TITLE: Architectural Design of the Pelvic Floor Is Consistent With Muscle Functional Subspecialization
AUTHORS: Lori J. Tuttle1, Olivia T. Nguyen2, Mark Cook3, Ward Samuel4, Lieber Richard5
INSTITUTIONS: 1. Department of Orthopaedic Surgery, University of California San Diego, San Diego, California.
2. Department of Bioengineering, University of California San Diego, San Diego, California.
3. Department of Integrative Biology and Physiology, University of Minnesota, Minneapolis, Minnesota.
4. Departments of Radiology, Orthopaedic Surgery and Bioengineering, University of California San Diego, San Diego, California.
5. Departments of Orthopaedic Surgery and Bioengineering, University of California San Diego, and VA San Diego Healthcare System, San Diego, California
PRESENTER: Lori Tuttle, PT, PhD
CONTACT: Lori Tuttle: mailto:[email protected]
ABSTRACT BODY:
Purpose/Hypothesis: Despite the prevalence of pelvic floor dysfunction in women, little is known about the skeletal muscle architecture of the pelvic floor. Skeletal muscle architecture is defined as the arrangement of muscle fibers in a muscle and predicts the functional capacity of a muscle in terms of its ability to generate force and produce excursion. The purpose of this project was to quantify female pelvic floor muscle architecture and thus to predict their function.
Number of Subjects: Muscle architecture was determined using 10 formaldehyde-fixed human female cadavers without known pelvic floor dysfunction (mean age 85 years, range 55-102 years).
Materials/Methods: Muscle architecture was measured according to the methods previously described by Lieber et al. (1990) for upper extremity muscles. Muscles of the pelvic diaphragm (coccygeus [CM], iliococcygeus [ICM], and combined pubococcygeus and puborectalis [PC/RM]) were first removed en bloc and subsequently divided and weighed bilaterally (n = 20 bisected pelvic floors). Primary outcome measures of physiological cross-sectional area (PCSA), normalized fiber length, and sarcomere lengths were determined using previously validated methods. One-way analysis of variance was used to compare PCSA, fiber length, and sarcomere length for each muscle with post hoc t tests as appropriate. Significance was set at [alpha] = 0.05. Results are mean +/- SEM.
Results: Differences were observed across these 3 muscles for fiber length, but there was no significant difference in PCSA or sarcomere length between muscles. The CM PCSA was larger than both ICM and PC/RM muscles, but this trend did not reach significance (CM = 0.71 +/- 0.06 cm2, ICM = 0.63 +/- 0.04 cm2, PC/RM = 0.59 +/- 0.05 cm2, P = 0.21). All 3 muscles were different from one another in normalized fiber length (CM = 5.29 +/- 0.32 cm, ICM = 7.55 +/- 0.46 cm, PC/RM = 10.45 +/- 0.67 cm2, P < .001). Average sarcomere length was not significantly different and was relatively short (CM = 2.05 +/- 0.02 mm, ICM = 2.02 +/- 0.02 mm, PC/RM = 2.07 +/- 0.01 mm; P = 0.15).
Conclusions: Pelvic diaphragm muscles have small PCSAs, long fiber lengths, and short sarcomere lengths relative to other skeletal muscles. Functionally, these muscles would be expected to produce small forces and have relatively large excursions, and stretch would place the muscles at a mechanical advantage on the muscle length-tension curve. Thus, as these muscles initially stretch, they would be expected to produce increasing forces, which is not true of all human muscles. Regarding individual muscles, CM is designed with short fibers and larger PCSA, making it an ideal stabilizer. PC/RM has the longest fiber lengths and is therefore designed for large excursions.
Clinical Relevance: Deviation from this architectural design due to injury or surgery would dramatically alter these muscles' functional capacities. Terminal sarcomere lengths in normal and parous women and by activity are a key focus of future studies. Understanding and application of these data may lead to improved strategies for surgical and nonsurgical rehabilitation of patients suffering from pelvic floor dysfunction.
TITLE: Correlation Between Vaginal Digital Manual Muscle Testing of the Pelvic Floor and External Surface Electromyography
AUTHORS: Jennifer Knight1, Kimberly Coleman2, A. Lynn Millar2
INSTITUTIONS: 1. Covenant HealthCare, Physical Medicine and Rehabilitation Department, Saginaw, Michigan, USA.
2. Physical Therapy, Andrews University, Berrien Springs, Michigan, USA.
PRESENTER: Kimberly Coleman, MSPT
CONTACT: Kimberly Coleman: mailto:[email protected]
ABSTRACT BODY:
Purpose/Hypothesis: The purpose of this study was to determine if there is a correlation between the modified Oxford scale for digital manual muscle testing of the levator ani and microvolt output from surface electromyography (EMG). A second purpose was to determine if there is a correlation between the modified Oxford scale and self-reported incontinence.
Number of Subjects: Thirty women between the ages of 18 and 75 years being evaluated by a physical therapist for urinary incontinence.
Materials/Methods: Thirty women completed a health history form that included questions regarding their urinary incontinence. A vaginal examination was performed to determine the strength of the levator ani on a 0 to 5 scale. Surface electrodes were placed at the perineal body to record electromyographic microvolt output during contraction.
Results: A Spearman rho coefficient did not show a significant correlation between the manual muscle test scores and average maximum microvolt production (r = 0.277) or the average of the difference between maximum and resting microvolts (r = 0.298). Results from the chi-square showed there was not a significant association between the manual muscle test score and self-reported incontinence ([chi]2 = 0.275).
Conclusions: Surface EMG should not be the only means by which a clinician evaluates the levator ani strength or quality of contraction. Surface EMG alone does not give the clinician a good representation of the patient's ability to contract the levator ani. Also, if the patient is performing exercises to prevent incontinence, the clinician may not see an improvement in the manual muscle test score even though the patient reports improved continence.
Clinical Relevance: Because there was not a significant correlation, using the manual muscle testing scale in outcome measures or in therapy long-term goals may not be appropriate to truly capture functional improvement. This study did not show an association between reported incontinence and manual muscle testing score. Through clinical practice, it has become evident that women can become continent with physical therapy treatment without a change in the levator ani manual muscle testing score. Achieving continence is likely not due to an increase in levator ani muscle hypertrophy, but instead due to external pelvic girdle muscle and levator ani coordination.
The results of this study illustrate the importance of the clinician's involvement in palpating the levator ani in order to obtain the most accurate information as to the quality of contraction. Surface EMG can be used as biofeedback to train levator ani endurance, but it should not be used as a measurement tool to identify the quality of muscle contraction.
TITLE: What Goes Up Must Come Down? An Analysis of the Periform Plus Intravaginal Sensor With Indicator Using Simultaneous Ultrasound Imaging and Surface Electromyography in Healthy Continent Women
AUTHORS: Ruth M. Maher, Jeanne Welch, Amy Bearinger, Brittany Cobb, Michael Gevontmakher, Lauren Shank
INSTITUTION: Physical Therapy, North Georgia College & State University, Dahlonega, Georgia, USA.
PRESENTER: Ruth Maher, DPT, WCS, BCB-PMD
CONTACT: Ruth Maher: mailto:[email protected]
ABSTRACT BODY:
Purpose/Hypothesis: The purpose of this study was to determine if direction and magnitude of the Periform Plus indicator displacement during a pelvic floor muscle (PFM) contraction could be validated with simultaneous ultrasound imaging (US) and transvaginal electromyography (EMG).
Number of Subjects: Five healthy college-aged continent women who could volitionally perform a volitional PFM contraction were recruited for this study.
Materials/Methods: Subjects completed 5 PFM contractions (5 seconds on and 5 seconds off) in 4 randomly ordered positions (supine, hooklying with knees at 908 of flexion, supine with feet flat against a wall and standing) with a 2-minute rest between testing positions. Direction and amount of displacement by the Periform Plus were assessed while simultaneous US and EMG data were acquired. Each subject completed a bladder filling protocol to allow for delineation of the bladder from the pelvic floor fascia and associated PFM. An appropriate PFM contraction presented as cranial displacement of the bladder when assessed in the transverse plane with US. The displacement was assessed with on-screen calipers.
Results: During PFM contractions, the external indicator moved downward in all subjects, regardless of testing position. Hooklying with knees bent produced the greatest mean displacement. Cranial displacement on US imaging was seen for most subjects in all positions. Caudal displacement was noted in 2 subjects: one subject for supine and supine feet flat against the wall and the other for supine. These positions were associated with higher EMG values and greater displacement of the Periform indicator.
Conclusions: The Periform intravaginal sensor instructions state that an appropriate contraction occurs when the indicator moves down or away from the body. Our results showed that despite all subjects displacing the indicator downward during a PFM contraction, US displacement was not in agreement. Caudal displacement on US is usually associated with a strategy, which results in coactivation of the abdominals with a concomitant increase in intra-abdominal pressure (IAP). The increase in EMG activity could suggest the PFM were eccentrically contracting to accommodate for the increase in IAP.
Clinical Relevance: Few studies have used US to confirm if vaginal biofeedback devices provide appropriate feedback. This study showed that the direction of the indicator on the Periform Plus did not always correlate with the direction of displacement on US. While coactivation of the deep abdominal muscles has been shown to occur during a PFM contraction, increases in IAP can impact a compromised pelvic floor, which could lead to further dysfunction. Clinicians or end users should not solely rely on biofeedback devices as a means of confirming appropriate PFM contractions without monitoring for strategies that excessively involve abdominal muscle recruitment and further compromise a pelvic floor dysfunction.
TITLE: Functional Training Using Local Muscle Activation and EMG Biofeedback to Treat Women Status Post Pelvic Organ Prolapse Repair: A Case Series
AUTHORS: Amanda Hoch, Beth Thorpe, Danielle Anderson, Lauren Webb, Nadia Van Diepen, Tess Allen, Erin Boshuizen, Laura L. Krum
INSTITUTION: Physical Therapy, Regis University, Denver, Colorado, USA.
PRESENTER: Amanda Hoch, PT, DPT
CONTACT: Amanda Hoch: mailto:[email protected]
ABSTRACT BODY:
Purpose/Hypothesis: The purpose of this prospective case series was to determine the effectiveness of a postoperative physical therapy protocol incorporating local muscle activation with functional training, manual therapy, and education to treat urinary and fecal symptoms, sexual dysfunction, and negative effects on quality of life in participants following surgical repair of pelvic organ prolapse.
Number of Subjects: Twelve subjects (n = 12) who had surgery to repair a cystocele and/or rectocele were referred to physical therapy for the treatment of postoperative urinary, fecal, and/or pain symptoms. Four participants (n = 4), aged 52 to 78 years, completed the study. Eight subjects (n = 8) did not complete the study due to illness, surgical complications, or inability to continue.
Materials/Methods: Participants received a thorough physical examination day 1, at discharge, and +/- weeks following discharge. This included electromyography (EMG) assessment of the pelvic floor muscles (PFM) and transverse abdominis (TrA) in various functional positions as well as strength testing of PFM. Subjective data, including perceived problem severity, urinary and fecal symptoms, sexual function, quality of life, and functional limitations, were also collected day 1, at discharge, and +/- weeks following discharge. Intervention was performed 1 to 2/week, for +/- to 8 weeks, and addressed strength, endurance, and coordination of the PFM and TrA. Initially, functional training of PFM and TrA began in supine and progressed to positions known to increase intra-abdominal pressure. Functional training was supplemented with the use of EMG biofeedback.
Results: Subjective reports of problem severity decreased from a median score of 6.5/10 upon initial evaluation to 4/10 at discharge and further decreased to 3/10 upon follow-up. Quality of life, as indicated by the Prolapse Quality of Life Questionnaire, Urogenital Distress Inventory, and Incontinence Impact Questionnaire, also improved. The Fecal Incontinence Severity Index Questionnaire decreased for 2 of the 3 participants experiencing these symptoms. Muscle strength of the PFM increased from 2/5 to 3/5 on average and all participants demonstrated improved coordination of the PFM and TrA.
Conclusions: While a causal relationship cannot be determined from this case series, it is evident that improved strength of the PFM and coordination of PFM and TrA during functional activities may result in a reduction in problem severity and urinary and fecal symptoms, as well as an increase in quality of life for patients following prolapse repair. This case series provides a sound basis for future higher-level research.
Clinical Relevance: Pelvic organ prolapse is a serious health issue affecting women at an increasing rate as they age. Surgical intervention is often necessary, yet not always successful at relieving the debilitating symptoms women may experience. Currently, there is limited evidence to guide clinicians in treating women following surgery who still present with urogynecological symptoms and functional limitations.
TITLE: The Value of Screening for Psychological Distress in Chronic Pelvic Pain Patients: A Case Series
AUTHORS: Stephanie Bush, Jason Beneciuk, Cynthia E. Neville
INSTITUTION: Brooks Rehabilitation, Jacksonville, Florida, USA.
PRESENTER: Stephanie Bush, DPT
CONTACT: Stephanie Bush: mailto:[email protected]
ABSTRACT BODY:
Background/Purpose: The purpose of this case series is to describe how screening for specific psychological factors in patients receiving physical therapy for chronic pelvic pain may provide valuable prognostic information for clinical outcomes and has potential for treatment monitoring purposes.
Case Description: Patients (n = 3) were referred to outpatient physical therapy for pelvic floor rehabilitation of pelvic pain diagnoses including pelvic pain, vulvodynia, and uterine prolapse. Patients were administered psychological screening measures for pain catastrophizing, pain-related fear (TSK-11), pain-related anxiety (PASS), and depressive symptoms (PHQ-9). Clinical outcomes consisted of self-report measures for female sexual function, functional pelvic pain (FPPS), and condition-specific quality of life (PFIQ). All measures were administered at initial evaluation and during follow-up assessment points. Patients underwent a standard physical examination and received treatment specific to their rehabilitation diagnosis.
Outcomes: Follow-up times ranged from 4 to 8 weeks. On average, all psychological and clinical measures improved following physical therapy management for pelvic pain symptoms. For psychological measures, improvements were measured in pain catastrophizing (10.3 points), TSK-11(3.0), PASS-20 (10.3), and PHQ-9 (2.7) scores. For clinical outcomes, improvements were measured in female sexual function (2.8 points), FPPS (5.0), and PFIQ (28.3) scores. In comparison to initial evaluation, greatest overall improvements at follow-up assessment related to psychological distress and clinical outcomes were detected in measures for pain catastrophizing, pain-related anxiety, and quality of life, respectively.
Discussion: Screening for psychological factors in patients receiving physical therapy for chronic pelvic pain has the potential to provide valuable prognostic information for clinical outcomes. Our findings indicate improvements were detected for all psychological and clinical measures, potentially indicating that pain symptom and functional improvements were positively related to improved psychological distress. Specifically, improvement in pain catastrophizing, pain-related anxiety, and condition-specific quality of life may be strongly associated. Physical therapy treatment was not standardized; however, we can speculate that clinical outcomes may have been more beneficial if interventions were incorporated to target psychological factors based on screening results. Our interpretation of findings is purely descriptive in nature; however, they have the potential to be integrated into the planning of similar future studies in this setting. Future studies should evaluate the clinical utility of psychological screening for patients with chronic pelvic pain syndromes in physical therapy settings with special focus on (1) integration of screening results into clinical decision-making processes (eg, prognostic indicators for clinical outcomes) and (2) evaluation of screening measure psychometric properties (eg, responsiveness to change for treatment monitoring).
TITLE: Knowledge, Beliefs, and Behaviors Concerning Osteoporosis Prevention Among Traditional College-Aged Women
AUTHORS: Sharon I. Bevins, Ellen Williamson, Thomas Bevins, Mary DiPrizio
INSTITUTION: Physical Therapy & Human Performance, Florida Gulf Coast University, Fort Myers, Florida, USA.
PRESENTER: Sharon Bevins, PhD, PT
CONTACT: Sharon Bevins: mailto:[email protected]
ABSTRACT BODY:
Purpose/Hypothesis: The purpose of this study was to determine the level of knowledge among college-aged women, 18-25 years of age, concerning knowledge, beliefs, and behaviors toward osteoporosis prevention. This research was conducted to better understand what young women currently know about osteoposis and what, if anything, they are doing to prevent it.
Number of Subjects: A total of 200 females between the ages of 18 and 25 years participated in a survey project concerning osteoporosis knowledge, beliefs, and behaviors. Participants consisted of English-speaking females currently enrolled at Florida Gulf Coast University. Health Professions (n = 71), Education (n = 31), and Other/Nondeclared (n = 98) majors were assessed, utilizing convenience sampling.
Materials/Methods: Participants completed a survey packet that included (1) demographic questions, including age and college major, (2) the Osteoporosis Health Belief Scale (OHBS), a 21-item instrument, and (3) the Osteoporosis Self-Efficacy Scale (OSE), a 12-item instrument. Participants were provided a brochure regarding osteoporosis from the National Osteoporosis Foundation upon completion.
Results: Overall, participants demonstrated knowledge about osteoporosis on the OHBS; however, few believed themselves to be at risk (29%). A majority reported that they did not see the ingestion of calcium-rich foods as a barrier (65%), and 84% agreed that exercising regularly prevents future pain; however, only half engaged in preventative behaviors such as eating a balanced diet and regularly engaging in an exercise program. Overall, there were no statistical differences related to age or major found on the OHBS. As measured by the OSE, 50% were at least moderately confident about exercise. Participants also generally felt they could increase their calcium intake and stick to a diet with adequate calcium. No statistical differences related to age and major were found on the OSE.
Conclusions: While young women surprisingly were aware of osteoporosis and the importance of maintaining a regular exercise program and adequate calcium intake, only half of the participants did anything to improve their health and lower their osteoporosis risk. Despite their knowledge, they did not feel at risk for developing osteoporosis. Knowledge did not equate with preventative behaviors. While providing education about osteoporosis is important, motivating women to adopt a healthy lifestyle is the greater challenge. The ability to generalize these findings beyond educated females between 18 and 25 years of age may be limited. Convenience sampling may have resulted in the recruitment of participants with an interest in health care.
Clinical Relevance: It is important to know that while many young women are knowledgeable about osteoporosis, they do not see their own are risk nor does it motivate them to adopt preventative behaviors. More attention must be given to increasing motivation to change their behaviors rather than relying on increasing education efforts.
TITLE: Women's Health Content in Physical Therapy Professional Programs: A Survey of Academic Faculty
AUTHORS: Carol Figuers1, Patricia Nelson2
INSTITUTIONS: 1. Duke University, Durham, North Carolina, USA.
2. Eastern Washington University, Cheney, Washington, USA.
PRESENTER: Carol Figuers, PT, EdD
CONTACT: Carol Figuers: mailto:[email protected]
ABSTRACT BODY:
Purpose/Hypothesis: Women's Health physical therapy practice has grown tremendously in the past 10 years, resulting in an updated description of specialty practice and an APTA-approved board certification in women's health. As the practice environment has changed, understanding the practice expectation level of new professionals is important. The purpose of this survey study was to provide information to update women's Health current curricula guidelines first published in 2005.
Number of Subjects: Faculty teaching the Women's Health content in 203 CAPTE-accredited professional physical therapy programs in the United States were encouraged to participate via an electronic survey.
Materials/Methods: Prior survey instruments and content experts were used to develop this academician survey tool. The survey was organized into 3 sections: (1) demographics, (2) specific women's health curricular content, and (3) content delivery methods. Demographic questions related to education, years of practice, and teaching. Section 2 contained topics based on conditions, knowledge, and skills used by Women's Health practitioners. Respondents were asked: (a) Is the item currently included in your curriculum (yes or no), and (b) if not included, should it be included (yes or no). Section 3 gathered information on instructional strategies with short-answer or open-ended responses allowed. The survey was field-tested by both academic and women's health specialists for item clarity, content depth, and breadth. Modifications from field tests were incorporated into the final survey tool. Survey fielding and data analysis were contracted to ensure anonymity of respondents. Descriptive analysis was completed using Microsoft excel (version 14.1.4).
Results: Out of 201 eligible surveys, 102 were returned, a 51% response rate. The majority of respondents were core faculty and had taught in an academic program for 11.4 years (0-35, 67.6) and 44% carried terminal doctoral degrees. All specific content areas were analyzed for percent agreement. An example of content analysis is internal examination of the pelvic floor as required content. This had 20% agreement that should be included. If included in the content, 43% recommended only lecture and visual instruction. Thirty-eight percent felt that internal pelvic floor examination skills should not be required content, while 14% suggested that this skill be taught in an elective course. Analysis of other key areas will be included in the final guideline.
Conclusions: Curricular content related to women's health is robust and demonstrates good consistency and agreement across many specific content topics. Barriers to effective delivery of this content exist and recommendations are made to address this.
Clinical Relevance: Women's Health curricular content guidelines will be updated and made available to all physical therapists to aide in standardizing content included during professional physical therapist education.
TITLE: Women's Health Content in Physical Therapy Professional Programs: A Survey of Women's Health Section Clinical Practitioners
AUTHORS: Patricia R. Nelson1, Carol Figuers2
INSTITUTIONS: 1. Physical Therapy Department, Eastern Washington University, Spokane, Washington, USA.
2. Doctor of Physical Therapy Division, Duke University, Durham, North Carolina, USA.
PRESENTER: Patricia Nelson, PT, ScD, OCS, FAAOMPT
CONTACT: Patricia Nelson: mailto:[email protected]
ABSTRACT BODY:
Purpose/Hypothesis: As Women's Health practice has become more specialized and has achieved clinical specialization, understanding practice expectations of new professionals is important. The purpose of this survey study was to provide information to update the Women's Health Professional Program Curricula Content Guideline first published in 2005.
Number of Subjects: All Women's Health Section members were invited to participate via an electronic survey.
Materials/Methods: Revisions were made to the Academician Survey tool after fielding to all US Professional Physical Therapy Programs. Content in the 3-section survey was modified in sections 1 and 3 to capture data related to clinical practice and clinical education of professional student's versus didactic teaching. Section 2 content focused on conditions, knowledge, and skills used by Women's Health practitioners and was unchanged; however, the response set was modified. It asked: (1) should this item be taught in entry-level curriculum (yes or no), and (2) if taught, what level of student mastery is expected. The choices were as follows: (a) Familiar-student is aware of the content but needs further instruction and significant mentoring to implement, (b) Proficient-moderate mentoring needed to implement with less complex clients, or (c) Mastery-autonomous implementation with any client with minimal mentoring. The survey was field-tested by Women's Health specialists for item clarity with feedback incorporated into the final survey tool. Survey fielding and data analysis were contracted to ensure anonymity of respondents. Descriptive analysis will be completed using Microsoft Excel (version 14.1.4).
Results: As the Clinical Practitioner Survey was still being fielded, the following is the analysis plan for this data. Demographic items will be used to describe practice setting and educational preparation of the survey respondents. Content items will be described by percent agreement to include, or exclude, specific content and then further analyzed to determine expected depth of student mastery. In addition, comparisons will be made to the Academician Survey results to assess level of content-specific agreement across the items in section 2. Finally, as many practitioners also teach in academic programs, analysis of responses by those who practice clinically to those who teach and practice will be made.
Conclusions: It is expected that solid agreement by Women's Health clinical practitioners will exist across many areas of Women's Health curricular content. Clinician expectations of entry-level physical therapist performance related to Women's Health content are unknown. We plan to make the updated guideline document available to both academic programs and clinical practitioners.
Clinical Relevance: Standardizing content expected during professional physical therapist education will help clinical educators and employers have realistic views of entry-level student performance with content related to Women's Health.