This video will discuss various elements of Pelvic Muscle Retraining including baseline assessments, retraining sessions, and teaching lifestyle modifications.
this session, we're going to be talking about pelvic muscle retraining for both fecal incontinence and constipation. Re training is a form of physical therapy that can be done either by a registered nurse or a physical therapist who has been trained in pelvic floor retraining. This is designed to correct and improve the function of the muscles that are required to control constipation or to defecate properly. So we're gonna be guiding the patient to contract, to relax the correct muscles and recruit the correct muscles while giving them a screen to watch the activity as they perform certain functions. The tools that we use for retraining include an E M G, which is a peri anal plug and sometimes E k G patches that have put on the abdominal muscles. Or we can use the in erectile Manama tree probe so that we can use pressure sensors and notice. We also use the balloon that is attached to the in erectile probe. When we re train, we use a feedback loop and basically we start with the brain. We have the brain tell the anal rectal sphincter to perform a certain motor command, and when we have that outcome. We assess the outcome based on a tracing on the screen, which then reinforces the brain to continue that motor command Patient selection is one of the most important parts of the retraining. The prerequisites is a motivated patient, the ability of that patient to process the instructions properly, the ability of the sphincter to contract and adequate sensation There should be able to detect at least 40 MLS of air or fluid in the balloon. And, of course, a motivated healthcare provider who are some of the poor candidates for retraining. First would be a patients with a sphincter defect, although sometimes we will do retraining before and after a surgical repair of that sphincter defect. So they really aren't necessarily a poor candidate. Patients who have a severe neuro genic and continents, such as people who have had a spinal cord injury um, M s or things like that or noncompliant patients. Some patients that fit into that category are patients who have dementia or Alzheimer's, or people who cannot follow instructions. There are three different types of pelvic muscle retraining. The first would be the strengthening exercises or the Kagel maneuvers, and for those of Manama, tree sensor are preferred. The second would be rectal sensory training, and you need the Manama tree centers because you need the balloon in order to retrain the patient for the sensation of rectal filling. The third would be the strain of the Val Salva training for obstructive defecation training. And for those we typically want to use E M G centers as those air more accurate to define the push maneuver that you want to retrain the patient. Some of the things that we can accomplish in retraining would include a modest improvement of resting tone if they have weak tone. But remembering that 80% 75 to 80% of the resting tone is smooth muscle. But you can improve that 20 to 25% of thes tried and muscle resting tone. You can improve squeeze strength because that is actually using these tried and muscle improvement of rectal filling or sensory retraining. And you can also work to retrain the external sphincter to contract at the time of rectal distension or improve the timing so that the patient does not hesitate when they feel the rectal feeling occur. Also, improvement of relax ation of the external anal sphincter. And the pew Barack tells muscle with ES training also can be improved. Let's first talk about fecal incontinence. Two of the things that we want to accomplish with fecal incontinence is strengthening of the muscle, so evaluate what they're resting. Pressure is and what they're squeezed, pressures are and where you want to improve, too. The second is sensory retraining. For those patients, you want to take a detailed history of their incontinence episodes. Do they have warning? When does it occur? What is their first sensation? So to both rapid and slow inflation. So if they have a delayed first sensation, we want to be able to improve that so that they don't have leakage of stool when they have lower volumes in the rectum for pelvic strengthening exercises. Our goal is to teach the patient to recruit the correct muscles to produce that contraction, the things that we want to improve our both strength and duration. In order to do this, we want to teach the patient to recruit the correct muscles and not to use the abdominal muscles or the gluteal muscles to be able to isolate the pelvic muscles. For example, the external anal sphincter muscle and the Pew Borek Tallis muscle. Here's an example of a patient who is using some of their abdominal muscles. When we ask the patient to squeeze so they're able to maintain their squeeze. We want to set a threshold that's a reasonable and attainable threshold. So we usually started about 10% above what they can accomplish during interactive Manama tree diagnostic testing. But we want to make sure that they do not recruit their abdominal muscles as well, because you're pushing to forces against each other. And if the sphincter is not strong enough, the abdominal muscles can override the sphincter muscle and causing continents. Now here's an example of the patient who is recruiting. Here's your resting tone. They're recruiting their their anal rectal sphincter muscles, but they're not recruiting the abdominal muscles, and this is a correct squeeze. So this is our goal. When you're doing your strengthening exercises, the patient is expected to do some homework, so you want to be able to make sure that the patient can perform the exercises correctly. So give them enough practice sessions when they're there so that they understand what to do when they go home. You want the patient to be able to recognize the sensation of the squeeze when it's performed correctly. How should it feel? They should be able to feel that rise of the sphincter and the tightening of the sphincter and keep their abdominal muscles relaxed? You want to give them sets of squeezes just like you would at the gym. So you want to give them several sessions a day in different positions so that their strengthen the muscles and give them enough rest time in between. Give the patient a diary to take home with them so that they can keep track of when they're incontinent when they have normal bowel movements. How many times they've done their sessions, because when they come back, you want to be able to evaluate their diaries, set up their subsequent visits now for people in the United States, make sure that you have authorized enough such sessions with the insurance company. You may need to do some diet modification and also provide tapes, if you can, to give the patient something to listen to while they're doing their exercises. If you the diary with their patient and assess their complaints with their exercises. The next thing that you want to do is to do an initial assessment or diagnostic squeeze to evaluate where they are in comparison to the last visit, adjust your thresholds accordingly and then reinforce their exercise technique, giving them longer duration and, ah, higher threshold. So always start lower and work your way up from session to session. Start with a five second squeeze and hold, and eventually, hopefully, you're gonna end up with a 22nd duration, assess the success with concurrent treatment and provide motivation for them to continue. Explain to the patient that this could take several visits and several months for them to see improvement. So set their expectations appropriately. Make sure that you set a reasonable threshold. I usually will set my thresholds in about 10 to 15% higher than what they're squeeze Effort is when I get do their diagnostic squeeze. So, for example, if this patient had a squeeze off about 55 millimeters of Mercury, I would set this at 60 and then ask the patient to squeeze and hold their the same with the duration. If I can get them to squeeze and hold for five seconds and they can stay above the threshold. Then I'll increase their duration to 10 seconds and each visit. I'll increase their duration. For those patients who have impaired sensation for rectal filling, we will want to do rectal sensory training. So our goal for sensory training is to improve the threshold by re sensitizing the patient to smaller volumes of rectal distension. We want to be able to improve the pelvic muscle awareness and recruitment of those muscles when they sense the rectal distension and to squeeze the external anal sphincter. In response to that distension during the first session, we want to teach the patient to recruit the correct muscles for the strengthening exercises. So basically we're identifying those the pelvic muscles and we're improving the rapid recruitment of the squeeze when they feel the rectal distension. So the first thing we want to do is to just improve the squeeze on the left. You'll see that when we asked the patient to squeeze, it was just a very slow onset of the squeeze. So we want to improve the recruitment and increase that rapid recruitment of that squeeze. So we want to go from a slower recruitment to a faster recruitment and a stronger recruitment. During the second session, we're going to start to inflate the balloon with a volume that the patient consents. So refer back to your anal rectal Manama tree diagnostic testing to see at that point where the person first felt the balloon inflation go above that and start inflating the balloon. I'll typically have the patient watch me and watch the screen as I do that, and I'll show them that I'm inflating the balloon so that they can see it. I will repeat this several times so that the patient is reinforced with that sensation. Once the patient can feel that sensation and be consistent, then we start to decrease the volumes now, understanding that while the patient's watching that they will pretty much always tell you that they feel it. Once I get the patient to get used to that volume, then I will take away the visual, and then I'll ask the patient to tell me when I inflate. Once I know that they're accurate with their sensation, that's when I will start to decrease their volumes. In the beginning, you will tend to notice that it takes the patient a few seconds to tell you whether or not they feel that that balloon or the balloon being inflated or the rectal filling to occur. What the next goal will be is to get them to respond quicker so that they're more sure of themselves, that that's what they feel. Once you see that they're confident in that inflation of the balloon than you would move onto the next less volume In this slide, you'll see that this is a an inflation of 30 Emil's of air with no response of the sphincter, and the patient did not feel that balloon volume. So our goal is to get the patient to feel the volume and to respond appropriately so they did not feel it, and there was no activity in this sphincter. In this example, you'll see that the patient successfully identified the volume, but it took them a while before they actually responded with the sphincter. So there was a delay. There's a bit of a delay, and so we need to improve that because when the rectum fills with volume, if they don't respond quickly enough, they will have fecal leakage. Now, in this example, this is also with 30 emails. After several visits, the patient is responding quickly, and they're also responding with ease. Squeeze or this sphincter is responding almost immediately upon rectal filling on the left, you can see that this was a negative sensation and a no response with the sphincter. And here there's a positive sensation, and the squeeze is happening at the onset of the rectal filling. When the patient goes home for retraining sessions, you want them to be more aware of that rectal filling. So as you've been inflating the balloon during the sessions, you're instructing the patient to be aware of what it feels like and that when they go home, you want them to be more aware of that rectal filling. I even asked them to keep that in their diary for sensory retraining. You typically want them to come back a little bit quicker because it's very difficult for them to really practice the sensory part of that. So typically, you'll have the patient return in about 3 to 7 days for another session. For repeat sessions, you're going to assess their symptoms and their compliance with their exercises. They're strengthening exercises. You're going to start out by assessing where they last felt volume at their last session. So when you inflate the balloon with the volume that they last felt, make sure that they're still feeling that on their subsequent visit and then start decreasing to the next increment lower. This next section has to do with obstructive defecation retraining. This is a very difficult training to do. Your goal for this is to guide and teach the patient to relax both the pube A row tells muscle and the external anal sphincter when attempting to defecate. Typically, you'll use an E M G plug, and that's positioned in the anal canal, and you can have the patient sitting in a normal position, either on a CA mode or in a chair with your feet flat on the floor. Assuming a more normal position, take a detailed history of the patient's symptoms. You'll you'll find that these patients have had a long time of constipation or defecation disorder. Ah, so many times it's most of their life, so understanding that this has been a habit that's been occurring for most of their life, it's going to take a long time to retrain those muscles to do things correctly. Set the appropriate goal for your patient so that they understand that this is going to take some time and some dedication both on your part and on their part. Have them describe the type of stool when they do defecate. What is the stool? Use the visual scaling system because that will also help guide you as faras. Pulling in external resource is how often does the patient having a bowel movement once a day, once a week, once every two weeks. Make sure that you understand what their normal routine is and what methods has the patient used to correct their defecation disorder? So are they using medications? Are they using Animas Pernille splitting or digital assistance during the first session? Typically, you're going to perform strengthening exercises using the M G sensor and abdominal leads on the abdomen. The goal of this is to just teach the patient which muscles that they're using so that they can separate the different muscle types and which ones they want to recruit for each type of activity. So before you even start asking them to push, we're going to start with the squeeze and getting the patient to understand what it feels like, which muscles are being contracted and how it feels when they squeeze. So during this session, you want to have them squeeze and appreciate that sensation of the squeeze and then to quickly relaxed so that they can feel the dissension of this sphincter during that relax ation phase. So a quick squeeze with a quick relax ation and have them get that sense of what each thing feels like when the patient goes home, the first thing you're asking them to do or strengthening exercises. So explain to the patient that you're just trying to isolate the muscle types so that you're going to have them. Just do strengthening exercises with a quick squeeze with a quick release and a quick squeeze in a quick release. The next thing you want to have them start to do from the very first session is to start doing bowel habit training. So that means going into the bathroom at the same time every day to try and have a bowel movement to get the body used to trying to have a bowel movement at the same time every day to not ignore the signals of defecation or suppress that urge because sometimes they will suppress that urge for days on end. So you want to teach them to really recognize the signals of defecation and to go in the bathroom and try and have a bowel movement. Even if they're not successful to at least not ignore those signals, it should not feel like a squeeze when they're attempting to defecate. So when you're teaching the patient, you have already taught them what it feels like to squeeze. And when they're defecating, make sure that it does not feel the same way. Maintain the diary. That's going to be very important for you to see if you see any improvement. I include a diet diary, a stool diary on activity diary. In the second session, we're going to do something a little different. We're going to ask the patient to squeeze and then to relax and then push at the end of the relax ation phase. So what we want to do is to kind of almost overshoot the relax ation. So as they squeeze, they can feel the the rise of the anal sphincter. And then as they start to relax, they feel the dissension of this sphincter, and then as they push, you want to get them to push further through it and push down through the chair. Now here. When we asked the patient to relax and then to push, they didn't go further below their resting. But again they started to squeeze that muscle. So we want to make sure that they're not doing that squeeze. Here's an example of Ah, a session where the patients started to get the idea of what they're supposed to be doing. Now here's their resting pressure. Now, when they do the squeeze, they're doing a quick recruitment of the squeeze and then a quick relax ation and following all the way through with the push so that that tracing should go below the resting. So you can see here that they actually did an appropriate push at the end of that squeeze during the third sequence. Now the second sequence may take several sessions for them to get the hang of it, but after they accomplish that goal, then the third goal is to be able to do a push without the squeeze. So you want to push from the abdomen, so if you look on the top of the tracing. You'll see that the abdominal muscles are starting to increase in pressure while the sphincter muscles are decreasing. So in the first one you can see that the resting tone stayed the same. The increased our abdominal muscles but did not relax their sphincter muscle On the second attempt. You can see that at the onset of the increase of abdominal pressure, the sphincter pressure decreased. After subsequent attempts, you can see that they're doing a better and better response with these relaxations they Sometimes they'll have a little bit of a squeeze, but you want them to really relax below their resting tone. You want the sphincter muscle to quiet down during those push maneuvers, especially with patients who have obstructive dedication disorders. You want to consider concurrent treatments. You can't always just do the retraining sessions alone. You have to consider the following things diet, improving their fiber, improving how much liquid they're drinking, etcetera medications. Um, there are some things that are gonna be causing problems for them that they may not be able to stop, but there are some things that you can do to help them bowel habit training is important, getting them to try and defecated the same time every day. And sometimes it's important to have a psychological intervention for those patients. Some of these patients are under a lot of stress, either at home or at work, or have had other issues that have happened to them that they could use a psychological intervention for so bowel retraining. What does that really mean? It means that you want to be able to train the bowel to pass stool every day around the same time every day and take advantage of the gastric colic reflex and get the patient to have a bowel movement and promote defecation as a routine. So what does that mean? What does that entail? Thes air? Some of the things that can get that patient to have a routine set for every day. So you want to have them set a time every day that they're going to go in the bathroom and try and have a bowel movement. Whether or not they're successful in the beginning is not important. To just get them to get into the routine is typically morning is the best time because you could take advantage of that gastro colic reflex, and you want to do that after a high fat meal. So although most cardio just wouldn't be happy with that, encouraging a high fat breakfast and some caffeinated beverage will help this to occur and go for casual. Walk for about 10 to 15 minutes. Do not do aerobic exercise because that will slow down the gastric colic reflex. So a nice, casual slow walk around the block or around the house for about 15 minutes, and then to sit on the commode for 20 minutes and stay relaxed. Attempt to defecate with any urge to dedicate. Sometimes a suppository can help and repeat this every day. The bow will start to accommodate to this routine and will start to be able to evacuate without the assistance of a suppository. And you will have that urge at that same time every day. If you can follow this routine every single day in summary, the elements of muscle retraining include a based on assessments you want to assess either by Manama Tree and E. M. G. You want to set up your retraining sessions, make sure that you've pre authorized them if you need to teach lifestyle modifications and practical management, set up goals for your patient and also provide the emotional support that a lot of times they don't get it home. Bring in team members as you need them to fill in the gaps in the United States you cannot use by a feedback for reimbursement you. It has to be muscle retraining, public muscle retraining, and the CPT code is 90911 You can use a brief office visit for the non physician cpt code of 90211 especially when you're doing your evaluation. And sometimes I'll do an evaluation sometimes in the middle of the sessions, maybe after three or four sessions and then again at the end. Um, so you can build for those sessions. Some of the tools that we use to help as faras the evaluation of our patients are some of the diaries that I've talked about today. First one is the Diet Diary. I usually give this patient to the patient for at least one week and sometimes more to evaluate what their diet is in relation to fluid intake, amount of fiber that they take vegetables, fruits, proteins and carbohydrates. I explain to them what a serving is. I give them a diet diary and I have them keep track of that. Maybe for three days or so each session, or sometimes I'll do a full full one week at the beginning of the sessions. Ah, stool diaries also important. You want to keep track, especially for those patients who have fecal incontinence as as far as when they have leakage of stool, but also patients who are having, um, obstructive constipation issues you want to look at? How many times a day or week are they having bowel movement? So come up with some kind of a stool diary will be very helpful for your patients. Use some type of a stool scale when you're evaluating the type of stools that they're passing. This is an example of the Bristol stool scale, so whatever stool scale you'd like that usually helps the patient with a description and kind of a picture of what the stool would look like. And that helps them to describe their stools. And last but not least, you want to look at the quality of life scale. How have you improved their life? Have you improved their ability to function during the day. Can they go to social activities? Etcetera. How many times can they spontaneously do things without worrying about being incontinent or having issues? Always send your patient home with instructions of what's expected of them until the next session, whether it be strengthening exercises which is provided here Or, um, you know, defecation exercises or bowel training, etcetera. Give them specific instructions based on what you expect for them for the next session. Thank you for listening. And I hope this has helped you with your pelvic floor retraining.
