ABSTRACT BODY:
Purpose/Hypothesis: To explore student perceptions on what women's health (WH) physical therapist practice means, perceived need for WH information, and barriers. We expected that student perceptions would differ based on presence of a faculty member who is also a leader in the WH section.
Number of Subjects: Eleven physical therapy programs with a WH leader (WHPTP) identified and matched on institutional characteristics with 11 physical therapy programs without a WH leader (PTP). Ten programs agreed to participate (7 WHPTP and 3 PTP) and sent recruitment e-mail to students who had completed >80% of didactic curriculum.
Materials/Methods: Survey consisted of respondent characteristics questions and recalled exposure to 27 diagnoses/conditions associated with WH across 3 broad categories. Open-ended questions to explore students' perceptions. Students completed survey online.
Results: Eighty-three surveys returned. What WH physical therapist practice means fell into 1 of 2 definitions: WH defined as (1) treatment of pelvic floor disorders and pregnancy-related issues; or (2) a broad scope of caring for women throughout their life span, included multiple diagnoses related to women, quality of life, education, and health and wellness. Respondents (96%) thought they need to know information about WH issues, but depth of needed knowledge varied. Fifty-three were interested in future full- or part-time WH practice. Groups differed on the proportion who thought their need for WH information was being met. Barriers for both groups were not enough time in the curriculum and lack of faculty with WH experience. PTP respondents also cited classmates uncomfortable with pelvic floor examination and newness of the specialty as barriers. Groups differed on recalled exposure to common and complex/rare WH diagnoses/conditions.
Conclusions: Student WH interest may not be based on faculty role model, but a Section leader faculty member may make a difference in the WH-related education students recalled receiving and student perception on information needs being met. It is unclear if recalled exposure represents real exposure (eg, students recalled orthopedic-related conditions common among women, but is WH aspect stressed?). Compared to Section members who felt pelvic floor issues are important to include in entry-level curriculum but disagreed on importance of obtaining clinical experience, our study found many students (68%) recalled classroom exposure to urinary incontinence but fewer (42%) recalled clinical exposure. Exposure to other conditions involving pelvic floor dysfunction was recalled less frequent. Of concern is the finding that WH physical therapist practice is still considered "new" despite a 34-year history as an APTA section.
Clinical Relevance: Many students are interested in WH practice in the future and will seek postprofession- al clinical and didactic experiences. The section on WH can be a resource for these new professionals. However, since WH is still perceived by many as a new area of practice and almost half of students do not understand the breath of WH practice, the section needs to address these misperceptions for the field to grow.
TITLE: Measurement of Inter-Recti Distance: Are Calipers and RUSI Comparable?
AUTHORS: C. M. Chiarello1, J. McAuley2
INSTITUTIONS: 1. Program in Physical Therapy, Columbia University, New York, New York.2. Department of Physical Therapy, Touro College, New York, New York.
ABSTRACT BODY:
Purpose/Hypothesis: Accurate assessment of diastasis rectus abdominis (DRA) is essential for examination and intervention and has been measured as the inter- recti distance (IRD) via finger-tip palpation, digital and dial calipers, and more recently real-time ultrasound imaging (RUSI). RUSI is reliable and valid, comparable to direct measurements performed during surgery, but requires expensive equipment and significant examiner training. IRD measurements with inexpensive, portable digital calipers have been shown to be reliable in pregnant and postpartum women but have not been validated. The purpose of this study is to investigate the concurrent validity of digital calipers with RUSI for measuring IRD.
Number of Subjects: To date we have enrolled 48 normal subjects (males 9; females: 16 nulliparous, 12 primiparous, and 11 multiparous) between the ages of 19 and 64 years.
Materials/Methods: IRD was measured in all subjects with both tools, a digital caliper (Mitutoyo America Corporation, Aurora, Illinois) and with the RUSI (GE Logiq-Book XP ultrasound unit with a 5 MHz curvilinear transducer, Waukesha, Wisconsin), at 2 locations; 4.5 cm above and 4.5 cm below the umbilicus, during 2 conditions; active and passive. Passive measurements were performed with the subject in hook- lying and actively the subject raised his or her head and neck to the scapular spine. For each tool, a single examiner performed all IRD measurements blinded to the results from the other tool.
Results: Pearson correlations with linear regressions were computed for each location of IRD between the caliper and RUSI both active and passively. Results of IRD measured passively above the umbilicus revealed a significant moderate correlation (r = 0.66, P < .0001; 95% confidence interval, 0.467-0.797) and 44% of the variability (r2 = 0.439) in the caliper measurement can be attributed to the IRD measured with RUSI. A significant but low correlation with active muscle contraction above the umbilicus (r = 0.44, P < .001; 95% confidence interval, 0.176-0.642) was found with only 19% (r2 = 0.191) of the variability of the caliper measurement explained by the RUSI. All other comparisons were not significant. Twenty subjects exhibited an IRD that was too small to measure by either technique at a single location and condition.
Conclusions: Measurement of IRD with digital calipers above the umbilicus is somewhat comparable to the direct RUSI technique. There is no apparent association between the caliper and RUSI measurement of IRD below the umbilicus. With RUSI, IRD is determined directly as the most medial aspect of the recti negating the effect of skin or subcutaneous tissue. Calipers may not reach the same depth, thus measuring an IRD using a different part of the muscle. These findings may be consistent with other reports of anatomical variations below the umbilicus.
Clinical Relevance: When assessing DRA, caliper and RUSI forms of measurement may not be used interchangeably.
TITLE: Assessing Physical Therapy Outcomes for Women With Urinary Incontinence
AUTHORS: J. Dusi1, D. Borello-France2, D. Somers2, A. Phelps2, S. E. George3
INSTITUTIONS: 1. California University of Pennsylvania.2. Duquesne University, Pittsburgh, Pennsylvania.3. Centers for Rehab Services, Pittsburgh, Pennsylvania.
ABSTRACT BODY:
Purpose/Hypothesis: Purposes of this study were to (1) determine the efficacy of physical therapy (PT) interventions to improve pelvic symptoms and health- related quality of life in women with urinary incontinence (UI); (2) determine the relationship between selected patient-related characteristics and treatment success; and (3) describe PT interventions administered to manage the care of women with UI.
Number of Subjects: Data were obtained from the records of 100 females with UI.
Materials/Methods: A pragmatic study design was used to explore study aims. Data from routine clinical care were entered into an electronic database. The Patient Global Index of Improvement (PGI-I) scale was administered postintervention to determine treatment success. Improvements in pelvic symptoms and quality of life were also measured by pre- and postin- tervention Pelvic Floor Distress Inventory-20 (PFDI- 20) and Pelvic Floor Impact Questionnaire-7 (PFIQ- 7) change scores, respectively. Relationships between patient-related characteristics and PGI-I scores were explored using logistic regression.
Results: Sixty-six percent of women met the study criteria for treatment success, indicating symptoms were "much better." In addition, sample mean pre- to postin- tervention PFDI-20 and PFIQ-7 change scores were statistically significantly reduced. The mean age and number of PT visits differed between women who did and did not achieve treatment success. Women who achieved treatment success had a lower mean age (51.86 +/- 15.59 vs. 59.29 +/- 13.15 years) and attended more PT visits (9.05 +/- 5.51 vs. 5.74 +/- 2.55 visits) than those who did not perceive symptom improvement. Additionally, the occurrence of barriers between women who did and did not perceive treatment success was different from what would be expected by chance. When age, presence of barriers to intervention recommendations, and the number of PT visits were entered into the logistic regression model, only barriers to intervention recommendations (odds ratio [OR], 12.82; 95% CI, 4.05-40.55) and the number of PT visits (OR, 1.26; 95% CI, 1.07-1.50) were influential in predicting treatment success. Women in the study received a combination of PT interventions including education, exercise, modalities, and manual PT procedures.
Conclusions: PT interventions provided within a pragmatic setting improved the pelvic symptoms and health-related quality of life of women with UI. Two- thirds of women achieved the PGI-I study criteria for treatment success. Patients without barriers to intervention recommendations and patients who attended more PT visits were more likely to attain treatment success. Commonly used interventions for women in the study included patient education on diet modification and relaxation techniques, PFM training, core stabilization exercises, and manual PT procedures.
Clinical Relevance: This investigation found that women with UI seeking PT services often complain of additional pelvic symptoms. Moreover, PT interventions were effective in improving UI and other coexisting pelvic symptoms. Patients without barriers to intervention recommendations who attended more PT visits were more likely to attain treatment success.
TITLE: Resisted Hip Rotation Versus Pelvic Floor Muscle Training in the Treatment of Female Stress Urinary Incontinence, a Randomized Clinical Trial
AUTHORS: B. Jordre1, J. M. Rasmussen1, E. J. Woodruff1, N. F. Liming1, W. E. Schweinle2
INSTITUTIONS: 1. Physical Therapy, University of South Dakota, Vermillion.2. Physician Assistant Studies, University of South Dakota, Vermillion.
ABSTRACT BODY:
Purpose/Hypothesis: Resisted hip rotation (RHR) is a component of Janet Hulme's Roll for Control method of treating stress urinary incontinence (SUI). This method is gaining popularity in continuing education courses for physical therapists and has become a common addition to clinical practice, although it lacks critical analysis in peer-reviewed publications. The purpose of this study was to compare a standard pelvic floor muscle training (PFMT) protocol to an RHR exercise program. We hypothesize that the RHR group will show improvements equal to or greater than that of the PFMT group.
Number of Subjects: To date, 17 subjects have enrolled and been randomly assigned: 7 in the RHR group and 10 in the PFMT group. Ten subjects have completed the program. Six subjects are actively enrolled in the study. We anticipate complete data from at least 20 additional subjects before results are presented at CSM.
Materials/Methods: Female subjects over the age of 18 years were recruited via local clinics and advertisements. Inclusion/exclusion screening was conducted by phone and e-mail. Each subject was randomly assigned to either the RHR or PFMT group. Exercises were performed for a total of 6 weeks. Exercises in both groups were designed to last approximately 5 minutes and were performed in an upright sitting posture, 2x/day. Subjects in the RHR group performed hip external rotation with a resistive band and hip internal rotation against a 9" ball. Those in the PFMT group performed quick flicks and 5-second holds with the pelvic floor musculature. All subjects were given standard bladder health information. Each subject attended weekly rechecks to assure appropriate exercise performance and adherence to their assigned protocol. The Urogenital Distress Inventory and Incontinence Impact Questionnaire were completed at baseline, week 3, and week 6 of the intervention. Measures collected weekly included subjective improvement, single leg stance time, exercise logs, and a 3-day bladder diary. Rechecks at week 2 and 4 were via phone.
Results: Ten subjects, mean age 53.2 years, currently have complete data for analysis, 5 in the treatment group and 5 in the control group. Preliminary results suggest that after 4 weeks of exercises, subjects in the RHR group experienced approximately 66% fewer leaks per week than subjects in the PFMT group, although leak frequency diminished in both groups. Similarly, subjects in the RHR group subjectively reported 68% improvement in their condition, whereas PFMT subjects reported only 47% improvement.
Conclusions: These preliminary findings suggest that RHR exercises may be at least as effective as traditional PFMT methods, if not more so, in reducing the frequency of leaks for female patients with SUI. With no adverse effects and simple exercise instructions, RHR may be a preferred choice of clinicians seeking an effective, yet conservative method for the treatment of female SUI.
Clinical Relevance: Clinicians treating female patients with SUI should consider the addition of RHR exercises to their interventions.
TITLE: The Effects of a 6-Week Osteoporosis Group Education and Exercise Program on Strength, Flexibility, and Quality of Life in Postmenopausal Women
AUTHORS: M. E. Hager, A. Bandy, A. Ballentine, M. Cooper, M. Wolff-Burke, K. E. Abraham-Justice
INSTITUTION: Division of Physical Therapy, Shenandoah University, Winchester, Virginia.
ABSTRACT BODY:
Purpose/Hypothesis: Osteoporosis is a disease characterized by decreased bone mineral density, which increases the risk of fracture in postmenopausal women. Prevention programs may decrease the economic costs associated with osteoporosis. The purpose of this study was to examine the benefits of a 6-week group exercise and education program on strength, flexibility, quality of life, and knowledge of osteoporosis in postmenopausal women.
Number of Subjects: Fifteen postmenopausal women (age = 50-78 years) enrolled in a 6-week group exercise and education program, called Healthy Bones, led by a physical therapist.
Materials/Methods: All measurements were taken before the initiation of the exercise program and at the completion of the program. Quality of life was evaluated using the Qualeffo-41 questionnaire for osteoporosis, and an educational questionnaire was given to determine knowledge of the osteoporosis disease process. Strength of the bilateral hip flexors and gluteus medius, endurance of the back extensors, and flexibility of the pectoralis minor, hip flexors, and hamstrings were measured bilaterally. All data were entered into SPSS version 18.0.
Results: There was a significant improvement in hip flexor (P = .004 and .007) and gluteus medius (P = .001 and .002) strength bilaterally after completion of the program. Back extensor strength showed a significant improvement (P = .00). Hamstring and hip flexor length improved bilaterally. The Qualeffo-41 total scores significantly improved (P = .00) as well as scores on the osteoporosis knowledge questionnaire (P = .00).
Conclusions: Muscle strength, quality of life, and knowledge of osteoporosis significantly improved after completing a 6-week exercise and education program.
Clinical Relevance: The current study suggests that a 6- week group exercise and education program can result in improvements in strength, flexibility, and quality of life. The data suggest that even a short-term program may be beneficial for postmenopausal women at risk for or diagnosed with osteoporosis/osteopenia. Long- term follow-up is necessary to determine if lifestyle changes are maintained or prevention or delay of the disease process may result.
TITLE: Initial Examination of Outcomes for Patients Seeking Outpatient Rehabilitation for Pelvic Floor Dysfunction
AUTHORS: D. L. Hart1, Y. Wang2, J. E. Mioduski2
INSTITUTIONS: 1. Consultation and Research, Focus on Therapeutic Outcomes, Inc, White Stone, Virginia.2. Consulting and Research, Focus on Therapeutic Outcomes, Inc, Knoxville, Tennessee.
ABSTRACT BODY:
Purpose/Hypothesis: Identification of which outcome constructs are pertinent to people with pelvic floor dysfunction (PFD) and which outcomes instruments should be used to assess treatment outcomes for this population need to be examined. The purpose of this study was to begin the psychometric property analysis of an introductory multiconstruct outcomes data set where people with PFD who received therapy in outpatient clinics are described and outcomes data are collected.
Number of Subjects: Data from 2458 adult patients (mean = 50, SD = 17, min = 18, max = 91 years) being treated in 57 outpatient therapy clinics in 20 states (USA) for their PFD were analyzed.
Materials/Methods: Each Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), Pain Disability Index, and several new surveys that quantified the functional impact of PFD. Patients took relevant surveys. Items were analyzed for initial psychometric properties including interitem correlations, factor analyses, and 1-parameter Item Response Theory modeling including item hierarchical construct validity, internal consistency reliability, discriminating ability, and expected vs empirical Item Characteristic Curve (ICC) analyses.
Results: Of the 2458 patients with intake data, 1002 had discharge data. Intake data per survey ranged from 78 to 1338, the latter being the ULS. Using the ULS data as an example, data were fit to the Partial Credit Model. All but 1 item fit the model well (fit statistics ranged from 0.70 to 1.07). Items had good person reliability (0.99). The scale exhibited good person separation (10.71). Item hierarchy appeared clinically logical supporting good construct validity. Factor analyses suggested 20 items formed 1 unidi- mensional scale. ICC analyses suggested adequate model fit.
Conclusions: Several scales had adequate introductory psychometric properties. Data suggest continued data collection and analyses are warranted for several scales. Plans for report organization and use of the stronger scales were formulated, so future data collection and reporting are facilitated.
Clinical Relevance: To our knowledge, this is the first large, multiconstruct data collection for patients with PFD receiving outpatient therapy. Results suggest matching the outcomes data described with demographic data in this PFD population may form a reasonable foundation for future improvement and may assist patient management designed for improved outcomes.
TITLE: Describing Patients Seeking Outpatient Rehabilitation for Pelvic Floor Dysfunction
AUTHORS: D. L. Hart1, Y. Wang2, J. E. Mioduski2
INSTITUTIONS: 1. Consultation and Research, Focus on Therapeutic Outcomes, Inc, White Stone, Virginia.2. Consulting and Research, Focus on Therapeutic Outcomes, Inc, Knoxville, Tennessee.
ABSTRACT BODY:
Purpose/Hypothesis: People with pelvic floor dysfunction (PFD) are not uncommon in outpatient physical therapy clinics. To date, descriptive statistics have not been collected or analyzed that would begin the process of describing the characteristics of this population. The purpose of this study was to analyze an introductory data set describing people with PFD who received therapy in outpatient clinics, which could be used to improve the outcomes data collection process and reporting methods for this population.
Number of Subjects: Data from 2458 adult patients (mean = 50, SD = 17, min = 18, max = 91 years) being treated in 57 outpatient therapy clinics in 20 states (USA) for their PFD were analyzed.
Materials/Methods: Each patient entered demographic data into a computer, using outcomes data collection software modified specifically for patients with PFD. Patients also entered outcomes data from several surveys selected by the treating clinician, but only demographic data will be analyzed. Demographic data consisted of problem (urinary, bowel, pelvic pain, and all combinations of the problem); if urinary, issue (leakage, frequency, retention); if bowel, issue (leakage, constipation, or straining); if pelvic pain, location (abdominal, rectal, sacroiliac, vaginal); impairment description (like failure to store or empty); gender; age; symptom acuity; and exercise history. Descriptive statistics were used.
Results: Some frequencies may not sum to 100% because patients had multiple problems. By problem: 67% of patients had urinary problems; 27% had bowel problems; 38% had pelvic pain. By combinations of problems: 39% urinary; 7% bowel; 17% pelvic pain; 10% urinary and bowel; 10% urinary and pelvic pain; 3% bowel and pelvic pain; 8% urinary, bowel and pelvic pain. If urinary, 82% leakage, 59% frequency, 27% retention. If bowel, 47% leakage, 70% constipation or straining. If pelvic pain, 56% abdominal, 25% rectal, 27% sacroiliac, 62% vaginal. Impairment, 16% failure to store, 11% pelvic floor pain, 9% other urinary or bowel dysfunction, 3% failure to empty. By gender: 92% female, 8% male. By age: 37% 18 to <45; 40% 45 to <65; 23% 65 years or older. By symptom acuity: 6% acute; 13% subacute; 82% chronic. By exercise history: 41% at least 3/wk; 22% 1 to 2 times/wk; 36% seldom or never.
Conclusions: Data suggest most patients with PFD receiving outpatient therapy have urinary problems affecting leakage, are female, are younger than 65 years, have chronic symptoms, and exercise at least 1 time a week. Combinations of urinary, bowel, and pelvic floor pain impairments are common.
Clinical Relevance: To our knowledge, this is the first data set describing patients with PFD receiving outpatient therapy. Data will be used to improve patient description and classification, which could lead to improved risk-adjusted modeling of pertinent treatment outcomes.
TITLE: The Role of Exercise in the Management of Pelvic Girdle and Low Back Pain in Pregnancy: A Systematic Review
AUTHOR: J. S. Boissonnault
INSTITUTION: Ortho Rehab, University of Wisconson-Madison.
ABSTRACT BODY:
Purpose/Hypothesis: To systematically and critically assess the literature regarding the effectiveness of exercise as a modality to ameliorate or prevent pelvic girdle and/or low back pain in pregnancy.
Number of Subjects: Three independent researchers to review articles for inclusion in final review; 2 researchers to complete reviews of 11 articles selected for final review.
Materials/Methods: A systematic review of prospective clinical trials related to exercise for pelvic and low back pain in pregnancy. A search of CINAHL, MEDLINE, PEDro, and the Cochrane databases, and reference screening was conducted for prospective clinical trials published in English. Three reviewers used a consensus process to select articles for final review. Two of the reviewers then independently reviewed the selected articles according to the PEDro Scale. Where available, the reviewer's results were compared against PEDro Reviews and reviewer scores were altered if both reviewers agreed that the published PEDro Score was more accurate.
Results: Eleven studies were reviewed. Four were of deemed to be of good quality (range 7-10/10), 5 of moderate quality (range 4-6/10), and 2 of poor quality (0-3/10). High-quality studies support the intervention of exercise, either alone or combined with advice or other treatment (support belts, acupuncture) as a means of prevention or management of pelvic girdle and low back pain. One study found aquatic-based exercise to be of greater benefit than land-based exercise. Another found acupuncture superior to exercise, which was, in turn, more effective than "standard treatment." Addition of pelvic support belts to exercise intervention did not further decrease pain. Reports of sick leave conflicted across studies.
Conclusions: Exercise appears to decrease low back or pelvic girdle pain in pregnancy as reported on visual analog scales. Heterogeneity of study methodology and outcome assessment makes comparison difficult. Most studies were of moderate to poor quality.
Clinical Relevance: Pelvic girdle and low back pain are common in pregnant women with prevalence rates averaging near 50% at some time during a woman's pregnancy. Assessment of exercise intervention studies may provide the physical therapist with evidence to assist in care of the pregnant population with these dysfunctions.