ABSTRACT BODY:
Background & Purpose: Pelvic and low back pain is a common complaint in the pre- and postpartum female. Pelvic pain has been found to be 4 times more common than low back pain during pregnancy. Almost all of the postpartum females still suffering from pain greater than 6 months following delivery have pelvic pain. The pathogenesis of pelvic pain in pregnancy is poorly understood, leading to a lack of clearly defined diagnostic nomenclature, disparity in reported incidence, and, therefore, a lack of effective intervention. This single-case design investigated the ability of the physical therapist to (1) accurately assess anterior pelvic ring dysfunction in the postpartum female, (2) effectively apply manual therapy techniques to correct pubic symphyseal and sacroiliac joint arthrokinematics, and (3) employ progressive trunk stabilization techniques to assist in restoring stability and function in the post partum patient.
Case Description: A 39-year-old female, 2 weeks status post-vaginal delivery, which was complicated by the baby's shoulder becoming fixed in the pelvis during descent, resulting in perineal tearing and immediate, severe pubic pain. This pelvic condition manifested in left lower extremity (LE) weakness, an inability to weight bear through the left LE, and difficulty with bed mobility, sit-to-stand transfers and lifting her infant. The patient presented with tenderness to palpation of the pubic symphysis, tightness of the hip musculature, strength deficits throughout the (L>R) LE, L5/S1 myotomal weakness, and a 2.5 finger rec- tus diastasis. She demonstrated bony landmark asymmetries and diagnostic testing consistent with an anterior innominate and pubic symphyseal dysfunction. She ambulated with a wide base of support, with decreased cadence, stride length, and weight shifting through the left LE. Physical therapy intervention included (9 visits over 5 weeks) consisting of myofas- cial release techniques, pubic symphyseal and sacroil- iac joint muscle energy techniques, progressive trunk stabilization exercises, and a home exercise program.
Outcomes: The patient reported a 50% reduction in pain following 2 physical therapy sessions. She rated her pain a 6/10 on a Visual Analog Scale initially and reported no pain upon discharge (0 on a VAS). At discharge, tenderness at the pubic symphysis was eliminated, pelvic ring arthrokinematics and stability were restored, LE strength was improved by 1/2 grade throughout, and gait was normalized. The patient reported no pain with ambulation, bed mobility, transfers, and lifting during activities of daily living.
Discussion: Pelvic pain is a significant problem in pre and post partum females, which is inconsistently reported, poorly classified, and viewed as a consequence of childbearing. As such, it is commonly overlooked and rarely treated in a timely manner. These findings suggest that proper diagnosis and specific manual therapy intervention are effective in alleviating post partum pelvic pain and restoring function.
TITLE: Symptoms of Peripheral Neuropathy in Women Treated for Breast Cancer
AUTHORS: C. H. Gill, S. Anderson, J. Edwards, M. Hirsch, B. Wise, M. Treuth
INSTITUTION: Physical Therapy, University of Maryland Eastern Shore, Princess Anne, Maryland.
ABSTRACT BODY:
Purpose/Hypothesis: A potential side effect of treatment for breast cancer is peripheral neuropathy. The purpose of this study was to characterize perception of function, strength, manual dexterity, sensation, balance, and quality of life (QOL) in women treated for breast cancer (WTBC) who have symptoms of peripheral neuropathy.
Number of Subjects: This cross-sectional study compared 8 women treated for breast cancer (62.1 years) with 7 age-matched controls (60.3 years).
Materials/Methods: The subjects completed a demographic and a Disabilities of the Arm, Shoulder & Hand (DASH) questionnaires. Strength measures included grip and pinch. Manual dexterity, thresholds for light touch and vibration, kinesthetic awareness, and balance using a Neurocom Balance Master were also measured. WTBC also completed a FACT-B to measure QOL. Nonparametric Mann-Whitney U tests were used to compare groups. Spearman's rho correlations were used to examine the relationships among variables. Significance was set at the .05 level.
Results: The characteristics of the WTBC include 83.9 +/- 48.4 months since diagnosis; treated with mastectomy (50%) and with lumpectomy (50%) chemotherapy (75%), and radiation (87.5%); and treated with pain medication (62.5%). The most commonly reported symptom was muscle cramping with 87.5% reporting difficulty with manipulating small objects with fingers. No differences were found between the 2 groups for age. The DASH score was higher in the WTBC (35.4 +/- 19.2 vs 8.8 +/- 7.5, P = .01). The mean grip strength was lower in both hands in WTBC; the left-hand grip strength was approaching significance (15.0 +/- 3.7 vs 9.4 +/- 5.7, P = .08) and was significantly lower in the right hand (17.5 +/- 3.4 vs 11.5 +/- 5.5, P = .04). Two of the three pinch strength values were lower in the WTBC, although this was not significant. Manual dexterity of the right hand and assembly scores were significantly lower in the WTBC (12.1 +/- 2.0 vs 15.2 +/- 1.8 pieces, P = .02 and (22.6 +/- vs 29.2 +/- 5.3 pieces, P < .05, respectively). Vibration perception threshold was lower at all test locations in WTBC and was significantly lower at the left great toe and left medial malleolus (21.8 +/- 11.9 vs 9.9 +/- 3.8 volts, P = .03 and 23.5 +/- 13.0 vs 11.6 volts, P = .05, respectively). Directional control (balance) was significantly lower in the WTBC (73.5 +/- vs 80.7 +/- 3.1%, P = .04). Unilateral sway with the eyes closed for the left foot was significantly different between groups (P < .05). Sway velocity in double leg stance with eyes open and eyes closed was also significantly different between groups (P = .03 and P = .05, respectively). WTBC demonstrated a low QOL score (98.9 +/- 21.9). There were no significant correlations between strength and balance, between strength and sensation, and between balance and sensation.
Conclusions: WTBC perceived decrements in upper extremity function and demonstrated deficits in balance and manual dexterity compared to age-matched healthy women.
Clinical Relevance: WTBC should be examined for symptoms of peripheral neuropathy and appropriate interventions should be initiated to improve function.
TITLE: Factors Associated With the Presence of Diastasis Rectus Abdominis: A Pilot Study
AUTHORS: J. McAuley1, C. M. Chiarello2, S. Ohlsen2, L. Verna2
INSTITUTIONS: 1. Department of Physical Therapy, Touro College, New York.2. Program in Physical Therapy, Columbia University, New York.
ABSTRACT BODY:
Purpose/Hypothesis: Diastasis rectus abdominis (DRA), the abnormal midline separation of the abdominal muscles, may be associated with pregnancy, abdominal circumference obesity, gender, and age. DRA may also be seen clinically in persons with low back pain, pelvic floor dysfunction, and pelvic pain. The purpose of this study was to identify factors that may influence the occurrence of DRA. This study was conducted concurrently with a validity measurement study of DRA.
Number of Subjects: To date, we have enrolled 48 normal subjects (males 9; females: 16 nulli- parous, 23 parous) between the ages of 19 and 64 years.
Materials/Methods: Variables measured were age, gender, body mass index (BMI), parity, low back pain (LBP), urinary incontinence (UI), umbilical circumference (UC), and the active straight leg raise (ASLR) test. DRA was measured as the inter-recti distance in all subjects with a digital caliper (Mitutoyo America Corporation, Aurora, Illinois) and with the real-time ultrasound imaging (RUSI) (GE Logiq-Book XP ultrasound unit with an 5 MHz curvilinear transducer, Waukesha, Wisconsin), at 2 locations; 4.5 cm above and below the umbilicus, during 2 conditions; active and passive. Subject self-reported data consisted of age, parity, LBP, and UI, while BMI, UC, and ASLR test were directly measured.
Results: Measured passively, the mean DRA above the umbilicus was 1.76 cm (SEM = 1.29) for the caliper and 1.58 cm (SEM = 1.05) for RUSI and the DRA mean below the umbilicus was 2.06 cm (SEM = 1.09) for the caliper and 0.67 cm (SEM = 0.75) for RUSI. Measured actively, the mean DRA above the umbilicus was 1.44 cm (SEM = 0.86) for the caliper and 1.44 cm (SEM = 0.85) for RUSI and the DRA mean below the umbilicus was 1.50 cm (SEM = 0.81) for the caliper and 0.69 cm (SEM = 1.29) for RUSI. Multiple stepwise regressions were calculated for each tool at each location for all the variables measured. Measured passively below the umbilicus with the calipers there were no factors that predicted DRA whereas parity was predictive for RUSI. Measured passively above the umbilicus, gender, parity, and ASLR were predictive of DRA for both the caliper and RUSI. Measured actively above the umbilicus, LBP and ASLR were predictive of DRA for both the caliper and RUSI. Measured actively below the umbilicus, there were differences in the predictors for each tool. Further statistical analysis is ongoing to specify the nature relationships in greater detail.
Conclusions: Depending on the tool and location, factors that consistently explained the variability in the DRA were gender, parity, low back pain, and ASLR. Inconsistent findings between tools and conditions suggest that there may be multiple factors operating which were not investigated. Further research is necessary to fully characterize the factors and conditions impacting DRA.
Clinical Relevance: In examining patients with a clinical presentation of LBP or UI, assessment for DRA should be performed including an ASLR especially in multiparous women.
TITLE: Exercise Behaviors and Prevalence of Urinary Incontinence in Young Women: Is There a Relationship?
AUTHORS: P. R. Nelson, T. Kuhn
INSTITUTION: Eastern Washington University, Spokane, Washington.
ABSTRACT BODY:
Purpose/Hypothesis: Urinary incontinence (UI) impacts 20 million US women across the lifespan. While pregnancy and obesity are known causes of UI, these are not mechanisms for the reported 28% of young women affected by UI who have never been pregnant (nulliparous). Instead, impact exercise, muscle weakness, and toileting habits are suspected causes. The aim of this investigation was to confirm the high rate of UI and explore the relationship between exercise behavior and UI in nulliparous females.
Number of Subjects: Subjects were recruited through social networking systems as well as posted flyers providing a link to an online, anonymous survey. Ninety-seven subjects completed surveys. Surveys were included in analysis if subjects were aged 18 to 30 years, nulliparous, and had not had pelvic surgery or congenital pelvic defect. Eight were excluded due to missing data or not meeting inclusion criteria, leaving 89 valid surveys for analysis.
Materials/Methods: Participants completed a questionnaire regarding their health and physical activity. The Incontinence Impact Questionnaire (IIQ-7), a valid and reliable measure of UI, was used to determine UI status and measure the impact of UI on quality of life. Descriptive and relational statistics were calculated using Excel (Microsoft 2007).
Results: Eighty-nine females aged 19-30 years (x = 24) participated, with 35 (39%) reporting UI. Of the 35 women with UI, 17 reported negative quality-of-life impact (x = 23%) and 18 reported no negative impact from UI. Exercise impact level and intensity data were categorized as high, moderate, or low. All subjects performed regular exercise with most women reporting high-impact (76%) and moderate-intensity (45%) workouts of 31- to 60-minute duration (66%). In women with UI, 74.3% participated in high, 8.6% in moderate, and 17.1% in low impact exercise, while 37% participated at high, 54% at moderate, and 9% at low exercise intensity. Relationship of exercise duration (P = 0.83), impact level (P = 0.69), and intensity (P = 0.45) to UI status was not significant.
Conclusions: These young nulliparous subjects reported an 11% higher rate of UI than expected. As UI is a condition that is difficult to discuss, an anonymous survey may have led to more ease in reporting the presence of this condition. Surprisingly, self- report of exercise impact, intensity level, or duration was not related to UI status. While exercise impact is thought to contribute to presence of UI, this study population of regular exercising young women did not demonstrate this relationship. Thus the specific aspects of exercise that contribute to UI remain unclear.
Clinical Relevance: Physical therapists often work with nulliparous, young women and should screen for UI presence and impact. Ongoing research is needed to identify the specific causal mechanisms of UI in the nulliparous population.
TITLE: Using the Guide to Physical Therapist Practice in the Management of a Patient With Secondary Lymphedema of the Lower Extremity: A Case Report
AUTHORS: J. Hakey Brusgul1, D. B. Vittone1, K. Sleeman2
INSTITUTIONS: 1. The Sage Colleges, Troy, New York.2. Southwestern Vermont Medical Center, Bennington.
ABSTRACT BODY:
Background & Purpose: Physical therapists acknowledge the importance of using the APTA's Guide to Physical Therapist Practice (The Guide) to support their practice but find incorporating this information into daily practice difficult. An outpatient clinic at Southwestern Vermont Medical Center, designed a standard of care document called the Cardiovascular- Pulmonary Standard of Care for the treatment of patients with the diagnosis of lymphedema. The purpose of this case report was to demonstrate how The Guide could be incorporated into physical therapist practice for a patient with the diagnosis of secondary lymphedema of the lower extremity in an outpatient clinic.
Case Description: The patient was an 82-year- old woman who developed secondary right lower extremity lymphedema 10 years after being diagnosed with ovarian cancer and resultant pelvic surgery to remove the cancerous tissue. The patient received 32 visits of therapy over a span of 9 months. The physical therapy plan of care followed a sequence of the core components, which included a complete decongestive therapy program and elements in The Guide Cardiovascular/Pulmonary Preferred Practice Pattern 6H: Impaired Circulation and Anthropometric Dimensions Associated with Lymphatic System Disorders.
Outcomes: The patient's right lower extremity edema was reduced by 10.2 cm and the pitting edema resolved. The patient was independent in the self-management of her lymphedema. The patient reported walking and activities of daily living improved 3 points and 5 points, respectively, on the Patient Specific Functional Scale for which the minimally clinically important difference (MCID) is 3. Patient reported a high satisfaction for goal achievement and quality of care received. Her right knee flexion range of motion increased by 20[degrees] (MCID = 5[degrees]). Pain measured on the Numeric Pain Rating Scale decreased from 5 to 1 (MCID = 3).
Discussion: Clinical guidelines improve the quality of health care by assuring providers involved in a patient's care follow a standardized approach. The use of the Cardiovascular- Pulmonary Standard of Care document provided a standardized approach that resulted in a successful and efficient management of a patient with secondary lymphedema. The documents provided a framework for examination, evaluation, and intervention for patients with lymphedema. This standardized approach included the key components of the ICF model (body structure and functions, activity limitations, participation restrictions, and environmental and personal factors). The design and implementation of this document demonstrated how The Guide could be incorporated into clinical practice.
TITLE: Examining Balance Performance, Functional Mobility, and Fall Status in Community-Dwelling Older Women With and Without Urinary Incontinence
AUTHORS: P. R. Nelson, T. DeRuwe
INSTITUTION: Eastern Washington University, Spokane, Washington.
ABSTRACT BODY:
Purpose/Hypothesis: Urinary incontinence (UI) affects 38% of community-dwelling older women. Research has found decreased balance and increased pelvic floor and trunk muscle activation in women with compared to women without UI. However, there have been few studies that examine how balance performance and fall status differ between these 2 groups. The purpose of this study was to compare balance performance, functional mobility, and fall status in women with and without UI.
Number of Subjects: Subjects included 31 women aged 65 and older who lived independently in a senior living community in the northwest region of the United States. To participate, subjects had to provide informed consent and be able to walk independently within their home (with or without the use of an assistive device).
Materials/Methods: Subjects completed functional balance performance measures including the Berg Balance Scale, an established measure of static and dynamic balance and the Four Square Step Test, a dynamic balance measure. Subjects also completed valid, reliable functional mobility performance measures including the Tinetti Assessment Tool (Tinetti) and the Timed Up and Go. For each instrument, subject scores were compared to established threshold values to classify fall risk. Subjects provided demographic information and fall history for the previous year. A fall was defined as an unintentional movement resulting in coming to rest on a lower surface like the floor or ground. Descriptive statistics were calculated using SPSS v. 17.0. The relationship between falling and continence was measured using chi-square test, and group mean differences were explored using a 2-tailed t test.
Results: UI symptoms were self-reported by 12 (39%) of subjects. There were no significant differences between women with and without UI on any of the balance and mobility measures. Self- report of "balance is worse" over the past year was significantly different in women with (8/89%) and without (6/33%) UI (P = .047). Of women with UI, 5 (42%) reported falling (x = 2.6). For those without UI, 5 (26%) reported falling (x = 2.2). The relationship between fall status and continence was not statistically significant.
Conclusions: Surprisingly, balance and functional mobility performance of women with and without UI was similar. Although a greater percentage of women with UI had experienced falls compared to women without UI, this difference was not statistically significant. While UI is a recognized risk factor for falling, these variables were not related in this study population. The relationship between UI and falls is an important issue that warrants further exploration.
Clinical Relevance: The results of this study provide physical therapists with balance and functional mobility performance data in community-dwelling, well-elderly females with and without UI.
TITLE: Pelvic Floor Functional and Impairment Limitations in a Female With Hip Osteoarthritis
AUTHORS: M. L. Buss1, D. Borello-France2
INSTITUTIONS: 1. Centers for Rehab Services, Pittsburgh, Pennsylvania.2. Rangos School of Health Sciences, Duquesne University, Pittsburgh, Pennsylvania.
ABSTRACT BODY:
Background & Purpose: Approximately 0.5/1000 people in the United States suffer from hip osteoarthri- tis (OA). This diagnosis is based on the report of anterior groin pain and confirmed with radiographic evidence of joint changes. Research has shown physical therapy (PT) interventions including stretching, strengthening, and functional activities to be effective in decreasing disability and pain associated with hip OA. Some patients fail these interventions and are advised by their physicians to pursue surgery. In these cases, a coexisting neuromuscular cause of pain may be present, and specialized PT would be indicated. This case report describes the PT management of a woman with a primary diagnosis of hip OA who failed traditional PT management. Subsequent intervention by a specialized women's health physical therapist identified other neuromuscular contributors of pain and dysfunction. In particular, this case illustrates the importance of investigating pelvic floor dysfunction in persons with hip pain.
Case Description: The patient was a 53-year-old female with a 5-year history of left groin pain, which recently increased in intensity. Prior PT for the diagnosis of hip OA temporarily decreased her pain but did not improve her function or reduce her disability. Because she had a long history of constipation and pain with vaginal insertion, the PT examination included internal vaginal palpation. Palpation of the obturator internus (OI) reproduced the unresolved groin pain. Initial PT interventions were aimed to decrease pain and included soft tissue massage of the OI and joint mobilizations of the hip and surrounding areas. Education in posture and body mechanics was also provided to prevent further muscle and joint dysfunction. Subsequent interventions included core stabilization activities to maintain pelvic symmetry and hip strengthening exercises to offload pressure on the OI.
Outcomes: The patient reported significant improvements on the Lower Extremity Functional Scale, VAS Pain Scale, Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire, and Oswestry Disability Index immediately prior to the discontinuation of care. She also improved her posture and body mechanics and was independent with her home exercise program.
Discussion: In patients with radi- ographic evidence of hip OA, other neuromuscular causes of pain and dysfunction may coexist, preventing optimal physical therapy outcomes. This case report illustrates the need for specialist intervention to determine if pelvic floor dysfunction coexists in persons with persistent pain following interventions targeting only the hip.
TITLE: Supervised Lower Extremity Strengthening Program to Improve Function in Women Over 50 With Knee Osteoarthritis: A Time Series Design
AUTHORS: S. Schuerman, J. B. Lemons, D. C. Sheesley, R. Sutton
INSTITUTION: Physical Therapy, University of Nevada Las Vegas.
ABSTRACT BODY:
Purpose/Hypothesis: A pilot study to develop a simple, self-paced lower extremity strengthening program incorporating functional activities for women over the age of 50 years to reduce functional limitations associated with knee OA. We hypothesized that a relationship would exist between all variables.
Number of Subjects: Subjects in this study included 8 community- dwelling women over the age of 50 (mean = 59.71, SD = 3.38) meeting the American College of Rheumatology's criteria for clinical diagnosis of knee OA.
Materials/Methods: Subjects began the 14-week program with 2 weeks of baseline treadmill walking. The following 12 weeks were divided into 3 phases, 4 weeks each, consisting of a 10-minute walking warm-up, 18-minute stepping protocol, and a 10-minute walking cool-down. The stepping exercise included forward stepping, minisquats, side-stepping, and calf raises. Step height progressively increased each phase to 4", 6", and 8". Outcome measures included Limits of Stability and Sensory Organization Test on the NeuroCom Smart Equitest, The Western Ontario and McMaster's University Arthritis Index (WOMAC), quad strength using a hand-held dynomometer, and pain rating using a Visual Analog Scale.
Results: A repeated-measures analysis of variance was used to determine if there was a difference in WOMAC score and right and left quadriceps muscle strength. A statistical significance was found for WOMAC scores, F4,28 = 6.2 1 8, P < .001. Pairwise comparisons revealed a significant difference between the means at pretreatment and week 10 (pre = 19.13, SD = 9.57; week 10 = 13.5, SD = 7.54, P = .03). Statistical significance was found in both right and left quad strength measurements (right quad: F4,28 = 27.774, P < .0005; and left quad: F4,28 = 34.306, P < .0005). Pairwise comparisons for the right quad revealed a significant difference between week 2 and week 6 (P = .034), and all treatment times when compared to the posttreatment score (pre = 15.0, SD = 3.38; week 2 = 14.63, SD = 2.88; week 6 = 17.88, SD = 1.96; week 10 = 18.75, SD = 2.43; week 14 = 25.25, SD = 4.03) (Ps < .009). Pairwise comparisons for the left quad revealed a significant difference between pretreatment and week 10 (P = .029) and all treatment times when compared to the posttreat- ment score (pre = 14.75 SD = 2.49; week 2 = 15.13, SD = 2.64; week 6 = 18.13, SD = 1.25; week 10 = 19.5, SD = 1.84; week 14 = 25.63, SD = 3.99) (Ps < .005). No statistical significance was found for NeuroCom tests.
Conclusions: Subjects demonstrated an increase in quadriceps strength especially in the final phase of the step program when the step height was raised to 8". WOMAC scores revealed significant changes between pre and week 10 treatment functional levels, suggesting the extension of the final phase might maintain improvements in WOMAC scores.
Clinical Relevance: The strength gains seen within this subject group in a limited time frame suggest the need for a long-term study of similar design. With knee OA being a prevalent and functionally limiting disease, a simple-step protocol that focuses on quadriceps strengthening could prove valuable in this population.
TITLE: Outcomes of Physical Therapy Treatment in a Male Patient Diagnosed With Chronic Pelvic Pain: A Case Report
AUTHORS: L. M. English, M. J. Alappattu
INSTITUTION: Physical Therapy, University of Florida, Gainesville.
ABSTRACT BODY:
Background & Purpose: Males with chronic pelvic pain (CPP) have physical, social, psychological, and economic burdens. Due to the inconsistent efficacy of traditional medicinal treatments, pelvic physical therapy is emerging as a helpful adjunct intervention for men with CPP. There is little evidence that addresses the benefits of physical therapy in young men with CPP. The purpose of this case report is to describe outcomes of physical therapy interventions in a young male with CPP.
Case Description: The patient was a 17-year-old Caucasian male diagnosed with dysuria, pain with ejaculation and defecation, and pelvic floor myalgia for greater than 12 months. He reported increased pain with prolonged sitting, urination, defecation, and ejaculation. The location of the pain was the base of the penis and was described as dull in nature, except for sharp pain with urination and ejaculation. Additionally, he reported sharp pain at the anus with defecation. External palpation of the uro- genital triangle revealed pain and tightness of the left bulbospongiousis, ischiocavernosus, and superficial transverse perineal muscle, in addition to 1/5 pelvic floor muscle strength. Physical therapy interventions included manual external and internal pelvic floor muscle stretching, lower extremity stretching, visceral mobilization, and core strengthening. Modalities included electrical stimulation and EMG biofeedback for the pelvic floor muscles. The outcomes measures included the Numerical Pain Rating Scale (NPRS), 8-Item Short Form Health Survey (SF-8), Pain Catastrophizing Scale (PCS), and short-form McGill Pain Questionnaire (sf-MPQ). The measures were taken at initial evaluation (week 1), week 3, and week 7.
Outcomes: The patient's pain rating on the NPRS was the only measure that demonstrated a clinically meaningful decrease over time (week 1: 4; week 3: 3; week 7: 3). The other 3 measures, although not clinically meaningful, showed trends reflecting progression toward decreased burden of pain. The PCS scores decreased over the 7 weeks (week 1: 17, week 3: 8, week 7: 5). The scores on the sf-MPQ decreased over the course of treatment (week 1: 10, week 3: 4, week 7: 5). On the SF-36, the physical component scale score increased from week 1 to week 7 (34.8, 39.3), and the mental component scale fluctuated over time (week 1: 40.6, week 3: 46.3, week 7: 44.9).
Discussion: This case report provides insight into physical therapy as a conservative treatment for men with CPP. Our results indicate that physical therapist-directed interventions were helpful in relieving patient-reported pain and pain-related catastrophizing in a young male with CPP sequelae. Future therapy practice should consider these types of interventions compared to other commonly used interventions for male pelvic pain.
TITLE: Best Physical Therapy Practice Guidelines for the Management of Diastasis Recti Abdominis in the Peripartum Population
AUTHORS: B. C. Zenerovitz, M. Aremu-Cole, S. Dumbleton, S. Hardee, A. Speights, A. Stoner
INSTITUTION: Duke University, Durham, North Carolina.
ABSTRACT BODY:
Purpose: The purpose of this paper is to determine evidence-based guidelines for management of diastasis recti abdominis (DRA) in the peripartum population based on its potential impact on this patient population.
Description: Diastasis recti abdominis is a separation of the 2 bellies of the rectus abdominis at the linea alba. This systematic review of published literature examined history and risk factors, physical examination, secondary complications, and the recommended interventions to treat DRA. Furthermore, the authors investigated the current expert clinical opinion from practicing clinicians in order to create best practice guidelines. Primary predisposing factors for developing DRA during the peripartum period include obesity, older age, ethnicity, obstetric history, degree of soft tissue laxity, and activity level prior to and during pregnancy. The traditional method of screening for DRA is through finger-width palpation; however, more accurate and reliable measurement tools are also discussed.
Summary of Use: After evaluating risk factors and best diagnostic methods, evidence supports the use of specific core strengthening exercises and neuromuscular reeducation in conjunction with modalities and passive realignment to correct DRA and improve function.
Importance to Members: This summary of evidence is to be utilized by clinicians to increase patient awareness about DRA. It also serves as an additional resource and practice guide for treating peripartum patients with DRA.
TITLE: Pregnancy-Related Low Back Pain and the Effectiveness of Maternity Support Garments: A Single-Subject Design
AUTHORS: N. Friederich, A. Snider, M. L. Peterson, K. Neelly
INSTITUTION: Physical Therapy and Health Science, Bradley University, Peoria, Illinois.
ABSTRACT BODY:
Purpose/Hypothesis: Low back pain during pregnancy occurs due to a variety of reasons. One of these reasons is the biomechanical changes that occur with weight gain, which may shift the mother's center of gravity and, consequently, alter the curvature of the spine, while placing greater demands on the hyper- mobile spine and pelvis. Maternity supports are one treatment option for pregnancy-related low back pain (PLBP) and are intended to decrease pain by offering support in the lumbar spine and/or pelvic regions. This single-subject study was designed to compare pain, function, and posture between wearing 2 types of maternity supports or no support at all.
Number of Subjects: The participant for this study was a 45-year- old Caucasian female in her third trimester of pregnancy who reported experiencing low back pain brought on by pregnancy. The subject was recruited by word of mouth.
Materials/Methods: A single-subject, ABACA, study design was conducted to compare the effectiveness of 2 types of maternity support garments in terms of lumbar lordosis and reported pain. Two commercially available pregnancy supports were used, including a belt support (Stork S'port) and a vest support (Belly Bra). Each support was worn for 3 consecutive days followed by a 3-day period where no support was worn for a total of 15 days. The participant was advised to continue with her typical activities of daily living. Pain and function were logged daily using a journal consisting of a Visual Analog Scale (VAS) to report overall pain as well as categories of specific activities that caused increased pain. At each data collection, the participant completed the Revised Oswestry Low Back Pain Disability Index and spinal curvature was measured using the flexible ruler.
Results: There was no significant difference found in change of lumbar lordosis when wearing a maternity support garment as opposed to wearing no support. An increase in lordosis was found after wearing the Belly Bra; however, this was not related to a change in pain reported by the subject. Pain as measured by the VAS was found to be lowest during the first 2 days wearing the Stork Support. Pain reportedly increased for the subject while wearing the Belly Bra.
Conclusions: The decreased pain reported by the participant while wearing the Stork Support as opposed to the Belly Bra indicates that compressive forces at the lumbopelvic region may provide relief in PLBP for women in their third trimester of pregnancy. No change was noted in lumbar lordosis after wearing either support garment suggesting that a change in lor- dosis may not be a causing factor of PLBP. Therefore, a maternity support belt such as the Stork Support may offer relief to women with PLBP in their third trimester of pregnancy.
Clinical Relevance: Back pain during pregnancy limits many aspects of daily life. Pregnancy supports may offer a cost-effective method of alleviating this pain. Greater study of their effectiveness may increase their utilization by health care providers.
TITLE: The Risks of Performing Manual Lymph Drainage Therapy on a Patient With Congestive Heart Failure: A Case Report
AUTHOR: M. M. Vaassen
INSTITUTION: Physical Therapy, Clarke University, Dubuque, Iowa.
ABSTRACT BODY:
Background & Purpose: A variety of diagnoses result in lower extremity edema, such as deep vein thrombosis, cellulitis, venous stasis insufficiency, and congestive heart failure (CHF). CHF is a diagnosis that, depending on the acuteness of the episode, may be appropriate to treat with manual lymph drainage (MLD). Manual lymph drainage massage is a gentle light touch massage technique used in standard treatment for lymphedema patients. The purpose of this case report is to describe the dynamics of the lymphatic system with pathology of CHF and how to develop a safe plan of care.
Case Description: The patient was a 69-year-old female with bilateral lower extremity lymphedema and open draining wounds. The patient had past history of asthma and emphysema but denied any past medical cardiac history, no past cardiac procedures, and no past medical history of CHF. Treatment consisted of MLD, remedial exercises, and compression wrapping.
Outcomes: In 3 weeks the patient had 4 L of decreased volume. Her wounds had healed, she regained independence with her functional mobility, and she had no reports of pain. However, her fatigue and shortness of breath had worsened. She was referred back to her physician for further testing due to suspicion of acute onset of CHF. The results indicated mild onset of CHF. She was fitted with a low compression (10-15 mmHg) garment for bilateral lower extremities and was discontinued from lymphedema treatment due to a complicating medical condition.
Discussion: This case report discusses the intimate connection of the cardiac/lymphatic systems primarily through the link of the thoracic duct. It is important to educate clients on how to recognize the signs and symptoms of CHF and to adjust the physical therapy treatment plan safely and accordingly.
Clinical Relevance: There are many patients seeking lymphedema management that have comorbidities of lower extremity edema and shortness of breath. It is important to determine the etiology of both, the lower extremity edema and the shortness of breath, before developing a physical therapy plan of care.
TITLE: Moving Forward: Breast Cancer Survivor Exercise Program. A Pilot Study
AUTHORS: K. Wingert1, S. Hotchkiss1, S. Sayers1, V. L. Parker2
INSTITUTIONS: 1. Physical Therapy, University of Missouri, Columbia.2. Cancer Rehabilitation, Ellis Fischel Cancer Center, Columbia, Missouri.
ABSTRACT BODY:
Purpose/Hypothesis: Cancer survivors who incorporate a healthy diet and moderate to vigorous physical activity into their daily lifestyle could reduce their cancer recurrence risk by half. The goal of Moving Forward was to develop a comprehensive nutrition and health program for breast cancer survivors that was easily replicated in other settings. The purpose of this study was to evaluate the effectiveness of the exercise portion of this program.
Number of Subjects: Twenty- one women from central Missouri at least 1 year post- treatment for breast cancer were enrolled in the study. The data presented include 11 women (age 53.1 +/- 5.7 years; height = 160.8 +/- 8.6 cm; weight = 81.4 +/- 18.6 kg) present for all outcome evaluations.
Materials/Methods: "Moving Forward" was a 12-week supervised program of exercise instruction and education followed by 12 weeks of self-directed exercise at a community exercise facility in Columbia, Missouri. Participants were offered unrestricted facility access for 6 months but were required to meet with the research team once a week for the first 12 weeks for 30 minutes of educational instruction followed by resistance training (RT) and/or aerobic exercise. Participants were instructed on the use of 10 upper and lower body RT exercise stations and aerobic exercise equipment. The 6-minute walk, the Timed Up- and-Go (TUG), and balance using the single-leg (SL) stance with eyes open (EO) and eyes closed (EC) were evaluated at baseline, 12 weeks, 18 weeks, and 24 weeks. Analysis of variance (ANOVA) and unpaired t tests were used to evaluate changes over time. Statistical significance was accepted at P < .05. A questionnaire evaluating psychosocial aspects of exercise was also administered.
Results: Six-minute walk improved from baseline to 24 weeks (ANOVA; P = .005). Paired comparisons showed improvement from base-line (562.1 +/- 35.7 m) to 12 weeks (626.7 +/- 71.0 m; P = .001), 18 weeks (607.2 +/- 54.6 m; P = .001), and 24 weeks (598.0 +/- 53.9 m; P = .006). There was a strong trend in TUG improvement from baseline to 24 weeks (ANOVA; P = .06). Paired comparisons showed improvements from baseline (10.6 +/- 2.2 s) to 18 weeks (7.0 +/- 1.0 s; P < .001) and 24 weeks (7.0 +/- 1.2 s; P < .001) only. SL stance with EO improved from baseline to 24 weeks (ANOVA; P = .001). Paired comparisons showed improvement from baseline (18.0 +/- 7.7 s) to 12 weeks (23.7 +/- 3.5 s; P = .002), 18 weeks (24.3 +/- 3.4 s; P < .001), and 24 weeks (22.4 +/- 4.8 s; P = .02). SL stance with EC improved from baseline to 24 weeks (ANOVA; P = .01). Paired comparisons showed improvement from baseline (5.5 +/- 3.3s) to 18 weeks (10.3 +/- 6.1 s; P = .002) only.
Conclusions: A 12-week supervised exercise program, combined with education, resulted in significant increases in function and balance immediately postex- ercise that were maintained during an additional 12 weeks of self-directed exercise.
Clinical Relevance: Questionnaire data suggest that social aspects of exercise with peers in similar health circumstances may have been a strong component in empowering women to maintain exercise behavior even after the supervised portion of the study was over.
TITLE: Physical Therapy for Pelvic Organ Prolapse
AUTHORS: A. Sadowy, D. B. Underwood, K. Montgomery, J. Richter, T. Stangle, C. Vize, J. H. Hollman
INSTITUTION: Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota.
ABSTRACT BODY:
Purpose/Hypothesis: An estimated 1 in 3 adult women in the United States has a pelvic floor disorder such as urinary/defecatory dysfunction or pelvic organ prolapse (POP). Evidence supports pelvic floor muscle training (PFMT) for urinary/fecal incontinence, but there is a paucity of evidence for physical therapy (PT) for POP. Symptoms of POP may include vaginal pressure/bulging, painful intercourse, and/or urinary/defecatory difficulties. Symptoms may negatively impact quality of life (QOL). The purpose of this poster is to report early results of a larger, ongoing randomized trial to observe QOL outcomes in women with POP who participate in PT. A secondary outcome, transversus abdominus (TrA) performance, was assessed using real-time ultrasound imaging (RUSI).
Number of Subjects: Five premenopausal females.
Materials/Methods: The following data were collected at baseline and 12 week follow-up: Pelvic Floor Distress Inventory-20, Pelvic Floor Impact Questionnaire-7, POP/Urinary Incontinence Sexual Function Questionnaire, and TrA ratio using the RUSI. All subjects were taught PFMT, abdominal bracing, spine protection, and the "knack," a quick, strong contraction of the pelvic floor muscles prior to increased intra-abdominal pressure. Intravaginal examination confirmed pelvic floor muscle contraction. Three subjects randomly assigned to a treatment arm of the study received 4 additional sessions of PT for a motor learning progression. These subjects were taught the canister concept of diaphragm, TrA, pelvic floor muscles, and multifidus coordination for lum- bopelvic and postural stability. Neuromuscular reeducation of TrA was performed with RUSI to the lateral abdominal wall, and reeducation of the pelvic floor muscles was performed with RUSI suprapubi- cally. Women practiced this coordination standing, walking, and during core exercises. Women were taught how to incorporate the canister concept into their daily activities and received practical instruction of body mechanics. Women were taught bowel and bladder care and sexual comfort measures.
Results: One of 2 women in the minimal intervention group experienced clinically meaningful improvement on the Pelvic Floor Distress Inventory-20 and the Pelvic Floor Impact Questionnaire-7, and improvement on the Sexual Function Questionnaire and stronger TrA ratio. The other woman experienced clinically meaningful improvement on the Pelvic Floor Distress Inventory-20. Three of 3 women in the treatment group experienced clinically meaningful improvement on the Pelvic Floor Distress Inventory-20 and the Pelvic Floor Impact Questionnaire-7. They also demonstrated improvement on the Sexual Function Questionnaire and stronger TrA ratio during RUSI.
Conclusions: Early results of a larger, ongoing randomized trial suggest that women with symptomatic POP may benefit from PT. A continued need exists for high-quality research regarding PT for women with POP.
Clinical Relevance: Based on this analysis, PFMT and dynamic lumbopelvic stabilization progression open- and closed-kinetic chain may improve QOL of women with symptomatic POP.
TITLE: The Effect of Heel Height on Pelvic Floor Muscle Activity: A Pilot Study Using 1-Inch and 3- Inch Heel Heights With Ultrasound Imaging, Surface Electromyography, and Digital Inclinometry
AUTHORS: R. M. Maher, R. Giertz, K. McClure, W. Earle, M. Morgan, J. P. Welch, P. B. Palmer
INSTITUTION: Physical Therapy, North Georgia College & State University, Dahlonega, Georgia.
ABSTRACT BODY:
Purpose/Hypothesis: The purpose of this study was to determine if shoe heel height affected pelvic floor muscle activity in healthy college-aged females.
Number of Subjects: Ten nulliparous college-aged healthy females were recruited for this study. All participants were screened for the ability to perform an appropriate pelvic floor contraction and to ensure they had no SI joint dysfunction.
Materials/Methods: Each participant completed a bladder filling protocol to allow for delination of the pelvic floor from other pelvic structures. Bilateral suface EMG (sEMG) electrodes and digital inclinometers were adhered to the perineum, ASIS and PSIS, respectively. Heel heights were randomly assigned and each participant performed three 5-second volitional pelvic floor contractions with a 5-second rest between each contraction. US imaging was acquired with a curvilinear array oriented in the transverse plane suprapubically while simultaneous sEMG and digital inclinometry data were captured at each heel height and standing barefoot on a level floor.
Results: A repeated-measures analysis of variance (RM-ANOVA) evaluated the effect of heel height, pelvic inclination, and sEMG activity on PFM activity. Significant interaction between sides and heel height was found (P = .004). Univariate analysis showed a significant effect for sEMG (P < .007) and no significant effect for incli- nometry (P > .06). Heel height had little effect on resting or maximum sEMG values statistically.
Conclusions: Results did not show a statically significant effect of heel height on PFM activity; however, clinically relevant data were noted. As heel height increased to 3 inches, the pelvis rotated relatively posteriorly and sEMG activity decreased but approached symmetry bilaterally. US imaging showed all subjects presented with asymmetries at rest and during PFM contraction, which resolved somewhat at a heel height of 3 inches. Observed differences in right- and left-side PFM sEMG activity with changes in heel height may indicate a neuromuscular imbalance in healthy women.
Clinical Relevance: Pelvic floor dysfunction, though often overlooked, is reported by 24% of women in the United States; this number includes more than 15 million who present with urinary incontinence. This pilot study sought to investigate the effects of high heels on pelvic floor muscle activity in healthy women. Further research on a larger sample size of those with and without pelvic floor dysfunction is required to determine if the posture associated with wearing high heels affects pelvic floor muscle activity and/or function.
TITLE: The Effect of Imposed Pelvic Inclination Angle on Pelvic Floor Muscle Activity-A Pilot Study Using Ultrasound Imaging, Digital Inclinometry, and Surface Electromyography
AUTHORS: R. M. Maher, C. Carter, L. Dunning, W. Earle, E. Green, P. B. Palmer, J. P. Welch
INSTITUTION: Physical Therapy, North Georgia College & State University, Dahlonega, Georgia.
ABSTRACT BODY:
Purpose/Hypothesis: The purpose of this study was to determine the effect imposed pelvic and ankle angles had on pelvic floor muscle (PFM) activity in healthy college-aged women.
Number of Subjects: Ten healthy females, aged 18-45 years, were recruited. All participants completed a bladder-filling protocol to facilitate delineation of pelvic structures during ultrasound imaging (US).
Materials/Methods: Each participant stood barefoot on a slant board at 5, 10, and 15 degrees of dorsi and plantarflexion. A neutral position defined as standing on a flat surface was also assessed. Each ankle position was randomly assigned across participants as they performed 3 volitional pelvic floor contractions of 5 seconds duration with a 5-second rest between contractions. US imaging of pelvic floor muscle activity was acquired suprapubi- cally in the transverse plane with a curvilinear transducer. Surface electromyography (sEMG) sensors and digital inclinometers were placed bilaterally on the perineum, ASIS and PSIS, respectively, to capture activity from the pelvic floor muscles and assess pelvic inclination angle.
Results: No statistical significance was found. However, clinically relevant trends were noted. Participants presented with side-to-side differences in sEMG and US. Left-sided sEMG output was less than right-sided sEMG across all participants. Left-sided PFM contraction showed less encroachment on the bladder than the right side, particularly in dorsiflexion. Symmetrical encroachment of the bladder was evident for most participants in plantar flexion, with concomitant increases in sEMG activity noted, which approached symmetry at 15 degrees of plantar flexion. A relative posterior pelvic tilt at 15 degrees of plantar flexion facilitated symmetrical PFM contraction as seen with US imaging.
Conclusions: Despite there being no statistical significance between pelvic floor activity and induced pelvic angle, clinically relevant data were evident when comparing sEMG side-to-side activity with side-to-side pelvic floor contractions assessed via US. Asymmetries in sEMG were mirrored on US imaging. Furthermore, pelvic inclination angle and US asymmetry were inversely related to sEMG output. That is, when pelvic inclination angle decreased across ankle positions up to 15 degrees of plantar flexion, the PFM contraction became more symmetrical on US imaging and sEMG activity increased.
Clinical Relevance: Pelvic floor dysfunction is associated with stress urinary incontinence, which is usually addressed with pelvic floor exercises to address strength and coordination deficits. In order to enhance the efficacy of physical therapy interventions, the normal population requires study initially before results can be generalized. This study sought to determine the effects pelvic and ankle inclination angles had on pelvic floor muscle recruitment in healthy women. This information could assist with customizing interventions to optimize pelvic floor muscle activity.
TITLE: Improving Sexual Function Using a Multi- disciplinary Approach for a Breast Cancer Survivor: A Case Report
AUTHORS: K. Snowden, C. Moretz
INSTITUTION: Lehigh Valley Health Network, Allentown, Pennsylvania.
ABSTRACT BODY:
Background & Purpose: Breast cancer treatment often results in sexual dysfunction. Treatment affects a woman's body image, relational dynamics, and vaginal integrity. This case report describes the multidisci- plinary management of a woman with breast cancer and the recovery of her sexual function.
Case Description: A 39-year-old female with infiltrating ductal carcinoma of the right breast was treated with a mastectomy, tram flap reconstruction, anykalating chemotherapy, and tamoxifen. Chemical ablation of her ovaries resulted in premature menopause. She became disinterested in and avoided sex, causing marital discord. She was referred for psychotherapy with a diagnosis of hypoactive sexual desire disorder and dyspareunia. Interventions aimed to improve body image, desire, and relational dynamics. The psychologist recommended collaborating with a pelvic floor physical therapist for treatment of the dyspareunia. Physical therapy treatment included pelvic floor manual therapy, relaxation training, and a home program of lumbar stretching and use of vaginal dilators. Physical therapy goals were to reduce her vaginal pain with penetration and back pain and obtain independence in self-care strategies.
Outcomes: The patient attended 10 psychotherapy and 9 physical therapy sessions in 6 months. She reported 50% greater comfort with her new body, improved desire, and initiated approximately 30% of her sexual encounters. She gained effective coping strategies for managing her feelings of resentment, which impacted her sexual interest. She and her spouse became independent in pelvic floor muscle stretching manually and using vaginal dilators. She had less back pain and experienced pain-free intercourse.
Discussion: This case study highlights the benefits of multidisciplinary treatment for a woman with sexual dysfunction following breast cancer treatment. Concurrently addressing somatic pain generators and psychological avoidance behaviors enhanced recovery for this patient.
TITLE: Reliability and Validity of IIQ-7 and SF-36 for Stress Urinary Incontinence in Bangladeshi Women Post-Caesarean Section and Vaginal Delivery
AUTHOR: L. Walton
INSTITUTION: Applied Medicine & Rehabilitation, Indiana State University, West Lafayette.
ABSTRACT BODY:
Purpose/Hypothesis: The purpose of this study is to establish the validity and reliability measures for both the Bengali translated IIQ-7 and SF-36 for female postpartum population living in Bangladesh.
Number of Subjects: 1. Test group 1: (n = 20) 18-54 years of age, vaginal or caesarean section delivery in last 3 years. 2. Control group 2: (n = 20) 18-54 years of age, no vaginal or caesarean section history.
Materials/Methods: Translation of the IIQ-7, informed consent form, and SF-36 into Bengali language were obtained from a certified Bengali language translator. Reliability and validity studies were conducted utilizing the IIQ-7 and SF-36 Bengali language translation for a population of Bangladeshi females 18-54 years of age (n = 40). Subjects were randomly selected from the medical record data set at Center for Rehabilitation for the Paralyzed and were recruited into 1 of 2 groups: (1) previous birth delivery in last 3 years and (2) no birth delivery history. After voluntary consent was obtained, each subject completed IIQ-7 and SF-36 twice within the same day. Translation of Informed Consent, IIQ-7 & SF-36: Translation of the SF-36 into Bengali language was already established by previous studies. The IIQ-7 and Informed Consent form were translated by a Certified Bengali Language Translator and checked for errors by 2 Bengali language experts.
IRB & Ethics Committee Approval: Written approval was obtained from the Ethics Committee at Center for Rehabilitation of the Paralyzed and Internal Review Board at Nova Southeastern University prior to beginning data collection.
Results: Test retest reliability for both the IIQ-7 and SF-36 were good to excellent with ICC = 0.74-0.93 for preliminary data. Internal consistency was measured using Cronbach's alpha for the Bengali version of the SF-36 and IIQ-7 and ranged from 0.72 to 0.92. For the IIQ-7 patients with history of previous birth demonstrated higher scores than those with no history of birth delivery.
Conclusions: The SF-36 Bengali version demonstrated good reliability and validity when applied to patients in the postpar- tum period after birth delivery. *This research reflects only partial data collection and final research results will be published upon completion of complete data set on all subjects.
Clinical Relevance: The establishment of a valid and reliable tool in Bengali language for utilization for future research in women's health related to postpartum quality of life and incontinence is necessary to promote research regarding Bangladeshi postpartum physical therapy needs in the future.