TITLE: Pelvic Floor and Abdominal Motor Control Strategies for Treatment of Stress Urinary Incontinence Post-Prostatectomy
AUTHORS/AFFILIATIONS: Sineway J, Bush S. St. Anthony's Hospital, St. Petersburg, FL; Brooks Rehabilitation, Jacksonville, Florida, UNITED STATES.
Background and Purpose: Prostate cancer is the most common form of male cancer, typically managed with radical prostatectomy. Surgical insult can damage supportive continence structures, most commonly the urethral sphincter, resulting in stress urinary incontinence (SUI) in the majority of affected individuals. Prior abdominal wall surgeries can further predispose an individual to decreased ability to manage increased intra-abdominal pressure with active movements. Current literature is supportive for the treatment of SUI for men in the early postoperative stages of prostate cancer utilizing pelvic floor muscle (PFM) training and biofeedback; however, there is less evidence available for physical therapy management nearing 1-year postprostatectomy. The purpose of this case report is to describe the physical therapy management of a patient 9 months postlaparoscopic prostatectomy utilizing pelvic floor and abdominal motor control strategies for SUI. Case Description: The patient was a 66-year-old physically active, Army-retired male who presented to outpatient physical therapy 9 months following laparoscopic prostatectomy with complaints of SUI with standing from a chair quickly, bending down, strenuous exercise and lifting, nocturia, and erectile dysfunction (ED). Significant medical history included an umbilical hernia repair and bilateral knee replacements. His physical therapy diagnosis was intra-abdominal pressure impairment associated with overactive pelvic floor muscles leading to primary symptoms of SUI. The patient's plan of care focused on neuromuscular re-education including sEMG biofeedback-assisted PFM downtraining, followed by therapeutic exercise and activity for coordination of PFM contraction during functional activities with exhalation to manage intra-abdominal pressure without urinary leakage. Outcomes: The patient was seen for 14 visits over a period of 9 weeks. International Consultation on Incontinence Questionnaire and Incontinence Impact Questionnaire scores met minimal clinically important difference (MCID) for urinary symptoms, International Index of Erectile Function score decreased from moderate to mild severity of ED, and NIH Chronic Prostatitis Symptom Index scores demonstrated positive changes in each domain of pain, urinary symptoms, and quality of life. Improved bladder habits included reduced nocturia from 2 times per night to 1, decreased symptoms of urinary urgency, frequency and amount of leakage with strenuous exercise, and lifting per subjective report. Discussion: Pelvic floor and abdominal motor control strategies were successfully used outside of acute postsurgical time frame to improve SUI and ED, which is less available in current evidence.
TITLE: Gait Retraining in the Management of Two Runners With Chronic Stress Urinary Incontinence: Case Reports
AUTHORS/AFFILIATIONS: Steimling M, Roberto M, Good Shepherd Penn Partners, Philadelphia, Pennsylvania, UNITED STATES.
Background: Stress urinary incontinence (SUI) is the complaint of involuntary leakage of urine upon exertion or during impact activities. The pelvic floor (PF) is a group of muscles that encloses the inferior aspect of the pelvic ring and is responsible for the maintenance of urinary continence during dynamic activity. Impact activity generates a rapid increase in intra-abdominal pressure, which may cause an overload of the PF resulting in SUI during running. Both ground reaction force (GRF) and PF activity increase with increased running velocity, which may suggest a relationship between changes in GRF and PF demand. There has been a myriad of literature to support the use of running gait retraining in the management of running injuries. This research explored the reduction of GRF through the manipulation of gait variables. Case Descriptions: Case 1: A 43-year-old female with chronic SUI with coughing, sneezing, and running since birth of first child 5 years ago. Initial physical therapy interventions focused on pelvic floor and hip muscle strengthening. After 9 visits over 2.5 months, her SUI was abolished with coughing and sneezing. She continued to present with SUI with running 4 miles. Running assessment revealed a cadence of 166 steps/minute (s/m) and dynamic knee valgus bilaterally. Running retraining was initiated using a metronome for external feedback to run at a cadence of 180 s/m. Case 2: A 45-year-old female with chronic SUI with coughing, sneezing, and running since birth of second child 8 years ago. Initial physical therapy interventions focused on pelvic floor and hip strengthening. After 4 visits over 1 month, SUI symptoms were abolished with coughing and sneezing. She continued to present with SUI with running 2 miles. Running assessment revealed increased vertical excursion, decreased cadence of 156 s/m, and increased noise at initial contact. Feedback was provided to reduce the noise generated with each foot fall. Outcomes: Case 1: After 4 visits of gait retraining over 1 month, patient was able to progress her running distance to 10 miles symptom free. During gait reassessment she demonstrated a cadence of 180 s/m without external feedback and no longer demonstrated dynamic valgus. Her Pelvic Floor Distress Inventory (PFDI) total score decreased from 42/300 to 14/300. Case 2: After 3 visits of gait retraining over 1 month, the patient was able to run 2 miles daily symptom free. During gait reassessment she demonstrated a decrease in vertical excursion and decreased noise with footfall. An 8-week follow-up revealed that the patient remained symptom free, the PFDI decreasing from 51/300 to 4/300. Discussion: These patients experienced meaningful improvements in symptoms related to SUI following standard treatment consisting of pelvic floor and hip strengthening but only achieved resolution of symptoms with running after running gait modification. It may be that, in these cases, the patients' improvements were associated with running gait modification in addition to the standard of care. Further research into pelvic floor function with manipulation of running gait parameters would help to elucidate the role of gait retraining in the management of patients with SUI.
TITLE: Physical Therapy in the Management of Recurrent Clogged Milk Ducts in Breastfeeding: A Case Report
AUTHORS/INSTITUTIONS: Divine K, Shenandoah University, Division of Physical Therapy, Winchester, Virginia, UNITED STATES.
Background and Purpose: Breastfeeding has many known health benefits for mother and baby, including, but not limited to, reduced risk of breast cancer, strengthening of the maternal bond, accelerated weight loss postdelivery, and reduced risk of sudden infant death syndrome. Many women experience barriers to successful breastfeeding, one being recurrent clogged milk ducts. Clogged milk ducts can lead to pain, breast engorgement, frustration, and mastitis. The purpose of this case report was to describe how a physical therapist utilized patient education, therapeutic ultrasound, and moist heat to manage recurrent clogged milk ducts in a lactating woman. Case Description: A 34-year-old female was referred to physical therapy (PT) for recurrent clogged milk ducts in bilateral (B) breasts after unsuccessful self-management. She had mastitis twice within the past 3 months and was considering cessation of nursing. She reported daily clogged milk ducts B, 7/10 pain on the visual analogue scale with nursing sessions, and feelings of incomplete draining of the breasts. She was seen for a total of 5 PT visits over a 3-week period. PT treatment included the application of moist heat followed by therapeutic ultrasound (100% duty cycle, 1 MHz, 2 W/cm2, 2x effective radiation area × 8 minutes per clogged duct) and patient education. Education focused on breastfeeding positions, avoiding sleeping prone/tight clothing, staying hydrated, preparing nipple for proper latch, use of moist heat, anti-inflammatory medication, and self-massage. Outcomes: The patient reported a reduction in breastfeeding pain from 7/10 to 1/10, had resolution of clogged ducts immediately following PT treatment, reported a minimal recurrence of clogged ducts with subsequent breastfeeding sessions and remained infection free after a 2-month follow-up. She was able to continue breastfeeding >1 year. Discussion: Therapeutic ultrasound, moist heat, and patient education were successful in opening clogged milk ducts, reducing breast pain, and limiting reoccurrence. Physical therapy may play an integral role in providing nursing mothers with support, education, and conservative treatment for managing clogged ducts to optimize successful breastfeeding.
TITLE: Nurses' Perception of Acute Physical Therapy for Postpartum Women: A Focus Group
AUTHORS/INSTITUTIONS: Divine K, Abraham K, Duvall P, Weicht L, Shenandoah University, Winchester, Virginia, UNITED STATES.
Hypothesis/Purpose: Postpartum women are at increased risk for physical impairments following delivery, which include but are not limited to back pain, urinary incontinence, diastasis recti abdominis, pelvic floor muscle injury, and pregnancy-related pelvic girdle pain. Physical therapists are in a unique position to address these concerns and provide education to women during the acute postpartum stay. However, there is a lack of utilization of physical therapy (PT) services during postpartum recovery. Mother-baby (MB) unit nurses work with postpartum mothers on a daily basis; therefore, the purpose of this study was to gain nurses' perspectives of the need for PT services and their knowledge of the role of PT in the acute postpartum setting. Subjects: Subjects were recruited from MB unit nursing staff at a regional medical center and a small community hospital. There were 8 MB nurses, 1 certified nurse midwife, and 1 recently graduated nursing student with MB experience who participated in the study. Materials/Methods: Two focus groups were conducted, one at each facility. A questionnaire was used to gather demographic information and was distributed prior to the session. A student moderator led a semistructured interview process with 3 preselected open-ended questions. The discussions were audio recorded and 2 to 3 students took field notes that were then transcribed and peer debriefed for accuracy and validity. Transcriptions were analyzed using Dedoose software to identify key themes and develop a comprehensive concept map. Results: There were 5 participants present for each focus group, with an average of 9.8 years of work experience in MB units. There were 4 main themes that emerged through theme coding and data analysis. The main themes included lack of understanding of PT scope of practice/exposure to PT services, limited time for services in the acute setting, role overlap (PT/nursing), and appropriate timing of PT intervention. Conclusion: MB nurses demonstrated limited understanding of the PT scope of practice and its potential benefit in the acute postpartum setting. Despite identifying opportunities for PT intervention during the acute stay, the nurses were reluctant to advocate for PT intervention except with complex patient cases. This lack of interprofessional knowledge/collaboration may limit postpartum recovery. Clinical Relevance: This study identified limitations in the knowledge of health care professionals regarding the potential role of PT in the acute postpartum setting. Therefore, it may be beneficial for future research to examine the impact of educational programs targeted at both health care providers and postpartum women and the effect of that education on physical therapy referrals and postpartum physical impairments.
TITLE: The Impact of Gender on Wellness Center Participation and Outcomes in Persons With Disabilities
AUTHORS/AFFILIATIONS: Mulroy S, Kiseljak-Dusenbury S, Rancho Los Amigos Rehabilitation Center, Downey, California, UNITED STATES.
Purpose: Research on the health and wellness of women with disability is limited. The few studies of the physical activity patterns of women with disabilities suggest that they are not engaging in physically active lifestyles. Understanding the role of gender in wellness behavior is critical to meeting the specific needs of women. The purpose of this research report is to explore differences between women and men in meeting physical and emotional expectations through attending activities in a hospital-based wellness center. Subjects: 11 men and 20 women, who were wellness center members and patients, with various disabilities, in the outpatient clinics of a large public rehabilitation hospital. Methods: An anonymous survey, with 18 questions on attendance frequency, service utilization, and extent of meeting physical and emotional expectations, was administered to the subjects. A χ2 test was used to test the associations between gender and whether or not participants attended fitness classes, recreation classes, support groups, and gym exercise. A Mann-Whitney U test was used to compare the number of fitness and recreational classes attended between men and women. Spearman's rank correlation test was used to calculate nonparametric correlations separately for men and women between the extent of meeting physical and emotional expectations and participation in wellness center activities. Results: There were no statistically significant differences between men and women in participation in any type of wellness activity or in the number of fitness (P = .43) or recreational (P = .56) classes attended. Men and women reported having their emotional expectations met to an equal extent (55% vs 50%), but men were more likely to have their physical expectations met or exceeded than women (64% vs 25%, P < .05). For women, the factor most strongly correlated with the extent of meeting physical expectations was the number of recreational classes attended (ρ= 0.68, P < .001) followed by attending any recreational classes (ρ= 0.59, P < .01). For men, although not statistically significant, the factor most strongly correlated with the extent of meeting physical expectations was attending any fitness classes (ρ= 0.50, P = .12) followed by the number of fitness classes attended (ρ= 0.40, P = .23). For men no factors were significantly correlated with the extent of meeting their emotional expectations, while for women the extent of meeting their emotional expectations was most strongly correlated with the number of recreational classes attended (ρ= 0.64, P = .01) followed by attending any recreational class (ρ= 0.61, P = .01). Conclusions: For women, attending gym and fitness classes alone was not sufficient to meet physical and emotional expectations in women. Participation in recreational classes, however, was strongly related to improving subjective physical and emotional status in women. Clinical Relevance: Physical therapists are increasingly integrating wellness services in their practice. To optimize the impact of wellness services on clients' well-being, it is important to consider the role of gender. Physical therapists should consider recreational classes when creating a wellness plan for female patients.
TITLE: Conservative Management of Overactive Bladder Symptoms in a 23-Year-Old Nulliparous Female: A Case Study
AUTHOR(S)/AFFILIATIONS: Roth S, Ohio State University Wexner Medical Center & Catholic Health Initiatives, Columbus, Ohio, UNITED STATES.
Background and Purpose: It is generally believed that urinary incontinence (UI) is associated with older age and women who have given birth. However, an overall prevalence of UI of any type ranged from 1% to 42.2% in nulliparous women. The purpose of this case study was to assess the effectiveness of a comprehensive conservative treatment plan on reducing overactive bladder (OAB) symptoms in a 23-year-old nulliparous female. Case Description: The patient presented with symptoms of urinary urgency, frequency, urge incontinence, and nocturia that started approximately 3 years ago and worsened over time. The patient was referred from her urogynecologist and her medical history examination findings were unremarkable. The patient reported daytime urinary frequency of every 1.5 hours on average, 1 void at nighttime, and once daily leakage episodes varying from moderate amounts to occasional large amounts. Outcomes: The patient's examination findings: pelvic floor muscle assessment revealed muscle power, endurance, and repetitions of maximal contractions, and fast/quick flick contractions (PERFECT) scheme score of 3/10/7/7. Outcome measures taken at baseline included: International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) = 12/21 and Overactive Bladder Questionnaire-Short form (OAB-q SF) with symptom severity transformed score = 63.3, and total health-related quality of life (HRQL) subscales (coping, sleep, and social) transformed score = 76.9. Interventions performed included: education on pelvic floor anatomy, pathophysiology of OAB symptoms, behavioral strategies (eg, urge suppression, water intake, and bladder irritants), pelvic floor muscle retraining, manual therapy to periurethral structures, visceral mobilizations to ligaments of the bladder, and home-based use of transvaginal electrical stimulation. The participant was seen for 10 visits over the course of 8 months. The patient's re-examination findings at discharge revealed PERFECT scheme score of 4/10/10/10. Discharge outcome measure scores included: ICIQ-SF score = 10/21 (2-point improvement) and OAB-q SF symptom severity subscale transformed score = 33.3 (30-point improved score), and total HRQL subscale transformed score = 95.3 (18.8-point improved score). Discussion: The patient demonstrated improvement on the PERFECT with pelvic floor muscle assessment, exceeded the minimal detectable change (MID) of 10 points on all OAB-q SF subscales, and had a 2-point improvement on the ICIQ-SF. Although the patient demonstrated improved scores on all outcome measures, additional conservative treatment options including pharmacological therapy were discussed due to continued reported decreased quality-of-life factors, difficulty with increasing voiding interval >2 hours, and urge incontinence episodes 2 to 3 times/week. The outcomes of this case study suggest that conservative physical therapy measures alone may not always be enough for improved symptom resolution and quality of life for patients with OAB. Pharmacological therapy is shown to be an effective first-line treatment option for OAB and may need to be discussed as an option with patients earlier in their rehabilitation if progress is slow, minimal, or significant quality-of-life factors persist as a result of their OAB symptoms.
TITLE: Cardiovascular Endurance Is Significantly Related to Urinary Incontinence Post-Robotic Assisted Laparoscopic Prostatectomy
AUTHORS/AFFILIATIONS: Wood A, Payne J, Villane A, Cahalin L, University of Miami Health System, Miami, Florida, UNITED STATES.
Purpose/Hypothesis: Two types of urinary incontinence, stress (SUI) and urge (UUI), and associated urinary symptoms such as urgency and frequency are common postoperative complaints of men with prostate cancer who undergo a robotic-assisted laparoscopic prostatectomy surgery (RALP). Many of these individuals undergo pelvic floor physical therapy to aid in recovery of continence, which typically consists of strengthening and coordination training of the pelvic floor musculature, hip and core muscle strengthening, behavioral retraining, electrical stimulation to the pelvic floor muscles, and patient education. Cardiovascular conditioning is not typically included in most pre- or postoperative pelvic floor physical therapy plans of care; however, it is widely utilized in other populations of cancer survivors. The commonly used functional and cardiovascular endurance measure, the 6-minute walk test (6MWT), has been shown to be a valid outcome measure in individuals with cancer and has been explored as a predictor of various outcomes in different cancer populations such as esophageal, colorectal, breast, and lung. There is limited literature exploring its predictive outcome abilities in the prostate cancer population. This study investigated the hypothesis that there is a correlation between baseline 6MWT distance and baseline I-PSS and ICIQ-SF scores of urinary incontinence severity post-RALP. Subjects: 13 subjects post-RALP. Methods: The 6MWT and 2 urinary symptom-based questionnaires [The International Prostate Symptom Score (I-PSS) and the International Consultation on Incontinence Short Form (ICIQ-SF)] were measured at the initial postoperative evaluation. Results: A significant relationship was found between cardiovascular endurance as measured by the 6MWT distance and baseline I-PSS scores (r =−0.67; P = .01). There was also a significant relationship between age and 6MWT distance (r =−0.83; P = .0001). There was no significant relationship found between 6MWT distance and baseline ICIQ-SF scores. Conclusions: Greater cardiovascular endurance may be associated with fewer urinary symptoms as measured by the I-PSS post-RALP in this small initial sample. The relationship between age and 6MWT distance is also of interest, as previous literature has reported younger age as a factor for improved continence outcomes postprostatectomy. A key difference between the 2 measures of UI is that the I-PSS questionnaire captures symptomatology more consistent with urinary urgency and UUI, whereas the ICIQ-SF captures symptoms more consistent with SUI. Clinical Relevance: Greater 6MWT performance appears to be associated with improved baseline urinary symptom complaints as measured by the I-PSS. Exercise training (ET) before and after prostate cancer surgery may improve both cardiovascular endurance and urinary-related complaints. This relationship should be explored in a larger sample of patients post-RALP, as well as the effects ET may have on exercise tolerance and urinary symptoms in the prostate cancer population.
TITLE: Inspiratory Muscle Performance Is Significantly Related to Urinary Symptoms and Quality of Life Post-Prostatectomy
AUTHORS/AFFILIATIONS: Wood A, Payne J, Villane A, Cahalin L, University of Miami Health System, Miami, Florida, UNITED STATES.
Purpose/Hypothesis: Urinary incontinence (UI) and associated symptoms are common postoperative complaints of men with prostate cancer who undergo a robotic-assisted laparoscopic prostatectomy (RALP), affecting an estimated 52% of patients in the first 2 months postoperatively. Many individuals undergo pelvic floor physical therapy to aid in recovery of continence, which typically consists of strengthening and coordination training of the pelvic floor musculature, hip and core muscle strengthening, behavioral retraining, electrical stimulation to the pelvic floor muscles, and patient education. While previous studies have shown an inverse correlation between UI and physical activity in individuals without cancer, as well as a significant relationship between UI and reports of dyspnea, the influence of baseline inspiratory muscle performance (IMP) measures on UI is not well established in the prostate cancer population. This study investigated the hypothesis that there is a correlation between IMP and urinary symptoms and quality-of-life scores post-RALP. Subjects: 13 subjects post-RALP. Methods: IMP and urinary symptoms questionnaires [The International Prostate Symptom Score (I-PSS) and the International Consultation on Incontinence Short Form (ICIQ-SF)] were measured at the initial post-RALP evaluation. IMP was measured via the test of incremental respiratory endurance (TIRE) using the Pro2fit device and application. Subjects were instructed to perform a maximal inspiratory pressure (MIP) and sustained maximal inspiratory pressure (SMIP) following exhalation from residual volume to total lung capacity. A total of 3 to 5 trials were performed with a 1-minute rest between each trial; the greatest measure of IMP was used in analyses. TIRE testing also provided inspiratory duration (ID) and fatigue index test (FIT) score. Results: Significant relationships (P < .05) were found between the ICIQ-SF score and 3 IMP measures: SMIP, FIT, and ID (r =−0.72, −0.63, and −0.56, respectively). A significant relationship was also found between the QOL-IPSS and SMIP (r =−0.60). A trend between I-PSS and ID was observed (r =−50; P = .09). Conclusions: Greater levels of IMP appear to be associated with fewer urinary symptoms and better quality of life at baseline post-RALP in this small initial sample. IMP before and after prostatectomy should be further explored with a larger sample size to determine its role in postprostatectomy rehabilitation. How these measures relate to the effects of exercise training pre- and postprostatectomy due to the importance of blood flow to the urogenital triangle of the pelvic floor for overall healing, as well as the relationship between the strength of both the diaphragm and the pelvic floor, should also be further explored. Clinical Relevance: Improving IMP may have an impact on urinary symptoms and quality-of-life measures post-RALP. Therefore, inspiratory muscle training may be of value to include in pre- and post-RALP rehabilitation programs to optimize outcomes.
TITLE: Physical Therapy to Prevent Medical Intervention During Delivery
AUTHOR/AFFILIATION: Jandreau J, University of Washington, Seattle, Washington, UNITED STATES.
Background and Purpose: In February of 2017, the American College of Obstetricians and Gynecologists (ACOG) published a committee opinion advocating decreased interventions during labor and delivery, acknowledging some interventions do not have evidence to support their use in low-risk women. Increased medical intervention during labor and delivery since 2000 has not decreased maternal and fetal mortality rates. Minimizing maternal interventions may lead to improved outcomes for mother and infant. This case will illustrate the successful use of physical therapy to prevent maternal interventions and facilitate a vaginal birth for a fetus presenting in transverse lie at 37 weeks. The sacrum, coccyx, and ilium must move during delivery to allow the fetus to move through the pelvis and vaginal canal. Though movement is minimal, every millimeter gained by optimizing this motion impacts the fetus's progress. A fetus in transverse lie must either turn into a head down (vertex) position or be delivered via cesarean due to certain uterine rupture in a vaginal birth. Currently, External Cephalic Version (ECV) is attempted with a success rate of 50% for fetuses in a breech position, though fetuses in a transverse lie rarely turn. The fetus at 37 weeks is considered term. Considering the decreasing space, this is the optimal time to facilitate a change in fetal position. There are fewer obstetricians skilled in ECV due to past preference for medical intervention. The procedure can also be uncomfortable for the mother. Alternative approaches are desirable. Case Description: The patient in this case is a 32-year-old female 37 weeks' pregnant with her second child. Her pregnancy has been uncomplicated and the patient reports exercising regularly. Her first delivery was an unmedicated vaginal birth, which is again her preference. The patient reports a fast labor with her first child and a second-degree perineal tear. During a routine ultrasound, her fetus was found to be in a transverse lie. An ECV and cesarean section were scheduled. The patient presented to physical therapy with the goals of avoiding the ECV, avoiding the cesarean section, and avoiding a perineal tear during delivery. Following a physical therapy examination, the patient was prescribed an exercise program to allow fetal movement and instructed in labor positions to decrease her risk of perineal tearing. Outcomes: After 3 days of following the exercise program, the fetus turned to a favorable vertex position. At a follow-up appointment with her obstetrician, the patient was found to have an amniotic fluid leak and labor was induced. She was able to deliver vaginally and did not have a perineal tear. Discussion: Physical therapy can minimize maternal interventions and promote positive birth outcomes. A fetus in a transverse lie rarely turns to vertex. The patient in this case followed an exercise prescription that included positioning and movements to encourage fetal repositioning taking advantage of normal physiologic bony movements of the pelvis. Physical therapists' in-depth knowledge and comprehension of the musculoskeletal system makes them uniquely qualified to prescribe exercises that are helpful in decreasing maternal interventions during labor and delivery. We cannot exclude our role in her amniotic fluid leak though the patient had been performing activities more rigorous than our prescribed exercises. It is prudent to wait until 37 weeks' gestation to avoid premature labor. Larger studies of women who utilize positioning and directed exercise to avoid ECV are recommended.
TITLE: Early Intervention for Postpartum Urinary Incontinence and Prolapse: A Case Reflection
AUTHORS/AFFILIATIONS: Stauder A, Borello-France D, University of Pittsburgh Department of Physical Therapy, Pittsburgh, Pennsylvania, UNITED STATES; Duquesne University Department of Physical Therapy, Pittsburgh, Pennsylvania, UNITED STATES.
Background and Purpose: In the United States, the prevalence of women with one or more pelvic floor disorders, including urinary incontinence (UI), fecal incontinence, and pelvic organ prolapse (POP), is 25%. Pregnancy, vaginal delivery in particular, is a known risk factor for these disorders. Vaginal delivery can also cause musculoskeletal injuries, including levator ani tears, which are associated with increased risk of POP and UI. Pelvic floor disorders can negatively impact a woman's quality of life, physical and sexual activity, and social participation. Women's health physical therapists are uniquely qualified to manage these postpartum patients. The purpose of this case reflection is to describe the effectiveness of early physical therapy (PT) intervention for a patient with postpartum UI and POP. Case Description: The patient was a 28-year-old female, 6 weeks postpartum (first pregnancy and delivery) with the diagnoses of uterovaginal prolapse, rectocele, pelvic floor dysfunction, and grade III LA tear. The patient reported a sensation of her uterus “falling out,” and vaginal heaviness with walking and running. She also complained of UI with running, coughing, laughing, and sneezing. The patient reported underlying stress and anxiety related to intercourse and exercise and exhibited fear-avoidance behaviors. PT examination demonstrated decreased postural stability, decreased pelvic load transfer, decreased strength and coordination of abdominal and gluteal muscles, and decreased pelvic floor muscle (PFM) strength, endurance, range of motion (ROM), and coordination. PT interventions included soft tissue and joint mobilizations, pelvic floor muscle training (PFMT), biofeedback, and exercises for gluteal and abdominal muscle strengthening, ROM, coordination, and functional endurance. Outcomes: The patient attended at a total of 11 PT visits over an 8-week episode of care. The patient met all PT goals including: walking and running with no UI; reduction of heaviness and pelvic discomfort with activities of daily living; improved LA contraction with static positions and dynamic movements; pelvic symmetry; resolution of PFM spasm; improved LA strength; and independence with her home exercise program. The patient showed a clinically significant reduction of dysfunction as demonstrated by the Pelvic Floor Distress Inventory-20 (PFDI-20) and Pelvic Floor Impact Questionnaire-7 (PFIQ-7) scores. Discussion: Physical therapy interventions utilizing manual therapy, PFMT, biofeedback, and functional lumbopelvic stability were effective at reducing the patient's postpartum physical impairments, activity limitations, and participation restrictions. The knowledge gained from this case can be applied to improve outcomes and quality of life for future patients with UI and POP, and supports early PT intervention postpartum to prevent progression of pelvic floor dysfunction.
TITLE: Utilizing Pelvic Floor Prehabilitation for Chronic Pelvic Pain Prior to Gynecological Surgery: A Case Report
AUTHORS: Breslin K, Bush S.
Background and Purpose: The literature strongly supports the utilization of prehabilitation for orthopedic surgeries for improved outcomes, but there is little research in the domain of gynecological surgery. A uterine myomectomy is a surgery commonly performed to remove a fibroid thought to be the cause of symptoms such as increased bleeding, pelvic pain, increased urinary frequency, urinary incontinence, and constipation. Chronic pelvic pain (CPP) is often associated with symptoms of dyspareunia and is typically multisystemic in nature. Physical therapy management of CPP is highly supported in the literature as part of a multimodal treatment approach. The aim of this case report is to determine the efficacy of utilizing prehabilitation for improved outcomes and symptom relief of deep dyspareunia and pelvic pain after a large uterine myomectomy. Case Description: The patient was a 30-year-old female presenting to outpatient physical therapy for evaluation and treatment of dyspareunia, before undergoing a uterine myomectomy in 1 month. The patient presented with primary symptoms of pelvic pain and both superficial and deep dyspareunia, and secondary symptoms of intermittent constipation and fecal incontinence and urgency urinary incontinence. The patient's physical therapy diagnosis was overactive pelvic floor musculature with pudendal nerve irritation contributing to symptoms of dyspareunia and CPP. The patient's plan of care was set at 2 visits per week for 4 weeks, leading up to her surgical date. Interventions included manual therapy for pelvic floor muscle downtraining and improved abdominal wall myofascial mobility, patient education, therapeutic exercise, and neuromuscular re-education for improved motor control of pelvic floor and abdominal muscles. Outcomes: After 9 visits of physical therapy, the patient demonstrated improved pelvic floor muscle function, decreased pain during intercourse, and improved ability to perform household chores. The patient met the minimal detectable change (MDC) for the Numeric Pain Rating Scale (NPRS) with a 2-point decease in pelvic pain at discharge with functional activities. The patient experienced a 20% decrease in pain as seen in the Pelvic Girdle Pain Questionnaire, and a 15-point increase in scores on the Female Sexual Function Index (FSFI) from evaluation to discharge. All self-reported outcome measures and pain level on the NPRS decreased 2 weeks postoperatively, with the exception of FSFI, as it could not be assessed due to surgical restrictions. Discussion: This case report shows the potential benefit of physical therapy management prior to gynecological surgery. This case also supports previous research in demonstrating the benefit of a multimodal treatment approach for those with dyspareunia and CPP including medical management, activity modification, surgical intervention, and physical therapy.
TITLE: Validity of the Body Scan Scanner® and Structure Sensor to Measure Limb Volume in Healthy Adults
AUTHORS/AFFILIATIONS: Fisher MI, Viola MC, Brueckner NJ, Wolfe ME, Kremer RL; University of Dayton, Dayton, Ohio, UNITED STATES.
Purpose: Secondary lymphedema is a chronic condition that can develop in approximately 30% of women treated for breast cancer. It is important to measure limb volume changes for early detection of lymphedema, when it is possible to reverse the swelling (stage 1). Common clinical measures carry concerns of infection control (water displacement), are time consuming (truncated cone calculation using circumferential measures), or expensive (perometry). Use of a portable 3-dimensional (3D) scanner addresses these concerns, but the validity is unknown. The purpose of this phase I study is to investigate the validity of the Body Scan Scanner and Structure Sensor to measure limb volume in healthy volunteers. Participants: A convenience sample of 6 female and 9 male adults with a mean age of 23 (range 22-25) years without any medical conditions resulting in limb swelling. Methods: Participants underwent the measurement of limb volume bilaterally with 3D infrared scanning using the Body Scan Scanner (TechMed 3D, Montreal, ON, Canada) and the Structure Sensor (occipital, San Francisco, CA). Limb volume for both 3D images were calculated using MSoft 3.0 (TechMed 3D, Montreal, ON, Canada). The reference standard was water displacement. Descriptive statistics for age and body mass index (BMI) were calculated. Separate Pearson's r tests were used to correlate the water displacement with the Body Scan Scanner and the Structure Sensor limb volume measurements. Results: For the Structure Sensor, 3 scans on the right and 2 scans on the left could not be used due to lack of visual landmarks on the processed scan for measurement. The mean BMI of all participants was 23.99 (±4.47). The mean volumes for water displacement, Body Scan Scanner, and Structure Sensor on the right were 1916 mL (±458), 1960 mL (±448), and 2270 mL (±-536), respectively. The mean volumes of the left limb were 1862 mL (± 407), 1929 mL (±392), and 2034 mL (±459). Both 3D scanning methods were significantly correlated (P ≤ .01) for both limbs. The Body Scan Scanner right and left correlated at r = 0.993 and r = 0.990, respectively. The Structure Sensor right and left correlated at r = 0.988 and r = 0.985, respectively. Conclusions: The limb volume measurements taken with the 3D Body Scan Scanner and Structure Sensor are strongly correlated with the reference standard of water displacement for limb volume measures. Clinical Relevance: Portable 3D scanning shows promise to be an efficient and cost-effective method to measure limb volume. Further research in individuals with breast cancer-related lymphedema is needed.
TITLE: Back Pain and Pelvic Floor Dysfunction Amongst Babywearing Caregivers: Results of a Survey
AUTHORS/AFFILIATIONS: Havens KL, Vilanueva Johnson E, Stames C, Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, California, UNITED STATES; Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, California, UNITED STATES; Department of Mathematics and Computer Science, Belmont University, Nashville, Tennessee, UNITED STATES.
Purpose/Hypothesis: Among postpartum mothers, low back and pelvic girdle pain, urinary incontinence, and pelvic floor dysfunction are common. These physical challenges come when the need to carry and care for baby is paramount. Carrying an infant on the body using an ergonomic aid (ie, “babywearing” [BW]) has grown in popularity. Proposed benefits for baby include increased mother-infant attachment, increased breastfeeding length, and reduced baby agitation. However, current practices and self-identified benefits or challenges among American caregivers have not been identified. That was this study's purpose. We hypothesized that the most frequently cited physical challenge would be pain and benefit would be the ability to hold child while performing other tasks. We also hypothesized that increased frequency and more experience with BW would be associated with decreased low back pain and pelvic floor dysfunction. Number of Subjects: Participants were caregivers (n = 3931); most (99.1%) identified as women. Age was 32.9 ± 5.0 years. Materials and Methods: A quantitative research design, utilizing Qualtrics electronic survey tool, was used to determine physical health and perceived benefits and challenges to BW. Specifically, Modified Oswestry Low Back Pain Disability Questionnaire (ODI), Pelvic Organ Prolapse Distress Inventory (POPDI-6), and Urinary Distress Inventory (UDI-6) were included. Counts and percentages were used to describe physical challenges and benefits while medians and ranges were used to describe scale scores. One-way analysis of variance (ANOVA) and t tests were used to investigate whether differences existed between OSW, POPDI-6, and UDI-6 based on frequency of use or experience level. Analyses were conducted using SAS v9.4. Results: Most respondents (71%) reported BW at least weekly, and 90% reported their experience level as at least intermediate. Pain prevented 31% of respondents from BW at some point. Of these, 47% indicated that pain caused them to stop BW. The most commonly cited physical health benefit was the ability to hold child while performing other tasks (96.17%), and challenges were climate (50.21%) and learning curve (46.46%). Median ODI was 4.0 (range 0-70), POPDI-6 was 20.8 (0-87), and UDI-6 was 25.0 (0-100). ODI but not POPDI-6 or UDI-6 differed with frequency of use (P = .0026). Individuals indicating more frequent BW had smaller ODI than infrequent BW respondents (P < .05). Differences were not found in these scores based on experience level. Conclusions: Respondents to this survey were experienced at BW and frequently wore their child. While most had minimal disability/dysfunction based on median scores, there was a large range, indicating that some suffer. Over 1100 indicated that pain had prevented them from BW, but pain was not the most frequently cited physical challenge. Those with back pain may wear baby less frequently. Surprisingly, no meaningful relationships were identified to pelvic floor health. Clinical Relevance: Understanding the perceived physical health challenges and benefits of caregivers to postpartum care and babywearing helps to inform targeted therapies to reduce pain in this population and promote future efforts to study babywearing biomechanics.
TITLE: Early Inpatient Interventions for a Woman Who Is Postpartum Day One With Pelvic Girdle Pain
AUTHORS/AFFILIATIONS: Bryant L, Smoot B, Stock Berdoulay C, University of California San Francisco/San Francisco State University Doctor of Physical Therapy Program, San Francisco, California, UNITED STATES; University of California San Francisco, Sonoma, California, UNITED STATES; Kaiser Permanente, San Mateo, California, UNITED STATES.
Background and Purpose: Expert opinion recommends women begin exercise as soon as medically stable after giving birth. Evidence suggests that women with pelvic girdle pain (PGP) benefit from early treatment by a physical therapist (PT). However, standard practice in the inpatient setting is to treat these patients as if they had general surgery and to refer them to an outpatient pelvic floor PT who sees them at 6 weeks postpartum. The purpose of this case study is to describe the use of safe therapeutic exercises for postpartum PGP following caesarian section delivery days 1 and 2 in the inpatient setting, and to advocate for a better model of care for women during the early postpartum period. Case Description: A 36-year-old woman, postpartum with PGP, was seen for physical therapy in the inpatient setting following delivery of her first child. She had a history of spondylolisthesis and an onset of PGP during her first trimester, leading to placement on disability assistance and then bed rest. She was treated postpartum days 1 and 2 in the acute care hospital after prolonged labor and then C-section. She presented with decreased bed mobility, decreased ambulation distance, and inability to activate muscles of the abdominal canister. Outcomes: Treatment included traditional inpatient interventions such as log roll and ambulation practice with PGP-specific education about avoiding rotational forces and for breathing cues to incorporate functional activation of the abdominal canister. Diaphragmatic breathing, pelvic tilts, and pelvic floor contractions were also taught with a handout provided to bridge the 6-week gap until the patient's pelvic floor PT appointment. Coordinated care was provided by collaborative discussion with patient on pelvic floor PT plan and interteam member communication. On discharge from hospital at postpartum day 2, caregiver training was completed for bed mobility, her ambulation distance doubled, and she was able to activate her pelvic floor, diaphragm, and rectus abdominis muscles. More importantly, she had a referral to an outpatient pelvic floor therapist and a home exercise program to bridge the 6-week gap until her appointment. Data obtained from her outpatient PT evaluation indicated that the home exercise program was effective in improving functional mobility but that pain from her PGP continued to affect her ability to return to work, causing the patient distress. Discussion: Early therapeutic interventions were easily implemented and well tolerated. These interventions were likely effective in the patient's improvement, which is consistent with the current literature. However, her activity restrictions and discontinuation of disability assistance added to her psychological stress, which led to the patient reporting feelings of depression. The chronicity of her PGP without PT intervention and the physician-ordered bed rest prior to delivery may have negatively impacted her prognosis. The complexity of the patient's course suggests that a stronger support network for women who are postpartum is needed, including early PT, but also improved mental health services. More research is needed to determine when is the best time for postpartum exercise education (including potentially prenatally) and how to reach more women with skilled services that target the unique trauma associated with pregnancy and delivery.
TITLE: Prevalence of Urinary Incontinence Throughout an Adolescent Female Population: A Retrospective Review
AUTHORS/AFFILIATIONS: Crowe BM, Reid A, Selhorst MC, Becks Mansfield C, Sports and Orthopedic Physical Therapy, Nationwide Children's Hospital, Columbus, Ohio, UNITED STATES.
Purpose/Hypothesis: Over half of all adult females report urinary incontinence (UI). Typical risk factors for UI include pregnancy, history of childbirth, and advanced age; however UI can begin in nulliparous and younger individuals. The prevalence of UI in adolescents is not understood, as the majority of research is conducted in adult females. Therefore, the purpose of this study was to gain a preliminary understanding of the prevalence of UI in the adolescent female population. A secondary purpose was to determine the prevalence in specific subgroups including younger compared to older adolescents and those with chronic pelvic pain. We believed UI would be prevalent in adolescents, although less so than in adults. Additionally, we hypothesized UI would be more prevalent in adolescents with chronic pelvic pain. Number of Subjects: Seventy-four adolescent females (15.3 ± 1.9 years) were included in this retrospective review with 22 younger adolescents (10-14 years) and 52 older adolescents (15-19 years). Materials and Methods: A retrospective chart review of all adolescent females treated by the investigators since January 2019 was performed. Charts were included if the female was an adolescent (10-19 years) and urinary incontinence was assessed through the Urogenital Distress Inventory (UDI 6). Assessment of the UDI 6 was standard clinical practice of the investigators for all their female patients. UI was defined by any reports of urine leakage on the UDI 6. Stress incontinence was defined by leakage with physical activity and urge incontinence was defined by leakage with a sense of urgency on the UDI 6. Data Analysis: Chi-square statistics were used to compare reported incontinence between groups. Results: General urinary incontinence was reported in 30% of the adolescent females (n = 22), urge incontinence was reported in 15% (n = 11), and stress incontinence was reported in 16% (n = 12). Incontinence was noted more often in young adolescents (46%) than in older adolescents (23%), although this difference did not quite achieve statistical significance (P = .054). Fourteen (19%) of the adolescent females reported chronic pelvic pain. Adolescent females with chronic pelvic pain reported incontinence more frequently than those without (43% vs 27%) (P = .23). Mean UDI 6 scores were 9.7 ± 12.5. UDI 6 scores were slightly higher in young adolescents (13.1 ± 15.6) compared to older adolescents (8.3 ± 10.1). Finally, adolescent females with chronic pelvic pain had significantly higher UDI 6 scores than those without chronic pelvic pain (19.9 ± 13.9 vs 7.3 ± 11.0). Conclusions: This study found that urinary incontinence was fairly common among adolescent females, although it appears to be less common than in adults. As hypothesized, adolescents with chronic pelvic pain had greater prevalence of urinary incontinence and higher UDI 6 scores. Based on this retrospective study, there is a need to further assess the prevalence of UI in this population with larger prospective studies. Clinical Relevance: Although less common than adults, urinary incontinence is prevalent in adolescent females and should be screened for by clinicians.
TITLE: Does Core Stability Predict Low Back, Sacro-Iliac and Pelvic Ring Dysfunction in Long Distance Runners?
AUTHORS/AFFILIATIONS: Walton LM, Raigangar V, Moustafa I, Kalsoom Naqashband N, Gadgieva N, Wangde Qasim K, Basem Mahmoud Najjar O, Fady Mahfouz B, University of Sharjah, Sharjah, United Arab Emirates.
Purpose/Hypothesis: To see if core endurance and stability were able to predict outcomes of low back, sacroiliac joint (SIJ) or pelvic ring dysfunction in a sample of recreational long distance runners. Materials and Methods: Prospective, cross-sectional, predictive correlation study of 35 male and female runners. Research Ethics Committee Approval was obtained prior to recruitment and data collection. All subjects who volunteered to be in the study signed an informed consent and completed a battery of tests, including: Pelvic Floor Incontinence Questionnaire (PFIQ) and Oswestry Low Back Pain Disability Index, Active Straight Leg Raise (ASLR) (isolation in 5 categories: lumbar, pelvic ring, hip, transverse abdominis, and abdominals), Posterior Pelvic Provocation Test (PPPT), and Long Dorsal Ligament Test (LDL), Passive Straight Leg Raise (PSLR), Double Leg Lowering Test (DLLT), Single Leg Hop Test (SLHT), and McGill Core Endurance Test (MCET). Results: Our study found a high prevalence of low back (31.5%), SIJ (66%), and pelvic ring instability (26.3%). Core stability on the McGill was not a significant predictor of low back, SIJ or pelvic ring dysfunction. A weak, but significant, correlation was found between DLLT and SLHT (r = 0.34, P < .05). The entire sample scored below the norm for the McGill (MCET) Core Test for Right Plank (Mean = 38.2 ± 20.3): Left Plank (Mean = 35.5 ±18.2) ratio (Mean Ratio R Plank: L Plank = 1.08), L Plank Side: Extension (Mean Ratio = 0.76), and R Plank Side: Extension (Mean Ratio = 0.82). However, flexion (M = 43.2 ± 24.4) and extension (46.2 ± 20.3) reported normal ratio scores for the sample (Mean Ratio Flexion: Extension = 0.94), overall, with females scoring lower than males in all categories. Conclusions: Our study sample of 35 long-distance runners reported a high prevalence of low back, SIJ, and pelvic ring instability and pain. Subjects reported no significant predictive relationship between measurement of core stability or core endurance and outcomes of low back, SI Joint, or pelvic ring instability on the McGill or DLLT, common tests used in the clinic for return to function. Future research should focus on development of more sensitive standardized measures of core stability and endurance for implication in athletic populations and investigate the role of pelvic ring instability in high-impact sport activity. Clinical Relevance: This research may be used to validate the need for more sensitive standardized measurement for core stability and endurance in return to sport activity and to investigate the role of pelvic ring dysfunction during high-impact sport activity for improved clinical measurement tools leading to improvement in screening assessments for athletic populations.
TITLE: Barriers and Facilitators to Pelvic Floor Muscle Exercise Adherence in Women With UI and POP: A Systematic Review
AUTHORS/AFFILIATIONS: Bossom M, McNertney S, Morgan R, Kerbel L, Heath AE, Simmons University Department of Physical Therapy, Boston, Massachusetts, UNITED STATES.
Purpose: Pelvic floor muscle exercise (PFME) is recommended as the first-line intervention for pelvic floor dysfunction, as it is effective, low-risk, and low-cost. PFME is a major component of pelvic floor physical therapy (PFPT) for conditions of low muscle tone, which include urinary incontinence (UI) and pelvic organ prolapse (POP). However, the success of PFME is largely a function of adherence to PFME home exercise programs. Research has identified that adherence is high when patients are taking part in supervised physical therapy (PT), but declines over time after discontinuation of PT. Given the prevalence of pelvic floor dysfunction and its negative impact on quality of life, it is valuable to determine what factors lead to improved long-term PFME adherence. This systematic review aims to explore common reported barriers to performing PFME for the treatment of UI or POP. Number of subjects: Six hundred fourteen participants included in the 6 articles reviewed. Methods: A systematic review was conducted in which 7 online databases were searched using combinations of key terms relating to physical therapy, pelvic floor, and adherence (“physical therapy” or “physiotherapy” or “rehabilitation,” “pelvic floor,” and “adherence” or “non-adherence” or “compliance” or “non-compliance”). Using these search terms, 2519 articles were retrieved. Following a title review, only 17 studies appeared to meet the search criteria based on their title. The abstracts of these 17 studies were then read by 2 reviewers each and assessed for eligibility. Each article was assessed for quality by at least 2 reviewers. Disagreements were mediated via discussion by all 4 reviewers. The reviewers independently assessed the methodological quality of each included trial using the STROBE checklist. Data were extracted to identify patterns of adherence in short-, medium-, and long-term follow-up periods and to identify factors that increase or decrease adherence. Results: Six studies were included in the final review. All studies were of high quality according to the STROBE checklist, but were Level III or IV evidence, limiting their strength and generalizability. Four studies reported data on women diagnosed with UI and 2 studies reported data on women diagnosed with POP. There was variation among follow-up time frames, ranging from 3 months to 2 years after supervised PFME. A variety of unvalidated outcome measures were utilized across 5 of the 6 studies. The sixth study utilized semistructured, conversational-type interviews to assess outcomes. Conclusion: Adherence to PFME declines over time after discontinuation of supervised PT. Common factors that increase patient adherence include self-efficacy, motivation, and commitment. Common barriers that decrease adherence include forgetting to do exercises, boredom with exercises, difficulty finding time to exercise, and difficulty remembering the correct performance of the exercises. Clinical Relevance: Knowledge of these common facilitators and barriers could help physical therapists increase patient adherence to PFME in order to maintain improvements with UI and POP symptoms over time. Further high-quality research is needed to more robustly document changes in adherence over time. There is a need for valid and reliable questionnaires to assess PFME adherence and patient-specific factors such as self-efficacy, motivation, and commitment that influence long-term adherence.
TITLE: The Piriformis: Effect of Hip Position on Function and Hip Rotator Strength
AUTHORS/AFFILIATIONS: Maher RM, Morrison C, Department of Physical Therapy, Philadelphia College of Osteopathic Medicine Georgia, Suwanee, Georgia, UNITED STATES; Creighton University/Creighton Therapy & Wellness, Omaha, Nebraska, UNITED STATES.
Background: The primary actions of the piriformis are hip external rotation and abduction; however, studies have reported that the line of force changes over different degrees of hip flexion causing a reversal of action. Studies have used string models to determine findings and assumed universal tendinous attachment sites despite some evidence to the contrary. More recently a cadaveric study reported that the piriformis was maximally lengthened by 105° of hip flexion and 10° adduction and relaxed by hip extension and abduction, whereas another cadaveric study reported the piriformis lengthened with the hip and knee flexed to 90° with the addition of adduction or external rotation with the former providing the most lengthening of the muscle. Consequently, hip position may affect hip rotator strength and efficacy of interventions. Purpose: This study dynamically assessed the effect of hip position on the action of the piriformis in real time with ultrasound imaging in addition to the effect on strength of the external (ER) and internal (IR) hip rotators as a group in healthy young adults. Number of Subjects: Twenty-five (8 males, 17 females) adults. Methods: The experimental limb was randomly selected and assessed under 4 randomly assigned testing conditions: hip ER and IR performed in prone (HE) with knee flexed to 90° and in a seated 90/90 position (HF). Ultrasound (US) data were acquired using a curvilinear transducer initially orientated in the transverse plane lateral to the sacrum and moved caudally in the direction of the posterior superior Iliac spine (PSIS) and sacroiliac joint (SIJ) until the piriformis was visualized exiting the greater sciatic foramen. The transducer was then oriented parallel to the muscle fibers and passive motion of the hip differentiated it from the gluteal. Subjects were prompted to perform 3 IRs and 3 ERs at a rate which was standardized with a metronome while US cine loops were recorded while the thigh was stabilized by an examiner. A concentric contraction was defined as a shortening of the piriformis muscle observed from its distal toward its proximal attachment while an eccentric contraction was defined as a lengthening from its proximal toward its distal attachment. A hand-held dynamometer was used to assess strength across all testing positions. Results: US showed the piriformis shortened during ER and lengthened during IR regardless of hip position. A significant interaction effect was noted between hip position (HF, HE) and strength (IR, ER) (P < .001). Post hoc analysis revealed hip IRs (P < .001) and hip ERs (P = .01) were significantly stronger in the seated 90/90 position (HF) versus prone (HE) position. Furthermore, effect size (Cohen's d) values were small (d = 0.2) and large (d = 0.9) for ER and IR, respectively. Conclusions: While strength of the ER as a group was stronger in HF when compared to HE, the effect was small and the piriformis muscle function did not appear to change its action per US imaging. IR was significantly stronger in HF; however, this does not appear to be due to a reversal of action of the piriformis. Furthermore, recent anatomical studies have shown variability in the dimensions and attachment of the distal tendon, which prevents a reversal of action. Implications: Stretches for the piriformis are based on the belief that the piriformis becomes an IR when the hip is flexed at or above 90°; however, these findings are primarily based on cadaveric studies or more recent static CT and 3D computational modeling studies. The results of this study are clinically significant in that they provide a functional dynamic visual record of the piriformis in vivo: the piriformis functioned as an ER in the HF position despite the effect of hip position on rotator strength. This finding may merely reflect a change in moment arm length and/or length tension relationships and not a reversal of muscle action as previously thought. Further imaging studies across a variety of hip positions may provide a true representation of piriformis muscle function.
TITLE: Effectiveness of Soft Tissue Mobilization to Reduce Chronic Scar Pain After Cesarean Section: A Review
AUTHORS/AFFILIATIONS: Simonds AH, Hanley M, Johnson K, Patel A, Ramos K, Redziniak J, Salkowski T, Rutgers, The State University of New Jersey, Blackwood, New Jersey, UNITED STATES.
Purpose: Over 1 million women undergo cesarean section (CS) annually in the United States. Chronic CS pain negatively affects approximately 80% of women at 2 months and 20% at 1 year. Chronic CS pain negatively impacts physical health and quality of life. Analgesic and opioid medications are commonly used to manage chronic CS pain. Nonpharmacological interventions, such as soft tissue mobilization (STM), are routinely used by physical therapists to reduce scar pain in postsurgical populations. The purpose of this review was to explore the effectiveness of STM on pain in women with chronic CS scar pain. Subjects: NA. Materials/Methods: Database searches were conducted in September to December 2018 in PubMed, CINAHL, Cochrane, and Scopus. Search terms included “cesarean section,” “chronic pain,” “incisional pain,” “scar pain,” “physiotherapy,” “physical therapy,” “soft tissue mobilization,” “scar massage,” and “manual therapy.” Studies in English published after 2010 utilizing STM interventions within the scope of physical therapy practice for the reduction of scar pain in adult women after CS were included. Studies not published in English, published before 2010, nonintervention studies, and those using interventions not directed at the CS scar or applied before CS were excluded. Included studies were critically appraised by 2 reviewers using the Centers for Evidence Based Medicine (CEBM) Levels of Evidence. A third reviewer was utilized to resolve differences. Results: 248 studies were identified with 4 studies retained based on criteria. Quality of evidence ranged from Levels 1b to 4. Chronic CS pain was defined inconsistently, ranging in duration from >6 months to >3 years. STM techniques applied to CS scar and surrounding musculature included effleurage, petrissage, superficial scar rolling, deep scar mobilization, myofascial release, and myofascial induction therapy. Duration of STM intervention varied from 2 weeks to 2 months. Total STM intervention time ranged from 27 to 240 minutes. STM to CS scar resulted in statistically significant pain reductions that exceeded the minimum detectable change in all studies, regardless of specific STM technique. Statistically significant improvements in pressure tolerance, scar flexibility, quality of life, and disability were also reported. Conclusions: STM significantly improved pain, scar characteristics, quality of life, and disability in women with chronic CS scar pain. Heterogeneity in STM intervention parameters, coterminous delivery of interventions with STM, and methodological limitations reduce generalizability. Research exploring mechanisms of observed therapeutic effects of STM for chronic CS scar is needed. Clinical Relevance: Chronic pain after CS is commonly managed with pain medications and is associated with adverse health outcomes. Physical therapists routinely utilize STM to reduce pain in populations with chronic scar. STM was shown to be effective to significantly reduce chronic CS scar pain.
TITLE: Center of Pressure Characteristics Differ Between Pregnant and Nulliparous Females
AUTHORS/AFFILIATIONS: Bagwell J, Reynolds N, Lam K, Runez H, Walaszek M, Katsavelis D, Kyvelidou A, California State University Long Beach, Long Beach, California, UNITED STATES; Creighton University, Omaha, Nebraska, UNITED STATES.
Purpose: During pregnancy, falls are the most common cause of minor injury and account for 60% to 70% of fetal losses. Pregnant females demonstrate increased stance width, increased sway, and reduced variability of center-of-pressure (COP) measurements during bilateral standing. However, in response to perturbations during bilateral stance, pregnant women showed reduced initial sway, total sway, and sway velocity when compared to nonpregnant females and when pregnant fallers were compared to pregnant non-fallers. Because falls often occur during activities involving single-leg tasks, the purpose of this study was to compare COP characteristics during single-leg stance with eyes open and closed (SLS_EO and SLS_EC) between pregnant and nulliparous females. Subjects: Nineteen pregnant and 19 matched nulliparous females (age: 31.5 ± 3.3 years; height: 1.68 ± 0.24 m vs age: 31.9 ± 3.4 years; height: 1.65 ± 0 .55 m) were included. Methods: Pregnant participants performed 3 trials of SLS_EO and SLS_EC on each leg on a force plate for up to 20 seconds on 3 visits [second trimester (2T), third trimester (3T), and 4-6 months postpartum (Post)], while nulliparous controls were tested once. Mean SLS_EO and SLS_EC stance time, root mean squared (RMS) and sway in mediolateral (ML) and anteroposterior (AP) directions, mean velocity, median frequency, and frequency dispersion were calculated from the COP data and averaged across limbs for each participant. Independent t tests were used to compare nulliparous and pregnant females at each time point. Results: For SLS_EO, during 2T and 3T, pregnant females had lower sway and mean velocity (P < .01) compared to nulliparous females. During 3T and post, pregnant females had lower frequency dispersion (P < .01), and during 3T, ML range was also lower (P = .04). For SLS_EC, during all pregnancy time points, mean velocity was lower (P < .05) compared to nulliparous females, during 2T and 3T, pregnant females had lower stance time (P < .04), sway (P < .01), and mean velocity (P < .01), and during 3T, ML RMS and median frequency were also lower (P < .03). Conclusion: Despite an increased fall risk in pregnant females, across SLS_EO and SLS_EC pregnant females demonstrated lower sway, velocity, and variability of COP, particularly in the ML direction. These results differ from previous research reporting greater sway during double-limb stance but are consistent with the greater rigidity of COP reported during double-limb stance and with lower sway in response to double-limb perturbations in pregnant females and pregnant fallers. During double-limb standing, pregnant females may be able to partially compensate for instability by increasing stand width; however, during a single-limb task or perturbation, perhaps reduced sway and increased rigidity are protective strategies to enhance stability. Clinical Relevance: SLS mimics many dynamic movements incorporated in functional activities such as walking, running, or climbing stairs. Specific balance training during pregnancy may benefit pregnant females by decreasing rigidity and/or improving confidence.
TITLE: Normative Pelvic Floor Parameters in Adults Assessed Using Transabdominal Ultrasound: A Descriptive Study
AUTHORS/AFFILIATIONS: Khowailed I A, Disney H, Lee H. Department of Physical Therapy, College of Rehabilitative Sciences, University of St. Augustine for Health Sciences, San Marcos, California, UNITED STATES; Department of Physical Therapy, College of Rehabilitative Sciences, University of St. Augustine for Health Sciences, San Marcos, California, UNITED STATES; Gachon University, Department of Physical Therapy, Incheon, Korea.
Background: Successful management of pelvic floor muscle (PFM) dysfunction hinges on retraining inappropriate pelvic floor muscle recruitment. Transabdominal ultrasound has been established as an appropriate method for visualizing and measuring pelvic floor muscle function. The purpose of this study was to describe normal reference values of the pelvic floor displacement in healthy adult population. Methods: A total of 200 healthy adults, including 70 males and 127 females, consented to participate in this study. Subjects were screened and were free of any pelvic floor muscle dysfunction disorders. Bladder base displacement was measured using a sagittal curved linear array 2- to 5-MHz transducer over the suprapubic region. The amount of bladder base movement on ultrasound was measured in all subjects and considered as an indicator of PFM function. Pelvic floor muscle contraction was explained, and displacement was measured 3 times including the direction of movement/displacement from freeze frame ultrasound images. Results: The average age of subjects was 26.1 ± 2.6 years (24.4 ± 3.7 BMI). Statistical analysis revealed a significant difference in transabdominal ultrasound measurement for PFM function (P = .00000). The bladder base displacement was significantly greater in male subjects (0.64 ± 0.38) compared to female subjects (0.37 ± 0.35). A positive correlation was found between the pelvic floor muscle function and the subject's weight (P = .0041). Conclusion: The function of the pelvic floor muscle has been stratified in a normal distribution of a large sample of healthy adults, creating a baseline for the clinic to both prevent and establish a baseline for the normal percentile of pelvic floor muscle function.
TITLE: Characteristics of Responders and Non-Responders to Resistance Training and Biofeedback in Patients With Fecal Incontinence
AUTHORS/AFFILIATIONS: Barr G, Belchamber M, Ekmecic V, O'Reilly L, Stephens P, White M, Swartz J, Tuttle LJ, San Diego State University, San Diego, California, UNITED STATES.
Purpose/Hypothesis: Fecal incontinence (FI) is a condition that affects 14.4% of individuals. There is currently a paucity of data exploring the effectiveness of resistance training of the pelvic floor musculature (PFM) intra-anally as a potential intervention. Due to the invasive nature of this intervention, it is important to characterize populations that may or may not benefit. We hypothesized that resistance training would increase strength of the PFM, resulting in greater maximum anal and vaginal squeeze pressures, and a reduction of FI symptoms. Subjects: Fourteen women with FI (62.50 ± 14.99 years; 23.98 ± 4.00 BMI) participated for 12 weeks. Materials/Methods: Integrity of the PFM (puborectalis and external anal sphincter muscles) was assessed via transperineal 3D ultrasound at initial visit using previously reported methods for rating muscle damage. The functional lumen imaging probe (FLIP), a planimetry catheter with a distally mounted balloon, provided resistance during weekly exercise sessions and visual feedback of PFM contraction and anal canal lumen closure to both the patient and therapist. Initial exercise volume and progression was determined by the ability to completely close the anal canal lumen around the catheter. Weekly visits consisted of patient education and PFM-strengthening exercises using the FLIP. Patients were also instructed to complete a daily home exercise program. High-definition anal manometry (HDAM) and FLIP data were collected pre- and posttreatment to assess PFM function (anal squeeze pressures). Symptoms were assessed using the Pelvic Floor Distress Inventory-20 (PFDI-20), and Fecal Incontinence Severity Index (FISI). Responders and nonresponders were classified based on a significant posttreatment increase in FLIP squeeze pressure at 50 mL. Data are means ± SD. One-way analyses of variance (ANOVA) were used to compare differences between responders and nonresponders. Results: Seven patients significantly increased anal squeeze pressure at 50 mL after treatment (479.4 ± 193.2 vs 385.5 ± 169.9 Nm) and were labeled responders. They had lower baseline maximum anal tension (297.9 ± 88.9 vs 479.1 ± 183.9 Nm) and less PFM damage (0.86 ± 0.69 vs 1.71 ± 0.49) than their nonresponder counterparts. All patients displayed a significant improvement in symptoms after 12 weeks of intra-anal resistance training. There were no significant differences between responders and nonresponders in pretreatment HDAM data, external anal sphincter (EAS) damage, BMI, age, vaginal births, instrumented delivery, baby weight, or symptoms (P > .05). Conclusions: Resistance training of the PFM intra-anally appears to be effective in reducing symptoms irrespective of improvements in squeeze pressure, further supporting the notion that incontinence is a multifactorial disorder. Clinical Relevance: Intra-anal resistance training may be most beneficial to those with lower baseline strength and greater PFM integrity. Diagnostic ultrasound may be an important tool to determine if resistance training of the PFM is a viable treatment option, or if other interventions may be more appropriate.
TITLE: Drop Jump Landing Biomechanics Differ Between Women With and Without Self-Reported Stress Urinary Incontinence
AUTHORS/AFFILIATIONS: Hartigan E, McAuley JA, Lawrence M, DeSilva M, University of New England, Portland Campus, Portland, Maine, UNITED STATES.
Purpose/Hypothesis: Women with stress urinary incontinence (SUI) have lesser hip external rotation (ER) and abduction (ABD) maximal voluntary isometric strength compared to women without SUI. Conversely, women with SUI present with greater internally generated hip ER and ABD moment impulses (MI) during gait compared to women without SUI. Given these differences between the groups, whether biomechanics differ during a drop jump landing task is of interest and to our knowledge has not been studied. Number of Subjects: There were 11 women with SUI (age: 36.5 (7.7) years, body mass index (BMI): 21.5 (2.3) kg/m2, 8 parous and 3 nulliparous) and 24 women without SUI (age: 25.0 (3.3) years, BMI: 23.0 (2.8) kg/m2, 1 parous and 23 nulliparous). Inclusion criteria were adult women with regular menses who self-report SUI with cough, sneeze, physical activity, and/or exercise. Exclusion criteria were urge UI, pregnancy, current pain, and any medical or orthopedic history that would influence landing. Materials and Methods: Three bilateral drop jump trials were performed. Maximal (max) and minimal (min) angles and internal joint MI (moments over time) were calculated for the hip (all planes) and knee and ankle (sagittal and frontal planes) during the landing phase of the jump (initial contact to minimum center of mass). The dominant (D) limb was defined as the limb used to kick a ball. Independent and paired t tests were used to explore group and limb differences, respectively; significance set at P < .05. Results:Group Differences: Women with SUI's nondominant (ND) limb max knee adduction (ADD) angles (SUI: 3.9° ADD; no SUI 0.4° ABD; P = .003) and max hip flexion (FL) moments (SUI: 0.040 Nms/kg; no SUI 0.028 Nms/kg; P = .050) were greater than women without SUI's ND limb. Limb Differences: Women with SUI had between-limb differences for max angles [knee FL (ND: 91.8°; D: 87.6°; P = .026) and ankle dorsiflexion (ND: 32.1°; D 29.3°; P = .014)] and moments [hip extension (EX) (ND: 0.228 Nms/kg; D: 0.185 Nms/kg; P = .042) and knee ADD (ND: 0.020 Nms/kg; D: 0.046 Nms/kg; P = .028)]. Women without SUI had between-leg differences in the frontal plane angles [min hip (ND: 2.2° ABD; D: 1.9° ADD; P = .007); max hip (ND: 7.3° ABD; D: 3.6° ABD, P = .014); min knee ABD (ND: 0.4°; D: 1.9°; P = .032) and max knee ABD (ND: 9.0°; D: 11.3°; P = .036)] and moments [hip FL (ND: 0.028 Nms/kg; D: 0.034 Nms/kg; P = .032), hip ABD (ND: 0.031 Nms/kg; D: 0.053 Nms/kg; P = .026), hip internal rotation (IR) (ND: 0.003 Nms/kg; D: 0.005 Nms/kg; P = .011), knee ABD (ND: 0.013 Nms/kg; D: 0.006 Nms/kg; P = .001) and knee ADD (ND: 0.019 Nms/kg; D: 0.043 Nms/kg; P = .002). No other group or limb differences were found for angles (P > .064) or moments (P > .074). Conclusions: Limited between-group differences were found (ie, women with SUI landed with greater knee ADD angles and hip FL moments in the ND limb compared to the ND limb in women without SUI). Both groups presented with greater knee ADD moments in the D limb. However, unique between-limb differences were found across planes and joints. Limb differences unique to women with SUI were that they landed with a relatively straighter D limb position (ie, less knee FL and ankle DF) and used lesser hip EX moments compared to their ND limb. In contrast, the D limb in women without SUI generated statistically greater hip moments in all planes (ie, FL, ABD, and IR) and lesser peak knee ABD moments compared to their ND limb. Clinical Relevance: Notably, unique between-limb differences observed during drop jump landing were different from those observed during gait in women with and without SUI. Landing biomechanics should be evaluated, particularly on the D limb, in women reporting SUI with loaded activities, such that a drop jump simulates. Further investigation as to whether neuromuscular re-education on landing mechanics influences symptoms is warranted. This may be especially relevant in women who present with SUI, yet do not present with pelvic floor muscle impairments.
TITLE: Rural vs. Urban Postnatal Educational Practices in a Midwestern State
AUTHOR(S)/AFFILIATIONS: Adamson A, Harris M, Mensen E, Uecker C, Physical Therapy, University of South Dakota, Vermillion, South Dakota, UNITED STATES.
Purpose/Hypothesis: The study's purpose was to survey the prevalence of postnatal education and to compare educational content and physical therapist (PT) utilization within rural and urban settings. Number of Subjects: Respondents included 68 licensed nurses (63.2% rural practice setting) with postnatal primary practice experience and certainty about whether postnatal classes were offered in their facility. Materials and Methods: Licensed nursing providers from one Midwest state were invited via e-mail to participate in this nonexperimental study administered via an online survey platform. The survey comprised questions about provider demographics, postnatal classes offered, topics covered during the classes, frequency of referral to the classes, and frequency of PT instructing the classes. Questions also fielded attitudes about the value of PT involvement in postnatal care. Results: Postnatal classes were offered in 28 of 68 (41.2%) of respondent's facilities. Urban facilities (17 of 28; 60.7%) offered postnatal classes at a statistically significant (P < .001) greater frequency than rural facilities (11 of 28; 39.3%). Urinary incontinence (UI), diastasis recti (DR), pelvic organ prolapse (POP), and pelvic pain (PP) were among educational topics frequently reported as not discussed routinely during postnatal classes; further, 29.4% of nurses reported they “didn't know” what topics were routinely discussed. UI, DR, POP, and PP were also frequently reported as not discussed routinely by nursing during the patient's postnatal hospital stay. Nearly 20% (n = 61) reported routine recommendation or referral to a postnatal class at a frequency of “always” or “most of the time.” Although 92.8% (n = 56) of respondents reported value of PT involvement in postnatal educational programming, 95.8% (n = 48) responded that PT is “never” or “rarely” involved in the instruction of a postnatal class. A high percentage (88.2%) of nursing providers reported they would benefit from additional information how a PT can be valuable to postnatal care. Conclusions: Few nurses from a Midwest state reported postnatal educational course offerings; most facilities that offer programming are located in urban areas. Few patients are referred to postnatal classes. While nurses believe that PTs are valuable to postnatal care, they report a lack of information, and PTs continue to be underutilized when considering the value they may bring to the postnatal team. Clinical Relevance: Providers need to advocate for their patients and encourage facilities to offer and enhance postnatal education, especially in rural areas. PT is not utilized to help educate patients during postnatal classes, yet the majority of nurses feel there is value in PT contributing to these classes and the labor/delivery team. PTs are trained in assessing and treating pelvic health conditions and can help raise the standard of education, outcomes, and quality of life in patients who receive postnatal care.
TITLE: Movement Impairments in Women With and Without Urinary Urgency/Frequency: Preliminary Results
AUTHORS/AFFILIATIONS: Foster SN, Spitznagle TM, Harris-Hayes M, Program in Physical Therapy, Washington University School of Medicine, Saint Louis, Missouri, UNITED STATES; Program in Physical Therapy and Department of Obstetrics and Gynecology, Washington University School of Medicine, Saint Louis, Missouri, UNITED STATES; Program in Physical Therapy and Department of Orthopedic Surgery, Washington University School of Medicine, Saint Louis, Missouri, UNITED STATES.
FUNDING SOURCE: The Foundation for Barnes-Jewish Hospital, NIH T32HD007434 and UL1TR002345, Washington University in St. Louis Program in Physical Therapy
Purpose/Hypothesis: Due to muscular attachments between the hip and pelvic floor and spinal innervation of lower urinary tract, spine, pelvis, and hip movements should be considered as contributors to urinary urgency and frequency (UUF). Urge provocation with hip or spine tests has been retrospectively reported in patients with UUF, but this has not been prospectively studied. We hypothesized (1) more participants with UUF than asymptomatic participants (CON) would demonstrate movement impairments, (2) urge provocation with hip or spine tests would occur in those with UUF but not CON, and (3) urge would be relieved with movement pattern correction (MPC) not sham (SHM). Number of Subjects: 19. Materials and Methods: Women age 18–60 years with and without UUF (bothersome urgency and/or day/night frequency, <2 hours between voids or > once per night) were recruited. Movement tests of the hip, pelvis, and spine included forward bend (FB) and return (FBR), single-leg stance (SLS), and stork test. Positional urge provocation tests included side-lying (SL) and seated passive hip internal (IR) and external rotation (ER). Prior to and during each test, urge was documented. Movement patterns and positioning of the thoracic and lumbar spine, pelvis, or hips were observed. If a movement or positional impairment was noted, 2 follow-up tests were done: MPC (eg, use of support or cuing to change observed movement pattern or position) and SHM (eg, repeat with examiner's hands on participant's pelvis). Frequencies for each variable were tallied and compared between groups with Fisher's exact test. Results: 11 women with UUF (age = 31.9 ± 14.9 years, BMI = 24.19 ± 3.3) and 8 CON (age = 25.6.1 ± 2.14 years, BMI = 25.1±3.4) were tested. All 11 UUF and 7 of 8 CON (P = .42) had ≥1 movement impairment. Between-group differences were noted for excess hip adduction (11 UUF vs 2 CON, P = .001), excess thoracic flexion (9 UUF vs 1 CON, P = .005). No differences were noted for excess or limitation in hip IR/ER (10 UUF vs 4 CON, P = .11) and positive stork (8 UUF vs 3 CON, P = .18). Urge was reported before tests in 6 UUF, 1 CON. Three UUF reported increased urge during tests (3 w/SL, 2 w/FBR, 1 w/FB) versus 1 CON (FBR), P = .60. MPC in ≥1 test relieved urge in 5 UUF versus 0 CON, P = .045. SHM did not relieve urge in any participants. Correcting the following movement patterns relieved urge in those with UUF: excess hip adduction (4 w/SL), excess thoracic rotation (3 w/SL), excess thoracic side bend (2 w/SL), excess end range lumbar extension (2 w/FBR), early lumbar extension (2 w/FB), excess hip medial rotation (1 w/SL), and excess lumbar side bend (1 w/SL). Conclusions: Women with and without UUF demonstrated impaired movement patterns and positioning. Some with UUF reported increased urge during testing, as did one control. MPC including correction of hip, thoracic and lumbar movement, and positioning relieved urge in some women with UUF but no controls. Clinical Relevance: Monitoring urge provocation and relief during hip and thoracic or lumbar spine movement and positioning may be relevant in those with UUF.
TITLE: Hip and Pelvic Floor Strength in Women With and Without Urinary Urgency/Frequency: Preliminary Results
AUTHORS/AFFILIATIONS: Foster SN, Spitznagle TM, Tuttle LJ, Sutcliffe S, Lowder JL, Meister M, Ghetti C, Mueller MJ, Harris-Hayes M. Program in Physical Therapy, Washington University School of Medicine, Saint Louis, Missouri, UNITED STATES; Program in Physical Therapy and Department of Obstetrics and Gynecology, Washington University School of Medicine, Saint Louis, Missouri, UNITED STATES; Doctor of Physical Therapy Program, School of Exercise & Nutritional Sciences, San Diego State University, San Diego, California, UNITED STATES; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, UNITED STATES; Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics and Gynecology, Washington University School of Medicine, Saint Louis, Missouri, UNITED STATES; Urogynecology & Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Kansas Medical Center, Kansas City, Kansas, UNITED STATES; Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics and Gynecology, Washington University School of Medicine, Saint Louis, Missouri, UNITED STATES; Program in Physical Therapy and Department of Radiology, Washington University School of Medicine, Saint Louis, Missouri, UNITED STATES; Program in Physical Therapy and Department of Orthopedic Surgery, Washington University School of Medicine, Saint Louis, Missouri, UNITED STATES.
FUNDING SOURCE: The Foundation for Barnes-Jewish Hospital, NIH T32HD007434 and UL1TR002345, Washington University in St. Louis Program in Physical Therapy
Purpose/Hypothesis: Patients often experience only partial relief and/or bothersome side effects from medical treatments for urinary urgency and frequency (UUF); thus, more effective treatments are needed. Many with UUF are prescribed pelvic floor muscle (PFM) training although PFM strength has not been quantified in patients with UUF. Though there is strong evidence to support use of PFM training for stress incontinence, it may not be effective for UUF. Hip strength has been shown to be important for PFM function, but has not been studied in patients with UUF. We hypothesized that women with UUF would demonstrate (1) decreased hip external rotator and abductor strength and (2) diminished endurance and similar PFM vaginal squeeze pressure as controls. Number of Subjects: 10. Materials and Methods: Women with UUF (bothersome urgency and/or day/night frequency, <2 hours between voids or > once per night), without stress incontinence, ages 18 to 60 years were matched 1:1 with women without UUF (CON) on age, body mass index (BMI), and vaginal parity. All completed the Lower Urinary Tract Symptom (LUTS) Tool and Pelvic Floor Impact Questionnaire (PFIQ). A Peritron perineometer was used to measure PFM force production via peak vaginal squeeze pressure (PEA) and endurance via average pressure×duration or area under the curve (AUC). Participants were cued to contract their PFMs as strongly as possible and hold for 10 seconds. A microFET3 hand dynamometer was used to measure hip abductor (ABD) and external rotator (ER) force using make tests. Three trials of each strength measure were averaged for analysis. Related-samples Wilcoxon Signed rank tests were used to compare matched UUF and CON. Results: 5 women with UUF (age = 23.8 ± 1.1 years, BMI = 22.1 ± 2.7, nulliparous) and 5 CON (age = 25.1 ± 1.9 years, BMI = 23.3 ± 0.9, nulliparous) were tested. In these preliminary analyses, UUF had significantly worse LUTS Tool Storage Symptom and Bother and PFIQ Urogenital subscores. Hip strength also appeared to be weaker in UUF than CON: results were statistically significant for left ABD and ER, and suggestive for right ABD and ER. No differences were observed for PEA or AUC.
Conclusions: In this small, preliminary sample, hip strength was weaker in women with UUF than matched participants without UUF, whereas PFM strength and endurance were not significantly different. Clinical Relevance: For women with UFF, hip muscle weakness may represent a factor to address through rehabilitation.
TITLE: Men's Pelvic Health: Exploration of Entry-Level DPT Curricular Content Based on a National Faculty Survey
AUTHORS/AFFILIATIONS: Dripps M, Kolch K, Prestegard S, Weeks L, Seller E, Lefebvre K, Johnson S, Concordia University-St. Paul, Saint Paul, Minnesota, UNITED STATES.
Purpose: With a small number of physical therapists specializing in pelvic health, the Academy of Pelvic Health has recognized need to increase awareness of pelvic disorders. The purpose of this study is to examine the current delivery of entry-level content on men's pelvic health in Doctor of Physical Therapy programs and establish support for future program development within DPT curricular content. Subjects: Program directors or individuals responsible for teaching pelvic health content design and delivery employed at CAPTE-accredited DPT programs across the United States. Methods: A mixed-methods approach was utilized for this study. Online surveys were sent to the 239 CAPTE-accredited DPT programs across the United States. Response was received from 55 (22.7%) programs. The survey collected qualitative and quantitative data to explore delivery of content on men's pelvic health including data on barriers, discrepancies, demographics, and educator opinions/attitudes concerning men's pelvic health curriculum. Survey inquiries were modeled after a similar study exploring women's health DPT curricular content. Qualitative data were analyzed by 2 independent researchers with a third outside reviewer to corroborate themes and subthemes. Quantitative data were analyzed using SPSS version 23.0. Results: Responding institutions were evenly distributed geographically with 13 (24%) located in the midwest, 17 (31%) in the southeast, 8 (15%) in the northeast, and 7 (13%) in the southwest or west. Ten (18%) did not provide geographic information. Thirty-four (62%) of CAPTE-accredited DPT programs reported less than 3 hours of men's pelvic health curricular content at their institution, with 11 of those programs (20%) reporting less than 1 hour of curricular content. Only 2 programs reported greater than 7 hours of curricular content on men's pelvic health (3%) even though almost 50% (23) programs reported having a full course in their curriculum dedicated to women's health. Qualitative themes identified include lack of time in DPT schedule/curricula, faculty knowledge to instruct, viewed as a specialty PT, and lack of curricular guidelines. Conclusions: Men's pelvic health is an essential piece of therapy practice. This data has identified barriers to the implementation of this content in entry-level DPT curriculum and may be used to develop entry-level guidelines for educators, and consequently, provide higher quality care for all patients experiencing pelvic floor disorders. Clinical Relevance: Introduction of imperative findings to enhance curricular content and clinical awareness of pelvic health for male patients for educators and clinicians.
TITLE: What's Happening Below the Belt? The Effect of a Pelvic Support on Pelvic Floor Function
AUTHORS/AFFILIATIONS: Maher RM, McColery A, Department of Physical Therapy, Philadelphia College of Osteopathic Medicine Georgia, Suwanee, Georgia, UNITED STATES; CHI Health, Omaha, Nebraska, UNITED STATES.
Purpose/Hypothesis: Pelvic stability belts (PSBs) are a common therapeutic intervention for patients. Their mechanism of action is to improve form closure, assist in force closure, and neuromotor control through decreased activation of stabilizing muscles. Studies have determined that wearing PSBs decreases muscle activation several proximal and distal muscle to the PSB. Decreased activity of the ipsilateral abdominal muscles, adductor longus, rectus femoris, iliacus and biceps femoris muscle has been reported in healthy nulligravida. Similar activation effects have also been reported in the latissimus dorsi, lumbar multifidi, oblique internus abdominis, rectus abdominis, external oblique, rectus femoris, bicep femoris, and adductor magnus suggesting the PSB provides form closure. Since impaired form and force closure mechanisms through the pelvis are associated with lumbopelvic pain and stress urinary incontinence, this preliminary study examined the effects of wearing a PSB during PFM contractions in healthy women as assessed by bladder base displacement noted on transabdominal ultrasound imaging (TAUS) in 2 different positions: supine and standing. Number of Subjects: Twelve healthy continent females with a mean age of 26 years (22-35 years) and a mean BMI of 23.75 (22-26) were enrolled in this study. Materials/Methods: Seventeen females were screened and only those who could perform PFM contraction as assessed via TAUS were enrolled (n = 12). Three of the subjects reported a history of sacroiliac joint (SIJ) dysfunction and 1 subject reported mild SUI and constipation. All subjects were assessed for form closure deficits via the alternate straight leg raise (ASLR) test. A single examiner was assigned to TAUS. Subjects performed PFM contractions with and without a PSB in supine and standing and were instructed to “squeeze and relax” 3 times while TAUS cine-loops were acquired following a standard bladder filling protocol. The order of testing was randomly assigned and subjects were blinded to TAUS. The mean bladder base displacement (BBD) of 3 PFM contractions was used for data analysis across all testing conditions. A correct PFM contraction was defined as bladder base elevation on TAUS. Results: A 2×2 repeated-measures analysis of variance (ANOVA) analyzed the data. There was no significant difference in BBD associated with the use of a PSB in either position for those with or without a history of SIJ dysfunction. However, a significant difference was noted for position (P = .023), with BBD during standing being significantly greater than supine. Post hoc analysis via t tests revealed a significant difference for supine and standing (P = .01 and P = .03), respectively. Conclusions: There was a positional effect on PFM function regardless of the PSB and this finding has already been reported in the literature. Wearing a PSB had no impact on PFM function as determined by the magnitude of BBD. Our findings may be explained by the fact that PSBs are used to supplement or substitute for force closure deficits and none of our subjects presented with apparent force closure deficits. Clinical Relevance: A salient finding was that 29% of those screened could not perform a PFM contraction and that wearing a PSB had no effect on PFM function in women without apparent force closure deficits.