Demand is coming-Are you ready?
Sometimes in life, you have to take a look deep inside and step outside the box. In this case study, that’s just what the researchers did. They stepped outside of the box and right into the pelvic floor!
Pelvic organ prolapse (POP) is a dysfunction that occurs when the muscles and ligaments that support the visceral structures have become compromised. The muscles of the pelvic floor play a pivotal role in reducing POP. Approximately half of all women who have given birth experience POP, with 3% to 21% having symptoms of vaginal protrusion, pelvic heaviness, musculoskeletal issues, sexual dysfunction, or bladder/bowel problems. Clearly, POP is a condition that impacts a large portion of the population.
Traditionally, treatment for prolapse has included pelvic floor exercises, biofeedback, electrical stimulation, pessary placement, and patient education along with an appropriate home program. “While this treatment approach may work for some, it seems to be insufficient for individuals who wish to return to high impact activities. Considering this, additional treatment options need to be explored to target individuals who wish to return to high-impact activities.” This case report shows that blood flow restriction training may be a potential option.
This case study involves a 39-year old woman who was gravida 5 para 3 (5 pregnancies and 3 live births). She presented to physical therapy with complaints of a “falling out”–type feeling particularly with increased physical activity. She also reported stress incontinence with coughing, sneezing, and running. “The patient’s pelvic symptoms were consistent with underactive pelvic floor, decreased coordination of movement, and POP.”
So what was the intervention? The patient was initially treated with education to perform PFM exercises with both quick contractions and sustained hold (up to 10 seconds) performed 3 times per day. Contractions were performed in this fashion to address slow and fast twitch muscle fibers, given that the PFM comprises 70% slow twitch muscle fibers and 30% fast twitch muscle fibers (who knew?!?!?). Functional activities such as lifting, squatting, resisted side stepping, stair climbing, lunging, and jumping with pelvic floor contraction were added as progressions. She made steady improvements with traditional therapy, however she was still unable to return to running without symptoms. As a result, the clinician decided to use BFR training to compliment traditional treatment for POP and stress incontinence.
A cuff was placed on the proximal most part of the R thigh and was inflated to pressures between 180mmHg and 210mmHg. A perceived rating of pressure was also used, and the cuff was inflated to a 6 to 7/10 rating, which corresponded to the values between 180 and 210 mm Hg. The patient performed side lying hip adduction and end range hip extension off of a table with the knee flexed to 90 degrees. “The patient performed 30 repetitions of the first exercise, followed by a 45- second rest period, during which time the cuff remained inflated. The remaining 3 sets were performed at 15 repetitions with 45-second rest between each set. The cuff was deflated and removed at the end of the last set of 15 repetitions. The cuff was then placed on the left leg and the process was repeated.” Five minutes of rest was allowed before restricting the same extremity for subsequent exercise. The patient was also instructed to perform a 100% sustained PFM contraction while performing each set. This was done 2-3 times per week.
The patient made improvements in subjective outcomes, biofeedback readings, and pelvic floor strength following the BFR intervention. She also noted greater than 75% improvement in “falling out” feeling and no difficulty with interval training following the BFR intervention. She was able to increase her running time to 35 minutes and reported no urinary incontinence with running, coughing, and sneezing.
The authors concluded that, “BFR may be a viable treatment option for patients with relapsing POP when combined with traditional pelvic floor treatment methods, particularly those who wish to return to high-impact activities.”
What do you think? Should BFR training be included in the treatment of POP and stress incontinence? Is more research needed at this time? What are your thoughts?
Kennedy-Guess, Sheila PT, DPT, CLT; Johnson, Andrea J. PT, DPT, OCS; Jacobs, Patrick G. PT, DPT, ATC Blood Flow Restriction and Its Potential Use in Women With Pelvic Organ Prolapse and Stress Incontinence: A Case Report, Journal of Women’s Health Physical Therapy: October/December 2019 – Volume 43 – Issue 4 – p 194-201
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