TITLE: Reinterpretation of Obstetric Pubic Symphyseal Diastasis Biomechanics

AUTHOR: Jerry W. Hesch

INSTITUTION: Hesch Institute, Henderson, Nevada.

ABSTRACT BODY:

Purpose: To present radiographic images in support of reinterpretation of obstetric pubic symphyseal diastasis (OPSD), to describe manual evaluation and treatment, and report research on optimal pelvic support placement.

Description: OPSD is a painful widening of 10 mm or more in response to ligamentous softening, fetal growth, and parturition resulting in significant functional limitations. Recent CT images suggest a different biomechanical trajectory beyond simple obstetric pelvic widening. CT images (n = 7, 1989-2011 database search) demonstrate OPSD with SIJ gapping and unreported inferior/posterior retroarticular approximation. A flexible ligamented anatomical model was utilized to simulate obstetric joint mechanics. Upon encountering a distinct end-point, blunt dissection introduced a complete diastasis. Congruent with the CT images, moving the pubes and ilia in the transverse plane in a cam-like manner maximized the pelvic outlet.

Summary: Diagnostic images may already exist in the medical record, and manual testing of transverse plane movement dysfunction may have utility for the symptomatic subacute and chronic pubic dysfunction population. Manual intervention is presented. The location of pelvic support application is typically suboptimal (at ASIS or just below). In contrast, trochanteric application is superior per published case studies and cadaveric studies indicate 40% greater compression in the joints using accelerometers.

TITLE: Pelvic Joint Mobilization for False Positive Late Pregnancy Instability

AUTHOR: Jerry W. Hesch

INSTITUTION: Hesch Institute, Henderson, Nevada.

ABSTRACT BODY:

A 29-year-old female in the 32nd week of pregnancy had progressive pelvic pain and perceived instability feeling that her pelvis was coming apart in the front. She maintained hip adduction with all positional changes. Gait was antalgic, with a narrow base of support and shortened stride length. Pelvic instability in pregnancy is a well-established concept due to the enhancing size of the fetus, with a background of hormonal priming, particularly relaxin and estrogen. Evaluation was performed in a very cautious and limited manner with the expectation that significant pelvic instability would be encountered. Instead, micromotion testing revealed a surprising, significant hypomobility in multiple directions. Within a single intervention her posture and mobility were much improved, along with significant pain reduction. She reported significant improvement in bladder control and went on to have an easy natural delivery. In this case the subjective sense of instability was most likely a reflection of the visceral and neural tension and compression in response to the 3-dimensional nonphysiological positioning of the pelvic articulations with induced spasm. This case of true hypomobility presenting as subjective "instability" underscores the utility of joint micromotion testing, AKA springing with awareness. Hypomobility and hypermobility are relevant peripartum constructs.

TITLE: Physical Therapy Management of Shoulder Dysfunction Following Mastectomy

AUTHORS: Nicole A. Baldridge¹, Diane Borello-France²

INSTITUTIONS: 1. WomensRehab Men's Health, UPMC Center for Rehab Services, Pittsburgh, Pennsylvania.

2. Department of Physical Therapy, Duquesne University, Pittsburgh, Pennsylvania.

ABSTRACT BODY:

Background & Purpose: In the United States (US) alone, about 1 out of 8 women will develop invasive breast cancer. 2009 statistics indicate about 2,747,459 US women were reported to have this disease, including those undergoing active treatment, and those who have been treated successfully. Axillary lymph node surgery is essential for the treatment of breast CA, but can produce short- and long-term morbidities, including lymphedema, shoulder restriction, numbness, weakness, and pain syndromes. Axillary webbing (AWS), or cording, is a visible web of skin overlying palpable cords of tissue in the axillary fossa extending into the distal upper extremity (UE), frequently to the elbow or wrist, affecting 40% to 72% of patients after ALND. Upper-limb morbidity may interfere with the activities of daily life and quality of life. Muscle/myofascial trigger points can play an important role in the evolution of postmastectomy pain. Postsurgical scarring can create pressure and tightness on the chest wall and can lead to an anterior protective posture. Researchers note abnormal scapular motion among breast CA survivors. Range of motion (ROM) and strength deficits in the UE may result from scapular dyskinesis. This case report describes the physical therapy management of a patient following mastectomy with ALND surgery including examination of and interventions to decrease postsurgical myofascial restrictions/AWS, anterior protective posture, scapular mobility, and scapular dyskinesis.

Case Description: A 65-year-old female post right breast mastectomy, sentinel lymph node biopsy, and subsequent ALND presented with chest skin tightness; incisional pulling with overhead movements; numbness/tingling on lateral chest wall, axilla, and medial upper arm; AWS (1-inch-thick bisecting axilla; scapular dyskinesis; and decreased right shoulder ROM with difficulty performing overhead activities). PT interventions included myofascial release, anterior chest wall flexibility, scapular stabilization, kinesiotaping, and postural reeducation.

Outcomes: Right shoulder ROM improvements were improved by 33 degrees and 82 degrees in flexion and abduction, respectively; and motions were pain-free. Scores on the Disabilities of Arm, Shoulder, and Hand (DASH) improved from 19 to 3 (MCID 15pt difference). Bilateral UE girth circumference measurements revealed <2 cm difference, a decrease of right elevated and upwardly rotated scapula resulted in symmetry of scapula bilaterally.

Discussion: This case report illustrates the role of the PT in managing postoperative complications of breast CA. In addition, it suggests that myofascial release techniques may be beneficial to decrease mobility restrictions and pain and may assist in regaining ROM. It also illustrates the need for early introduction of scapular stabilization exercises for prevention of shoulder impingement.

TITLE: Use of Pelvic Floor Muscle Training to Improve Sexual Function in a Patient With Anorgasmia

AUTHORS: Elizabeth R. Northrop, Cynthia E. Neville, Jason Beneciuk

INSTITUTION: Brooks Rehabilitation, Jacksonville, Florida.

ABSTRACT BODY:

Background & Purpose: Sexual dysfunction and orgasmic disorder affect many women. Though there are many suggestions in the literature as to the etiological process of anorgasmia, there are few treatment options that have been proven effective. Sexual dysfunction and urinary incontinence often coexist in women who have pelvic floor disorders. The purpose of this case report is to describe a pelvic floor muscle (PFM) training approach to improving sexual function in a patient with a physical therapy diagnosis of underactive PFM, with associated anorgasmia and stress urinary incontinence.

Case Description: The patient in this case report was a 65-year-old female. Her chief complaint was that she was unable to have an orgasm during intercourse, but she had had normal orgasms up until five years prior. She was experiencing symptoms of urinary incontinence, though she stated it was not significant. She stated that her goal was to be able to have pleasurable intercourse. The patient was initially instructed in PFM exercises to improve her coordination of contracting and relaxing the PFM, and with the intent to revascularize the pelvic floor. Her exercise program was progressed in order to improve the strength of the PFM. The patient was encouraged to try using a vibrator during intercourse for additional clitoral stimulation in order to achieve an orgasm. sEMG biofeedback was performed using an internal vaginal sensor for tactile stimulation. Neuromuscular electrical stimulation was applied over pudendal nerve, specifically to two of its branches: the dorsal nerve of the clitoris and the perineal nerve. The perineal nerve innervates the transverse perineal muscle and the urethral sphincter, while the dorsal nerve of the clitoris innervation bulbospongiosus and ischiocavernosus.

Outcomes: This patient was seen once a week over a 6-week period for a total of 6 visits. She demonstrated an improvement in her sexual function with a 9.4-point increase in her FSFI score to 31.2 out of 36. A score below 26.5 is indicative of sexual dysfunction, potentially suggesting that this patient demonstrated normal sexual function following treatment. The patient was able to achieve strong orgasms during intercourse with the use of a vibrator for clitoral stimulation, and she met her goal of being able to have pleasurable intercourse with her partner. She reported that she was able to achieve an orgasm about 25 percent of the time when she had intercourse, an improvement compared to zero percent prior to treatment.

Discussion: The findings from this case report indicate that PFM training may be effective in improving sexual function in a patient with anorgasmia, who has a history of normal orgasm capacity. This is reasonable, considering that PFM dysfunction is thought to be a cause of sexual dysfunction, so treating the weakness and incoordination pelvic floor would likely improve sexual function. There is a gap in literature addressing the effect of PFM training on anorgasmia, so there is absence of comparison for this patient's case.

TITLE: Physical Therapy Management of Lower Extremity Lymphedema in an Endometrial Cancer Survivor

AUTHORS: Alaina Newell¹, Diane Borello-France²

INSTITUTIONS: 1. WomensRehab and Men's Health, UPMC Centers for Rehab Services, Pittsburgh, Pennsylvania.

2. Rangos School of Health Services, Duquesne University, Pittsburgh, Pennsylvania.

ABSTRACT BODY:

Background & Purpose: Compared to other gynecological cancers (CA) among US women, endometrial CA has the highest incidence. The first line of treatment for this CA is a total hysterectomy with lymph node dissection (LND). Following surgery, reports indicate that 1.2%-42% of patients develop Secondary Lymphedema and 17%-32% experience pelvic pain.^1-5 Women's Health Physical Therapist (PT) poses the necessary tools to manage this patient population.

Case Description: The patient was an active 69-year-old female at 17 weeks status post laparoscopic hysterectomy with LND for treatment of Grade 3 Mixed Endometrial CA. She presented with Stage II Secondary Lymphedema, isolated to the right ankle that began 6 weeks postoperatively. She reported numbness in bilateral fingers, toes, and dorsum of feet, and tightness, swelling, and aching around her right ankle. She denied balance difficulties, fall history, urinary and fecal incontinence, and pelvic pain. Upon examination, the patient independently ambulated without gait abnormalities and demonstrated equal, bilateral lower extremity strength and range of motion. She had significant fibrosclerotic, pitting edema with altered right ankle joint definition. However, circumferential measurements were within +1% (21 mL), bilaterally. Activity limitations included pain difficulty donning shoes, inability to manage edema despite self-prescribed 8-15 mmHg compression stocking, and exercise (unable to hike >35 minutes; yoga without modifications). At baseline, she scored a 77/80 on the Lower Extremity Functional Scale (LEFS), indicated a pain intensity of 1-4/10 on the numeric pain rating scale and was above the proposed cutoff for detection of lymphedema via the Gynecologic Cancer Lymphedema Questionnaire (9/20). The patient attended 7 physical therapy visits over 7 weeks. Interventions included Complete Decongestive Therapy (CDT), including a modified compression system, manual lymphatic drainage, exercise, skin/nail care, and patient education. The patient was fitted with a 20-30 mmHg compression stocking and performed nighttime bandaging with a Caresia bootie to maintain the fibrosclerosis reduction.

Outcomes: After 4 weeks (6 visits), the patient was transitioned to self-management (Phase II CDT). She donned shoes without difficulty, returned to hiking (2-4 hours), and resumed her full yoga practice. Her volumetric measurements reduced by 7.5-8.7%, bilaterally with an asymmetry of +2.2% (46 mL) right vs. left. After 3 weeks of Phase II CDT, she maintained volumetric measurements and activity participation, reported a reduction in pain (0-2/10), and remained at 77/80 on the LEFS. She was independent with self-management CDT.

Discussion: Patients with gynecological CA who undergo a hysterectomy with LND are at risk for developing Secondary Lymphedema as well as pelvic floor dysfunction. A comprehensive Women's Health PT evaluation is warranted for patients pre- and post-operatively to identify activity limitations and to prevent secondary impairments to maximize patient outcomes.

TITLE: Combined Manual Therapy Techniques for the Treatment of Women With Infertility: A Case Series

AUTHOR: Mary Ellen Kramp

INSTITUTION: Relief at Hand, LLC, Seminole, Florida.

ABSTRACT BODY:

Purpose/Hypothesis: Current management options for infertility, including hormone therapy, intrauterine insemination, and in vitro fertilization, tend to be expensive, are not necessarily covered by insurance, and carry different levels of short-term and long-term health risks. Many of the issues that contribute to infertility can be traced to scar tissue, fascial restriction, and lymphatic congestion in the pelvic region. Manual therapy techniques exist to release fascial restrictions, to mobilize tight ligaments, and to drain congested lymphatics, all of which can be applied to the reproductive system.

Number of Subjects: 10 infertile women (per CDC definition of infertility).

Materials/Methods: Techniques utilized during treatment included muscle energy, lymphatic drainage, positional release, and visceral manipulation.

Results: Six of the 10 women conceived within 3 months of the last treatment session, and all 6 of those women delivered at full term.

Conclusions: The response of the treatment was equivalent to the rate of the normal population achieving pregnancy within 3 months (57%). Further research is warranted on a larger scale as well as assessing the efficacy of individual techniques.

Clinical Relevance: Therapists can use treatments that are already performed on other parts of the body and apply them to the reproductive system in a manner equivalent to normalizing its range of motion by using fascial releases and decreasing the swelling within the pelvis with lymphatic drainage to promote improved function of the uterus, uterine tubes, and ovaries.

TITLE: Anterior Cruciate Ligament Elasticity and Force for Knee Flexion During the Menstrual Cycle: The Effect of Estradiol Hormone and Tissue Temperature

AUTHORS: Haneul Lee, Jerrold Petrofsky, Lee Berk, Noha Daher, Michael Laymon

INSTITUTION: Loma Linda University, Loma Linda, California.

ABSTRACT BODY:

Purpose/Hypothesis: Numerous studies have been conducted on changes in knee ligament laxity during the menstrual cycle since there are more injuries in certain phases of the menstrual cycle. It is believed that since there are beta-estrogen receptors in ligaments and tendons, that estrogen alone could cause change in laxness in women. However, increased tissue temperature also causes ligament and tendon elasticity. The goal of this investigation was to evaluate the relationship between estradiol serum and knee laxness related to tissue temperature in young healthy women with a regular menstrual cycle.

Number of Subjects: 10.

Materials/Methods: All testing was performed 7 times depending on each subject's menstrual phase for 1 full menstrual cycle. Upon arriving in the examination area, the subjects rested comfortably in a regulated temperature room at 25[degrees]C for 20 minutes to stabilize their body temperature. First, a blood sample was taken to analyze estradiol serum concentration before measuring quadriceps and knee skin temperature. Next, to assess the baseline, the ACL, quadriceps muscle, and tendon flexibility were measured. After, 38[degrees]C heat pads were placed on each subject's quadriceps and knee for 20 minutes to control their leg temperature. Skin temperature, ligament laxity, and muscle and tendon flexibility measurements were repeated. In this manner, by comparing estradiol and the tissue temperature, the effect of temperature and estradiol itself could be deduced.

Results: ACL laxity and quadriceps elasticity were significant higher during ovulation where estradiol level peaks compared to the menstruation where estradiol is lowest. Leg skin temperature is relatively lower during ovulation than menstruation. However, there was no significant difference in muscle and tendon elasticity throughout the menstrual cycle after warming to 38[degrees]C while ACL was still influenced by estradiol hormone. In addition, quadriceps elasticity significantly increased after using 38[degrees]C heat in all phases except ovulation while no significant change was found on ACL laxity after using 38[degrees]C heat in all phases.

Conclusions: These findings indicate that estradiol hormone is more active at ambient temperature compared to at 38[degrees]C warming. However, heat has more impact on muscle and tendon elasticity than estradiol hormone at 38[degrees]C warming, which is nearly body core temperature.

Clinical Relevance: Using heat before exercise would be beneficial on increasing elasticity and it might help prevent injuries, the optimal time would be in the menstruation and early follicular phases, which the least elasticity was observed at ambient temperature.

TITLE: Diagnostic Accuracy of the Posterior Pelvic Pain Provocation Test for Pelvic Girdle Pain Syndrome

AUTHORS: Tessa Fraser, Amanda Peterson, Greg Wilmoth, Michael P. Reiman, Carol Figuers, Adam Goode

INSTITUTION: Community and Family Medicine, Duke University, Durham, North Carolina.

ABSTRACT BODY:

Purpose/Hypothesis: The Posterior Pelvic Pain Provocation (PPPP) test is a thigh thrust type of diagnostic test for Pelvic Girdle Pain Syndrome (PGPS). Previous reviews have supported its clinical use; however, the pooled diagnostic accuracy properties attributed to PGPS have not been reported. Therefore, the purpose of this study is to systematically review the literature and determine the pooled diagnostic accuracy properties of the PPPP test for PGPS.

Number of Subjects: 2774 subjects were included in the systematic review and 2574 were included in the meta-analysis.

Materials/Methods: This systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A computer-assisted literature search of PubMed, CINAHL, EMBASE, and SportDiscus databases was utilized with key words related to diagnostic accuracy and sacroiliac joint dysfunction. To be eligible, studies had to include postpartum or pregnant women and report the sensitivity (SN) and specificity (SP) values for the PPPP test. Studies reporting diagnostic values aggregated by the number of tests performed were excluded from pooled analyses. Quality assessment of bias and applicability was conducted using the Quality of Diagnostic Accuracy Studies-2 (QUADAS-2). Hierarchical summary receiver operating characteristic and normal bivariate models were used to produce pooled SN, SP, positive likelihood ratios (+LR), negative likelihood ratios (-LR) and area under the curve (AUC) estimates with their respective 95% confidence intervals (CI). Sensitivity and SP values >= 0.80 were considered good to excellent and +LRs from 5.0-10.0 or -LRs <= 0.20 were deemed likely to result in moderate shifts in the posttest probability. An I-squared (I²) value of >50% and Cochrane's-Q P-value of <0.10 were the criteria to indicate significant heterogeneity.

Results: Five articles met the criteria for inclusion, all of which found the PPPP test to have good diagnostic accuracy properties. QUADAS-2 results indicated high risk of bias in 4 of the 5 studies and low concern for applicability in all 5 studies. Four studies were eligible for meta-analysis producing a pooled SN and SP of 0.82 (95% CI: 0.71-0.89) and 0.90 (95% CI: 0.73-0.97), respectively. The positive likelihood ratio was 8.05 (95% CI: 2.57-25.23) and -LR was 0.20 (95% CI: 0.11-0.37). The diagnostic odds ratio was 40.0 (95% CI: 7.38-219.03) while the AUC was 0.90 (95% CI: 0.87-0.93). Significant variability (heterogeneity) was found between studies (I2 = 73% and Q-P-value = .02).

Conclusions: The PPPP test is an accurate diagnostic test with good-to-excellent pooled diagnostic properties. A positive PPPP test may result in a moderate increase in the likelihood of PGPS diagnosis whereas a negative PPPP test may result in a moderate decreased likelihood of PGPS. The high risk of bias in most studies may attribute to the significant variability between studies, which limits these findings.

Clinical Relevance: A clinician should consider the PPPP test in conjunction with a thorough history and examination to diagnose PGPS.

TITLE: Diastasis Rectus Abdominis and Function in Pregnancy

AUTHORS: Cynthia M. Chiarello¹, LaRae Klarenbeek-Mitchell², Tiffany Orlowski¹, Stephanie Stamas¹

INSTITUTIONS: 1. Rehabilitative and Regenerative Medicine, Program in Physical Therapy, Columbia University, New York.

2. Rehabilitative and Regenerative Medicine, Department of Therapy, Columbia University Medical Center, New York.

ABSTRACT BODY:

Purpose/Hypothesis: Currently no studies directly examine the impact of a Diastasis Rectus Abdominis (DRA) on daily function in pregnant women. The purpose of this exploratory pilot study was to examine the relationship between a DRA and functional activities in pregnant women with self-reported low back pain. We hypothesized that the larger the DRA a higher the level of disability and diminished function would occur.

Number of Subjects: Twenty-five women between 15 and 37 weeks of pregnancy (mean = 23.5 +/- 1.27), aged 23 to 38 years (mean = 32.3 +/- 3.57) with self-reports of low back pain participated.

Materials/Methods: DRA was measured as the Inter-Recti Distance (IRD) or the linear distance between the medial aspects of the rectus abdominis muscles at the linea alba using a nylon digital caliper (Mitutoyo America Corporation, Aurora, Illinois). IRD was measured passively with the abdominal muscles at rest and actively with the subject performing an active abdominal muscle contraction at 3 locations, 4.5 cm above the umbilicus, 4.5 cm below the umbilicus, and at the umbilicus. Function was determined with a modified Pregnancy Mobility Index (PMI), a 24-item self-report questionnaire with 3 subsections: daily mobility in the house, ability to perform normal household activities, and mobility outdoors. Percentages were calculated for the entire PMI and for each subsection with a higher percent, suggesting a greater degree of limitation.

Results: IRD was largest at the umbilicus for each condition (passive mean = 31.9 mm +/- 5.81, active mean = 23.7 mm +/- 6.15). Though similar, IRD was slightly larger above the umbilicus than below for each condition. Functional limitations found were an overall PMI of 38.4% +/- 20.81 and PMI subsections as follows: household mean = 46.2 +/- 22.53, ADL mean = 41.1+/- 23.03, outside mean = 27.9 +/- 21.03. Stepwise multiple regressions were computed for each location and condition using the PMI subscale percentages and age, weeks gestation, number of pregnancies, and umbilical circumference as predictor variables. This model explained 18% of the IRD variability measured actively at the umbilicus with weeks gestation the only significant predictor (P = .04). Above the umbilicus, 25% of the variability measured passively was explained with the number of pregnancies (P = .04) as a significant predictor and outside activities approached significance (P = .06).

Conclusions: Pregnant women exhibited a larger IRD than reported for nulliparous women. Minimal to moderate functional limitations were found by the PMI with outside activities impacted the most. The large variability of the PMI scores noted between subjects indicates the need of a larger sample size. Weeks gestation and number of pregnancies are also shown to be implicated in the size of a DRA.

Clinical Relevance: Understanding factors contributing to DRA and function in pregnancy can help direct interventions. This study introduces an objective measure of functional capabilities in pregnant women, allowing researchers to analyze deficits in household mobility, activities of daily living, and community mobility.

TITLE: Effect of Physical Therapy on Pain and Health Related Quality of Life in Chronic Pelvic Pain Syndrome

AUTHORS: L. A. Steiner, R. Maniar, Z. Basrai

INSTITUTION: MGH Institute of Health Professions, Boston, Massachusetts.

ABSTRACT BODY:

Purpose/Hypothesis: Chronic pelvic pain syndrome (CPPS) is a disabling condition affecting 14% women and 8% men in the USA. It can present differently in men and women, hence it is defined separately for them. The purpose of this review is to determine the common and the most beneficial PT treatments for CPPS.

Number of Subjects: 20 articles were included.

Materials/Methods: PubMed/OVID, CINAHL, and Google Scholar were searched for English language articles from 1985 to present. Inclusion criteria: men and women, age > 18 years, chronic or recurrent pelvic pain > 3 months, ROME 2-f2a criteria (for men), diagnoses of dyspareunia or vulvodynia (for women). Exclusion criteria: Active infection as a cause for CPPS, coccydynia, sacro-iliac joint dysfunction, anal fissure, intramuscular abscess, endometriosis, and dysmenorrhea. Randomized controlled trials (RCTs), case-control studies, case series, case reports, and pilot studies were included. Outcomes measures assessed were pain on VAS or NPRS, and health-related quality of life self-report questionnaires such as the Pelvic Floor Impact Questionnaire, Female Sexual Function Index, and the NIH Chronic Prostatitis Symptom Index. The PEDro scale and Sackett's level of evidence were used to determine quality. Two individuals rated the articles on the PEDro scale. A third rater reconciled differences.

Results: Of the 20, 7 were RCTs and the remaining were case series or case reports. PEDro scores ranged from 3 to 10 and that of Sackett's level of evidence from 1b to 4. TENS, biofeedback, myofascial release, aerobic exercises, and electromagnetic therapy were supported as effective interventions (PEDro score of 7 or more) and level of evidence (1b). Interventions such as manual therapy (7 articles) included massage, use of vaginal dilators, and trigger point release. Electrical modalities (6 articles) included TENS, High Voltage Pulsed Galvanic stimulation and electrical stimulation, Exercises (3 articles) such as pelvic floor muscle exercises, aerobic exercises and general stretching; and biofeedback (4 articles) were also studied. All of these showed significant improvements in the outcome measures as well but presented with lower quality (PEDro 3-4) and Sacketts level of 4. There were overall more studies on men, and those studies used more consistent outcome measures than the studies on women.

Conclusions: Since all interventions showed some degree of improvements in the treatment of CPPS, it is not possible to determine the most beneficial PT intervention at this time. However, the highest-quality studies support the use of TENS, MFR, biofeedback, aerobic exercise, and electrical stimulation. There is some evidence for a multimodal approach.

Clinical Relevance: The rate of occurrence of CPPS is higher in women than in men yet it seems to be understudied with respect to men. There is clearly a need for use of more consistent outcome measures and higher-quality studies in the female population with CPPS to help guide our clinical practice.

TITLE: Use of Visceral Mobilizations and Myofascial Release in the Treatment of Hip Osteoarthritis: A Retrospective Case Study

AUTHORS: Christine S. Martin¹, Eileen V. Johnson²

INSTITUTIONS: 1. Physical Therapy, UF & Shands Orthopedic and Sports Medicine Institute, Gainesville, Florida.

2. Physical Therapy, Shands Rehab at Magnolia Parke, Gainesville, Florida.

ABSTRACT BODY:

Background & Purpose: Sports and orthopedic physical therapists do not commonly assess or use visceral or external pelvic floor mobilization in the treatment of hip, sacroiliac joint, and lumbar conditions. Also, trauma related to previous abdominal, pelvic, or hip surgeries is often unaddressed. The purpose of this case study is to demonstrate the use of visceral mobilizations and myofascial techniques in the care of a patient presenting with hip pain and a history of abdominal surgery.

Case Description: The patient is a 55-year-old female with chronic right hip pain following a hysterectomy in October 2011. Her medical treatment consisted of a cortisone injection to the right hip and referral to physical therapy with a diagnosis of hip osteoarthritis. The patient reported pain when sitting cross-legged, moving from sitting to standing, walking fast, Zumba and yoga 3-4 times a week. Her initial Lower Extremity Functional Scale score was 44/80, and TSK-11 score was 29. The patient was limited in hip internal rotation, exhibited hypomobility in her inferior and posterior right hip capsule, and decreased muscle strength in hip flexion, extension, and abduction. She demonstrated tightness in bilateral iliotibial band and hip adductors and a positive FABER test. The pelvic floor examination found mild tenderness to palpation and moderate restriction to bilateral obturator internus musculature. She demonstrated moderate to severe restrictions with the bladder, recto-uterine and vesico-uterine pouch region in lateral, superior, inferior planes and with rotation, and moderate myofascial restrictions of her laparoscopic scars. The patient participated in 13 sessions of physical therapy which consisted of myofascial release to abdomino-pelvic fascia and laparoscopic scars, visceral mobilization, iliopsoas release, and mobilization of the SI and hip joints. She was also trained in diaphragmatic breathing exercises with pelvic floor muscle coordination and core stabilization exercises, including adductor and hip flexor stretching.

Outcomes: At completion of treatment, the patient returned to aquatic Zumba and yoga. Hip mobility returned to normal, despite no changes in hip internal rotation. Hip extension and abduction strength improved. Additionally, the patient's SI joint and pelvic innominate alignment were restored, and there was a reduction in abdomino-pelvic fascial restrictions along the iliopsoas, quadratus lumborum, and obturator internus and symmetry in mobility of the visceral restrictions. The patient demonstrated an improved LEFS score of 56/80 and TSK-11 score of 17.

Discussion: The abdominal viscera and pelvic floor musculature are not commonly assessed or treated in patients with hip pain, despite the overlap of referred pain sites in this region. The results from this case study suggest that visceral mobilization and other manual therapy techniques to the pelvic floor and surrounding regions may be useful in reducing hip pain, particularly if the patient has a history of abdominal trauma/surgery.

TITLE: What Happens the Piriformis When the Hip Goes Above 90 Degrees? A Double Blinded In Vivo Ultrasound Study

AUTHORS: Ruth M. Maher, Jeanne P. Welch, Katie Barron, Katelyn Crane, Jensine Jernigan, Karissa Sellors, Jessica Williams

INSTITUTION: University of North Georgia, Dahlonega, Georgia.

ABSTRACT BODY:

Purpose/Hypothesis: The purpose of this study was to determine whether the action of the piriformis changes in response to different hip positions.

Number of Subjects: Ten healthy subjects (5 males and 5 females) with normal hip anteversion angles were recruited from a physical therapy student body.

Materials/Methods: Participants underwent 4 testing conditions: hip external and internal rotation in prone with the hip in neutral and knee flexed to 90 degrees and in supine with the hip and knee flexed above 90 degrees. The ischial tuberosity, posterior superior iliac spine, and the greater trochanter were used as anatomical landmarks to locate the piriformis and the overlying skin was marked on a randomly selected lower extremity. Real time ultrasound images/movies (RUSI) were acquired with a curvilinear transducer oriented in the transverse plane over the piriformis while participants were cued to internally and externally rotate the hip. A lateral to medial motion with increases in cross-sectional area of the piriformis was defined as shortening (concentric contraction), whereas a medial to lateral motion with decreases in cross-sectional area was defined as lengthening (stretching). This translates physiologically as the distal attachment moving toward the proximal attachment (shortening/contracting concentrically) or vice versa (lengthening/stretching). Two blinded raters reviewed the data.

Results: Agreement between two blinded reviews of the RUSI was 100%, [chi]²(1, N = 10) = 0, P = 1. These findings confirm the piriformis concentrically contracted when performing external rotation with the hip in neutral and above 90 degrees of hip flexion. There was no RUSI evidence to suggest the piriformis changed its action.

Conclusions: We believe this novel study is the first in vivo study using RUSI to examine the function of the piriformis during different hip positions. Our preliminary findings do not support those from previous cadaveric studies which stated the piriformis acts as an internal hip rotator when the hip is flexed above 90 degrees.

Clinical Relevance: Cadaveric studies have reported the piriformis changes its line of pull when the hip flexes above 90 degrees. These findings have affecting how stretches are recommended for the piriformis and what information is included in text books for physical therapy students. Many of these studies removed all tissue and used radiopaque beads to determine the attachment points of the piriformis or determined the line of pull while manually flexing the hip while the pelvis was mounted. Consequently, findings do not reflect an in vivo analysis of the piriformis. This pilot study gave a real time visual record of the effect of hip position on the action of the piriformis in vivo. Since exercise programs are based on knowledge of muscle function and biomechanics, inappropriate exercises could exacerbate symptoms in those with a pathology related to the piriformis. Further studies are required in a larger population with a variety of anteversion angles to determine if our findings can be generalized.

TITLE: Factors Associated With Stress Urinary Incontinence in Female College Athletes: A Pilot Study

AUTHORS: Stacie Bertram, Taylor McDermott, Megan Sutherland

INSTITUTION: Bradley University, Peoria, Illinois.

ABSTRACT BODY:

Purpose/Hypothesis: To investigate the frequency of stress urinary incontinence (SUI) among female college athletes and factors that may be related to urinary leakage and stress incontinence.

Number of Subjects: 10.

Materials/Methods: Subjects were recruited via e-mail, flyers, and word of mouth to participate in this study. Ten female college athletes (softball, dance, volleyball, and soccer) were tested in February 2013. All subjects completed the Epidemiology of Prolapse and Incontinence questionnaire (EPIQ), a self-report questionnaire that screens for pelvic floor disorders. Items specific to SUI were used in data analysis for this study. All subjects' body mass index, lumbar lordosis, abdominal strength, and hip rotator strength were assessed.

Results: Lumbar lordosis indices as determined by flexible ruler measurement ranged from 8.82 to 16.32. Sixty percent of subjects reported having to empty their bladder at least every 3 to 4 hours, and 20% reported nighttime urination. Twenty percent of the subjects reported having to rush to the restroom to avoid urinary leakage and 50% reported that they experienced leakage with activity. No correlation was found between BMI, lumbar lordosis or hip rotator strength, and reports of SUI. Spearman's rho revealed a significant correlation between abdominal strength and reports of leakage with activity (rs [8] =-0.88, P < .002) and small amounts of urine leakage (rs [8] =-0.80, P < .003). The subjects with decreased abdominal strength reported more complaints of urine leakage with activity and of leaking small amounts of urine.

Conclusions: In this pilot study, abdominal weakness was related to urinary leakage and complaints of SUI in female college athletes.

Clinical Relevance: Stress urinary incontinence is more prevalent in younger women than previously thought. These findings suggest that abdominal weakness is related to urinary incontinence in female athletes more so than other factors such as lumbar posture. More research is warranted in this area with a larger sample to more thoroughly investigate factors associated with urinary incontinence in young female athletes.

TITLE: The Efficacy of Written and Verbal Pelvic Floor Exercise Discharge Instructions in Reducing Urinary Incontinence Among Postpartum Patients

AUTHORS: Ann Frost¹, Deb Trankel², Maureen Shannon³

INSTITUTIONS: 1. Women's Health Center, Queen's Medical Center, Honolulu, Hawaii.

2. OB-GYN Nursing, Queen's Medical Center, Honolulu, Hawaii.

3. School of Nursing and Dental Hygiene, University of Hawaii, Honolulu, Hawaii.

ABSTRACT BODY:

Purpose/Hypothesis: The purpose of this study was to determine the efficacy of written and verbal pelvic floor muscle exercise postpartum discharge instructions on decreasing the incidence, duration, and severity of urinary incontinence among postpartum patients.

Number of Subjects: A total of 128 (n = 64 in each arm) primiparous, vaginally delivered women, 18 years of age or older, were recruited to participate.

Materials/Methods: The study was a randomized clinical trial. Women in the control group (CG) received standard postpartum discharge instructions. Women in the experimental group (EG) received standard postpartum discharge instructions and were given written and verbal instructions about pelvic floor muscle exercises (PFME). Patient demographic characteristics and obstetrical history data were collected prior to delivery. Urinary incontinence, urogenital distress, and updated demographic information were collected by phone interview 6 to 8 weeks after delivery.

Results: Of the 128 women recruited, 30% were lost to C-section or follow-up. For the 31 in the CG and 41 in the EG whose data has been analyzed using SAS, there were no significant differences in demographic variables, obstetrical complications, or urinary symptoms at 6-8 weeks postpartum between the 2 groups. Fisher's exact tests were conducted to evaluate the impact of incontinence on quality of life and revealed a statistically significant association between urine leakage and feeling frustrated (P < .0065), perceptions of emotional health (P < .008), participation in social activities outside of the home (P < .014), ability to do household chores (P < .014), travel for 30 minutes from home (P < .014), and physical recreation (P < .000004). The remaining data which was collected is in the process of being analyzed and may or may not have a significant impact on results.

Conclusions: Preliminary analysis indicates that urinary incontinence in postpartum women is associated with decreased quality-of-life experiences. The lack of statistically significant differences between the CG and EG groups at this point in the study may be due to the small sample size available for analysis at this time or may reflect that postpartum women in both groups benefited from either approach to education about PFME. However, analysis does reveal that education about the impact of UI symptoms on quality of life for postpartum women should be assessed with reinforcement about continuing with PFME as a means of reducing UI symptoms.

Clinical Relevance: This study indicates that postpartum urinary incontinence has negative effects on quality of life for women. It paves the way for inquiry into best methods for educating women about urinary incontinence and its treatment and prevention. Given the high number of women who experience urinary incontinence in their lifetime effective teaching during the postpartum period may improve not only continence but also quality of life, both during and after the postpartum period.

TITLE: Predictors of Reduced Function and Quality of Life in Individuals With Fibromyalgia and Healthy Subjects

AUTHORS: Dana L. Dailey, Nicholas Cooper, Laura Frey Law, Kathleen A. Sluka

INSTITUTION: University of Iowa, Iowa City, Iowa.

ABSTRACT BODY:

Purpose/Hypothesis: Fibromyalgia is a widespread pain condition associated with fatigue, fear of movement, reduced function, and quality of life. We hypothesize that pain, fatigue, and fear of movement contribute to the decreased function and quality of life. The aim of the study was to determine the degree to which pain, fatigue, and fear of movement are predictors of function and quality of life in individuals with fibromyalgia and healthy subjects.

Number of Subjects: Fibromyalgia subject information was gathered from a previously completed study which included 43 individuals with fibromyalgia (42F, 1M) ages 25-76 years (mean 49.2 +/- 12 years). The healthy age matched control group included 38 individuals (37F, 1M) ages 25-76 years (mean 46.5 +/- 2.5 years).

Materials/Methods: Pain was assessed with a visual analog scale (VAS) and pressure pain thresholds (hyperalgesia). Fatigue was assessed with a VAS, Multidimensional Assessment of Fatigue (MAF), and the Modified Fatigue Impact Scale (MFIS). Fear of movement was examined with the Tampa Scale of Kinesiophobia (TSK). Function was assessed with the 6-minute walk test (6MWT), five time sit to stand (FTSTS), single leg stance (SLS), and quality of life was assessed with the Fibromyalgia Impact Questionnaire (FIQ). Hierarchical linear regression analysis examined separate models that include pain (VAS or PPT), fatigue (VAS, MFIS, or MAF), and fear of movement (TSK).

Results: Pain, fatigue, and fear of movement were significantly higher and function and quality of life were significantly reduced in people with fibromyalgia when compared to healthy controls (P < .01). There were moderate and significant correlations between pain measures (VAS, PPT), fatigue measures (VAS, MAF, MFIS), and fear of movement (TSK) (r = 0.32 to 0.89, P <= .01). Hierarchical linear regression analyses were completed demonstrating significant models (P = .001) that each included pain, fatigue, and fear of movement as predictors of function (6WMT, FTSTS, SLS) and quality of life (FIQ) in individuals with fibromyalgia and healthy controls. These models show the strongest predictors to be pain (30%-50%) and fatigue (30%-50%) for function outcomes with TSK showing minimal effects (5%-20%) on function: 6MWT (R²= 0.53, P = .001); FTSTS (R²= 0.54, P = .001); and SLS (R²= 0.51, P = .001). For quality of life, pain, fatigue, and fear of movement were all significant predictors explaining 82% of the variability (R²= 0.82, P = .001).

Conclusions: Thus, pain and fatigue alone can explain approximately 50% of the variability in function and pain; fear of movement was a smaller predictor of function. However, pain, fatigue, and fear of movement explained 82% of the variability in quality of life, suggesting these 3 factors are critical contributors to quality of life.

Clinical Relevance: The 3 domains of pain, fatigue, and function have a relationship that impacts quality of life, and thus it would be important to assess these symptoms during clinical and therapeutic activities.

TITLE: Typical Measures of Upper Extremity Function in Adult Women

AUTHORS: Mary I. Fisher¹, Tim L. Uhl², Taylor P. Langenkamp¹, Leah K. Schulze¹, Stacy L. Weible¹

INSTITUTIONS: 1. Doctor of Physical Therapy Program, University of Dayton, Dayton, Ohio.

2. Rehabilitation Sciences, University of Kentucky, Lexington, Kentucky.

ABSTRACT BODY:

Purpose/Hypothesis: Understanding typical levels of upper extremity (UE) functional performance is needed to be able to address deficits and these levels are not well documented in the literature. Furthermore, the effect of dominance on function is not known. The purpose of this study was to describe UE self-reported function, range of motion (ROM), strength, and muscular endurance (ME) in a healthy female population aged 30-69, examining the effect of dominance. We hypothesized that as age increases, self-reported function, ROM, strength, and ME would decrease. We also hypothesized that the dominant limb would have lower ROM and greater strength and ME than the non-dominant limb.

Number of Subjects: A convenience sample of 79 healthy women participated in this study. Participants were stratified into 4 separate decades (age), 30-39, 40-49, 50-59, 60-69, with 20 participants/decade except 60-69, which had 19.

Materials/Methods: Self-reported function was measured with the Disabilities of the Arm, Shoulder, and Hand (DASH). ROM of shoulder flexion (FLEX), external rotation (ER), and hand behind back (HBB) was measured bilaterally using digital photography and ImageJ software to calculate measures. Shoulder FLEX, ER, and internal rotation strength was measured using a hand-held dynamometer and normalized to body weight. ME was assessed using the Functional Impairment Test - Hand and Neck, Shoulder, Arm (FIT-HaNSA) subtests 2 and 3. Independent repeated measures of analysis of variance (ANOVA) with one within factor (limb) and one between factor (Age) were used to analyze each measure of motion, strength, and ME with the exception of the FIT-HaNSA subtest 3 as this is a bilateral test, which was analyzed with an ANOVA.

Results: DASH scores were not different between the 4 age groups (P > .16). Age was found to have a significant main effect on FLEX ROM (P = .01). The 60-year-olds (148[degrees]+/- 8) have less FLEX motion than 30-year-olds (159[degrees]+/- 10) across both limbs (P = .01). We observed less HBB motion on the dominant side (16.4 cm +/- 4.3) compared to the nondominant side (13.2 cm +/- 4.2) (P < .001) regardless of age. The dominant limb (9.6% +/- 3.1) was stronger than the nondominant limb (9.0% +/- 3.1) only in FLEX (P = .001). The dominant limb (271 +/- 54 sec) had greater endurance than the nondominant limb (266 +/- 63 sec) while performing the FIT-HaNSA subtest 2 (P = .03).

Conclusions: Shoulder FLEX ROM declines gradually as the only difference was between 30- and 60-year-olds, which did not support our hypothesis. Dominance has a significant effect regardless of age on particular motion, strength, and endurance parameters that partially support our second hypothesis.

Clinical Relevance: Through the ages of 30-59 there is not a significant change in shoulder mobility which suggests that full recovery of motion in UE pathologies should be expected. Dominance should be considered when rehabilitating patients with UE disorders as it may not be reasonable to expect arms should be symmetrical in recovery.

TITLE: Recommendations for Healthy Exercise for Overweight and Obese Women During the Prenatal Period: A Review of the Literature

AUTHORS: Jessica S. Boerger, Elizabeth Dias, Cara Heaton, Kaylene Kroemer, Christa Sturiale, Leigh Welsh, Carol Figuers

INSTITUTION: Department of Community and Family Medicine, Duke University, Durham, North Carolina.

ABSTRACT BODY:

Purpose: Maternal obesity is a high-risk health condition during pregnancy. Overweight and obese pregnant women are prone to adverse medical conditions that may jeopardize maternal and fetal health. Exercise is widely recognized as a way to manage excessive weight and prevent disease. However, there are currently no established exercise guidelines for this population. The aim of this literature review is to determine healthy exercise recommendations for overweight and obese women during the prenatal period. Barriers to exercise adherence and potential solutions are also elucidated.

Description: Methods: Through a systematic search of PubMed and CINAHL, as well as a hand search of reference lists, 11 articles were chosen for inclusion in this review. Inclusion criteria were the following: study population of overweight and obese pregnant women, exercise intervention, maternal health outcomes, and published after 2000. Studies were excluded if exercise was not the primary intervention, baseline BMI was not stratified in the analysis, or fetal measures were the primary outcomes. Recommendations for healthy exercise in this overlooked cohort were formulated from the articles' conclusions and critically appraised using the Section on Women's Health Levels of Evidence.

Summary of Use: Results: Aerobic and resistance exercise, for overweight and obese pregnant women, is safe for both mother and fetus. No adverse events occurred in any of the reviewed studies. Evidence supports that exercise should be individualized and monitored by a physical therapist or another healthcare provider. The articles in this review indicate that exercise may limit excessive weight gain, decrease average body mass index (BMI), decrease the prevalence of gestational diabetes mellitus (GDM), reduce insulin prescription in women with GDM, and improve glycemic control. Specific exercise parameters must be modified from those of healthy pregnant individuals to accommodate for unique physiological differences of this population. Addressing barriers to exercise in this generally sedentary cohort is critical to inaugurate an exercise program.

Importance to Members: Conclusions: With the increase of prenatal maternal obesity, it is important to disseminate education regarding the safety, benefits, and feasibility of exercise. This literature review gives physical therapists and other healthcare providers parameters to prescribe safe aerobic and resistance exercise for overweight and obese pregnant women. Future research should include further investigation of exercise mode, intensity, and dose response in this population with regard to health benefits and adherence to an exercise program.

TITLE: Early PT Education for Pre-surgical Breast Cancer Survivors: A Preliminary Pilot Study

AUTHORS: Ann M. Flores¹, Rebecca G. Stephenson², Mehra Golshan³, Natalie Lovitiz¹, Angela Marques¹, Meghan Taber¹, Mari Weinandy¹

INSTITUTIONS: 1. Physical Therapy, Northeastern University, Boston, Massachusetts.

2. Rehabilitation Services, Brigham & Women's Hospital, Boston, Massachusetts.

3. Breast Surgical Services, Brigham & Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.

ABSTRACT BODY:

Purpose/Hypothesis: Breast cancer (BCA) surgery quickly follows a diagnosis (days - about 2 weeks). The preoperative education standard of care for BCA surgical candidates targets incision and surgical drain care, and movement precautions. Nationwide, physical therapy (PT) is generally not a part of standard BCA preoperative education. The purpose of this ongoing pilot study is to determine acceptability and feasibility and estimate effects of early PT education (EPTE) for presurgical BCA survivors. Compared to controls, we hypothesize that intervention subjects will report: 1) satisfaction with the breadth, depth, content and delivery of EPTE; 2) fewer physical/functional impairments (e.g., range of motion, strength, lymphedema).

Number of Subjects: 15 subjects enrolled (recruitment goal = 30) and drawn from the Brigham & Women's Hospital's (BWH) Comprehensive Breast Health Center.

Materials/Methods: Subjects are randomly assigned to the intervention (IG) or control group (CG). The CG receives standard preoperative education (POE) whereas the IG receives the POE + EPTE (booklet, DVD, range of motion [ROM] wand, small ball). The EPTE booklet and DVD describes benefits and progression of exercise, lymphedema, and role of PT. Measurements are taken before surgery (T0), postop wk 2 (T1), & postop 3rd month (T2). Primary outcomes are EPTE acceptability and satisfaction using survey measures at T2. Secondary outcomes are shoulder ROM (degrees), deltoid and grip strength (ft*lbs), % fat mass (in kg), and extracellular fluid (liters). Intraclass correlation coefficients show that ROM and strength measurements are reliable (ICCs = 0.96-0.98). Data are analyzed with descriptive statistics, repeated-measures ANOVA, and general linear modeling (1-tailed P < .05) controlling for age, education level, income, medical history, and insurance status. We report T0 descriptive findings at this time.

Results: We have recruited 6 IG & 9 CG (from 30 eligible subjects; 50% recruitment). Of these, 11 have completed T0 measures, 2 have completed T0-T2; 2 dropped out for personal reasons, 2 withdrew due to new lymphedema diagnosis. Our subjects are 61 years old (SD +/- 8.92), white (90%), have <= 2 comorbidities, 32% fat mass, health insurance, and no history of shoulder impairments. Average ROM for T0 are 165 (flexion), 47 (extension), 160 (abduction), 80 (external rotation), and 67 (internal rotation), all of which are less than normal values. Deltoid and grip strength are 11 and 45 ft*lbs, respectively. On average, our subjects have 17.3 liters of extracellular fluid.

Conclusions: Our early preliminary data suggest that some physical and functional impairment may exist prior to surgery even with no history of shoulder problems and lymphedema. These data present baseline measurements for which comparisons will be made across time (T0-T2) to evaluate all primary and secondary outcomes.

Clinical Relevance: We expect the EPTE will be acceptable and feasible and, when compared to POE, will hasten physical and functional recovery after BCA surgery. We expect the EPTE will be revised and tested with a long-term randomized controlled trial.

TITLE: Does Urinary Incontinence Impact Balance Performance and Fall Status in an Elderly Female Population?

AUTHORS: Patricia R. Nelson, Kimberly K. Cleary, Kathryn Irish

INSTITUTION: Department of Physical Therapy, Eastern Washington University, Spokane, Washington.

ABSTRACT BODY:

Purpose/Hypothesis: The prevalence of urinary incontinence (UI) is estimated at 29% in women over the age of 65 years. Research shows that women with UI may have poorer balance than those without, and the presence of UI may increase fall risk in women. However, limited evidence exists as to the relationship of balance performance, fall risk and presence of UI, or fall status and UI type and severity among elderly women. The purpose of this study is to assess these relationships in a well elderly female population.

Number of Subjects: Thirty women aged 65 and older who met the inclusion criteria of independent living, ability to provide informed consent, and able to walk independently within their home (with or without the use of an assistive device) participated in this study.

Materials/Methods: Subjects completed questionnaires to provide demographic, medical screening, and fall history information. If a "yes" response was provided in medical screening for UI, subjects completed a more detailed UI assessment. The Urogenital Distress Inventory (UDI-6) and the Incontinence Impact Questionnaire (IIQ-y) are standardized measures of UI that assess type and severity of UI. Subjects then completed functional balance performance and mobility measures, as they were able. These measures included the Berg Balance Scale (BBS), Four Square Step Test (FSST), Tinetti Assessment Tool (Tinetti), and Timed Up and Go (TUG). Descriptive statistics were calculated using SPSS v. 19.0. Group mean differences in balance performance and UI assessment scores were compared via t test while relationship between balance performance and falling was explored using chi-square test.

Results: UI symptoms were reported by 12 (40%) of the subjects. There were significant differences in average balance performance scores in women with and without UI on the BBS, Tinetti, and FSST. Of the women with UI, 5 (41.7%) reported falling while only 1 (5.6%) woman without UI reported falling. Mean UDI-6 and IIQ-7 scores were higher in women who had fallen compared to those who had not fallen, but the difference was not significant. Type or severity of UI was not different for women who had fallen versus those who had not, although there was a higher percentage of women fallers who had moderate or more impact of UI compared to nonfallers.

Conclusions: There appears to be a link between balance performance and UI in this sample of women. Surprisingly, there were no significant differences in type or severity of UI and fall status, though the sample size in this study was smaller than desired to make conclusions on these relationships. UI is a recognized risk factor for falling and the results of this study emphasize the need to use standardized tools to measure fall risk and UI presence, and to provide treatment for both UI and balance dysfunction in the elderly female population.

Clinical Relevance: The results of this study provide data to support the fact that UI impacts balance performance and fall risk, although the exact nature of this relationship needs further study.

TITLE: Exercise Dosage and Pelvic Floor Muscle Function in Young Women With and Without Urinary Incontinence

AUTHORS: Patricia R. Nelson, Ashley Wilkens, Brianna DeWitt

INSTITUTION: Department of Physical Therapy, Eastern Washington University, Spokane, Washington.

ABSTRACT BODY:

Purpose/Hypothesis: Risk factors for urinary incontinence (UI) are obesity, pregnancy, and advancing age; however, UI has been found to affect 38% of healthy nulliparous women. In these young women, the mechanism causing UI is suspected to be pelvic floor muscle (PFM) dysfunction. Research suggests exercise intensity and dosage may have an effect on UI status, but this relationship remains unclear. It is suggested that high-intensity activity increases intra-abdominal pressure (IAbP) that in turn increases the stress on the PFM. The aim of this study is to determine if exercise dosage affects UI status and to describe the pelvic floor performance using trans-abdominal real-time ultrasound imaging (RTUS) in a young, nulliparous population.

Number of Subjects: Forty-eight nulliparous women aged 18-30.

Materials/Methods: After emptying their bladder, subjects completed questionnaires related to demographics, medical history, urinary status, and physical activity while ingesting 500 mL of water. A physical exam was performed to evaluate pelvic control, transversus abdominis (TrA), and PFM activation patterns. Next, trans-abdominal RTUS of the bladder floor was performed to observe PFM/bladder floor interface movement using a linear measure taken from the bladder floor, at the urethral opening to the superior fascial border. Measurements of bladder floor displacement were taken at rest, during PFM contraction, and during a Valsalva maneuver.

Results: Exercise dosage did not show a statistically significant difference between subjects with no to mild UI and those with moderate to severe UI when considering total MET minutes per week (P = .228). Bladder floor movement, viewed with RTUS, showed a lifting contraction in 29/48 (60.4%) of subjects. With contraction, subjects with moderate to severe UI could move the bladder floor on average 0.001 +/- 0.219 cm while those with no to mild UI could move 0.365 +/- 0.322 cm (P = .035). With a Valsalva maneuver subjects with moderate to severe UI showed, an average caudal movement of 0.964 +/- 0.752 cm while those with no to mild UI moved on average 0.801 +/- 0.703 cm (P = .699). Using RTUS as biofeedback, 9/19 subjects (47%) who initially could not perform a lifting contraction were able to complete a lifting contraction after a short 2-minute training session.

Conclusions: While the amount of vigorous activity is thought to contribute to PFM dysfunction and UI, the results of this study do not identify a difference that is statistically significant. The amount of PFM movement with contraction was less in subjects with moderate to severe UI and was found to be statistically significant. Furthermore, a trend toward more movement during a Valsalva maneuver was found in subjects with moderate to severe UI.

Clinical Relevance: UI status in young, nulliparous women is variable without clear relationship to exercise dosage or intensity. Poor PFM contraction was present in women with UI, supporting this as a potential factor for developing UI. RTUS biofeedback is helpful to improve PFM coordination, and as an efficient, noninvasive training option.

TITLE: Recognizing and Managing Female Athlete Triad in an Adolescent Cheerleader With Stress Fractures: A Case Report

AUTHOR: Amy W. Wagner

INSTITUTION: University of the Incarnate Word, San Antonio, Texas.

ABSTRACT BODY:

Background & Purpose: The female athlete may be prone to a condition known as the female athlete triad, which is an interrelationship between low energy availability, menstrual dysfunction, and abnormal bone mineral density. The athlete who trains excessively may have low energy availability, altering their bone density, and putting them at greater risk of fractures. A patient with any one of these 3 risk factors may present with a diagnosis of sprain or strain, when an occult fracture is actually present. This case report describes a patient who presented to physical therapy with a diagnosis of left knee sprain, but was found to have multiple tibial plateau fractures after red flags during the physical therapy evaluation process were found.

Case Description: A 16-year-old female presented to physical therapy with an inability to weight bear on her left lower extremity after performing a "front tuck" somersault from a standing height. She felt immediate pain and was seen by a physician in an urgent care clinic. The initial radiographs of her knee were negative. She was diagnosed with a knee sprain, given a rigid knee brace, crutches, and referred to an orthopedic clinic, where she was diagnosed with an MCL sprain and referred to physical therapy. The patient presented to physical therapy on crutches, unable to weight bear on the left lower extremity. Initial examination results demonstrated AROM of 30 degrees of knee flexion, point tenderness at patellar tendon with palpation, and 10/10 pain with active knee flexion. She reported pain with vibration. Ligamentous tests for the knee were negative. The patient reported that she trained several hours a day in the disciplines of gymnastics, cheerleading, and running. The examination findings did not correlate with typical knee sprain findings. The excessively high amount of training the patient performed put her at risk for low energy availability and altered bone density, a key component of the female athlete triad. It was hypothesized that due to these 2 factors, the patient should be recommended to get further imaging to rule out a fracture. She received an MRI which found multiple tibial plateau fractures in the left knee. She was casted in a long leg cast for 5 weeks, and returned to physical therapy 1 week after cast removal. After cast removal, she was able to ambulate without crutches, and had minor ROM, strength, and balance deficits. She received 12 sessions of physical therapy over 6 weeks, including aquatic therapy, manual therapy, balance training, strength training, and a home exercise program.

Outcomes: After receiving a proper diagnosis and timely intervention, the patient returned to full lower extremity function, including return to the varsity cheerleading squad.

Discussion: Knowledge of the female athlete triad, particularly the relationship of low energy availability and altered bone density, is important when evaluating the female athlete.

TITLE: The Role of Rehabilitative Ultrasound Imaging in the Management of Lumbopelvic Pain

AUTHORS: Adrienne H. Simonds, Kimberly Johnson, Lauren Koch, Bryan Rooney, Pooja Shah

INSTITUTION: Doctor of Physical Therapy Program-South Rehab & Movement Science, Rutgers, The State University of New Jersey, Stratford, New Jersey.

ABSTRACT BODY:

Purpose/Hypothesis: The purpose of this literature review was to determine the role of rehabilitative ultrasound imaging (RUSI) in the management of acute or chronic pain in the low back and pelvic girdle. Individuals with lumbopelvic pain (LPP) comprise up to 50% of outpatient physical therapy referrals and demonstrate decreased ability to participate in functional activities secondary to altered trunk biomechanics. Information is needed on how ultrasound imaging may be used in the physical therapy management of LPP.

Number of Subjects: NA.

Materials/Methods: This literature review was completed from September 2012 to January 2013 using CINAHL, PubMed, and Ovid databases. Inclusion criteria were publication dates 2009 to 2013, human and adult (19+ years) subjects, English language, and use of ultrasound imaging in the management of lumbopelvic pain. Search terms included rehabilitative ultrasound imaging, ultrasound imaging, ultrasound, pelvic girdle pain, lumbopelvic pain, low back pain, back pain. Articles included in the final review were independently evaluated by two researchers using the MacDermid Evaluation of Effectiveness and Study Design (MEESD) Scale. The MacDermid Scale ranges from 0 to 48, with 48 representing the highest score. Discrepancies in scoring were discussed until a consensus was reached.

Results: Ten articles were selected for the final review. MacDermid scores ranged from 23 to 35. All articles included in the final review utilized RUSI as a tool in the management of LPP. RUSI was used to visualize and measure muscle and/or connective tissue thickness, transitory movement, and structure. RUSI was used to visualize and measure tissues at rest, during diagnostic testing of the pelvic girdle and/or trunk, and during exercise interventions. Images of abdominal structures were utilized for pre- and postoutcome measures, biofeedback tools, and prognostic indicators for recovery. RUSI provides physical therapists with an objective, visual, real-time mechanism to gather information about connective tissue morphology and specific characteristics of core musculature both at rest and during activity. Characteristics measured through RUSI included muscle thickness, symmetry, mobility, and the patient's ability to isolate core muscle contractions, such as the transverse abdominis (TrA).

Conclusions: RUSI provides the PT and client a noninvasive, real-time image of deep abdominal structures, such as the transverse abdominis (TrA), at rest or during activity. Research is needed to establish standardization of RUSI application procedures and usage parameters for PTs in the management of LPP.

Clinical Relevance: Core stabilization exercises targeting deep abdominal structures, such as the transverse abdominis (TrA), are a key component in the management of LPP. RUSI provides an objective image of deep abdominal muscles and connective tissues. RUSI may be utilized by PTs during client sessions to identify abnormal morphology of soft tissues, measure changes during rehabilitation, and provide real-time, visual biofeedback for clients during core stabilization exercises.

TITLE: Physical and Psychosocial Comparisons Between Female Sedentary and Active Workers

AUTHOR: Susan J. Leach

INSTITUTION: The George Washington University, Washington, District of Columbia.

ABSTRACT BODY:

Purpose/Hypothesis: Depending on the sedentary or active requirements of a job, a decline in functional activity may be expedited or delayed. Women with sedentary jobs are more susceptible to increased health and musculoskeletal issues than women with more active jobs, whereas women who perform moderate to heavy activity jobs for > 20 years are strongly protected against hip fractures compared to those working in sedentary jobs. The purpose of this study was to perform physical and psychosocial comparisons of sedentary vs. active female workers. It was hypothesized that female active workers would present with better strength, range of motion (ROM), endurance, balance, and function than sedentary workers and that female sedentary and active workers would exhibit similar scores of pain, quality of life, and cognitive processing.

Number of Subjects: 21 females were divided into 2 groups. The sedentary group consisted of 11 computer users aged 24-39 years who used a visual display terminal for > 20 hours per week utilizing a touch-typing method. The active group consisted of 10 healthcare workers aged 25-37 years employed as clinicians for > 1 year in the fields of PT, OT, PTA, COTA, or Rehab tech.

Materials/Methods: Physical test categories of flexibility, strength, endurance, balance, and function took 1 hour to complete and included the following: body mass index, cervical ROM, sit and reach, Thomas Test, grip strength, pinch grip, Jackson Strength Evaluation System (JSES), 3-minute step test, Balance Error Scoring System (BESS) performed on a force platform, 4 square step test, Maximum Step Length, 5x Sit to Stand, and gait speed. Participants completed psychosocial measures including IPAQ, Nordic Musculoskeletal Questionnaire, SF-36, and Trail Making Test. The results were analyzed using descriptive statistics and Student's t-tests with P-value < .05.

Results: Regarding flexibility, the sedentary workers had significantly increased cervical extension versus active workers. The strength results showed that active workers had significantly greater nondominant grip strength, bilateral pinch grip strength, and JSES arm lift when compared to sedentary workers. In the balance category, the active workers had a significantly shorter trace length in double limb stance on firm and foam surfaces and single limb stance on a foam surface. In the psychosocial domains, the active workers had significantly faster times on the Trail Making Test Part A and a significantly higher total SF-36 score compared to the sedentary workers.

Conclusions: The sedentary workers had significant deficits in strength, balance, cognitive processing, and quality of life compared to the active workers. Remaining employed in a sedentary job puts these females at higher risk of experiencing falls and chronic pain and developing osteopenia.

Clinical Relevance: This study suggests that job selection predisposes female workers to greater risks during the lifespan. It is important for PTs to identify common deficits at all ICF levels for various groups of workers so that targeted prevention initiatives can be implemented.

TITLE: Lymphedema of the Lower Extremity Secondary to Desmoid Tumor Resection

AUTHOR: Amanda Palmeri

INSTITUTION: NYU Langone Medical Center, New York.

ABSTRACT BODY:

Background & Purpose: The purpose of this poster is to describe the management of secondary lymphedema following the resection of a desmoid tumor or "aggressive fibromatosis" from the antero/medial thigh region of a 27-year-old female.

Case Description: This is a case of a 27-year-old healthy female who was referred to physical therapy for the management of her right lower extremity lymphedema secondary to desmoid tumor resection and skin graft placement. Previous treatment included radiation treatments to her right lower extremity. Patient was previously treated following Desmoid tumor resection and skin graft replacement; however, she reported reduced compliance with treatment program and minimal results.

Outcomes: This patient was treated at this facility with CDT (Complete Decongestant Therapy) followed by a custom alternative compressive garment to accommodate her work-related tasks and social obligations in order to optimize patient compliance. She was seen for approximately 10 weeks and demonstrated improvements in final girth measurements, tissue texture, and quality-of-life assessment.

Discussion: The treatment of secondary lymphedema following Desmoid tumor resection with the use of traditional CDT as well as alternative compressive garments can improve girth measurements and quality of life.

TITLE: Novel Approach to Female Sexual Dysfunction: A Case Report on Treatment of Vaginismus Using Traditional Physical Therapy Techniques and Cognitive Behavioral Approach

AUTHOR: Sagira Sagira Vora, PT, MPT, WCS

ABSTRACT BODY:

Background/Purpose: Women's sexual health is an oft-neglected area of healthcare and has been identified as an area that needs more attention by the International Classification of Functioning, Disability and Health. The current case review deals with vaginismus, which is a poorly studied area of sexual dysfunction. Vaginismus is a diagnosis fraught with misunderstanding and poor diagnostic definitions. DSM has been defining vaginismus for 150 years as "muscle spasm." Vaginismus is defined as "recurrent, involuntary or persistent spasms of the outer third of the vagina that interferes with successful intercourse" (2). There is debate whether "muscle spasm" truly exists with this condition and that this definition does not include "fear and avoidance" component of the disorder (3). Ressing et al report "women in the vaginismus group also displayed a significantly higher frequency of defensive/avoidant distress behaviors during pelvic examinations and recalled past attempts at intercourse with more affective distress. These data suggest that the spasm-based definition of vaginismus is not adequate as a diagnostic marker for vaginismus. Pain and fear of pain, pelvic floor dysfunction, and behavioral avoidance need to be included in a multidimensional reconceptualization of vaginismus" (4). The current case review of a woman with vaginismus who was treated for the "spasm" or pelvic floor dysfunction, as well as for the "fear and avoidance" component of this dysfunction using cognitive behavioral approach and habituation, along with traditional physical therapy treatment with dilators.

Study Design: A 27-year-old woman with a life-long history of severe vaginismus and inability to tolerate penetration including digital pelvic floor muscle exam was treated for 8 visits. Patient was treated with relaxation/autogenic training, imagery, positive associations, and biofeedback prior to beginning dilator use. A "gradual exposure" technique was used, allowing the patient to gain muscle control on her own relaxation and dilators, and then as she gained muscle control on her own, partner was allowed in the room. At first, with just being present in the room as patient used dilators and subsequently partner was allowed to assist with dilator use. An essential part of treatment was the use of sensate focus, an intimacy building exercise, which allows couples to reduce anxiety related to intercourse. Sensate focus exercises or controlled sexual touch exercises were given for 3 times weekly as home exercise. Beginning with nonsexual touch, and advancing at each session to increasing sexual intimacy until couples feel comfortable initiating intercourse. Eventually a "script" was used for intercourse allowing the couple to follow the script to participate in intercourse. Marinoff Intercourse Scale and Female Sexual Function Index (FSFI) were used as outcome measures.

Outcomes and Discussion: Patient was able to successfully participate in intercourse after 2 months of treatment. Eight weeks after treatment was stopped, patient reported being pregnant, which was a goal for the couple. Patient's individual scoring prior to treatment was for Desire: 6, Arousal-4.5, Lubrication-5.4, orgasm-4.8, satisfaction-3.6, and Pain-1.2. Patient's composite score for FSFI was 25.5/36. Posttreatment scores were Arousal-6, Desire-4.5, lubrication-4, orgasm-4.8, Pain-6, satisfaction-4.8, Composite scores of 30.1/36. Scores on FSFI were significantly higher overall and particularly in the domains of pain and sexual satisfaction. Pain scores went up to 6 from 1.2, indicating that patient was able to mitigate the "fear and avoidance" component of her treatment, she was able to reduce her pain and overcome her fear of intercourse. The highest score was achieved on the Marinoff scale, with pretreatment score being 0/3 indicating no ability to tolerate intercourse to 3/3 indicating successful intercourse.

Conclusion/Clinical Relevance: The current treatment concepts in treatment of vaginismus involves a muscle stretching and muscle control approach, which may reduce pain with intercourse, but may not improve sexual satisfaction with intercourse and does not address the underlying behavioral avoidance. A wholistic physical therapy approach involves addressing muscle control as well the anxiety, fear, and avoidance related to intercourse and allows couples to build intimacy.

Key Words: vaginismus, pain with intercourse, sexual dysfunction

TITLE: Medical Management of Low Back Pain Among Hispanic Pregnant Women and Their Receptiveness to Physical Therapy

AUTHORS: Natalia Marrero¹, Helena L. Ramirez², Nayrin Medina, Ana L. Mulero Portela³

INSTITUTIONS: 1. PIES (Proyecto Interdisciplinario de Excelencia en Servicios - Clinicas de Salud), School of Health Professions, Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico.

2. Pediatric Hospital, Medical Center, San Juan, Puerto Rico.

3. Physical Therapy Program, Department of Graduate Programs, School of Health Professions, Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico.

ABSTRACT Body:

Purpose/Hypothesis: The purpose of this study was to: 1) describe the medical management of low back pain in a sample of pregnant women in Puerto Rico, who received prenatal care; 2) determine the receptiveness of this group to receive physical therapy interventions; and 3) identify cases of women with low back pain and describe the impact of such pain on their activities and participation.

Number of Subjects: Sixty pregnant women, averaging 26 years of age, were recruited through convenience sampling.

Materials/Methods: A questionnaire used by Wang et al. (2004) to assess prevalence, risk factors, and outcomes of low back pain was adapted for this study. The "Disability Rating Index" (Salen et al., 1994) was also administered. Both instruments were translated and culturally adapted for the use of Spanish speakers in Puerto Rico.

Results: Eighty-three percent (n = 50) of the women surveyed reported experiencing low back pain; 40% of them would accept pharmacological treatments in order to handle their low back pain, and 93% would accept nonpharmacological treatment related to the field of physical therapy (massage, good posture education, hot and cold therapies, aquatic therapy, and exercise). Eighty-six percent (n = 52) of these women indicated that the pain affected their sleep patterns; 90% indicated that it affected their daily activities; and 36% had to be absent from work because of the pain. They indicated that the activities that became more challenging were to bend over a sink and running. The most common recommendation given by their physicians to treat the low back pain was rest.

Conclusions: The results of this study confirm that low back pain is a problem that frequently affects the daily activities and work performance of pregnant women. Current evidence points toward the benefits of physical therapy in treating low back pain in this population. These benefits should be presented and discussed with physicians so that they can consider recommending physical therapy as an alternative to their patients. There is receptivity among pregnant women to receive physical therapy treatment. Since there is evidence that pregnant women have a growing need for this service, physical therapists should work toward the development of their practice addressing this need.

Clinical Relevance: Low back pain is a very common problem among women during their pregnancy, one that increases as the pregnancy advances. Their bodies experiment physiological changes that predispose them to present low back pain. This pain can interfere with their daily routines and with their level of productivity at workplace. Low back pain should not be left untreated during the gestational period as it affects women physically, and could have both social and financial consequences. The physical therapist is a qualified health professional who is able to handle this type of pain, and prevent it from being a factor that limits women's daily routine and social participation.

Key Words: Pregnant women, low back pain, activity and participation

TITLE: Thoracic and Lumbar Pain and Vasovagal Response in a Primigravida

AUTHOR: Laurie Kilmartin

INSTITUTION: Rusk Rehabilitation, NYU Langone Medical Center, New York.

ABSTRACT BODY:

Background & Purpose: Pain in the thoracic and lumbar spine is common during pregnancy, and can significantly impair ability to perform daily activities. Vasovagal response has been found in the prenatal population during the later stages of pregnancy. Literature describing physical therapy management of pain in the thoracic spine and episodes of vasovagal response in pregnant women has not been identified. The purpose of this case study report is to examine the physical therapy interventions and outcomes of treatment of a 37-year-old primigravida with thoracic and lumbar pain and vasovagal response.

Case Description: The case involved a 37 year-old primigravida diagnosed with thoracic and lumbar pain. She presented with poor postural awareness, thoracic and pelvic obliquity, core weakness and inefficient breathing patterns, and reported episodes of dyspnea, dizziness, and vasovagal response that were provoked by physical or emotional stress. She received physical therapy intervention including manual therapy, core strengthening and stabilization, relaxation exercises, lateral trunk stretches, postural reeducation, body mechanics, and education.

Outcomes: At the time of discharge, the patient had not had an episode of vasovagal response in several weeks, was free of pain in the thoracic and lumbar spine, and reported improvement in overall function. She reported onset of mild pain and discomfort in the pubic symphysis in the eighth week of treatment, and was discharged following onset of early labor.

Discussion: Following a course of physical therapy, the patient demonstrated improved postural awareness, symmetry in the pelvis and ribcage, increased efficiency during respiration, and proper body mechanics. With the assistance of her partner, she was independent with manual and relaxation techniques for self-management of her pain symptoms, was pain-free in the lumbar and thoracic regions, and had not had an episode of vasovagal response in several weeks. Because multiple interventions were implemented, it is difficult to show support for a single intervention for treatment in this population.

Key Words: thoracic spine, vasovagal response, pregnancy.