TITLE: Pelvic Pain, Pelvic Organ Prolapse, Urinary and Colorectal Distress Incidence and Relationship to Quality of Life and Birth Mode

AUTHORS/INSTITUTIONS: L. Walton, C. Abreu, A. Trautwein, S. Xavier, E. Jeffus, Physical Therapy, Andrews University, Berrien Springs, Michigan, UNITED STATES.

ABSTRACT BODY:

Purpose/Hypothesis: Caesarean Section (CS) incidence is reported at 32% nationwide, well above the safe rate of 10% recommended by the World Health Organization. Literature is conflicted regarding the role of birth mode in postpartum symptoms such as pelvic pain, colorectal distress, pelvic organ prolapse, and quality of life. 3 4 The purpose of this study is to determine the incidence/impact of pelvic pain, pelvic organ prolapse, urinary and colorectal distress and quality of life by birth mode for women in the chronic postpartum period.

Number of Subjects: This was a cross-sectional correlational research design utilizing purposive sampling of 21 subjects ages 18-45 postpartum female subjects from the local region, who were between 6-36 months postpartum. Exclusion factors included those with mixed birth mode, history of surgery, systemic neurologic disease or trauma affecting bowel or bladder, or those with previous history of physical therapy treatment.

Materials/Methods: Approval was obtained from Andrews University IRB in November 2012. Data collection took place at five childcare locations within a Midwest community. Each subject who agreed to volunteer for this research study and met the inclusion criteria were given three inventories to fill out: a Health History Questionnaire, the SF-36, and the Pelvic Floor Distress Inventory. Data was collected by the co-investigators and de-identified. Analysis was done utilizing SPSS 21.0 to calculate differences between the groups and correlations by birth mode.

Results: Incidence reports of UI were 80% in the CS group and 50% in the NVD group. The CS group reported significantly higher mean scores for PFIQb, UDI, POPDI, and CRADI compared to the NVD group. Age was negatively correlated with CRADI and pain (Chi-square = 7.02, p = .030). NVD group reported a significantly higher quality of life (as measured by the SF-36) in general and mental health compared to published norms and CS (p<.05). BMI had a significant moderate correlation (r = .682, p<.001) with pelvic organ prolapse.

Conclusions: Our study found significant increased incidence and impact of UI, CRADI, POPDI, and PFIQb symptoms and a decrease in QOL in CS compared to NVD. Age showed significant correlation with colorectal symptoms and BMI showed significant relationship to pelvic organ prolapse. Future studies should focus on CS, age, and BMI role in colorectal pain and prolapse is recommended, as well as research on specific physical therapy interventions to address these issues.

Clinical Relevance: This research directly relates to women's health physical therapy diagnosis of pelvic organ prolapse, urinary incontinence, colorectal distress, and pevlic pain. This study highlights specific variables such as age, BMI, and mode of birth that show direct relationship to pelvic symptoms and should be considered by women's health physical therapists for evaluation, examination, and intervention.

TITLE: Effect of an 8-week nutrition and physical therapy education program on pelvic and colorectal pain, prolapse, incontinence, and nutritional intake on quality of life for prenatal and postpartum women

AUTHORS/INSTITUTIONS: L. Walton, M. Hernandez, G. Krivak, C. Buddy, SPT, R. Vargas, Physical Therapy, Andrews University, Berrien Springs, Michigan, UNITED STATES.

ABSTRACT BODY:

Purpose/Hypothesis: Women in the postpartum period have reported co-morbidities such as pelvic pain, prolapse, urinary incontinence, and nutritional deficits, which decrease health related quality of life. Exercise and nutrition are important considerations for improving maternal health during the postpartum period (Walker & Wilging, 2006). Limited programs exist for women who are socio-economically challenged. The purpose of this study was to examine the effects of an 8-week nutrition and pelvic floor exercise education program in prenatal and postpartum women in a community based program (Women Infants and Children) for women living in challenging socio-economic situations.

Number of Subjects: This was a prospective, quasi-experimental, pre-test/post-test design with purposive sampling of 50 (n = 50) prenatal and postpartum female subjects, between the ages of 18-50, currently participating in Women Infants and Children (WIC) program, to examine the effects of an 8-week education program on urinary incontinence, pelvic pain, prolapse, colorectal distress symptoms, and nutritional status and effects on health related quality.

Materials/Methods: IRB approval was obtained in April 2013 from Andrews University and Memorial Hospital. Data collection was initiated immediately upon IRB approval of the study and completed within ten months for eight different cohorts (Four Spanish speaking and four English speaking cohorts). Pre and post intervention surveys were completed by all subjects including: (1) health questionnaire, (2) SF-36, (3) Food Frequency Questionnaire (FFQ), and Pelvic Floor Distress Inventory (PFDI). Two one hour pelvic stability exercise and nutrition education sessions were provided by a licensed physical therapist and registered dietitian. Data was analyzed utilizing SPSS Version 21.0 with dependent t-tests to analyze pre and post test outcomes, one way t-test to compare SF-36 norm values to the sample, and Linear Regression Analysis for predictive correlations between variables and health related quality of life.

Results: Preliminary results indicate a significant positive difference from pre to post test symptoms in UI, pelvic pain, nutritional status and HRQOL for all subjects. Results from the one way t-test and predictive correlations TBD by June 2014.

Conclusions: An 8 week physical therapy pelvic stabilization and nutrition education program showed significant positive changes from pre-post educational session intervention and may be considered as an adjunct to private services or as a low cost community based outreach program for prenatal and postpartum women that may not have access to private physical therapy and nutrition services.

Clinical Relevance: This research addresses a gap in the healthcare system for women who are socio-economically vulnerable and may not be able to attend private physical therapy or dietitian services.

TITLE: Pelvic Girdle Pain and Postpartum Depressive Symptoms in the First 12 Weeks after Delivery: A Pilot Study

AUTHORS/INSTITUTIONS: A.H. Simonds, Rehabilitation & Movement Sciences, Rutgers, The State University of New Jersey, Stratford, New Jersey, UNITED STATES;

C.J. Hill, M. Cheng, Nova Southeastern University, Fort Lauderdale, Florida, UNITED STATES;

K. Abraham, Shenandoah University, Winchester, Virginia, UNITED STATES.

ABSTRACT BODY:

Purpose/Hypothesis: Pelvic girdle pain (PGP) is defined as pain between the buttocks and low back and results in severe limitations in functional mobility and child care tasks such as lifting and carrying. New mothers are often sleep-deprived, recovering from childbirth, and adjusting to the life change of having a baby. The experience of PGP may contribute to the development of PPD symptoms. A relationship between pelvic girdle pain (PGP) and postpartum depression symptoms has been identified in a previous study at 3 months postpartum in European women. The purpose of this study was to explore the relationship between PGP and PPD symptoms in the first 12 weeks after delivery in American women, which is currently unavailable in the literature.

Number of Subjects: Twenty-one women within the first 4 weeks after delivery.

Materials/Methods: Women were enrolled within the first 4 weeks after delivery and surveyed at approximately 4, 8, and 12 weeks postpartum. Tools included a demographic questionnaire, a pain questionnaire, the Edinburgh Postnatal Depression Scale (EPDS), and the Oswestry Low Back Pain Disability Questionnaire. Statistical analysis included logistic regression. The study was approved by the Institutional Review Boards of Nova Southeastern University and Rutgers, the State University of New Jersey.

Results: Depressive symptoms at 4 weeks predicted PGP at 12 weeks (B = 0.46, SE = 0.22, p = 0.04, Exp(B) = 1.58, 95% CI: 1.02-2.45). Women with higher depressive symptoms at 4 weeks were 1.58 times more likely to have PGP at 12 weeks.

Conclusions: A relationship between PGP and PPD symptoms was found, supporting the work of previous authors. The interaction of PGP and PPD over time may suggest that in some women, PPD symptoms may precede PGP. This study contributes new knowledge about the relationship between PGP and PPD by identifying an effect of time. Women with higher depressive scores early in the postpartum period (4 weeks) were more likely to have PGP later in the postpartum period (12 weeks). The time effect suggests a possible neuropsychological basis for the development of PGP at 12 weeks, rather than the proposed chronic pain framework of other authors. Neuropsychoendocrine factors, such as inflammatory markers, may play a role in the development of musculoskeletal pain, such as PGP, in women with postpartum depressive symptoms. Findings should be reproduced in larger, more diverse samples before clinical recommendations are implemented.

Clinical Relevance: Evidence of a relationship between PGP and postpartum depressive symptoms was found. Physical therapists may consider screening for symptoms of depression and PGP in new mothers, as the two conditions may be related. The interaction between the two conditions is likely multi-factorial and may be influenced by time. The high rates of recurrence and substantial socioeconomic costs of depression and low back pain in the United States warrant further investigation into the relationships between the two conditions in childbearing women and the role of physical therapists.

TITLE: A Survey of Running Habits and Injury in a Postpartum Population

AUTHORS/INSTITUTIONS: E.S. Chumanov, B. Heiderscheit, Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, Wisconsin, UNITED STATES.

ABSTRACT BODY:

Purpose/Hypothesis: As running popularity has increased over the past decade, more women are choosing to run during and following pregnancy. However, little is known about the distribution of running related injuries in the postpartum population and if returning to running in the early postpartum period may be related to increased report of musculoskeletal pain and pelvic floor dysfunction.

The purpose of this study was to describe musculoskeletal pain and injury location distribution in women runners during and after pregnancy, and determine if pain and injury were more common in women returning to running in the early postpartum period (<=6wks).

Number of Subjects: 347 women responded to the survey, all had at least 1 child and were running a minimum of 1 time per week.

Materials/Methods: An anonymous, online survey consisting of questions related to running habits, childbirth, musculoskeletal pain (onset/location), was distributed to several running organizations across the U.S. At the start of the survey subjects were consented to participate and were asked to certify that they met the inclusion criteria.

Results: Over 40% of the 347 respondents reporting having a child within the prior 2yrs and 69% reporting having a child within 5yrs. Of the women that had a child within the prior 2yrs, 41% reported musculoskeletal pain during pregnancy and 37% reported pain when they attempted to return to running following pregnancy. Of women who reported pain during their most recent pregnancy, the low back, pelvis and hip region accounted for the majority of pain complaints (86%). Postpartum women (within 2yrs of pregnancy) the lumbopelvic region (66%) still made up the majority of pain complaints; however complaints at the knee (10%) and foot (12%) doubled compared to pain report during pregnancy. Thirty-four percent of women resumed running in the early postpartum period (<=6wks) reported musculoskeletal pain or injury compared to 39% in women who returned after 6wks. Over 34% of survey respondents reported stress urinary incontinence (SUI) and 75% of these started after pregnancy. Women with multiple children and <2yrs between children, SUI was more frequent (44%).

Conclusions: Pain in the lumbopelvic region was the most frequent injury reported. SUI was also common in this population and a higher report was related to the timeframe between children. Women who are within 2yrs of child birth have a self-report of running related injuries of 37% and there appears to be no major difference between those that return to running early postpartum compared to those that return after 6wks.

Clinical Relevance: Lumbopelvic pain and SUI are frequent musculoskeletal complaints in postpartum runners. A return to running early in the postpartum period does not appear to increase self-reported musculoskeletal pain, although this is likely dependent on the volume and intensity of running. Screening and rehabilitation programs may be of benefit early in the postpartum period to identify lumbopelvic and pelvic floor dysfunction to address pregnancy related musculoskeletal changes and to minimize pain complaints with activity.

TITLE: Inter-recti Distance is Improved with an 8 week Deep Abdominal Training Program

AUTHORS/INSTITUTIONS: E.S. Chumanov, M.R. Stiffler, B. Heiderscheit, Orthopedics and Rehabilitation, University of Wisconsin - Madison, Madison, Wisconsin, UNITED STATES.

ABSTRACT BODY:

Purpose/Hypothesis: Increased inter-recti distance is common post pregnancy, and strength deficits in the rectus abdominis can persist up to 12 months postpartum potentially compromising lumbopelvic control. Women with an increased inter-recti distance who return to activities such as running post-pregnancy may be at increased risk for lumbopelvic pain. Neuromuscular training of the deep abdominal muscles using real time ultrasound imaging is common; however it is unclear if training the deep abdominal muscles alone improves inter-recti distance.

The purpose of this study was to determine if an 8wk training program using real time ultrasound imaging and targeting the deep abdominal muscles in postpartum runners improves inter-recti distance.

Number of Subjects: 17 women participated in the study. All participants had at least 1 child, were within 2yrs of childbirth and were running at least 1 time per week. 14 participants demonstrated fair to poor deep abdominal muscle contraction on ultrasound exam and received an 8wk intervention targeting the deep abdominal muscles; the remaining 3 served as controls.

Materials/Methods: Participants in the intervention group were seen weekly and progressed on a standardized exercise program targeting recruitment and control of deep abdominal muscles. Real time ultrasound imaging was used to improve contraction of the deep abdominal muscles at each exercise session. Three data collection time points were obtained: baseline, 8wks (end of the intervention) and 14wks. A 10 MHz linear array ultrasound transducer was used to obtain inter-recti distance at each time point. Inter-recti distance was measured 2 cm above and below the umbilicus with the participant relaxed in the supine hook lying position. A repeated measures ANOVA ([alpha]<0.05) was performed to look at changes in inter-recti distance over time. Post-hoc comparisons were made with Tukey's HSD.

Results: Inter-recti distance significantly decreased in the intervention group (p<0.01) below the umbilicus from baseline (18.1 mm) to the 8 wk follow-up (13.5 mm) and was maintained at 14 wks (11.6 mm), while the control group remained similar across the study (15.6 mm). Inter-recti distance above the umbilicus had a decreasing trend in the intervention group (25.0 mm at baseline, 23.2 mm at 8 wks, 23.1 mm at 14 wks and 21.9 mm in the control group), however was not significantly changed over the course of the study (p = 0.40).

Conclusions: An 8 week intervention program targeting deep abdominal muscles in a group of postpartum runners was successful in reducing inter-recti distance below the umbilicus. The decrease below the umbilicus was largest immediately following the intervention and was maintained up to 6 weeks later.

Clinical Relevance: Inter-recti distance is altered post-pregnancy in a running population and can be improved with a training program targeting the deep abdominal muscles. Real time ultrasound imaging is useful as visual feedback and to adjust cuing for the deep abdominal muscles. This has potential implications for improving lumbopelvic control post-pregnancy and reducing risk of lumbopelvic pain.

TITLE: Health Concerns of Women in the Postpartum Period: A Qualitative Study

AUTHORS/INSTITUTIONS: K. Abraham, A. Alkire, J. Dyson, S. Messick, P. Richardson, A. Fergus, Shenandoah University, Winchester, Virginia, UNITED STATES.

ABSTRACT BODY:

Background/Purpose: Women experience many physical and emotional changes following the birth of a child. In previous studies, postpartum women have reported dissatisfaction with the information they received from healthcare providers. However, the optimal way to deliver this information remains unclear. The objectives of this qualitative study were: 1) examine the knowledge, beliefs, and barriers regarding return to normal physical function postpartum; 2) examine if there is a difference in knowledge, beliefs, and barriers and therefore educational needs between primaparas and multiparas; and 3) develop an educational program which specifically targets the needs and interests of the postpartum women with an emphasis on maximizing compliance.

Subjects: A total of 13 primipara women and 26 multipara women were recruited to participate in the study.

Methods: Seven focus group sessions were conducted. Two sessions consisted of primiparous women, 3 sessions consisted of multiparous women, and 2 sessions were held with a combination of primi- and multiparous women. Guiding questions were utilized to better evaluate the needs of postpartum women. All sessions were recorded and transcribed and peer debriefing was used to ensure trustworthiness. Themes were coded for both primi- and multiparous women and a concept map was developed.

Results: The primipara participants demonstrated increased concerns over caring for the new infant, a shift in priorities, general health, weight, and fear of returning to sexual activity. Multiparous women expressed more global needs based around balancing the needs of the family while caring for themselves. Multiparous women also expressed concerns regarding urinary incontinence. Both groups of women verbalized frustrations with the lack of communication and instruction that they received about postpartum care from their healthcare providers. Both groups stated that they would benefit from an individualized approach targeting their specific needs and more readily accessible information.

Conclusion: The educational needs of postpartum women are not being met. Concerns in the postpartum period differ between primiparous and multiparous women. The 6-week postpartum visit appears to be an optimal time to deliver information to both groups via personal instruction and/or the use of technology, such as a smart phone application or DVD.

Clinical Relevance: There is a need for an educational model that encompasses the needs of the individual patient. Physical therapists have the skills/knowledge to address many of the concerns of this population. Increased utilization of physical therapists to develop and/or deliver postpartum education may improve the health of these women.

TITLE: Self-reported Rehabilitation Needs and Physical Therapy Utilization of Breast Cancer Survivors

AUTHORS/INSTITUTIONS: A. Flores, Dept. Of Physical Therapy, Movement, and Rehabilitation Sciences, Northeastern University, Boston, Massachusetts, UNITED STATES;

J. Nelson, Biostatistics, Tufts University Medical Center, Boston, MA, Massachusetts, UNITED STATES.

ABSTRACT BODY:

Purpose/Hypothesis: Breast cancer survivors (BCS) are well known to experience lymphedema, pain and fatigue. The prevalence of lesser studied side effects concerning physical therapy (PT) practice and whether PT is utilized to treat side effects is lesser known. The purpose of this study is to estimate the prevalence of BC-related side effects and PT utilization by BCS.

Number of Subjects: 643 BCS

Materials/Methods: We contacted 1200 BCS previously enrolled in epidemiological studies. We used computer assisted telephone interviews for English speakers and face-face interviews for Spanish speakers. Our survey inquired about self-reported side effects (eg: shoulder range of motion, strength, skin sensation, abnormal posture, edema/pitting edema, skin texture and color impairments), lymphedema diagnosis and whether PT was utilized for treatment of side effects. Medical history and sociodemographics (age, race, ethnicity, years since cancer diagnosis, education, household income, health insurance, employment status) were also collected. We analyzed data with descriptive statistics (frequencies, mean, median, mode, standard deviation). Chi-square tests were used to examine the relationship between # of self-reported lymphedema signs/symptoms with lymphedema diagnosis (p<.05). Odds ratios and generalized linear models compared PT utilization by number and type of side effects, household income and insurance status. All data were analyzed using SAS. Northeastern University Internal Review Board approved this study.

Results: We recruited 643 BCS and, on average, participants are 56yo, 75% completed high school, survived > 12 years since diagnosis, 42% African American, 11% Puerto Rican descent and the remainder white/Caucasian. Approximately 50% report having > 3 side effects with > 90% reporting >= 1 side effect. Overall, 13% reporting any side effect report received PT to treat side effects. Twenty percent report pitting edema, skin hardening and darkening in the treated area however no significant relationship existed between these lymphedema signs/symptoms with a diagnosis of lymphedema (p>.05). Physical therapy utilization was significantly associated with household income > $40K, impaired shoulder range of motion, and private health insurance (p>.05). The poor reported a significantly higher number of side effects and were the least likely to have received PT even if they had health insurance (p<.05).

Conclusions. Our data suggest that the prevalence of BC-related physical and functional side effects may actually be higher than previously thought. PT seems to be under-utilized by BCS. The diagnosis of lymphedema appears to be random despite BCS reporting signs and symptoms consistent with lymphedema. Household income and health insurance appear to be the strongest determinants of PT utilization rather than the presence of side effects.

Clinical Significance: It appears that a serious unmet need for PT by BCS exists.

TITLE: Obturator Internus and Pelvic Floor Fuction

AUTHORS: E. DeLozier¹, K. Harter¹, S. Johnson¹, C. Plotts¹, J. Swartz¹, L.J. Tuttle¹

AUTHORS/INSTITUTIONS: E. DeLozier, K. Harter, S. Johnson, C. Plotts, J. Swartz, L.J. Tuttle; 1. Doctor of Physical Therapy Program, School of Exercise and Nutritional Sciences, San Diego State University, San Diego, CA

ABSTRACT BODY:

Purpose/Hypothesis: Pelvic floor disorders are estimated to affect more than half of women in the United States. Traditional rehabilitation strategies include Kegel exercises for pelvic floor muscle (PFM) strengthening, but often this strategy is not sufficient to resolve the underlying issue or may be an inappropriate intervention. There is evidence to suggest that other muscles surrounding the PFM (specifically, the obturator internus due to a shared fascial attachment with the PFM) may play an important role in normal function and provide a target for rehabilitation that is more easily accessible and amenable to a strengthening protocol. The purpose of this study is to investigate the effects of obturator internus strengthening on the strength of the PFM.

Subjects: 20 women without pelvic floor dysfunction (mean age 21 years) have completed the study to date-9 were randomly assigned to an exercise group (EX) and 11 were randomly assigned to a control group (CON).

Materials/Methods: Participants were randomly assigned to EX or CON. EX group completed a 12 week exercise program of 3 exercises targeting strengthening of the obturator internus muscle (hip external rotation). EX group performed 3 sets of 10 repetitions of each exercise 3 times per week for 12 weeks with one session per week observed by the study personnel. CON group participated in testing sessions and was instructed not to change activity or start an exercise program. Measures included hip external rotation strength measured using a hand held dynamometer and PFM strength based on vaginal pressure during a pelvic floor contraction using a Peritron pressure sensor. The tester was blind to group assignment. All measures were performed initially and after 12 weeks. Repeated measures ANOVA was used with [alpha]= 0.05 to compare external rotation strength and vaginal pressure for each group after 12 weeks. Results are mean +/- SEM.

Results: EX and CON groups were not different at the initial assessment in age, hip external rotation strength or PFM strength (p>0.05). EX group displayed an increase in PFM strength at 12 weeks based on vaginal pressure measures (23.9 +/- 6.8 vs. 32.1 +/- 5.8 cmH₂0 p= 0.02) and an increase in hip external rotation strength at 12 weeks (14.4 +/- 1.4 vs. 18.3 +/- 0.9 lbs p = 0.05). CON group did not significantly change in PFM strength at 12 weeks (28.6 +/- 5.0 vs. 26.0 +/- 3.7 cmH₂0 p= 0.32) and did not significantly change in hip external rotation strength (17.2 +/- 0.9 vs. 16.2 +/- 0.9 lbs p = 0.18).

Conclusions: Strengthening of muscles surrounding the PFM such as the obturator internus and hip external rotators was able to improve PFM strength. This provides initial evidence that muscles other than the pelvic floor may be appropriate targets for rehabilitation.

Clinical Relevance: Strengthening of the hip external rotators (obturator internus) was able to increase PFM strength in a group of young healthy women. Further study is needed to determine whether this intervention has similar effects in a population that is older and has pelvic floor dysfunction. Understanding and application of these data may lead to improved strategies for rehabilitation of patients suffering from pelvic floor dysfunction.