TITLE: Can Urinary Incontinence be Prevented in Pregnant Women?
AUTHORS/INSTITUTIONS: M.L. Brewer, H. Ojha, Temple University, Philadelphia, Pennsylvania, UNITED STATES.
ABSTRACT BODY:
Purpose/Hypothesis: To investigate the effectiveness of supervised versus unsupervised pelvic floor muscle exercise in decreasing risk of of postpartum urinary incontinence onset in healthy pre or post partum women?
Number of Subjects: Five randomized controlled trials were included representing 4 datasets and 2,100 individual subjects.
Materials/Methods: The databases of PubMed, Medline, CINAHL, and Web of Science, were last searched December 2013. The medical subject heading terms "urinary incontinence", "pelvic floor training" and "prevention" were combined with the Boolean operator "AND". The search was limited to articles published in English. This search was supplemented with a manual search. Selection criteria included studies comparing supervised pelvic floor muscle training program implemented by a physical therapists to an unsupervised exercise program. Level of evidence was rated using the CEBM scale and quality was further assessed with the NewCastle Ottawa Scale. Data was synthesized using the CEBM grades of recommendation.
Results: 1,501 articles were screened and 5 studies met criteria and were included in this review. There was grade B (consistent level 2) evidence that supervised exercise conducted by at physical therapists was more effective than an unsupervised program in decreasing risk of urinary continence onset.
Conclusions: This reports suggests that healthy pregnant women should receive supervised pelvic floor muscle training to decrease risk of urinary incontinence in the short term. Future research should investigate the benefits of supervised pelvic floor muscle training in the long term.
Clinical Relevance: Physical therapists should network with midwives, OBGYN physicians, and directly with consumers to share the results of this literature and serve in a primary care women's health role to decrease onset of pregnancy-related urinary incontinence.
TITLE: Validity and Reliability of a new "Intimate Partner Violence Screening Tool for Health Professionals"
AUTHORS/INSTITUTIONS: L. Walton, F. Muvuti, S. Milliner, Physical Therapy, Andrews University, Berrien Springs, Michigan, UNITED STATES.
ABSTRACT BODY:
Purpose/Hypothesis: Women who experience abuse from intimate partners often identify health-care practitioners as potential sources of support. However, assessment tools for the health professional are often lengthy, vague, or inefficient for clinical utilization. The purpose of this study is to test the validity and reliability of a new "Intimate Partner Violence Screening Tool for Health Professionals".
Number of Subjects: Seven experts, between the ages of 24-55, from various professional backgrounds were contacted to provide expert review of the new IPV Screening Assessment Tool.
Materials/Methods: Experts in social work, psychology, and women's health physical therapy were each provided with a copy of the "IPV Screening Tool for Health Professionals" and a rubric that was created by the primary investigators and based upon psychosocial, socio-economic, and physical abuse constructs in conjunction with current literature. The experts completed the rubric and provided qualitative and quantitative measurement of each of the constructs related to the new measurement tool, twice. Face, content validity, and construct validity were measured along with reliability measures for internal consistency of the measurement tool. ICC, Kappa's statistic, and Cronbach's alpha were calculated to determine the validity and reliability.
Results: Preliminary results from this study show that the "IPV Sceening Measurement Tool for Health Professionals" reported high internal consistency, face validity, content validity, and construct validity. Specific results to be determined and reported.
Conclusions: The new "IPV Screening Tool for Health Care Professionals" exhibited good face, content, and construct validity, as well as strong internal consistency. Future reliability tests, such as test-retest and inter-rater reliability tests should be conducted in a clinical setting to provide further practical utilization of this new tool.
Clinical Relevance: The IPV Screening Tool for Health Professionals may be an efficient and effective method for physical therapists and other health care professionals to identify Intimate Partner Violence and provide adequate referral for professional assistance in a timely fashion.
TITLE: Urinary Incontinence: The Silent Embarrassment of Female Collegiate Athletes
AUTHORS/INSTITUTIONS: L. Wingard, H. Kindel, S.M. LoRusso, Physical Therapy, Saint Francis University, Loretto, Pennsylvania, UNITED STATES.
ABSTRACT BODY:
Purpose/Hypothesis: The purpose of this study was to determine the prevalence of stress urinary incontinence (UI) among female Division I collegiate athletes. The hypothesis for this study is that female athletes in high impact sports will report more cases of stress UI than low-impact sports.
Number of Subjects: 121 Division I, collegiate, female athletes from cheerleading, cross-country, basketball, bowling, field hockey, golf, lacrosse, soccer, softball, swimming, tennis, track, and volleyball were surveyed.
Materials/Methods: Survey responses were divided into jump, continuous running, burst, and low impact activities based on the primary nature of the sport. The data was also analyzed as high impact (jumping and continuous running sports) and low impact activities.
Results: Overall, 36.4% of athletes surveyed experienced stress UI when participating in their sports, with the highest prevalence in athletes exposed to high forces, suggesting a direct relationship between the amount of impact and the prevalence of stress UI. The high impact group experienced two times more stress UI than the low impact group (43.4% and 21.1% respectively). Athletes in the jumping sports experienced the most stress UI at 65.4% with 13.6% in the low impact sports. Only 13.2% of athletes were aware of how to perform pelvic floor strengthening exercises with only 3.3% performing pelvic floor strengthening exercises three or more times per week, and 3.3% performing 1-2 second holds as well as 10 second holds.
Conclusions: These results suggest a direct relationship between stress UI and the amount of high impact activities an athlete experiences. As of 2011, 65.4% of Division I female athletes in high impact sports in this study reported stress UI. These results indicate that stress UI is an overlooked issue in this population that needs to be addressed both within physical therapy practice and the female collegiate sports arena.
Clinical Relevance: One existing hypothesis is that high impact sports may cause female athletes to stretch, overload, and weaken their pelvic floors. Therefore, strengthening the pelvic floor musculature using Kegel exercises should decrease the prevalence of stress urinary incontinence in this population. In this study, 32.2% of athletes surveyed reported knowledge of how to prevent stress urinary incontinence, but only 3.3% of the athletes reported strengthening their pelvic floor on a weekly basis. Treatment for and prevention of stress urinary incontinence is needed. Physical therapists, working in conjunction with strength and conditioning coaches, should begin educating female athletes of high impact sports at the high school level. Pelvic floor and core strengthening should be incorporated into high school and collegiate workouts, potentially decreasing the incidence of stress UI in college athletes.
TITLE: Meeting the Needs of an Underserved Population: Developing a Program to Address Pelvic Floor Dysfunction
AUTHORS/INSTITUTIONS: W. Ensor, P.D. Gillette, M. Davis, A. Dye, K. Williams, Doctor of Physical Therapy Program, Bellarmine University, Louisville, Kentucky, UNITED STATES.
ABSTRACT BODY:
Purpose: Pelvic floor dysfunction can result in pelvic pain and urinary incontinence and has been found to be prevalent in groups with a lower socioeconomic status. Women with low incomes living in the inner city with limited access to health care services are therefore considered a high-risk population for these conditions. A lack of physical therapy providers, insufficient knowledge of physical therapy scope of practice, and a lack of available assessment tools further hinder the provision of pelvic floor rehabilitation services to individuals in underserved areas. The purpose of this project was to survey the underserved area, determine the need for Women's Health physical therapy services, and provide the services indicated as necessary for those in need.
Description: Design: Descriptive.
Summary of Use: A survey consisting of seventeen closed-ended items designed to determine an individual's potential benefit from women's health physical therapy services was developed and distributed to local community health centers, educational centers, daycare facilities, and churches in a targeted area of Louisville, Kentucky. Criteria used to select locations included those, 1) within an urban area lacking access to physical therapy providers, and 2) in close proximity to a location currently offering pro-bono physical therapy services. To further inform the target population, an educational session describing various pelvic floor dysfunctions and how physical therapy services could address these conditions was held at one of the survey distribution points. Results of the collected surveys were analyzed, revealing a need for pelvic floor rehabilitation in the targeted geographic area. In addition, information including standardized pelvic floor testing measures, outcome measures, general treatment guidelines, and home program instructions was collected and provided in written and illustrated form at the student-run clinic to further aid the students participating in the delivery of these services. Information advertising the provision of these services was disseminated to local residents, health care providers, and community service providers. Ongoing provision of pelvic floor physical therapy was then integrated with the services already provided at the pro-bono clinic, with doctor of physical therapy students providing the pelvic floor physical therapy services under the supervision of a licensed physical therapist certified by the American Board of Physical Therapy Specialties as a Women's Health Clinical Specialist.
Importance to Members: This description of a model of provision of physical therapy designed specifically to meet the needs of an underserved population can serve as an example to health care providers and educators interested in providing a similar service. Providers involved in student-run pro-bono clinics can also use this model as an example of a means by which to develop provision of other services for which there is a need amongst underserved populations.
TITLE: Postpartum femoral nerve palsy: a case study and the role of electrophysiologic testing and NMES
AUTHORS/INSTITUTIONS: J.W. Bellew, B. Schoettelkotte, Physical Therapy, University of Indianapolis, Indianapolis, Indiana, UNITED STATES;
A.J. Nitz, Physical Therapy, University of Kentucky, Lexington, Kentucky, UNITED STATES.
ABSTRACT BODY:
Purpose/Hypothesis: The incidence of postpartum lower extremity motor or sensory dysfunction due to neurological injury in modern obstetric practice is between 0.008 and 0.5%. Rarer is femoral nerve injury with isolated quadriceps impairment. This case reports the onset, neurophysiologic exam, and intervention in a subject with such injury.
Number of Subjects: A 26y/o primipara reported impaired volitional activation isolated to the right quadriceps and paresthesia in the thigh and proximal leg distribution of the saphenous nerve following 18hrs labor and 45min induced vaginal delivery with epidural analgesia.
Materials/Methods: 11 days post-parturition electrophysiologic examination and measurement of muscle performance were completed. EMG/NCV showed 1) greater than 75% reduction of right femoral nerve motor evoked response (MER) vs left, 2) a one-third reduction in amplitude of right saphenous nerve sensory latency, and 3) a 1.2msec slowing of the right femoral nerve distal motor latency. EMG failed to identify significant ongoing membrane instability but noted decreased recruitment and evidence of motor unit disintegration in the right femoral nerve distribution only. EMG did not detect fibrillations, positive sharp waves or fasciculations at rest nor myopathic motor units during recruitment. There were no abnormalities in the ipsilateral adductor magnus or iliopsoas. Maximal voluntary isometric force (MVIF) of the knee extensors was 13.9lb on the right and 42.2 on the left. Maximal electrically elicited isometric force (MEIF) of right quadriceps was 24.3lbs. To facilitate recovery of quadriceps strength, the patient began a b.i.d. daily home program of NMES to maximal tolerance.
Results: Two weeks after initial examination, the right MVIF improved to 37.2lbs and MEIF was 24.2lbs. Two weeks later, the right MVIF improved to 73.8lbs and the left MVIF was 66.4. A second EMG/NCV at 6 weeks revealed a four-fold increase in amplitude of the right femoral nerve MER to within 70% of the left. EMG failed to reveal any signs of denervation with nearly full motor unit recovery in the quadriceps muscle and amplitude of the saphenous nerve sensory latency.
Conclusions: Quadriceps but not iliopsoas involvement suggests femoral nerve entrapment distal to the inguinal ligament-a rare presentation with more common symptoms being sensory only (i.e. meralgia paresthestica) or involving the iliopsoas. Greater than 50% axon loss initially but less than 50% at 6 weeks suggests neuropraxia with rapidly recovering partial conduction block underlying the neurophysiologic findings. Early identification and supportive NMES for motor recovery likely facilitated resolution of the impairment.
Clinical Relevance: Primiparas with prolonged 2nd stage labor are more likely to experience postpartum nerve injury with most insults due to intrinsic obstetric palsies not regional anesthesia or analgesia. Women presenting with postpartum quadriceps weakness should be examined for this entrapment.
TITLE: Out Patient Physical Therapy Management of an Antepartum Patient with Ehler's-Danlos Syndrome
AUTHORS/INSTITUTIONS: A. Wise, University of Pittsburgh Medical Center/Centers for Rehab Services, Pittsburgh, Pennsylvania, UNITED STATES;
D. Borello-France, Department of Physical Therapy, Duquesne University, Pittsburgh, Pennsylvania, UNITED STATES.
ABSTRACT BODY:
Background & Purpose: Ehler's-Danlos syndrome can be associated with numerous pregnancy complications, ranging from mild articular discomfort to maternal death (1,2). The likelihood and severity of pregnancy complications appear to vary according to the type of EDS (1,2). There are 3 major types of Ehler's-Danlos syndrome, Classical type I-II, Hypermobility, and Vascular, representing 30%, 10-30%, and 10% respectively (1). The estimated overall prevalence of EDS is 1 in 5000(1). The features of EDS that have the most impact on obstetric care include fragility and poor healing nature of the skin, potential for excessive bleeding, spontaneous pneumothorax, easy joint dislocations, valuvular prolapse, and spontaneous rupture of major vessels and viscera. (2) The majority of reported obstetric complications associated with EDS occurred in patients with the Vascular Type of EDS, in which the arterial, intestinal, and uterine tissues are fragile due to collagen deficiency (2). To date, there are few studies that report on significant complications during pregnancy, labor, and delivery associated with Hypermobility type EDS (2,3,4). Instead, women with Hypermobility type EDS may experience an aggravation of symptoms during pregnancy, mainly in the joint articulations, which may result in cesarean section (1,2,3). The PT management of hypermobility in women with EDS is not clear-cut. Especially when the hypermobility is exacerbated by the physiological changes associated with pregnancy (5, 6) This single case design presents the out patient physical therapy management of a woman with Hypermobility type EDS during pregnancy.
Case Description: A 34 year old woman, 15 weeks pregnant with single child, presented for out patient physical therapy management of multifocal joint pain with pregnancy with the diagnosis of Hypermobility type EDS. Treatment interventions included manual therapy techniques, therapeutic exercise modified for pregnancy, patient education, postural awareness during ADL's, and passive bracing/taping options (5,6).
Outcomes: At study completion, the patient was able to avoid bed rest, suffered no loss in muscle strength that would have become detrimental to her EDS, maintain her parental role to her 2.5 year old twins, and self manage her pain. She attended 19 PT sessions from 15 weeks to 35 weeks 5 days gestation at which time she learned she was developing severe pubic diastasis which limited her community based mobility.
Discussion: The patient carried this pregnancy to 39 weeks and her child was safely delivered via c-section. The findings of this study suggest the effectiveness of antepartum PT management in preventing detrimental physical changes that could occur with EDS and pregnancy. These efforts made during the antepartum period may also improve post-partum recovery.
TITLE: Non-invasive management of urinary incontinence utilizing surface electromyography biofeedback at the perineum as an adjunct to pelvic floor muscle training: A case report
AUTHORS/INSTITUTIONS: A. Hill, University of Florida, Gainesville, Florida, UNITED STATES;
M. Alappattuu, Pain Research and Intervention Center of Excellence, Gainesville, Florida, UNITED STATES.
ABSTRACT BODY:
Background & Purpose: Urinary incontinence (UI) is a prevalent health condition that has a detrimental effect on an individual's quality of life (QOL). A common non-invasive treatment for UI is surface electromyography (sEMG) biofeedback with pelvic floor muscle (PFM) training. A lack of consensus exists on the effectiveness of using sEMG biofeedback in conjunction with PFM training for UI. Additionally, there is a lack of evidence for using sEMG biofeedback compared to the more invasive intravaginal biofeedback probe. The purpose of this case report is to examine outcomes using sEMG biofeedback at the perineum with PFM training for UI.
Case Description: A 61-year-old woman diagnosed with UI presented to outpatient physical therapy (PT) with the following symptoms: nocturia 1-4 times per night on most days of the week, urine leakage with urgency, and urine leakage with sneezing and coughing. The patient reported limited participation in socializing and recreational activities as well as personal embarrassment due to her UI symptoms. The PT treatment consisted of six weekly sessions and included behavioral modification, PFM strengthening with and without sEMG biofeedback, and therapeutic exercises and activities with PFM contractions. The sEMG biofeedback was utilized during treatments 2-4 and discontinued during treatments 5-6. The UI symptoms and PFM evaluation were assessed at initial evaluation and four weeks post-initial evaluation using components of the PERFECT scheme (an acronym for power, endurance, repetitions, fast contractions, and every contraction timed), International Consultation on Incontinence Modular Questionnaire - Urinary Incontinence Short Form (ICIQ-UI SF), Incontinence Impact Questionnaire - Short From (IIQ-7), and the 3 Incontinence Questions (3IQ).
Outcomes: At four weeks post-initial evaluation, the patient's PFM strength increased from 2/5 to 4/5 and PFM endurance improved from sustaining 2-second holds to 10-second holds. The ICIQ-UI SF score decreased from 6 to 0, the IIQ-7 score decreased from 14.3 to 0, and the 3IQ responses indicated both urgency and stress-related UI at the two time points of assessment.
Discussion: The patient in this case report described subjective relief of UI symptoms, and standardized, objective measures indicated improved symptoms four weeks post-initial evaluation. These outcomes culminated in complete resolution of UI symptoms, greater participation in social and recreational activities, and the ability to decrease UI medication dosage without UI symptoms returning. Utilizing surface electrodes initially at the perineum appeared to be useful in assisting the patient to isolate her PFM. The patient successfully progressed her PFM training to advanced therapeutic exercises and activities without sEMG biofeedback at later sessions. These outcomes suggest that sEMG biofeedback at the perineum used with PFM training may be a useful, non-invasive initial intervention for treating women with UI.
TITLE: Do Physical Therapists Screen and Manage Issues Common in the Female Athlete?
AUTHORS/INSTITUTIONS: C.E. Rothschild, B. McCormick, Physical Therapy, University of Central Florida, Orlando, Florida, UNITED STATES.
ABSTRACT BODY:
Purpose/Hypothesis: To identify practice patterns related to the physical therapist's recognition and management of common issues found in female athletes throughout various settings and specialties. From this study, an effort will be made to identify influencing factors, patterns, and differences in the evaluation process of physical therapists regarding these issues.
Number of Subjects: 201
Materials/Methods: A 28 question electronic survey was developed and dispersed through Qualtrics survey platform to 2272 email addresses selected at random from the American Physical Therapy Association Membership Directory. Information was collected in the following areas: demographics, educational history, practice setting, women's health education and current practice patterns associated with recognition and management of conditions common in the female athlete. Descriptive statistics, frequencies and means were calculated for all variables. Correlational analysis was computed using a Chi-square tests and Pearson Correlation Coefficient for nonparametric data. Significance level was set at p<.05.
Results: 201 (21%) respondents completed the survey. 62.2% were female and 37.8% were male. Average age was 42.66 (sd = 9.88). Demographic categories with the greatest frequencies were as follows: 76.6 were married, 90% were Caucasian, and 77.6% were non-Hispanic. With regards to educational levels, 39.5% earned an entry-level PT degree at the Bachelor's level, 59.7% earned their highest degree as a Doctor of Physical Therapy, 44.8% held at least one ABPTS certification, and 49.8% held some type of additional certification. 39.8% of those surveyed did not receive entry-level education on women's health. 33.7% had over 21 years of experience. 65% primarily practice in the general outpatient setting. 64.6% felt that it was very to extremely important to screen for women's health issues common in the female athlete, while only 41.8% indicated moderate to complete comfort in identifying these issues. Positive correlations to level of confidence were found with reported level of confidence and practice setting. Positive correlation with level of importance was found with continuing education.
Conclusions: Physical therapists may lack sufficient knowledge on conditions common in the female athlete to effectively be able to recognize and manage in clinical practice. As a profession with direct access to patients, it is critical that therapists receive proper teaching of this topic area during entry-level education.
Clinical Relevance: According to the Guide to Physical Therapist Practice, conditions prevalent in the female athlete are within the scope of practice to screen for and treat for, however, may not be adequately taught in physical therapist education to enable a therapist to confidently manage.
TITLE: A Description of Outcomes from Subjects with a Caesarian Section Resulting in Chronic Scar Pain Treated with Fascial Scar Release Techniques: A Case Series
AUTHORS/INSTITUTIONS: J.B. Wasserman, M.A. Halkiotis, J.L. Steele, E.M. Riggins, J.S. Yuen, Physical Therapy, Franklin Pierce University, Manchester, New Hampshire, UNITED STATES.
ABSTRACT BODY:
Background & Purpose: Over 1.37 million Caesarian sections (C-sections) are performed annually in the US. It is estimated that 12.3% of those will develop chronic scar pain. There is anecdotal evidence supporting the use of fascial scar release techniques in reducing abdominal surgical scar pain, and yet almost no research has been published. The purpose of this case series was to describe the outcomes of 2 subjects with chronically painful C-section scars following an intervention of specific myofascial scar release techniques.
Case Description: Following a general request for subjects, two women met the study criteria and agreed to participate. Subject 1 was a 35 year old who underwent C-sections in 2005 and 2007. Subject 2 was a 33 year old who underwent C-sections in 2008 and 2012. Since that time both have experienced pain during bowel movements and when pressure is applied to the lower abdomen. Subject 1 also reports sharp pain (Numeric Pain Rating Scale (NPRS) 4 - 7) with bed mobility. Both reported a worsening of their pain each month in the week preceding menstruation. Neither subject had sought treatment for their chronic painful scars in the past. Four, 30-minute treatment sessions were conducted consisting of stretching of the scar in various directions until a release of the scar was felt by the treating physical therapist.
Outcomes: Outcome measures included threshold pain and pain tolerance using a Pressure Algometer, Adheremeter measurements of scar flexibility, and the NPRS. Measures were collected at baseline and repeated five days after the final treatment and again at a four-week follow-up to ensure that measures were done at the same time in the subject's menstrual cycle. Both patients demonstrated improved pressure tolerance. Subject 1's baseline pressure tolerance averaged 12.8 N pre-treatment and 23 N post treatment (an increase of 79%). Subject 2's baseline pressure tolerances averaged 16.3 N pre-treatment and 21.7 N post treatment (an increase of 33%). Scar mobility increased in subject 1 in all directions with the greatest improvement being a change from 8 to 24 mm. (a 200% improvement). Subject 2's greatest improvement in scar mobility was from 8mm to 18mm (a 125% increase) post scar release therapy sessions. Both subjects rated their pain for all previously painful activities at a zero during the pre-menstrual week following treatment for the first time since their surgeries, ranging from two to nine years ago.
Discussion: The results of this case series suggest that scar release techniques may help reduce chronic scar pain in women who have had C-section surgery. Future studies should continue to examine the effectiveness of myofascial scar release in this patient population through the use of randomized clinical trials.
TITLE: Do Physical Therapy Interventions Affect Functional Incontinence and Quality of Life in People with Multiple Sclerosis? An Evidence-Based Review
AUTHORS/INSTITUTIONS: V. Block, M. Rivera,. Melnick, D. Allen, Department of Physical Therapy & Rehabilitation Science, ucsf/sfsu, San Francisco, California, UNITED STATES.
ABSTRACT BODY:
Purpose/Hypothesis: Multiple sclerosis (MS) presents with many debilitating symptoms, including urinary incontinence (UI), which physical therapy (PT) may address. UI is surprisingly prevalent but consensus is lacking regarding effectiveness of non-surgical or pharmaceutical interventions. A meta-analysis of long-term, conservative treatment options may supply this deficiency. Our purpose was to analyze the current evidence for effectiveness of PT to decrease UI and improve quality of life (QoL) in persons with MS.
Number of Subjects: N/A
Materials/Methods: An electronic search conducted through November 26, 2013, included search terms: incontinence, bladder dysfunction, urinary incontinence, Multiple sclerosis, MS, physical therapy, physiotherapy, therapy and rehabilitation. Criteria for inclusion: diagnosis of MS, intervention involved PT focusing on UI or bladder dysfunction, outcomes assessed QoL and/or UI, and at least a 4/10 (PEDro scale) or a 2b level of evidence. Outcomes were combined across studies and effect sizes were depicted in forest plots.
Results: Six studies met the inclusion criteria. Between-group analysis revealed statistically significant differences in incontinence episodes, QoL participation and QoL activity level, though failed to reach significance for functional control mechanisms. Incontinence leakage episodes and QoL participation improved within groups.
Conclusions: Meta-analysis indicates support for PT for minimizing incontinence compared to pre-treatment, and affecting incontinence and measures of QoL in persons with MS more than control groups. Protocols were heterogeneous regarding the duration and type of PT intervention, and were applied in different types of MS. Further research may reveal the most effective combination and variety of PT interventions for persons with MS.
Clinical Relevance: Persons with MS have a high risk of UI and conventional medications have side effects that promote low adherence and therefore the problem persists. PT interventions can be an effective, safe first line treatment option to improve UI and QoL.
TITLE: Effectiveness of Rehabilitative Ultrasound Imaging in Muscle Re-education: A Systematic Review
AUTHORS/INSTITUTIONS: N. Kumbhani, C. Wu, L. Steiner, Physical Therapy, MGH Institute of Health Professions, Boston, Massachusetts, UNITED STATES.
ABSTRACT BODY:
Purpose/Hypothesis: Rehabilitative Ultrasound Imaging (RUSI) is a tool increasingly being used in muscle re-education, but it's effectiveness for facilitating correct muscle activation is unclear. Thus, the aim of this systematic review is to analyze the effectiveness of RUSI in muscle re-education for healthy subjects and in those with low back pain (LBP).
Number of Subjects: N/A
Materials/Methods: Computerized databases- PubMed, Medline (Ovid), Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane were searched for published articles from 2000 to July 2013. The studies were included if RUSI was provided as a tool to facilitate the contraction of transversus abdominis or multifidus. All subjects were adults over 18 years and they could be healthy or with a history of LBP. The 2 outcome measures were pain as measured by visual analogue scale (VAS) or numerical pain rating scale (NPRS) and/or muscle performance as measured by change in muscle thickness. Two reviewers independently assessed each study for methodological quality using the PEDro scale and Sackett's levels of evidence.
Results: The total number of articles in this systematic review was 15. Of these 15 articles, 2 articles recruited healthy subjects, 10 articles had LBP subjects, and 3 had both. On the PEDro scale, 7 articles received a score of 6 and above, which were considered as high quality studies, while the remaining 8 articles received a score of 4 and below. ICC for the total score was 0.953 (95% CI 0.859-0.984). The range of percentage of agreement was 40-100% and the Kappa value ranged 0.30-1 for the individual items on the PEDro. Ten of the 15 studies supported the use of RUSI, among which there were 4 high quality studies and 6 low quality studies. Among the 7 high quality studies, 4 supported and 3 didn't support the use of RUSI. Two studies compared exercise with and without RUSI. Van 2006 recruited healthy subjects and showed greater improvement in the group with RUSI, while Teyhen 2005 recruited subjects with LBP and didn't show difference between the two groups.
Conclusions: Among the high quality studies in this systemic review, there was no consensus whether RUSI is an effective biofeedback tool for muscle re-education in either healthy subjects or subjects with LBP that improves muscle re-education beyond the more traditional approaches now used, whereas the low quality studies support the use of RUSI. Further research needs to be done in order to reach an agreement regarding the effectiveness of RUSI as a biofeedback tool.
Clinical Relevance: The systematic review does not provide enough support to justify the use of RUSI and its considerable cost at this point of time. Therefore, further research with higher quality studies and specifically comparing its use and non use is necessary to determine the effectiveness of RUSI for muscle re- education in either healthy subjects or subjects with LBP.
TITLE: Factors Associated with Pelvic Girdle Pain at 4 Weeks Postpartum: 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, Wincester, Virginia, UNITED STATES.
ABSTRACT BODY:
Purpose/Hypothesis: A subset of postpartum women experience a unique, disabling combination of lumbar spine and pelvic symptoms, classified as pelvic girdle pain (PGP). Postpartum women with PGP experience pain and severe functional limitations after delivery. Studies have investigated factors associated with PGP during pregnancy, at 1 year, and up to 6 years after delivery. Little is known about factors associated with PGP at 4 weeks after delivery. The purpose of this study was to identify factors associated with PGP at 4 weeks after delivery.
Number of Subjects: Twenty-one women within the first 4 weeks after delivery
Materials/Methods: Women in the first 4 weeks after delivery were recruited through the community. Survey tools included a demographic questionnaire, pain questionnaire, and Oswestry Low Back Pain Disability Questionnaire. Statistical analysis included logistic regression, Chi-square, and Mann-Whitney U. Alpha level was set to 0.05. The study was approved by the Institutional Review Boards of Nova Southeastern University and Rutgers, the State University of New Jersey.
Results: Pelvic girdle pain (PGP) affected 24% of subjects (n = 5/21). Mean ODI score was 12.3 (0-34, SD = 10.9). ODI scores significantly differed between women with and without PGP. Women with PGP had higher ODI scores than women without PGP (U = 5.0, p = 0.002). A history of low back pain (LBP) and Caesarean Section (CS) delivery were associated with PGP. An association between PGP and history of lLBP was found, X2 (1, N = 21) = 6.43, p = 0.03. A higher prevalence of PGP was observed in women with a history of LBP. 57% of women with history of LBP reported PGP compared to 8% of women without history of LBP. An association between PGP and delivery method was found, X2 (1, N = 21) = 4.89, p = 0.05. A higher prevalence of PGP was observed in women after CS deliveries compared to vaginal deliveries. 50% of CS deliveries reported PGP compared to 8% in vaginal deliveries. CS delivery predicted PGP (B = -2.49, SE = 1.23, p = 0.05, Exp(B) = 0.08, 95% CI: 0.01-0.98).
Conclusions: Approximately one-quarter of postpartum women were affected by PGP at 4 weeks after delivery. Higher rates of PGP were found in women with a history of LBP and in women after CS delivery. ODI scores significantly differed between women with and without PGP. Recommendations are made cautiously because of small sample size. More research is needed to reproduce findings in larger, more diverse populations.
Clinical Relevance: 24% of women were affected by PGP. A history of LBP is a known predictor of PGP during pregnancy and may be a predictor of postpartum PGP. Effective preventative and intervention strategies for women with a history of LBP are needed during pregnancy and the acute postpartum period to minimize the risk of PGP development and transition to chronic low back pain. The increased trend of CS deliveries in the US warrants further investigation, especially related to PGP.
TITLE: Pelvic Floor Muscle Training for Pelvic Organ Prolapse Secondary to Ehlers-Danlos Syndrome: A Case Report.
AUTHORS/INSTITUTIONS: H. Ito, Physical Therapy, Rusk Institute of Rehabilitation Medicine/NYU Langone Medical Center, New York, New York, UNITED STATES.
ABSTRACT BODY:
Background & Purpose: Ehlers-Danlos Syndrome (EDS) is a heterogeneous connective tissue disorder characterized by joint hypermobility, skin hyperextensibility, and widespread tissue fragility. The underlying issue of EDS is the abnormal synthesis and metabolism of collagen. Since collagen adds strength and elasticity to the connective tissue, patients with EDS present with generalized weakness and fragility of skin, muscles, joints, blood vessels, and visceral organs. The severity of the disorder can may from mild to life-threatening, depending on the location and the type. Gynecologic and obstetric complications in female patients with EDS are recognized in several literatures. The purpose of this study is to identify and describe the uses of pelvic floor muscle training to treat a female patient with pelvic organ prolapse secondary to EDS.
Case Description: The patient was a female yoga teacher who was referred to outpatient women's health physical therapy clinic with a diagnosis of rectocele, cystocele and enterocele. Later, the patient was diagnosed with EDS, which explained her weak pelvic floor structural integrity. The patient's history revealed functional impairments due to pain, urinary urgency and frequency, chronic constipation and feeling of incomplete evacuation. These impairments limited her ability to instruct and participate in yoga classes. Physical therapy intervention consisted of pelvic floor muscle training, bladder retraining, biofeedback, colon mobilization, body mechanics, and education.
Outcomes: At the time of discharge, improvements were noted in pain and strength of pelvic floor, with pre- and post-measurement of 8/10 and 5/10 in Visual Analogue Scale and 2/5 and 4/5 in Manual Muscle Testing, respectively, resulting in an ability to return to premorbid function and ability to teach yoga classes with less symptoms.
Discussion: The eventual diagnosis of EDS explained the patient's pelvic organ prolapse. This case report supports the application of pelvic floor muscle training, neuromuscular re-training and education to improve pain, strength and functional activities for a female patient with pelvic organ prolapse caused by EDS.
TITLE: Normal parameters for rib cage and abdominal synchrony in healthy adult females.
AUTHORS/INSTITUTIONS: M. Abrams, A.M. Chaudhari, The Ohio State University, Columbus, Ohio, UNITED STATES.
ABSTRACT BODY:
Purpose/Hypothesis: Breathing quality and coordination play a role in many women's health diagnoses. Thoraco-abdominal asynchrony (TAA) is non-coincident movement of the rib cage and abdomen during breathing and is often seen in patients with diaphragm weakness. It is typically measured using respiratory inductance plethysmography (RIP), as the phase angle between the rib cage and abdomen signals, and it is used clinically as a sign of increased work of breathing. However, this measurement is highly variable and an upper limit of normal (ULN) has only been established for male adults at rest and during exercise. The purpose of this study was to establish ULN for female adults utilizing a variety of positions and breathing directives.
Number of Subjects: Subjects included 21 healthy, adult females with no history of diagnoses that would negatively impact their breathing or participation in activities that might enhance their breathing, such as playing a wind instrument. Participant mean age was 36 +/- 17, body mass index was 23 +/- 3, waist:hip ratio was 0.8, and functional capacity was 9.66 +/- 0.5 METs.
Materials/Methods: This was a single test, observational study. RIP band data was recorded for 1 minute during quiet and deep breathing in supine, sitting, and standing using a Bioradio data collection system (G. L. Neurotech, Valley View, OH). Average phase angles between the rib cage and abdomen signals were calculated using Vivosense (Vivonoetics, San Diego, CA), and then two standard deviations above the mean were calculated to define the ULN for both quiet and deep breathing in the three positions.
Results: The mean, standard deviation, and ULN of TAA for the various breathing directives and positions were as follows: deep breathing in supine - 15.17[degrees]+/- 9.93, 35.02[degrees]; deep breathing in sitting - 29.05[degrees]+/-39.05, 107.14[degrees]; deep breathing in standing - 36.46[degrees]+/-51.29, 139.03[degrees]; quiet breathing in supine - 8.57[degrees]+/-4.86, 18.28[degrees]; quiet breathing in sitting - 10.83[degrees]+/-5.00, 20.84[degrees]; quiet breathing in standing 13.56[degrees]+/-3.99, 21.54[degrees].
Conclusions: ULNs for breathing asynchrony vary by gender, position, and breathing directives, increasing with female gender, upright positioning, and deep breathing.
Clinical Relevance: For the interpretation of thoraco-abdominal asynchrony, it is important to use gender-, position-, and breathing directive-specific ULNs.
TITLE: The effects of a progressive exercise program on functional activity and quality of life for older overweight women with knee osteoarthritis
AUTHORS/INSTITUTIONS: S. Schuerman, T. Carlson, D. Edvalson, T. Peck, B. Robison, Physical Therapy, University of Nevada, Las Vegas, Las Vegas, Nevada, UNITED STATES.
ABSTRACT BODY:
Purpose/Hypothesis: Knee osteoarthritis (OA) is estimated by the CDC to affect 13.6% of women over the age of 60. The symptoms of knee OA are exacerbated in individuals who are overweight or obese. This study was designed to determine if 2 functional progressive exercise protocols (Walking and aerobic Stepping) could improve function and quality of life (QOL) in older, overweight women with knee OA.
Number of Subjects: 16
Materials/Methods: Women over the age of 60 with knee OA in one or both knees (radiographic diagnosis) and who were overweight (BMI>25 (34.21 +/- 7.28) were randomly assigned to a Walking or a Stepping Group. Both groups performed 10 minutes of warm-up and 10 minutes of cool-off walking in a hallway at a leisurely pace. Both groups were instructed to exercise at a pace that allowed them to speak comfortably with a walking or stepping partner. The Walking Group walked 15 minutes for 2 weeks, 30 minutes for 3 weeks, and 45 minutes for 5 weeks. The Stepping Group performed a stepping protocol that included forward step-ups, side step-ups, calf raises, and mini-squats. The stepping group exercised on a 4 inch step for 2 weeks, a 6 inch step for 3 weeks, and an 8 inch step for 5 weeks. Subjects exercised under the supervision of trainers 2 days per week and on their own at home with the same protocol 1 day per week. Pre-and post-tests included hip and knee isometric strength, lean & fat body mass in grams (DEXA), the SOT & LOS via the NeuroCom Smart Equitest, pain via a VAS, and self-reported outcomes measures on the KOOS.
Results: Significant improvement in the KOOS-QOL (p = 0.026) and function (p = 0.027) subscales and on the SOT (p = 0.022) occurred in the Walking Group. The Stepping Group made no significant changes. Combining the 2 groups resulted in significant findings in the KOOS-QOL (0 = 0.022) subscale, the SOT (p = 0.001), and the LOS (p = 0.024).
Conclusions: This study showed that a functional walking program improved function, QOL, and balance in this population of women. Significant improvement did not occur in the Stepping Group. Combining the 2 groups did result in significant improvement in function, QOL, and balance in the LOS in addition to the SOT.
Clinical Relevance: These results from a functional program that can be completed at home offer potential in the management of knee OA in older, overweight women. Improvements in these areas should allow older, overweight women with knee OA to remain active in their communities longer.
TITLE: The relationship between fetal weight and inter-recti distance in pregnant women with lumbopelvic pain: A preliminary investigation.
AUTHORS/INSTITUTIONS: C.M. Chiarello, S. Kleinstein, M. Lyon, K. Resha, Columbia University, New York, New York, UNITED STATES.
ABSTRACT BODY:
Purpose/Hypothesis: Diastasis Rectus Abdominis, measured as inter-recti distance (IRD), has been associated with pregnancy, parity, waist girth, obesity, and age. In cadavers, IRD was influenced by structures deep to linea alba (LA) as IRD increased with waist girth due to the size of the abdominal, but was not influenced by subcutaneous tissue superficial to the LA. The primary purpose of this study was to explore whether fetal size is a factor in the development of DRA during pregnancy. The secondary purpose was to determine if characteristics associated with fetal size (gestational age and abdominal circumference) were associated with DRA during pregnancy.
Number of Subjects: Twenty-two pregnant women between 20-36 weeks gestation, who were participating in a larger study on DRA and lumbopelvic pain and had at least one recent fetal ultrasound, participated.
Materials/Methods: IRD was measured at 3 locations using calipers and measured under two conditions, abdominal muscles at rest and during a curl-up. Subject abdominal circumference was measured with a tape measure. Fetal weight was estimated by certified sonographers from ultrasound images, (GE Voluson 730 Expert or Voluson E8, GE Medical System, Austria) who determined gestational age based on fetal crown-rump length (CRL) and measurements of head circumference, abdominal circumference and length of femoral diaphysis were collected in all cases. Estimated fetal Weight (EFW) was calculated based on Hadlock formula. As the fetal ultrasound did not occur on the same day as the IRD and abdominal circumference measurements, projected EFW (pEFW) was extrapolated from population EFW charts for each subject.
Results: Projected estimated fetal weight and gestational age were very strongly correlated (r = 0.97, p<0.01). Maternal age, height, and abdominal circumference were not significantly correlated with any measure of IRD. pEFW showed a moderate positive relationship with IRD in the passive condition at the level of the umbilicus and in the active condition at and below the level of the umbilicus. Gestational age showed a moderate positive relationship with IRD during a curl-up and below the level of the umbilicus. Abdominal circumference did not significantly contribute to IRD.
Conclusions: Fetal size and gestational age may influence the development of DRA in pregnant women. Future research which examines the relationship between these factors and IRD on the same day is required to further examine this possibility.
Clinical Relevance: Clinically, we recommend considering pEFW or gestational age as factors which. Pregnant women with a large fetus may be at greater risk for DRA especially in the advanced stages of pregnancy.
TITLE: Response of Inter-recti Distance to Active Abdominal Contraction
AUTHORS/INSTITUTIONS: A. McAuley, University of New England, Portland, Maine, UNITED STATES;
C.M. Chiarello, Columbia University, New York, New York, UNITED STATES.
ABSTRACT BODY:
Purpose/Hypothesis: Inter-recti distance (IRD) is expected to decrease with activation of the abdominal muscles during a curl-up maneuver. However, we previously observed an inconsistent pattern of IRD change during movement. The purpose of this investigation was to compare the IRD with the abdominal muscles at rest to the IRD during a curl-up. Secondarily we examined factors which could influence the change in IRD with the abdominal muscles at rest to the IRD during a curl-up.
Number of Subjects: A 56 subject sample of convenience, aged 19 to 64 years, was comprised of 11 males, 22 nulliparous females and 23 parous females.
Materials/Methods: IRD measurements were made in two locations, 4.5 cm above and 4.5 cm below the umbilical midpoint, by one examiner with ultrasound imaging (USI) using the LOGIQ Book XP (GE Healthcare, Waukesha, WI). IRD was measured at rest in hook-lying. For the partial curl-up, subjects crossed their arms over chest raising their head and lifting the scapular spines from the surface. Influencing factors measured were load transfer via ASLR, BMI, abdominal circumference, and self-reports of low back pain (LBP) and urinary incontinence (UI). Subjects were grouped post hoc according to whether IRD decreased or increased with curl-up and by location. Data was analyzed with separate stepwise regressions with the variables age, gender, parity, LBP, UI, BMI and ASLR computed for each location.
Results: Above the Umbilicus: IRD increased from rest to the curl-up in 25 subjects (Mean = 0.38 cm +/- 0.33) with stepwise regression analysis revealing that BMI explained a small (13.6%), but statistically significant (p = .043) amount of the variability. IRD decreased in 29 subjects (Mean = 0.56 cm +/- 0.61) from rest to the curl-up with no variables predicting this IRD change. In 2 subjects, no IRD change was exhibited. Below the Umbilicus: IRD increased in 17 subjects (Mean = 0.41 cm +/- 0.32) with the curl-up. IRD decreased in 24 subjects (Mean = 0.62 cm +/- 0.42) with the curl-up. No variables predicted IRD change below the umbilicus in either location. There was no IRD change in 15 subjects of which 14 showed no measurable IRD in either condition. In 9 subjects, IRD increased with curl-up both above and below the umbilicus with no variables predicting this change. In 18 subjects IRD decreased with curl-up both above and below umbilicus with none of the variables predicting this change.
Conclusions: IRD can both increase and decrease with a curl-up though the changes were small. BMI may be related to the response of the IRD to active contraction, but further research is needed.
Clinical Relevance: The abdominal muscle recruitment pattern during a curl-up was not the same in all individuals and may contribute to an increased IRD. A DRA may be associated with sub-optimal recruitment pattern of the abdominal muscles. We recommend clinicians assess the movement pattern of the abdominal muscles to determine its effect on each individual's DRA before prescribing exercises.
TITLE: Comfort Level of Entry-Level Physical Therapy Students in Addressing Sexual Concerns of Patients/Clients
AUTHORS/INSTITUTIONS: K. Abraham, L. Kihm, C. Bagley, W. Rheins, Shenandoah University, Winchester, Virginia, UNITED STATES.
ABSTRACT BODY:
Background/Purpose: Studies have suggested that practicing physical therapists have limited comfort with addressing sexual concerns with patients and do not regularly screen for or address sexual concerns unless initiated by the patient. There is no data on comfort level or preparation of entry level physical therapy students in addressing sexual concerns with patients/clients. Therefore, the purpose of this study was to examine the comfort and attitude of entry-level physical therapy students in the final year of a DPT program in addressing sexual issues with patients/clients.
Design/Methods: A survey was created for the purposes of this study consisting of four primary sections: 1) demographics, 2) preparation and likelihood of addressing sexual dysfunction, 3) Likert Scale items in which respondents rated their comfort with specific scenarios, and 4) open-ended questions regarding barriers to and suggestions for improving care. The survey was sent to the Program Directors of 230 accredited physical therapy programs in the United States via Survey Monkey asking them to forward the survey to students in the final year of their DPT program.
Results: A total of 249 physical therapy students completed the survey for an estimated survey response rate of 3.7%. 227/249 (91.2%) of surveys were complete and utilized for the analysis. Only 32.5% of respondents affirmed that they were comfortable addressing sexual concerns with patients. The respondents reported the greatest comfort when discussing sexual concerns with their spouse/partner (4.43/5) or health care provider (3.72/5). Students reported the least comfort with a scenario in which a therapist interrupts a patient masturbating (1.49/5)) or asking a patient about his/her prior sexual experiences (2.21/5)/practices (2.26/5). 55.6% of subjects reported receiving didactic training in addressing sexual concerns during their entry level education but only 40.6% felt they had the resources/skills necessary to address sexual function in their current clinical setting. Both women and men were more comfortable addressing sexual concerns with a patient/client of the same gender (Males p = 0.00; Females p = 0.001). Students were significantly more comfortable with addressing sexual concerns with females vs. males, married vs. single clients, and clients under 18 years old. Lack of experience and knowledge were the most commonly sited barriers to addressing sexual concerns.
Conclusion: Entry-level DPT students are similar to practicing physical therapists in their comfort level addressing sexual concerns with patients/clients. Students reported that education would be the best way to overcome barriers related addressing sexual issues with patients.
Clinical Relevance: Adding additional didactic instruction regarding the physical therapist's role in the screening and management of sexual dysfunction in physical therapy education programs may help students and clinicians be more comfortable with addressing patients' sexual concerns.
TITLE: Measures of diaphragm and transverse abdominis function in patients with chronic pelvic pain: a case series.
AUTHORS/INSTITUTIONS: M. Abrams, A.M. Chaudhari, The Ohio State University, Columbus, Ohio, UNITED STATES.
ABSTRACT BODY:
Background & Purpose: The diaphragm, transverse abdominis, and pelvic floor muscles work together for the functions of trunk stability, continence/elimination, respiration, and the maintenance of intra-abdominal pressure. Dysfunction of any of these three muscles seems to be related to dysfunction of the others, and has been demonstrated in patients with low back pain, SI joint dysfunction, incontinence, and respiratory disorders. However, this inter-relationship of dysfunction has not been examined in patients with chronic pelvic pain (CPP). The objective of this project was to test whether the diaphragm and transverse abdominis function of 2 patients with CPP significantly differed from defined parameters of normal.
Case Description: Both subjects were female with no history or diagnoses of breathing dysfunction. Patient A was 37, with a BMI of 24, a waist:hip ratio of 0.8, a National Institute of Health - Chronic Prostatitis Symptom Index (NIH-CPSI) score of 14 and an Oswestry Disability Questionnaire (ODQ) score of 16/50. Patient B was 51, with a BMI of 27, a waist:hip ratio of 0.85, an NIH-CPSI score of 33, and an ODQ score of 19. All measures were taken once and compared to established limits of normal for those measurements. As strength measurements for the diaphragm and transverse abdominis, maximal inspiratory and expiratory pressures were used respectively and measured via spirometer. Respiratory inductance plethysmography (RIP) was used to measure the ratio of rib cage:abdominal breathing (RC:AB) and the degree of thoraco-abdominal synchrony demonstrated during deep and quiet breathing in three positions: supine, sitting, and standing.
Outcomes: Both patients scored within normal limits for both maximal respiratory maneuvers and for RC:AB. Patient A demonstrated asynchrony above normal for deep breathing in sitting and standing, and for quiet breathing in standing. Patient B demonstrated asynchrony above normal for all deep breathing trials and for quiet breathing in standing.
Discussion: While these patients were able to produce inspiratory and expiratory forces within normal ranges and did not avoid abdominal breathing, they both demonstrated thoraco-abdominal asynchrony, which may reflect significant diaphragm and transverse abdominis dysfunction in the CPP population. These results also create a potential target for biofeedback training to restore normal breathing function in this population.