Herman & Wallace Pelvic Rehabilitation Continuing ...



‘The Male Kegel’ is a manual intended for physical therapists to educate male patients about the anatomy of the pelvic floor muscles, the importance of the pelvic floor muscles in men, correctly finding the pelvic floor muscles, how to appropriately exercise the pelvic floor muscles, and the relationship of these muscles after prostatectomy. This product will provide the physical therapist and patients written information and a home program that can be tailored for each patient. Also included in the manual will be information that can be utilized in marketing to Urologists for their post-prostatectomy patients. The manual will consist of educational information describing the function of the pelvic floor muscles, how to correctly contract the PFM, exercise progression, strengthening protocol, and other factors to consider. Specific exercises that can be utilized in PFM strengthening will be described in detail.The Male KegelThe Pelvic FloorDescription of the Pelvic Floor Muscles (PFM)Form a sling from the pubic bone to the tailbone and from hip to hipIn males, the urethra and anus pass through the PFMThe PFM consist of multiple layers of muscles Main Functions of the Pelvic Floor Muscles:SupportProvide constant support to the bottom of the body; a shelf for the bladder, prostate, and rectum.Work with the abdominal muscles to provide stability during activities such as breathing, coughing, vomiting, urination, and movements of the upper and lower body.StabilizationThe PFM work in balance with the other muscles of your trunk to support your spine and daily tasks. SphintericThe PFM are part of the urethral and rectal sphincters keeping them closed when they should be and relaxed during urination and defecation.Sexual The PFM assist with support of arousal and completion during intimacyWhat is a pelvic floor muscle contraction?When contracted correctly, the muscles squeeze together and lift up and into the body. Some individuals will incorrectly perform a kegel by bearing down (sensation of trying to push out or have a bowel movement). Some may sense that the pelvic floor muscles are contracting, however, this is not a correct contraction. This incorrect contraction puts stress and pressure on the pelvic floor muscles and can weaken the muscles. This will also result in increased pressure on your bladder possibly resulting in increased urine leakage.When should kegel exercises be considered and performed?Urinary or fecal incontinence (leaking)Weakness in core stabilityBefore and after prostatectomy surgery (the surgeon will advise when it is appropriate to resume exercises after surgery) Relationship of the PFM to incontinence, core stability, and prostatectomy surgeryWhen the PFM are weak, the urinary and/or rectal sphincter(s) will not be able to close off the urethra and rectum; therefore, leaking of urine or fecal matter may occur. The PFM assist in providing support to the hips, low back, and pelvic girdle along with the abdominals and low back musculature. These muscles are important in keeping the pelvis stable during upper and lower body movements. The prostate is a walnut sized gland, part of the male reproductive system, which produces the fluid to carry and nourish sperm. The prostate sits just below the bladder and right above the pelvic floor muscles. The urethra travels from the bladder through the prostate and then the pelvic floor muscles into the penis to the outside of the body. During prostate surgery, the sphincter muscles can be damaged or more likely the trauma of surgery and inflammation can irritate the PFMs causing them to not function properly, thus the sphincter doesn’t work well allowing for urinary leaking. Urinary incontinence can occur during activities such as coughing, sneezing, laughing, running, jumping, squatting, moving from sitting to standing, sports activities, etc. It is important to learn and understand how to properly contract the PFMs before having surgery as it may be difficulty to identify them properly after surgery due to soreness/discomfort. Do NOT perform kegel exercises while the catheter is still in your body after surgery. Your doctor will let you know when you can resume exercises. Also as the prostrate has grown in size during the course of prostrate cancer the pelvic floor muscles did not have to work as hard to keep you from leaking. The size of the prostate assisted with keeping the urethra sealed. Now that the prostrate has been removed the muscles are weaker from lack of use and leakage is occurring. By strengthening the pelvic floor muscles the leakage can be reduced.Prevalence of Urinary IncontinenceThe prevalence and incidence of incontinence post prostatectomy varies greatly in the literature. This can be due to methods of data collection, length of follow-up, and surgical techniques performed. Overgard et al. found a significant decrease in urinary incontinence 1 year after prostatectomy when participants were instructed in muscle training by a physiotherapist versus the control group which practiced the exercises on their own. Kegels (aka PFM Contraction) What does a kegel feel like?Individuals sense and visualize different things when contracting the pelvic floor. Below is a list of visualizations that can be helpful in describing a correct PFM contraction. Elevator (closing the openings and lifting the entire floor)Pulling underwear inStopping urine flowHolding gas inSqueezing ‘sits bones’ togetherPulling your tailbone to your pubic boneLifting the perineum off the chairAs the muscles become stronger, the sense of pulling up and in can become intensified. This is an appropriate sensation. In the privacy of their home, a male individual can stand in front of a mirror (without clothes on) and if they are contracting the PFM appropriately the penis will draw in and the scrotum will lift up. They may feel a tightening around the anus, but the larger gluteal muscles should not tighten. What not to do when performing a kegelThere should never be a sense of bearing down or pushing out when performing a kegel. If you were to put your hand on the perineum, the tissue should not push into your hand. During an appropriate contraction, the tissue should move away from the hand. The lower abdominal muscles should not push out or the buttock muscles (gluteals) should not tighten. If the buttock or lower leg muscles are tightening, you may be trying too hard or the PFM are weak and the brain is trying to help out by engaging other muscles. If this happens, refocus on just working on tightening the PFM before any other larger muscles engage. Exercise ProgressionIt is important that individuals are aware of the following when strengthening the PFM.Awareness of the pelvic floor muscles is learned. This is not necessarily a sensation that is innate or known to most individuals. It may take some time to gain a good awareness of what the muscles are doing. Encourage your patients to be patient. A pelvic floor muscle progression includes exercises for both fast and slow twitch muscle fibers. This can be described as sprinter muscles (fast twitch) and marathoner muscles (slow twitch). All skeletal muscles of our body contain both types.Exercises should be performed until muscle fatigue occurs. Example: If you only lifted a 2lb weight with your bicep, you would not be conditioned to have appropriate strength to lift a heavier object without the possibility of injury. As the muscle fatigues during exercise, the sensation of the contraction can become less. This can be a frustration for some individuals. We encourage you to continue working with the exercises prescribed. It is not uncommon for individuals to experience increased symptoms (i.e. incontinence) after beginning a consistent exercise program. This can be due to fatiguing the muscles during the exercises. This will quickly subside with consistent exercising. PFM exercises need to be continued on a maintenance program. Like any exercise program, without proper maintenance, the muscles can become weak. For urinary incontinence, Margaret A. Hayn et. al. found that at least 10 PFM exercises per day was effective. Strength assessment - It is important to have a pelvic physical therapist grade the pelvic floor muscle strength to determine the appropriate exercise protocol.The PFM are graded on a 0-5 scale. 0/5 = no muscle contraction; 5/5 = the strongest muscle contraction available. Contraction Time – Your therapist will determine the endurance of the muscles by having you hold a kegel as long as you are able. If you can hold for 5 seconds then this is the contraction time you will start at. Repetitions - measure the number of reps they can perform at the determined endurance time. It is recommended to have the patient perform 30-80 reps/day. Endurance fibers vs. fast twitch/quick reaction fibersSlow and fast twitch muscle fibers are present in skeletal muscles throughout the body. Slow twitch fibers are responsible for prolonged, sustained muscles i.e. posture muscles. Fast twitch fibers are responsible for quick reactions. The endurance (slow twitch) muscle fibers are present in the deepest of the PFM. About 30% of the fibers are slow twitch and they assist with maintaining tone and supporting the pelvic organs. The fast twitch fibers make up about 70% and are mainly responsible for rapid sphincter closure.Exercise positions (gravity assisted, supine/side lying, sitting, standing)If muscle strength is between 0-2/5 then begin exercises in a gravity-assisted position (ex. hips/buttock elevated on pillows), supine/hooklying (lying on your back), or in a sidelying position. Sitting contractions may be tried if there is a good awareness of a pelvic floor contraction. When the muscle strength is between 3-5/5 then strengthening can begin in sitting and standing. Advanced activitiesPFM contractions should be incorporated into movement activities. The following are good examples: ascending and descending stairs, lunges, side-stepping, walking, jumping, jogging/running, squats, etc. Your therapist will assist you and let you know when you should advance your exercises to these positions.How do I know the exercises are working?You should notice that your symptoms start to become less. Performing kegels does not automatically make everything better. It takes time to increase strength (see below). Most people notice their morning symptoms decrease faster than their afternoon and evening symptoms. This is due to your muscles becoming more fatigued as the day progresses. Also, strength to support jumping or impact activities takes the longest to gain thus you will have symptoms with these activities after incontinence with less forceful activities is gone. How long does it take to strengthen the muscles?It can take 12 weeks (3 months) to build new muscle fibers and thicken the muscles. Some individuals will begin to see results after a few weeks of consistent exercises. It can also take longer (5+ months) to see significant results depending on the initial strength of the muscles and the extent of the symptoms. After surgery, it can take up to a 1 year to see results from the exercises. Other situations to consider during strengtheningConstipationConstipation and valsalva creates pressure through the pelvic region and can weaken and stress the pelvic floor muscles. Repetitive or strenuous activitiesWhen we lift heavy objects or become tired when lifting, we have a tendency to create pressure in the abdomen/bear down (valsalva) and put more stress and pressure on the pelvic floor muscles and weaken them. KNACK: Is a technique that you can use to decrease leakage with cough, sneeze, laugh or other impact activities. When you have warning; before a cough, sneeze, laugh, or activity like jumping, perform a pelvic floor contraction as your therapist has taught you. This will train your muscles to close off the urethra and reduce the leakage that can occur with these activities. You are getting the “knack” of closing the urethra prior to increased abdominal pressure that may result in urinary leakage.Even if incontinence is being experienced, proper fluid intake should be continued. Many individuals will want to limit their fluid intake to decrease incontinence episodes. This can cause irritation to the bladder as your urine can become more acidic and concentrated resulting in being an irritant to the bladder and leading to further leakage.The surgeon may place restrictions on lifting, etc after surgery. Make sure to follow these guidelines. Exercise Program(Clinician Information)Endurance/Slow Twitch (Progression of exercises from easiest to hardest)Gravity Assisted (hips supported on a pillow or bolster)SidelyingHooklying/SupineSittingStanding (feet shoulder width apart)Advanced standing (feet wider than shoulder width)Fast Twitch (Progression of exercises from easiest to hardest)Gravity Assisted (hips supported on a pillow or bolster)SidelyingHooklying/SupineSittingStanding (feet should width apart)Advanced standing (feet wider than shoulder width)Advanced ActivitiesElevator exercise Tighten the pelvic floor muscles to 50% and hold for a set amount of time then contract to 100% and hold for a set amount of time then relax to 50% and hold for a set amount of time then fully relax. Ascending and descending stairsTighten the PFM as you walk up stairs and then down stairs. You may want to begin by working on keeping the PFM tight for 1-2 stairs to make sure you are aware of the contraction. Once you are confortable, begin holding the contraction for a ? to full flight of stairs. Weight shifting – Tighten the PFM then shift your weight side to side or front to back while maintaining the contraction. Lateral (side to side) Forward (front to back) Lunges – Tighten the PFM while performing a lateral or forward lunge. You may need to begin by keeping the PFM contracted during 1 lunge and retightening for each lunge. Once the muscles become stronger, you will be able to hold the contraction for a series of lunges. Lateral (side stepping with lunging) Forward Side-stepping – See same concept as lunges. With thera-band around anklesWalkingTighten the PFM while walking. Begin with keeping the muscles tight for 1-2 steps and progress to a set distance. Relax between set distances to allow the muscles to recover. JumpingTighten the PFM during jumping activities i.e. jumping in place, jumping jacks, or jumping rope. Mini squatsOnly need to squat 15-20 degrees from standing. Tighten the PFM as you squat down and return to standing. Relax the muscles and repeat. To make this exercise harder, stand with your feet farther than shoulder width apart and perform as above. REFERENCES: Margaret A. Hayn et. al. Compliance with Pelvic Floor Exercise Program; Maintaining Bladder Symptom Relief. Urologic Nursing. April 2000. Vol 20. No 2. Pelvic Floor Function, Dysfunction, and Treatment – PF1. Developed by Herman & Wallace-Pelvic Rehabilitation Institute. accessed July 2013. Resnick, NM, Improving treatment of urinary incontinence (commentary letter). JAMA. 1998;280 (23):2034-2035. accessed July 2013. accessed July 2013. Overg?rd M, Angelsen A, Lydersen S, M?rkved S. Does physiotherapist-guided pelvic floor muscle training reduce urinary incontinence after radical prostatectomy? A randomized controlled trial. Eur Urol. August 2008. 54(2):438-48Pelvic Floor Muscle (KEGEL) Program(Patient Handout)Endurance/Slow Twitch ExerciseTighten your pelvic floor using the visualization that works the best for you (add visualization here). Hold for ______ seconds x _______ reps _______/dayMake sure to NOT to allow your buttock or lower leg muscles to tighten. You may feel your lower abdominal muscles tighten. This is ok as long as you continue to focus on your pelvic floor. Fast Twitch ExerciseTighten your pelvic floor muscles using the same visualization as above for 1-2 seconds then relax the muscles for 1-2 seconds. Perform _______ contractions x _______ reps _______/day Advanced Exercise(add in any activity with a set amount of time or distance from the list above) How to Perform a Proper Kegel: Quick Guide(Patient Handout) A kegel is a contraction of the pelvic floor muscles. The pelvic floor muscles are located at the bottom of your body and work with your core muscles to provide stability. They provide constant support to the bottom of the body; a shelf for the bladder, prostate, and rectum. They work with the abdominal muscles to provide stability during activities such as breathing, coughing, vomiting, urination, and movements of the upper and lower body. Another function of these muscles is to keep the urinary and rectal sphincters working properly i.e. keep urine in the bladder and feces in the rectum until it is time to empty. How to perform a proper kegel:Below is a list of visualizations that can be helpful in performing a correct kegel. Elevator (closing the openings and lifting the entire floor)Pulling underwear inStopping urine flowHolding gas inSqueezing ‘sits bones’ togetherPulling your tailbone to your pubic boneLifting the perineum off the chairAs the muscles become stronger, the sense of pulling up and in can become intensified. In the privacy of your home, stand in front of a mirror (without clothes on) and if they are contracting the PFM appropriately the penis will draw in and the scrotum will lift up. You may feel a tightening around the anus, but the larger gluteal muscles should not contract. Some individuals will incorrectly perform a kegel by bearing down (sensation of trying to push out or have a bowel movement). Some may sense that the pelvic floor muscles are contracting, however, this is not a correct contraction. This incorrect contraction puts stress and pressure on the pelvic floor muscles and can weaken the muscles. Your pelvic physical therapist will instruct you on a specific exercise program fit for your needs. MARKETING(Topics to discuss with the Urologist)What can physical therapy offer pre and post prostatectomy patients? Physical examDetermining the strength of the pelvic floor muscles prior to surgery and (when appropriate) the strength of the muscles post surgery. A specific muscle grade will be determined allowing for a specific exercise program to be created for each patient. This will include a specific muscle grade but also endurance and coordination of the pelvic floor muscles for different functional activities.Patient specific exercise program/progressionEach exercise progression will look different. Based on each patient’s specific needs and level of activity, an exercise program will be created. BiofeedbackSome patients will benefit from the use of biofeedback to help them strengthen the pelvic floor muscles. The PT will determine if and when this is an appropriate modality. Patient EducationDescription of the pelvic floorFunctions of the pelvic floor and pelvic girdle in general and specifically with functional tasksProper kegel contraction Relationship of kegels to incontinence, surgery, core strengthening, balance, and constipationWhat can your patients expect when coming to PT?Patients can expect to discuss with the PT: Important medical historyAnatomy and function of the pelvic floor and pelvic girdleWhy proper kegels are important and the relationship to surgery (why you have referred them to PT)Physical exam Assessment of the external surrounding musculatureAssessment of the pelvic floor musclesDiscussion/educationSpecific exercise programPad use (different types of pads)ConstipationActivities to avoid ................
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