Treatments

Denise Alberto Specializes in

Diagnosis and Treatment

Comprehensive Physical Therapy Evaluations for

Musculoskeletal Dysfunctions of the

Following Diagnoses:

Musculoskeletal Pain
Chronic Pain
Urinary Incontinence: (Stress, Urge or Mixed)
Overactive Bladder and Bladder Pain Syndrome/IC
Postpartum Incontinence and Scar Tissue Pain (vaginal or c-section)
Abdominal Scar Tissue Management; post operative adhesions
Post Prostatectomy Pain and Urinary Incontinence Syndromes
Fecal Incontinence/Constipation
Pelvic Pain, Endometriosis, Pain with Intercourse, Unconsummated Marriage,
Vulvar Pain Syndromes
Rectal Pain Syndromes
Vaginismus with one on one dilator ed and trg to include partner trg
Pelvic Organ Prolapse Surgery
Spinal pain
Pre and Postpartum Musculoskeletal Problems, New Mother Support
Dysfunctions (back pain, buttock pain, pelvic muscle weakness, hip pain)
Post Mastectomy Breast Pain, Scar Tissue and Shoulder Immobility
Spine Dysfunctions
Post Hip and Knee Replacement
Sports Injuries, USTA tennis players, Professional Athletes

Classification of Pelvic Floor Dysfunctions - 4 categories

Laxity: may happen with habitual valsalva maneuvers with defecation, urination, vaginal delivery, normal aging, nerve damage, urinary and fecal incontinence and post abdominal surgery
Tension/Hypertonus: trauma (falls, coccyx fracture, episiotomies, sexual abuse), chronic constipation, interstitial cystitis, vulvar pain syndrome, obturator internus spasm, levator ani spasm, piriformis syndrome, post lumbar surgery complications or psychological factors (stress).
In-coordination: lumbo-pelvic muscle imbalance, length and tone problems, function versus strength, gait and balance issues.
Disuse: lack of use, no intercourse, lack of orgasm, or lack of body awareness.

Supportive Dysfunctions

Supportive dysfunctions are characterized by a loss of strength of the pelvic floor’s connective tissue and muscle fibers. This can lead to prolapse, urinary or bowel incontinence, or weaker orgasms or a lack of orgasm.

A prolapse is a condition in which the pelvic organs sag down toward the pelvic floor. You may experience a feeling of heaviness in the area of your vagina or anus. Prolonged strain on the muscles and ligaments of the pelvic floor can cause this. Support for these organs is lost.

Prolapse can occur for various reasons. For example, the increasing abdominal weight during pregnancy or chronic constipation leading to excessive strain on the pelvic floor during bowel movements can lead to different types of prolapse.

Urinary incontinence or bowel incontinence may be your problem……….

You may also have weaker orgasms or the inability to have an orgasm. This can be caused by muscle weakness of the superficial vaginal muscles. A result may be lack of enjoyment during foreplay and intercourse.

Hypertonus Dysfunctions

Hypertonus dysfunctions are characterized by tension or active spasm of the pelvic floor muscles. Causes might include sexual abuse such as rape, post-surgical pelvic pain, poor posture, social and emotional stress, athletic injuries of the groin region or a forceful blow to the pelvis.

A simple example includes a fall to the buttocks that can injure the tailbone or throw the pelvis out of alignment. In turn, the muscles supporting this area can go into spasm. These tender muscles can refer pain to areas such as the rectum, vagina, hips, groin, thighs, low back, tailbone and buttocks.

Physical Therapy Intervention in Organic Disease

Organic disease can be described as a dysfunction that affects a specific organ or organ system. For example, endometriosis can affect the uterus, fallopian tubes, ovaries, or bowel. Other examples of organic disease include ovarian cysts, interstitial cystitis, endometriosis, chronic urinary tract infections, and irritable bowel syndrome. These organic disease processes cause areas of swelling, inflammation, and /or infection, which can lead to scar tissue formation throughout the abdomen and pelvis. The scar tissue can lead to muscle and joint dysfunction, causing pain and restriction in daily activities. Physical therapy does not take away the underlying organic disease, but is instrumental in decreasing the body’s negative responses to the disease.

In a disease process where scar tissue and adhesions form it is essential to create mobility so the scar tissue and adhesions don’t lead to motion loss. Physical therapists determine where the scar tissue is and perform specific release techniques to the adhesions. The treatment includes special massage techniques called myofascial release and visceral mobilization to the abdomen and pelvis. This can be done externally or internally, vaginally or rectally.

Physical therapy intervention for organic disease processes may include some or all of the following:

Education about the anatomy and physiology of the organic disease and ways it may affect the rest of the body
Specialized massage techniques (myofacial release, visceral (organ) mobilization) to the abdomen and pelvis. Some techniques may need to be done through the vagina or anus.
Joint alignment techniques
Modalities such as biofeedback and electrical stimulation.
Instruction in proper posture and body mechanics for activities of daily living, voiding strategies, defecating, or sexual intercourse
Relaxation, diaphragmatic breathing, and imagery.
Specific home exercises and management program, which would incorporate some or all of the above listed interventions (self massage, stretching, strengthening, postural exercises, awareness exercises, etc.) With the goal of entering a community exercise program for long term health.
It is important to know that there is help for the pain associated with your organic disease.

Musculoskeletal Problems-Hypertonus as an example below

Hypertonus

Trauma- childbirth, tailbone fracture, sexual abuse, hamstrings or groin pull.
We will treat the above problems by a careful evaluation of how your spine and pelvis is lined up. You may suffer from being “out of alignment”. We check the ligaments to make sure they are strong and supportive, keeping the bones in place. We evaluate muscles looking at tone, strength and how well they function together by asking you to move in certain ways. We may then assess your superficial and deep muscles of the pelvic floor to see if the problem is coming from inside. We can then do joint mobilization, soft tissue massage, exercise instruction and pain relieving modalities such as ultrasound, ice and electrical stimulation to help ease the pain and restore more normal functioning. There may be a scar that is too tight and needs to be stretched so the muscle can then move like it should. We look at posture and your habits to see if they are contributing to your problems. We may use biofeedback to help you better relax or strengthen the pelvic floor muscles.

True Coccydynia- specific pain around the anus and tailbone because of some trauma
You may have fallen down the stairs and landed on your buttocks or fractured the coccyx bone during vaginal delivery. You usually complain of pain with sitting, or when you go to get up or have pain with bowel movements. Treatment usually involves mobilizing the coccyx bone through the anus in order to evaluate its position and be sure of the correct way to move it. We would then do massage to the delicate muscles attached to that area. We may use electrical stimulation and ice to help ease the pain as well as ultrasound to improve blood-flow to the area and speed up the healing process of the muscles. We would then provide you with ideas on how to sit and move more properly as to not injure the area any further. We would then give you an exercise program to do at home to improve relaxation of the area and strengthen if necessary.

Coccygeus Muscle Pain Syndrome “My Butt hurts”- pain around the anus and tailbone
You complain that your “butt hurts” when you sit and may have problems with bowel movements being painful. We try to find out why by testing other muscles in the area of the pelvic floor that may be forcing the anus to hold tight. We do massage, instruct in home exercise programs and may apply modalities for pain like electrical stimulation to the area. We may use biofeedback to help you gain control of this muscle in order to stop “holding tight” through the anus.

Pelvic Muscle Tension Syndromes- vaginismus, obturator internus spasm, levator ani spasms, piriformis syndrome. A specific trauma as stated earlier may be the reason for tight pelvic muscles. You may have poor awareness in this region of the body with chronic muscle holding. Poor postures with sitting and standing are a problem. You may be a highly trained athlete with overuse of the pelvic muscles (soccer, biking, and tennis). You may just hold your emotional tension or stress in that area. You may have pain with sexual intercourse because the outside or deep muscles of the vagina are too painful or tight. Some people have had surgeries in the pelvic/abdominal region resulting in pain or may not remember any cause at all.

Treatment

We treat all the above by doing manual therapy to include massage, myofascial release and joint mobilization to decrease spasms, restore movement and improve blood circulation. We may use ice, heat, home electrical stimulation and biofeedback to help with pain and restore tissue function. However, we use these modalities minimally in the treatment session and may recommend home use. We want to initially improve the functioning of your muscles by cluing them into what normal contraction and relaxation is. We would then encourage lots of stretching and strengthening only when we feel the muscles are ready. We would include information on self-care for home and maintenance as you are able to manage your problem.

Key words

Biofeedback- a training technique that enables an individual to gain voluntary control over autonomic bodily functions; the individual learns a desired response when the information is received (biofeedback) which indicates a specific thought or action has produced a desired response.
Myofascial release- manual treatment of releasing the fascia or fibrous sheets surrounding and separating the muscle tissue.
Joint mobilization- careful movement of joints in the body in order to improve gross motor movements and restore function of the specific area mobilized.
Obturator internus- a deep, external rotator muscle of the hip that lies in the obturator foramen of the pelvis.
Vaginismus- painful involuntary spasm of the vagina preventing intercourse.
Levator ani- a deep pelvic floor muscle group consisting of the pubococcygeus and iliococcygeus muscles.
Coccygeus- a deep pelvic floor muscle group attaching to the coccyx and is a primary mover for defecation.
Piriformis- external rotator muscle of the hip.
Sphincteric- relating to a sphincter, which is a muscle that encircles an orifice like the anus that with contraction, constricts the area.