TITLE: Pre- and Postoperative Pelvic Floor Physical Therapy Enhances the Return to Continence Following Robot-Assisted Laparoscopic Prostatectomy: A Case Report
AUTHOR: Natalie Herback
INSTITUTION: Physical Therapy Department, Scripps Memorial Hospital, La Jolla, San Diego, California, USA.
ABSTRACT BODY:
Background & Purpose: Prostate carcinoma is a leading cause of male mortality in the United States and is most often treated with surgical intervention. The preferred intervention method is robot-assisted laparoscopic prostatectomy (RALP) as this procedure is less invasive than alternative treatments, although urinary incontinence (UI) is a common complication. UI is thought to result from several possible causes, but most cases are attributed to sphincter insufficiency. Pelvic floor physical therapy (PFPT) is a conservative intervention for UI that can be initiated immediately postsurgery to reduce the severity and duration of postoperative UI. PFPT is used to increase the pelvic floor muscle strength and endurance to enhance sphincter function and assist the regular functional work of the pelvic floor muscles during activities that increase intra-abdominal pressure and lead to leakage. The benefit of PFPT following a RAP has not been reported in the current literature and thus must be inferred from the success reported from individual cases in which PFPT was used following a RAP. This case report describes the preoperative pelvic floor screening and postoperative treatment for a male patient undergoing a RAP. This report suggests that early patient education of pelvic floor muscle strengthening exercises and immediate postoperative intervention improves treatment outcomes and hastens the return to continence. Case Description: A 52-year-old man was referred to PFPT 41/2 weeks prior to RAP by the urologist. The patient reported good health overall and denied any UI symptoms. The patient returned to PFPT 13 days following surgery and 4 days following catheter removal. He reported constant leakage with all activity, use of 2 to 3 pads per day, use of 1 to 2 pads per night, and full saturation. At the preoperative visit, a full pelvic floor examination was performed, including electromyogram biofeedback. The patient displayed pelvic strength score of 5/5 with 8-second endurance contractions and an average of 66.5 mV on biofeedback. These quantitative measures were used to compare pre- and postoperative strengths. Outcomes: In this study, objective measures demonstrated the patient's success with PFPT. After 2 PFPT appointments, the patient's pelvic floor strength score returned to the presurgical strength score of 5/5. By the fourth visit, the patient's strength had surpassed his presurgical strength by more than 40%. Additionally, the Internal Index of Erectile Function and Urinary Distress Inventory were used as assessment scales. Discussion: UI is a common complication of RAP and is most effectively treated with conservative PFPT. PFPT has been found to be most effective if initiated preoperatively and then again immediately following catheter removal. This case report clearly supports this hypothesis, as the patient's postoperative physical therapy was initiated shortly after catheter removal and he was discharged 9 weeks later, fully continent.
TITLE: A Comparison of 2 Delivery Methods of Neuromuscular Electrical Stimulation on Pelvic Floor Muscle Contraction in Healthy Subjects: A Pilot Study
AUTHORS: Ruth M. Maher, Jill Crockett, Carrie Kozel, Erin Landers, Dharmisha Naik, Julie Vertucci, Melanie Wilkes
INSTITUTION (ALL): Department of Physical Therapy, North Georgia College & State University, Dahlonega, Georgia, USA.
ABSTRACT BODY:
Purpose/Hypothesis: Pelvic floor exercises are recommended as primary intervention for women with stress urinary incontinence. Since few women can volitionally perform pelvic floor exercises via verbal instruction, transvaginal neuromuscular electrical stimulation (NMES) is frequently used adjunctively. To the knowledge of the authors, no prior research has examined the effect NMES and subject position during NMES have on the pelvic floor muscle (PFM). The purpose of this study was to compare the effects of 2 different methods of NMES delivery and participant position on PFM contraction. Number of Subjects: Seven healthy nulliparous female participants aged 23 to 30 years were recruited for this study. The protocol order was randomly assigned and participants were tested on 2 separate occasions, with a minimum 24-hour washout period between sessions. Before testing, each participant completed a bladder-filling protocol to allow for delineation of the bladder from the pelvic floor fascia and associated PFM. Materials/Methods: Two methods of NMES delivery were used. One method used a conventional unit and a vaginal electrode with a stimulation area of 2.31 cm2. The other method used a novel investigational device using external electrodes with a stimulation area of 1526 cm2. PFM contraction was assessed with sonography, using a 3.5-MHz curvilinear array transducer in the transverse plane. The amount and direction of bladder displacement were assessed during volitional contractions and NMES to the PFM in supine and standing positions. Results: During volitional contractions, participants were found to have greater cranial displacements while in standing position than in supine position. In the standing and supine positions, greater cranial displacements were seen for the externally delivered NMES versus the transvaginal NMES. Only 1 participant exhibited a PFM contraction with transvaginal NMES despite all participants describing the sensation of a contraction. When comparing the external NMES in supine and standing positions, a statistically significant difference favored the standing position (P = .018). Conclusions: Previous studies have shown that NMES activates the PFM and inhibits detrusor contraction but have failed to describe how this was assessed. We are unaware of any study that used transabdominal sonography during NMES to assess the effect on the PFM. Given the outcome of this pilot study, it behooves clinicians to verify whether appropriate muscle contractions are occurring with NMES of the PFM. Clinical Relevance: The clinical use of NMES in promotion of muscle strengthening is long established, with many devices specifically manufactured for the treatment of pelvic muscle weakness. Many studies have shown NMES to be effective in decreasing the severity of symptoms associated with stress urinary incontinence; however, few, if any, studies have assessed whether an appropriate PFM contraction is occurring. Furthermore, failure to mention the location and size of the electrodes in addition to the current density makes it difficult for clinicians to replicate study outcomes.
TITLE: Treatment of a Patient With Postnatal Chronic Calf Pain Utilizing Instrument-Assisted Soft Tissue Mobilization
AUTHORS: Amy J. Bayliss, Frank J. Klene, Evelina L. Gundeck, Mary Loghmani
INSTITUTION (ALL): Department of Physical Therapy, Indiana University, Indianapolis, Indiana, USA.
ABSTRACT BODY:
Background & Purpose: Musculoskeletal pain is often reported by women during prenatal and postnatal stages of pregnancy, with the most common complaint being low back or pelvic pain. However, leg pain is also a symptom frequently reported by many women particularly in their third trimester as edema increases and may persist after delivery. The purpose of this case study was to illustrate how instrument-assisted soft tissue mobilization (IASTM) can be used to treat a patient with a 2-year history of postnatal chronic calf pain in an efficient and cost-effective manner. IASTM is an innovative treatment of soft tissue dysfunction; the technique provides a controlled amount of microtrauma into an area of excessive scar tissue or fibrosis, which is found to stimulate healing and reorganization of the affected tissue. Case Description: The patient was a 35-year-old woman who developed right calf pain during the last trimester of her pregnancy, following the onset of severe lower leg edema. The calf pain had been present for the 2 years following delivery and was described as a dull ache varying between intermittent and constant. Symptoms were variable, typically aggravated by direct pressure on the calf, prolonged standing, and use of stairs, and present frequently at rest. Before beginning her physical therapy, she had undergone extensive medical testing including radiography, magnetic resonance imaging (MRI) with contrast, and ultrasound Doppler study. The patient had no vascular or skeletal bone abnormalities; however, her MRI did show a soft tissue asymmetry in the same location as that of her symptoms. Impairments were minimal; the only asymmetrical objective findings were decreased ankle plantarflexor strength and multiple soft tissue restrictions detected on palpation in the right calf. The patient rated herself at 74/80 on the Lower Extremity Functional Scale. The treatment was a form of IASTM, the Graston technique, which utilizes specifically designed stainless steel instruments combined with a targeted stretching and strengthening exercise program. Outcomes: After 9 treatments over 8 weeks, tissue quality of the right calf was normalized upon palpation and the patient's symptoms had been resolved. She rated her right calf pain at 0/10 and scored herself as 80/80 on the lower extremity functional scale. A follow-up MRI was not performed since the patient became pregnant soon after the completion of the treatment. However, a follow-up visit was completed after 1 month and the patient had no pain or soft tissue restrictions detected in her calf. Discussion: The presence of postnatal musculoskeletal pain is unfortunately common; however, IASTM allows for a cost-effective and timely resolution of symptoms. The results of this case study are particularly interesting since the patient had few impairments except the soft tissue findings and pain reports. Additionally, since the case described appears to be primarily myofascial dysfunction, IASTM may also be a treatment option to consider for patients with chronic pain and unremarkable imaging studies.
TITLE: The Combined Effect of Exercise and Education in Patients With Fibromyalgia Compared to Exercise, Education, or No Intervention: A Systematic Review
AUTHORS: Joy C. Kuebler, Kristin Adams, Kristal Anderson, Taja Cowan, Avery Harps, Nicole Kendrick, Stacey Lee, Rebecca Suydam
INSTITUTION (ALL): School of Health Related Professions, Physical Therapy Program, University of Mississippi Medical Center, Jackson, Mississippi, USA.
ABSTRACT BODY:
Purpose/Hypothesis: Fibromyalgia is a widespread chronic pain disorder that has a negative impact on activities of daily living, with approximately 80% to 90% of patients reporting a decline in their normal function. There are numerous studies recommending interventions to improve quality of life, but none have been selected as the treatment of choice. The purpose of this systematic review was to investigate the combined effect of exercise and education on quality of life for patients with fibromyalgia compared with those receiving no intervention, receiving exercise alone, or receiving education alone. Number of Subjects: This is a literature review. Materials/Methods: The database used for this systematic review was PubMed. The search was performed during the second week of February 2009. Search terms were grouped into the following categories: "fibromyalgia" combined with "education," "physical therapy," "aerobic exercise," and "strength exercise." Specific search terms and strategies are presented. Limits placed on this review included humans, randomized controlled trial, and English language. Studies that met the inclusion criteria contained education, fibromyalgia patients, exercise, and Fibromyalgia Impact Questionnaire (FIQ). The FIQ is a self-administered questionnaire composed of 10 questions measuring morning tiredness, stiffness, physical functioning, anxiety, fatigue, pain, job difficulty, depression, and overall well-being. All studies included were evaluated using the Physiotherapy Evidence Database (PEDro) scale (10-point scale that measures internal validity) and the Oxford Centre for Evidence Based Medicine (CEBM) scale (level of evidencerating). Results: In the search strategy described, the electronic screen resulted in 24 studies. Application of the inclusion criteria resulted in 6 studies, all of which met the criteria. The studies had an average PEDro score of 6 out of 10. The PEDro scores ranged from 4 to 7. Of the CEBM levels of evidence scored, 2 studies were level I and 4 studies were level II. Conclusions: In all of the studies, the group that received exercise and education combined demonstrated improvements in subscales of the FIQ. Based on the studies identified in this systematic review, the evidence grade for exercise combined with education is a grade of B. The literature received this grade, because the majority of the studies were of level II on the CEBM scale. This grade was based on the lack of complete data and limited blinding of subjects and therapists in the studies. According to the results, patients presenting with fibromyalgia to physical therapy for intervention should receive exercise combined with education to improve quality of life. The studies revealed evidence supporting improved FIQ scores among patients who received exercise combined with education when compared with patients who received exercise alone, education alone, or no intervention. Clinical Relevance: This review supports the evidence that a greater improvement in the quality of life of patients with fibromyalgia can be achieved with the addition of education to an exercise program.
TITLE: The Effects of a Postpartum Education Program on Self-care and Healthcare-Seeking Behaviors in Mothers
AUTHORS: Karen E. Abraham-Justice1, Jean M. Irion2, Brittney Paisley2, Lindsey Scott2, Tricia Williams2, Heidi Herres1, Ashleigh Pepin1, Kara Prato1, Amy Shifflett1, Cynthia E. Neville3
INSTITUTIONS (ALL): 1. Division of Physical Therapy, Shenandoah University, Winchester, Virginia, USA.
2. Department of Physical Therapy, University of South Alabama, Mobile, Alabama, USA.
3. Women's Health Program, Brooks Health, Jacksonville, Florida, USA.
ABSTRACT BODY:
Purpose/Hypothesis: Currently, there is little consistency regarding the education that women receive postpartum regarding identification and management of common primary health concerns, eg, back pain, neck pain, and fatigue. Early identification and appropriate management of these concerns may improve functional ability and quality of life in the postpartum period and may prevent health issues later in life. Therefore, the purpose of this pilot study was to determine whether issuing an educational pamphlet to women after childbirth would result in a change in musculoskeletal complaints and health care-seeking behaviors as compared with women who do not receive the educational intervention. Number of Subjects: A total of 261 postpartum women from 4 hospitals, 2 teaching hospitals and 2 private hospitals, participated in this study. Materials/Methods: A total of 134 subjects received a postpartum educational packet (PEP) describing the appropriate identification, initial management, or prevention of common postpartum conditions prior to discharge from the hospital. The remaining 127 subjects did not receive the PEP and served as the control group. All study participants completed a survey at their 6-week follow-up appointment with their respective obstetricians/providers. Results: There were no significant differences between the groups, those that received the PEP and those that did not, in terms of age, ethnicity, education, income, number of children, weight of baby, time of delivery, and method of delivery. There were differences in pain complaints based on mode of delivery and receipt of specific information from a health care provider. Women who had a vaginal delivery were 119% more likely to experience pelvic pain (P = .45), whereas women who delivered via cesarean section were 55.5% more likely to experience headaches (P = .038) and 50% more likely to experience fatigue (P = .038). Women who had received specific education from their health care providers were more likely to complain of pelvic pain (P = .023), incontinence (P = .003), and pain during intercourse (P = .047). There were no differences between groups regarding report of physical symptoms. However, women who received the PEP were more likely to seek advice from a health care provider regarding fatigue (P = .034). Conclusions: Receipt of the PEP did not result in a change in the report of physical symptoms at 6 weeks postpartum but did result in a change in health care-seeking behavior. Six weeks postpartum may not be the best time to measure the impact of the PEP. Clinical Relevance: Future research is needed to identify the optimal methods of providing educational information to postpartum women and to identify how to measure the impact of these programs.
TITLE: Comparison of Noninvasive Tests to Determine Menstrual Cycle Hormone Surges
AUTHORS: Vicci Hill-Lombardi, Catherine Maher
INSTITUTION (ALL): School of Health and Medical Sciences, Seton Hall University, South Orange, New Jersey, USA.
ABSTRACT BODY:
Purpose/Hypothesis: Increased interest regarding the influence of hormone fluctuations on women's physiology with respect to injury rates warrants functional testing across different menstrual cycle phases. A reliable method to identify the menstrual cycle phase is blood sample analysis for hormone levels. This is invasive, inconvenient, and expensive. A noninvasive method is daily basal body temperature recordings throughout the month. Issues include inconvenience of measurement upon waking daily and that only pre- and postovulatory phases can be identified. By noninvasively detecting surges in the levels of preovulatory hormones, such as estrogen and luteinizing hormone (LH), it is possible to identify preovulatory, ovulatory, and postovulatory phases. The purpose of this study was to compare a saliva test (estrogen) and a urinary test (LH) to determine appropriateness for predicting menstrual cycle phase. Number of Subjects: Six women, 18 to 28 years of age; normal menstrual cycle length, 26 to 34 days for 6 months; no hormone supplement or oral contraceptive use for 3 months; no previous history of lower extremity injury for 6 months; no previous lower extremity surgery. Materials/Methods: Subjects tracked their menstrual cycle onset, length, and daily hormone changes by using the Saliva Ovulation Q Test (Mediplex) and Urine Ovulation Stick Test (Mediplex) for estrogen and LH, respectively, for 2 cycles. Test results were recorded daily by the subjects, according to the specific product criteria. Saliva test recordings were evaluated for crystal formations. Urine test recordings were evaluated for test line appearance in comparison to a control line. Daily recording sheets of saliva results were kept separately from those of urine results. Results: In a comparison of the estrogen peaks detected by strong crystal "ferning" in dried saliva samples versus the LH peaks detected by dark test line coloration, 5 of the 6 subjects demonstrated estrogen peaks within 24 hours prior to their LH peaks. Conclusions: The expected progression in the saliva samples from simple crystal formation proceeding through to strong "ferning" occurred, indicating estrogen peak. This progression was demonstrated by most subjects as a sporadic surge, not as a steady, incremental increase. The estrogen peak should immediately precede or coincide with the dark appearance of the test line on the LH strip, indicating LH surge. The LH peak immediately precedes ovulation. All but one subject demonstrated this trend. Reasons for this could include difficulty with using the products and interpreting the results. Testing of more subjects is warranted to verify findings. Clinical Relevance: Because the influence of hormone fluctuations on many aspects of female physiology has not been thoroughly investigated, functional testing across menstrual cycle phase is critical. Identifying phase via reliable, noninvasive techniques allows continued investigation in a variety of research settings.
TITLE: A Magnetic Resonance Imaging (MRI) Measure of Intramuscular Fat in Pelvic Floor Musculature of Nulliparous Women
AUTHORS: Laura L. Krum1, James M. Elliott2, Meghan Adams1, Katherine Anderson1, Kristin Johnson1, Angela Mueller1, Delayna Shorter1, Eric Utes1
INSTITUTIONS (ALL): 1. School of Physical Therapy, Regis University, Denver, Colorado, USA.
2. Centre of Clinical Research Excellence in Spinal Pain, Injury and Health (CCRE Spine), The University of Queensland, St Lucia, Queensland, Australia.
ABSTRACT BODY:
Purpose/Hypothesis: Stress and strain to the pelvic floor muscle (PFM) caused by weight gain during pregnancy, weight of the baby in utero, and the physical trauma of vaginal delivery are believed to cause pelvic floor dysfunction (PFD). Pathologies related to PFD include urinary and fecal incontinence, pelvic organ prolapse, and dyspareunia. The presence of symptoms of PFD after giving birth can be predictive of long-term pelvic floor damage. To date, magnetic resonance imaging (MRI) of PFM has been used to delineate anatomical muscular subdivisions, muscular tears, avulsions, and pelvic relaxation. No current method exists to quantify intramuscular pelvic floor damage. The purpose of this study was to pilot a simple method of quantifying muscle/fat constituents in PFMs of asymptomatic nulliparous adult women that may be used in future comparative studies investigating PFM changes following vaginal birth and cesarean delivery. Number of Subjects: Eight healthy nulliparous women aged 26.5 +/- 3.5 years. Exclusion criteria were a history of PFD (ie, pelvic fracture, pelvic radiation treatment, urinary incontinence, fecal incontinence, pelvic organ prolapse, dyspareunia, or any surgery associated with these dysfunctions) and contraindications to MRI. Materials/Methods: MRI of the PFMs was performed. The muscle and fat signal intensities on axial spin-echo T1-weighted images were quantitatively classified by taking a ratio of the pixel intensity profiles of muscle against that of intermuscular fat for the pubovisceral, puborectalis, and obturator internus muscles bilaterally at the levels of the proximal, middle, and distal urethra. Inter- and intraexaminer agreement for the measures was examined. Results: The average values of fat within the pubovisceral, puborectalis, and obturator internus musculature relative to intermuscular fat have been established in this pilot cohort with good intrarater and interrater reliabilities. Conclusions: A quantitative measure of muscle/fat constituents for the pelvic floor in nulliparous women has been developed. Clinical Relevance: Identifying variations in the PFM morphometry within a specific asymptomatic nulliparous sample provides the basis for future cross-sectional investigations examining the MRI signal intensity changes in the PFM and the potential relationships to symptoms of pain, PFD, strength, motor unit recruitment, and quality-of-life measures in symptomatic and/or postpartum women. The recognition of fatty infiltration in the muscles of these patients may prove to be helpful diagnostically. Further research can further establish normative data and use them as a basis for comparing the presence and significance of any fatty infiltration observed in the PFMs of women postpartum.
TITLE: Treatment of Urinary Incontinence After Hip Fracture Utilizing a Diagnostic Model: A Case Report
AUTHORS: Stacy L. Tylka, Theresa Spitznagle
INSTITUTION (ALL): Program in Physical Therapy, Washington University School of Medicine, St Louis, Missouri, USA.
ABSTRACT BODY:
Background & Purpose: Urinary incontinence after hip fracture and related surgical repair is common among elderly women. To date, there are no reports detailing behavioral therapy for urinary incontinence (bladder urge suppression and intra-abdominal support techniques, fluid intake training, and pelvic floor muscle exercises) occurring or worsening after hip fracture and surgical repair. The purpose of this case report is to describe the diagnosis and behavioral therapy treatment of urinary incontinence that was exacerbated after hip fracture repair. Case Description: The patient was an 84-year-old white woman with increased urinary incontinence after a surgical intertrochanteric fracture repair. Evaluation and diagnosis were performed using the pelvic floor muscle movement diagnoses as described by Spitznagle. Key examination findings included thoracic kyphosis, decreased length and strength of the pelvic floor muscles, and perineal bulging with valsalva during coughing and head-lifting activities. Key treatment items were patient education regarding techniques for urge suppression and a home exercise program that focused on intra-abdominal pressure regulation during pelvic floor muscle exercise and functional activities with emphasis on coordination of the abdominal, pelvic floor, and diaphragm muscle contractions. Long- and short-duration pelvic floor muscle exercises in various body positions were prescribed: supine, hooklying, and standing. Outcomes: After evaluation, the patient was assigned a diagnosis of movement pattern coordination deficit, type II. After 7 physical therapy visits and a twice-daily home exercise program performed over 14 weeks, the patient demonstrated improvements in frequency of urinary incontinence, nocturia, pad use, pelvic floor muscle and abdominal muscle strength, and SF-36 (36-Item Short Form Health Survey) scores. Although the patient's muscle strength improved over the course of care, her functional improvement of decreased urinary incontinence was largely dependent on her ability to appropriately contract her pelvic floor and abdominal muscles against increases in intra-abdominal pressure and during episodes of urgency. Discussion: This case report is the first to describe successful behavioral therapy treatment for a patient with urinary incontinence that was exacerbated by a hip fracture and subsequent surgical repair. The patient demonstrated an 80% improvement in frequency of urinary incontinence; this finding is consistent with behavioral therapy interventions for urinary incontinence in other female populations (39%-82.3% improvement). The use of a diagnostic model was helpful in determining the focus of treatment for this patient. We believe that pelvic muscle strengthening alone would not be sufficient to maintain long-term results of decreased incontinence.