal volume, altered insulin sensitivity,

cause for inc RR in pregnancy

due to inc progesterone. metabolic rate inc -> inc CO2 -> inc RR

causes for inc blood plasma volume during pregnancy

increases in estrogens, progesterones, relaxin, hCG, arginine, and vasopressin. inc SV, BP and CO

changes in renin-angiotensin system during pregnancy

inc in NA retention -> inc blood volume, BP and swelling

altered insulin sensitivity in prengancy

greater sensitivity to insulin in 1st half of pregnancy (hypoglycemia is concern), eat smaller meals more frequently. 2nd half of pregnancy insulin resistance and shift to fat metabolism for energy needs (elevated blood glucose for baby, more plasma glucose

MSK changes during pregnancy

Ligamentous laxity due to estrogen and relaxin, pelvis and wrist most effected. some report posture changes

T/F significant inc in pain in general during pregnancy and lumbopelvic is most common

true

phys activity guidelines for pregnant women

150 min of mod intensity aerobic activity every week. BP greater than either 140 or 90 indicates gestational HTN disorder

impact of ex on mom and fetus

ex at

absolute contraindications for exercise (pregnant women)

ruptured membranes, prematuer labor, unexplained vaginal bleeding, placenta previa after 28 weeks gestation, preeclampsia, incompetent cervix, intrauterine growth restriction, high-order multiple pregnancy, uncontrolled type 1 DM, uncontrolled HTN, uncontrolled thyroid disease

relative contraindications to ex (for pregnant women)

recurrent pregnancy loss, gestational HTN, hx of spontaneous preterm birth, mild/mod CVD or respiratory disease, sx anemia, malnutrition, eating disorder, twin pregnancy after 28th week

neuromuscular consequences of pregancy, childbirth and postpartum period

dec strength limits functinoal mobility and performance. increased fatigability limits performance, inc risk of injury, dec tolerance to phys activity

treatment of DRA (Diastasis Recti)

exercise can help. decreased inter-recti distance afters 6 weeks. abdominal muscle training

summary of ex and pregnancy

ex is safe for pregnant and PP females, ex may reduce inter-recti distance after birth, ex can dec pain sensitivity in PP females, sport and pelvic floor PT's should work together after birth

NEAT

calories burned through daily activities that are not planned ex or sport

TEF

thermal effect of food. met rate inc after eating, digestion, absorption, transport nutrients

BMR

basal metabolic rate. lowest energy required to perform cellular processes at rest. 75% of all energy expenditure. changes in BMR need to be met w mods in calorie intake or changes in body mass will occur

BMI dx of obesity

obese = >30kg/m^2

morbidly obese = >40kg/m^2

waist circumference dx of obesity

inc risk at >88cm for female and >102cm for men