TITLE: Accuracy of Subjective History for Identification of Stress Urinary Incontinence in Women
AUTHORS: Gina Clark, Lauren Murphy, Rebecca Reisch
INSTITUTION: Pacific University, Hillsboro, Oregon, USA.
CONTACT: Rebecca Reisch: mailto:[email protected]
ABSTRACT BODY:
Purpose: Urinary incontinence affects approximately 10% of middle-aged women on a daily basis and 75% of middle-aged women on a weekly basis. Genuine stress incontinence (GSI), defined as leakage during effort, exertion, sneezing, or coughing, is a type of urinary incontinence that can be successfully treated with physical therapy intervention. Genuine stress incontinence negatively influences women's quality of life. This may result in decreased participation in physical and sexual activity as well as feelings of embarrassment and isolation. The gold standard for diagnosing GSI is costly urodynamic analysis carried out by urogynecology specialists. The purpose of this report was to analyze the accuracy of using subjective history to diagnose GSI.
Description: An evidence-based appraisal of the literature by the authors showed that GSI can be confidently ruled out in women aged 18 to menopause by using either subjective questioning or the Urogenital Distress Inventory 6 questionnaire. Data from 2 articles showed that question number 3 from the Urogenital Distress Inventory 6 had a 85% to 90% sensitivity, with small 95% confidence intervals (CIs). A third article showed that taking a subjective history was 78.0% sensitive (95% CI, 70.0%-86.0%) and 84.0% specific (95% CI, 76.9%-91.1%), indicating usefulness in ruling out and ruling in GSI.
Summary of Use: Based on these data, subjective history can accurately rule in or out GSI in patients who present with urinary incontinence symptoms to the physical therapy clinic, and initiation of conservative treatment could be expedited. This will allow an improvement in time and cost-effectiveness by avoiding additional appointments and expensive urodynamic evaluations. Using these methods in the physical therapy clinic requires no extra time or cost on the part of the physical therapist. These methods are accessible, inexpensive, and accurate for ruling out and in GSI in women in the physical therapy clinic.
Importance to Members: Physical therapists can accurately use subjective history to rule in or rule out GSI in women who present to the physical therapy clinic with urinary complaints.
TITLE: Study of Maternal Mortality and Morbidity in Postpartum Women Living in Bangladesh and Implications for Postpartum Programs in Physical Therapy: Comparison by Birth Mode
AUTHORS: Lori M. Walton1, Dawn Brown-Cross2
INSTITUTIONS: 1. Physical Therapy, Nova Southeastern University, Fort Lauderdale, Florida, USA.
2. Applied Medicine and Rehabilitation, Indiana State University, West Lafayette, Indiana, USA.
CONTACT: Lori Walton: mailto:[email protected]
ABSTRACT BODY:
Purpose: The purpose of this study was to review the current literature regarding maternal mortality and morbidity in postpartum women living in Bangladesh after cesarean section, assisted vaginal delivery, and normal vaginal delivery and to provide evidence-based support for future postpartum programs.
Description: Bangladesh continues to have one of the highest maternal mortality and morbidity rates for developing countries. Current, reported maternal mortality rates are 380 of 100 000, according to the World Health Organization (WHO), the United Nations Children's Fund, and the United Nations Population Fund in the 2010 report (WHO, 2010). Although maternal mortality has reduced significantly from previously reported rates of 450 of 100 000 in 2005 and 724 of 100 000 in 1990, it does not approach the WHO goal of 123 of 100 000 or a 75% reduction by 2015 for the Millennium Development Goal 5 (Hogan et al, 2010).
Maternal morbidities and resulting disabilities also pose a problem during the postpartum period, with a relationship demonstrated between maternal morbidity and mortality in several studies (Islam et al, 2004; Fortney et al, 1999; Jejeebhoy, 1997). Over 75% of the maternal deaths in Bangladesh can be attributed to complications occurring in the postpartum period (Afsana and Rashid, 2000). Several studies demonstrated an increased incidence in mortality for women in Bangladesh who experience one or more morbidities in the postpartum period (Islam, Chowhury, Chakraborty, Bari, and Akhter, 2004; Fortney and Smith, 2005).
Prenatal, postpartum, and women's reproductive programs are part of a national plan to reduce maternal mortality in Bangladesh. These programs include family planning, prevention of sexually transmitted disease, comprehensive abortion care, pharmaceutical management and nutrition, utilization of skilled birth attendants, prenatal care, and postpartum care (Prata, Passano, Sreenivas, and Gerdts, 2010). While the majority of these initiatives have helped reduce maternal mortality, there is still a need to reduce the mortality rate in Bangladesh further and to explore programs from a physical therapy perspective.
Cesarean section procedures occurring in Bangladesh have increased to 15% to 25%, with very little known about the potential risk factors for postpartum women (WHO, 2010). This study seeks to provide evidence-based understanding to the specific morbidities of postpartum women and detailed needs of postpartum women, according to birth mode.
Summary of Use: This study will be utilized to assist in evidence-based, comprehensive planning for postpartum programs to meet the specific needs of the postpartum programs, according to specific birth mode needs.
Importance to Members: A need exists to examine the postpartum complications by mode of birth delivery to determine the problems arising in the postpartum period that may lead to increased maternal morbidities and mortality rates.
TITLE: Effect of Exercise and Mechanical Loading on Radius Bone Density and Quality in Females With Primary Hyperparathyroidism
AUTHORS: Neal Scibelli, Britt Tinch, Geraldine Yu
INSTITUTION: Program in Physical Therapy, Columbia University, New York, New York, USA.
CONTACT: Neal Scibelli: mailto:[email protected]
ABSTRACT BODY:
Purpose/Hypothesis: Primary hyperparathyroidism (PHPT) results in decreased bone mineral density (BMD). It is the most common endocrine disorder in the United States and primarily affects postmenopausal women. The purpose of this study was to determine if forearm exercise and mechanical loading of the upper extremity improves BMD and bone quality in 2 postmenopausal females, 1 with PHPT and 1 without PHPT. The authors of this study hypothesize that exercise and mechanical loading will stimulate the anabolic pathway of parathyroid hormone to positively affect bone metabolism.
Number of Subjects: Two postmenopausal females. One subject with osteopenia secondary to PHPT, and one patient with osteopenia of insidious causes.
Materials/Methods: This case series investigated the effects of exercise and mechanical loading on BMD and bone microarchitecture. The study design included 2 postmenopausal females, both women were enrolled in an exercise program. The exercise program emphasized upper extremity weight-bearing and isotonic forearm exercises. Forearm exercises were performed every other day. Both patients perform walking for 30 minutes at a moderate pace on the days that they were not performing forearm exercise.
Primary outcome measures were BMD and bone quality. Bone mineral density was measured via dual-energy x-ray absorptiometry scans of the distal 1/3 radius. Microarchitecture was assessed using high-resolution peripheral qualitative computed tomography with a 2-dimensional detector array using a 0.08-mm point-focus x-ray tube that allows for an in vivo evaluation of bone at a voxel size of 82 mm and a 9-mm region of interest approximately 9.5 to 18.5 mm proximal to the radius endplate. Bone mineral density and bone microarchitecture were assessed at baseline, month 6, and month 12. Grip strength was assessed with a force dynamometer at baseline, month 3, month 6, month 9, and month 12.
Results: The results for both the subjects showed that exercise and mechanical loading improved BMD and bone quality. The subject with osteopenia without PHPT demonstrated increased values for BMD, microarchitecture, and grip strength over the 12-month study duration. Increases in BMD and bone quality were observed at each assessment, indicating a consistent, progressive improvement in both the measures. The subject with PHPT demonstrated improvements in all outcome measures from baseline to 6 months.
Conclusions: This study demonstrates that exercise and mechanical loading improved BMD and bone quality in postmenopausal women with PHPT. The results suggest positive effects of exercise and mechanical loading on grip strength, BMD, and bone quality in the distal 1/3 radius and in both osteopenic women with PHPT and without PHPT.
Clinical Relevance: The findings suggest that the performance of the prescribed upper extremity exercise protocol incorporating isotonic and weight-bearing exercises was effective in increasing BMD and improving bone quality in postmenopausal, osteopenic females with PHPT and without PHPT.
TITLE: Orthopedic Considerations When Treating Vaginismus: A Case Report
AUTHOR: Allison Ariail
INSTITUTION: Parker Adventist Hospital, Parker, Colorado, USA.
CONTACT: Allison Ariail: mailto:[email protected]
ABSTRACT BODY:
Background/Purpose: Vaginismus is a condition in which the muscles around the distal vagina involuntarily contract with vaginal penetration, causing intense pain and possibly preventing penetration altogether. Causes of vaginismus range from physical reasons such as infection and pelvic trauma to nonphysical reasons such as fear and anxiety. Often, there is no known cause for the muscle spasm. This case report describes a patient with vaginismus and how treating her underlying orthopedic conditions influenced her recovery.
Case Description: An 8-month postpartum 28-year-old female presented with inability to tolerate vaginal penetration. Her pregnancy resulted in a C-section delivery that required the fetus to be pushed from the vaginal canal back into the pelvis via the vagina. During pregnancy, the patient began experiencing pain with intercourse. The severity of the pain increased following delivery, resulting in the inability to tolerate vaginal penetration of a finger, tampon, or penis. Examination results demonstrated instability in her left sacroiliac joint and shearing at her pubic symphysis. Electromyogram readings showed resting levels to be 4 uV in supine and 12 uV in standing postion, with inability to get resting level less than 10 uV after return to supine. Resting tone was unstable and demonstrated paradoxical contractions, as well as delayed recruitment. Real-time ultrasound imaging revealed an elevated bladder base on the left and inability to isolate a pelvic floor muscle (PFM) or transverse abdominus contraction. A pelvic clock examination revealed tenderness in the bulbocavernosus, superficial transverse perineal muscles, and perineal body. Upon internal examination, minimal pain was present in the external PFMs; pain and tenderness were present in the left levator ani and bilateral obturator internus. After 1 minute of internal work, the patient's bilateral bulbocavernosus and superficial transverse perineal muscles began to spasm, increasing pain to an 8 of 10. Treatment consisted of electromyogram biofeedback, dilator use, and manual release for facial and muscular tightness (external and internal techniques as tolerated). As the patient stabilized the resting tone of her PFM, and progressed with the dilator use, the overall pain in her PFM decreased. She could tolerate insertion of a finger or tampon; however, intercourse continued to be intolerable. With continued treatment, it became clear that her vaginismus symptoms were worse after exercise or increased standing activities. Additional treatment included manual therapy for pelvic ring alignment, wearing a sacroiliac joint belt, and stabilization of the pelvic ring including transverse abdominus strengthening by using real-time ultrasound imaging as visual biofeedback.
Outcomes: After the patient stabilized her pelvic ring, her vaginismus symptoms improved, enabling her to be able to tolerate intercourse.
Discussion: Treating underlying orthopedic conditions made a significant positive difference in this patient's progress. Orthopedic conditions should not be overlooked when treating patients with vaginismus.
TITLE: A Novel Taping Technique for Posterior Pelvic Girdle Pain in Parous Women
AUTHORS: J. Adrienne McAuley, Elizabeth Barkus, Andrea Bogyo, Emily Munn, Sherry Tyan, Sari Weissbard
INSTITUTION: Department of Physical Therapy, Touro College, New York, New York, USA.
CONTACT: J. Adrienne McAuley: mailto:[email protected]
ABSTRACT BODY:
Purpose/Hypothesis: The objective of this study was to determine the effects of a novel taping technique developed by the first author on posterior pelvic girdle pain in parous women. A pelvic belt has been shown to provide stability and reduce pain and dysfunction, but the belt can be bulky and compliance is low. We hypothesized that this technique will provide sufficient stability to reduce pain and improve function.
Number of Subjects: Two.
Materials/Methods: Two subjects with pregnancy-related posterior pelvic girdle pain, the onset of which was either during pregnancy or within 1 year postpartum, participated in the study. After completion of informed consent and demographics, the subjects completed a visual analog scale (VAS) for pain and the Oswestry Low Back Disability Questionnaire (ODQ) for function. Subjects were excluded if they had a positive prone instability test, indicating lumbar, not pelvic girdle, involvement. Subjects were randomly assigned (by coin toss) to condition A or condition B. Condition A performed the active straight leg raise (ASLR) with tape, followed by VAS, and then after 5 minutes of rest, ASLR and VAS were measured again without tape. For condition B, ASLR and VAS were measured without tape first, and then after 5 minutes of rest, the subject repeated the ASLR and VAS with tape. The tape application involved the following: the subjects were prone over pillow and Cover-Roll was placed spanning 1 to 2 cm wider than the PSIS-to-PSIS distance, followed by Leukotape secured from right PSIS to left PSIS and a second piece from left PSIS to right PSIS. If subjects reported less pain and less effort during ASLR with tape, the tape was then worn for 48 hours. A 48-hour follow-up to reassess pain (VAS) and function (ODQ) was completed after the initial testing session.
Results: Subject 1 was 32 years old and subject 2 was 24 years old, both G1P1. The ASLR composite score for subject 1 was 6 without tape and 1 with tape. The ASLR composite score for subject 2 was 2 without tape and 0 with tape. The initial VAS score for subject 1 was 5.50, and after wearing tape for 48 hours, it was 0.40. The initial VAS score for subject 2 was 0.30, and after wearing tape for 48 hours, it was 0.03. The initial ODQ score for subject 1 was 10s and after wearing tape for 48 hours, it was 0. The initial ODQ score for subject 2 was 26, and after wearing tape for 48 hours, it was 10.
Conclusions: The findings of our study demonstrate improvement in pain intensity, function, and ASLR ability with a novel tape technique in 2 parous women with posterior pelvic girdle pain. A randomized control study with a large sample size is needed to provide further evidence that this tape technique may be used as an alternate source of stability to decrease pain and improve function in parous women with pregnancy-related posterior pelvic girdle pain.
Clinical Relevance: This novel taping technique may be a reasonable option to a pelvic belt for pelvic girdle stability in a parous population with posterior pelvic girdle pain. It is less bulky, less costly, and patients are more likely to demonstrate compliance.
TITLE: Efficacy of Mechanical Stimulation for the Treatment of Osteoporosis and Osteopenia in Postmenopausal Women: A Systematic Review
AUTHORS: Emily McVey, Christopher McGuffey, Paula Stubbs, Kirby Smith, Andrew Baker, Jarrod Bryant, Jennifer Lepard, Kathryn Nance
INSTITUTION: Physical Therapy, University of Mississippi Medical Center, Jackson, Mississippi, USA.
CONTACT: Paula Stubbs: mailto:[email protected]
ABSTRACT BODY:
Purpose/Hypothesis: The purpose of this study was to explore the efficacy of mechanical stimulation in the prevention or reversal of bone loss in patients with osteoporosis or osteopenia. Osteoporosis is a common metabolic bone disease affecting the aging population of adults in the United States.
Prevalence of the disease is 2 to 3 times higher in women than in men and can lead to hospitalizations for pain and fracture in susceptible areas of the skeleton. The risk of developing osteoporosis is even higher in postmenopausal women. Mechanical stimulation through vibration is a relatively new intervention to combat the degenerative effects of bone loss in osteopenic and osteoporotic populations. It is thought that vibration while weight bearing may help to increase mechanical strain and, therefore, stimulate bone growth.
Number of Subjects: Not applicable.
Materials/Methods: The database used for this systematic review was PubMed through February 20, 2012. Search strategies involved combinations of the terms osteoporosis, osteopenia, and vibration, with specific strategies to be presented. The 3 electronic limitations were human, English language, and adults 191 years. Inclusion criteria implicated for this review included randomized controlled trial, peer-reviewed, and adult postmenopausal females, while the exclusion criteria omitted systematic reviews and fractures. Two scales were used to assess the selected studies. The PEDro scale is made up of 10 items used to evaluate the internal validity of physical therapy intervention studies with a randomized controlled trial design. Higher PEDro scores reflect greater levels of internal validity. The CEBM (Oxford Centre of Evidence-Based Medicine) 2011 is a 5-level scale used to determine the strength of evidence based on the study design and control of research bias. A CEBM rating of I indicates the highest level of evidence.
Results: Six randomized clinical trials matching the criteria were found and examined. The average PEDro score was 6.8 and ranged from 5 to 10. These included 3 level II, 2 level III, and 1 level IV studies, as ranked by the CEBM 2011.
Conclusions: Three of the 6 studies reported between-group differences that varied among tested sites, with no 1 site consistently demonstrating the difference. Controls consisted of individuals doing as little as their normal daily activity and as much as moderate-intensity exercise. Evidence for WBV's effects on bone loss can be graded as a B, having a mixture of studies from levels V to X on the PEDro scale and CEBM scores from IV to II.
Clinical Relevance: Based on these results, it can be concluded that interventions to improve or slow the loss of bone mineral density in postmenopausal women utilizing WBV have seen very slight to no positive outcomes when compared with controls.
TITLE: Estrogen and Muscle Injury
AUTHORS: Allison Kosir, Dawn A. Lowe, Tara Mader
INSTITUTION: Program in Physical Therapy and Rehabilitation, University of Minnesota, Minneapolis, Minnesota, USA.
CONTACT: Allison Kosir: mailto:[email protected]
ABSTRACT BODY:
Purpose/Hypothesis: Evidence suggests that estrogens play a role in the susceptibility of skeletal muscle to contraction-induced injury. The objective of this study was to determine if force loss following contraction-induced injury was greater in mice with low estrogens and mitigated in mice with relatively high estrogen.
Number of Subjects: Male and female C57BL/6J mice were initially compared. In a second study, female mice were randomly divided into ovarian-intact (Sham) and ovariectomized (OVX) groups.
Materials/Methods: Uterine mass and vaginal cytology were analyzed to verify success of ovariectomy. Mice were anesthetized, and maximal preisometric torque of the left anterior crural muscles was assessed in vivo by using percutaneous needle electrodes to stimulate the common peroneal nerve. Muscle injury was induced by performing 150 eccentric contractions, and then postisometric torque was reassessed 2 minutes later. Data were analyzed by a Student t test.
Results: Isometric torque following eccentric contractions was similar between males and females (48 +/- 4% and 52 +/- 4% of preinjury torque, respectively; P = .555) and between Sham and OVX females (39 +/- 1% and 42 +/- 2% of preinjury torque, respectively; P = .185).
Conclusions: Mice with relatively low estrogen, males, and OVX females, did not have greater susceptibility to force loss following in vivo eccentric contraction-induced injury.
Clinical Relevance: Further investigation into the functional effect of estrogens on muscle injury and recovery is needed to identify potential therapeutic strategies aimed to improve quality of life for postmenopausal women.
TITLE: Functional Lower Extremity Deficits With Sensory Changes and Quadriceps Weakness in a 29-Year-Old Female Post Labor and Delivery: A Case Report
AUTHOR: Timothy J. Madson
INSTITUTION: Physical Medicine and Rehabilitation, Mayo Foundation, Rochester, Minnesota, USA.
CONTACT: Timothy Madson: mailto:[email protected]
ABSTRACT BODY:
Background/Purpose: Maternal peripheral nerve injuries during labor and delivery are rare. Mechanism of injury is believed to involve compression, traction, and ischemia with demyelinazation. Other factors include effects of regional anesthesia, time in the lithotomy position, and extremes of lower extremity positioning during labor.
Case Description: A 29-year-old female with complaints of right quadriceps weakness was referred to physical therapy 3 weeks postpartum.
Physical examination findings included decreased weight-bearing ability on her right lower extremity. Quadriceps strength was 4 of 5. Functional lower extremity testing by using the Stair-Climbing Test (SCT) and the 5-Times Sit-to-Stand Test (FTSST) revealed baseline scores of 15.5 and 14 seconds, respectively.
The patient listed the following activities as difficult for her to perform, using the Patient Specific Functional Scale: (1) rising from a chair without using her arms to push herself up, (2) rising from a toilet seat, and (3) running or jogging 3 to 5 miles. Practice pattern diagnosis was 5F: Impaired Peripheral Nerve Integrity and Muscle Performance Associated with Peripheral Nerve Injury.
Patient's short-term goals included (1) climb a flight of stairs safely using alternate step over step method in 4 weeks without using a handrail, and (2) rise from a toilet seat safely without using her arms in 4 weeks. The long-term goals included able to jog 3 to 5 days per week, 3 to 5 miles per session in 4 months.
Therapy plan of care focused on facilitating hip muscles and quadriceps strength. Exercises included both open and closed kinetic chain variety. Patient was seen 2 sessions per week for 2 weeks to check her response to the exercises and modify as needed. She was seen again at 2 and 6 months and at 1 year via a phone follow-up.
Outcomes: At 2 months, she was able to extend her knee antigravity with multiple repetitions without fatigue. She had normal quadriceps strength. Her thigh paresthesias had resolved. The SCT and FTSST scores had improved by 68% and 71%, respectively. Her Patient Specific Functional Scale had improved by 4 points or 55% for 2 of her 3 baseline activities. She was able to rise from a chair and toilet seat without using her arms.
At 6 months, she had reached her long-term goal and was actively running or jogging 4 days per week. The SCT and FTSST scores reflected additional improvements of 38% and 10%, respectively, from her 2 month follow-up. At a 1-year phone follow-up, she reported no lower extremity functional strength deficits.
Discussion: Maternal peripheral nerve injuries during labor and delivery have been recognized. Several factors have been associated with their occurrence. Based on these factors, recommendations for a reduction of time in the lithotomy position and allowing women to be more mobile throughout labor, including being ambulatory, is recommended.
Physical therapists practicing in the women's health field should be aware of postpartum peripheral nerve injuries and their prognosis.
TITLE: The Effect of Ankle Position in Standing on Pelvic Floor Muscle Activity in Healthy Young Continent Women: A Pilot Study Using Simultaneous Transvaginal Electromyography and Ultrasound Imaging
AUTHORS: Ruth M. Maher, Jeanne Welch, Dawn M. Hayes, Amy Bearinger, Brittany Cobb, Michael Gevontmakher, Lauren Shank
INSTITUTION: Physical Therapy, North Georgia College & State University, Dahlonega, Georgia, USA.
CONTACT: Ruth Maher: mailto:[email protected]
ABSTRACT BODY:
Purpose/Hypothesis: The purpose of this study was to examine the effect of ankle position on pelvic floor muscle (PFM) activity in healthy young continent women.
Number of Subjects: Ten healthy college-aged continent women who could perform a volitional PFM contraction were recruited for this study.
Materials/Methods: Subjects completed 5 PFM contractions (5 seconds on and 5 seconds off) at 3 different ankle positions (neutral, 158 of plantar flexion [PF], and 158 of dorsiflexion [DF]) randomly ordered, using a slant board. Two-minute rest was provided between each testing position. Simultaneous electromyogram (EMG) and ultrasound (US) imaging data were recorded. On-screen callipers measured bladder displacement during PFM contractions. An appropriate pelvic floor contraction was defined as cranial displacement of the bladder by the PFM when assessed in the transverse plane with US imaging. Each subject completed a bladder-filling protocol to allow for delineation of the bladder from the pelvic floor fascia and associated PFM.
Results: Significant differences were found in resting EMG at DF compared with PF (P = .017) and between EMG at rest and maximal contraction in all positions, neutral (P = .008), DF (P = .005), and PF (P = .005). US bladder displacement was also significant between neutral and PF (P = .047) and DF and PF (P = .022). Maximal EMG activity was greater in DF than in neutral and PF, with the greatest amount of US bladder displacement observed in PF standing (10.13 mm 6 4.07), followed by neutral standing (7.71 mm 6 2.23) and then DF standing (7.08 mm 6 3.39).
Conclusions: Previous studies have assessed the effect of different postures (sitting, standing) on PFM activity, but limited knowledge exists on the effect of ankle position on PFM activity in standing. Stance on a slant board imposes a postural change, which our results found had an effect on PFM function. While EMG has limitations, US displacement has been shown to represent the ability of an individual to recruit elective motor units and the literature has shown it to be highly correlated with perineometry, which is a measure of strength. This pilot study showed that those with the lowest resting EMG values produced the greatest cranial displacement on US imaging, with the greatest US displacement occurring in PF standing position. This finding suggests that the PFM could maximize the benefits of its length-tension relationship in producing a PFM contraction.
Clinical Relevance: Few studies have explored the ideal ankle position for optimal PFM contraction. Our findings found that plantar flexion stance facilitated greater cranial displacement on US imaging, which has been shown to be a valid measure of PFM function. Further study is required on the normal population and those with pelvic floor dysfunction before the findings of this study can be generalized.
TITLE: Effectiveness of Biofeedback Training on Stress Urinary Incontinence: A Systematic Review
AUTHORS: Sarah R. Downey, Erika D. Eisenbach, Meaghan A. Grenaldo, Marie A. Newkirk, Barbara Reddien Wagner
INSTITUTION: University of Scranton, Scranton, Pennsylvania, USA.
CONTACT: Meaghan Grenaldo: mailto:[email protected]
ABSTRACT BODY:
Purpose: The purpose of this systematic review was to assess the effectiveness of biofeedback training to treat stress urinary incontinence in women.
Number of Subjects: Not applicable.
Materials/Methods: A literature search was conducted of CINAHL, MEDLINE, and ProQuest (2002-2012) to identify studies evaluating the effectiveness of biofeedback training on stress urinary incontinence. Inclusion criteria were peer reviewed, English language, adult female subjects with stress urinary incontinence, and outcomes measures related to leakage or pelvic floor muscle strength. Studies were excluded if they were nonexperimental research, and surgical or pharmacological interventions were used. Two reviewers independently assessed each study for methodological quality based on PEDro guidelines.
Results: A total of 428 titles and abstracts were screened for review. One hundred sixteen articles were selected for further evaluation through the abstract review process. Of these, 7 met the inclusion criteria and were included in the systematic review. The quality assessment ranged from a PEDro score of 5 to 8 of 10 with an average of 5.7. All 7 articles focused on women with stress urinary incontinence, 5 focused on pelvic floor muscle training (PFMT) with biofeedback, 1 looked at biofeedback training versus digital palpation, and 1 compared biofeedback training with interferental current. The interventions were not carried out in a uniform setting, and treatment protocols all varied dependent on the study. Sample size ranged from 14 to 103 subjects, with a total of 298. Five of 7 studies had a comparison or control group, and 4 of those showed clinically significant results supporting biofeedback training. Two of the 7 studies did not have a comparison or control group, and both had clinically significant findings to support biofeedback training.
Conclusions: Our systematic review on the effectiveness of biofeedback training on stress urinary incontinence showed positive findings and clinically significant trends toward decreasing urinary leakage and increasing pelvic floor muscle strength. Limitations include small sample sizes, lack of uniformity of interventions, and limited follow-up with subjects. Biofeedback training shows promise of being a routine part of treatment; however, more randomized control trials need to be conducted to determine the optimal parameters and setting for the treatment.
Clinical Relevance: Biofeedback training provides visual or auditory feedback during PFMT sessions to achieve a more effective form of strengthening. Biofeedback-assisted PFMT shows promise as a routine part of conservative treatment to decrease stress urinary incontinence.
TITLE: Physical Therapy Management of Paradoxical Diarrhea in a Female With Ulcerative Colitis
AUTHORS: Jessica C. Strobel1, Diane Borello-France2
INSTITUTIONS: 1. WomensRehab and Men's Health, UPMC Centers for Rehab Services, Pittsburgh, Pennsylvania, USA.
2. Rangos School of Health Sciences, Duquesne University, Pittsburgh, Pennsylvania, USA.
CONTACT: Jessica Strobel: mailto:[email protected]
ABSTRACT BODY:
Background/Purpose: Persons with ulcerative colitis (UC) are often referred to a specialized women's health physical therapist to manage symptoms of fecal incontinence (FI). However, upon physical therapy (PT) examination, symptoms of constipation including straining with bowel movements and other pelvic muscle dysfunctions that were previously unrecognized by the patient or other health care providers are often diagnosed. This case report describes the PT management of a patient with UC and illustrates the importance of a thorough PT examination, including medical history, orthopedic impairments, and patient behaviors contributing to the presence of pelvic symptoms.
Case Description: The patient was a 48-year-old female who reported a 1-year history of FI and stress urinary incontinence. Her medical history included UC with accompanying enteropathic arthritis of her lumbar spine. Flat-plate radiographs of the colon revealed a moderate level of fecal stasis, coinciding with the patient's report of occasional straining with bowel movements and implicating paradoxical diarrhea as a contributing factor in her presentation. Internal vaginal examination revealed levator ani (LA) and obturator internus muscle spasms that were greater on the left side, possibly due to fecal stasis and the preferential effect of ulcerative colitis in the distal colon. The patient also demonstrated kyphotic posture and lumbar instability with decreased activation of lumbopelvic stabilizing muscles, upon orthopedic examination. Initial PT interventions were aimed at decreasing LA or obturator internus muscle spasms and improving posture, lumbopelvic stabilization (to minimize strain on pelvic floor muscles [PFMs]), and LA activation during functional activities. Behavioral education in diet, toileting mechanics, and PFM relaxation during toileting was provided, with the aims of improving bowel function and urinary symptoms. In addition, she was educated in self-management of her enteropathic arthritis-related lumbar pain.
Outcomes: The patient's stool consistency (Bristol Stool Score), Colorectal-Anal subscale scores on the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaires, and score on the Constipation Scoring System improved before the discontinuation of care. Subjective improvement in continence of stool and urine and the ability to participate fully in physical and social activities were also reported.
Discussion: In patients with FI and/or UC, fecal stasis and constipation along with PFM dysfunction may contribute to incontinence. This case report illustrates the need for a thorough PT examination and comprehensive PT plan of care that addresses the full range of pelvic symptoms, orthopedic impairments, and patient-specific behaviors to achieve optimal PT outcomes.
TITLE: Comparing Exercise and Foot Pressure Response to Walking in Conventional Running Shoes and Rocker-Sole Shoes
AUTHORS: Cristina Baric, Heather Mitrisin, Jessica Storey, Cynthia L. Lewis
INSTITUTION: Department of Physical Therapy Education, Elon University, Elon, North Carolina, USA.
CONTACT: Cynthia Lewis: mailto:[email protected]
ABSTRACT BODY:
Purpose/Hypothesis: To determine if rocker-sole shoes (RS-shoes) increase energy expenditure during graded treadmill (MT) walking and describe their effect on peak pressures (PeakP) during the gait cycle when compared with conventional running shoes (CR-shoes).
Number of Subjects: A total of 14 female (18-30 years) completed the study, from a sample of convenience. Participants had no known medical or orthopedic conditions that precluded their participation.
Materials/Methods: TM walking: Subjects provided signed consent and were randomly assigned to their initial shoe style, which was then reversed for the second session. Subjects completed 2 graded TM walking sessions. Data collected included heart rate, oxygen uptake (
O2), rate of perceived exertion, and respiratory exchange ratio. Stages were 5 minutes each: stage I, warm-up with a speed of 2.0 mph and at 0% grade; stage II, 3.0 mph at 0% grade; stage III, 3.5 mph at 2% grade; and stage IV, 4.0 mph at 5% grade. GAITRite Walking Protocol: each subject completed 3 walking trials over the GAITRite mat at self-selected speed. The conditions were walking barefoot and randomized walking in RS-shoes and CR-shoes. The data were analyzed for each foot, measuring medial and lateral PeakP throughout the gait cycle.
Results: A SAS statistical package was used to run a multivariate analysis of variance on the data, followed by appropriate post hoc tests. No significant statistical differences were observed at any walking stage between the RS-shoes and CR-shoes for heart rate,
O2, rate of perceived exertion, or respiratory exchange ratio. No statistical differences were found when comparing medial and lateral PeakP during heel strike and toe off of the gait cycle between the 2 styles of shoes. However, a substantial rise in medial and lateral PeakP was observed in the RS-shoes during midstance or foot-flat phase of gait when compared with the CR-shoes. (Medial PeakP was 12.27 + 2.02 for the RS-shoes and 3.81 + 3.27 for the CR-shoes; lateral PeakP was 9.08 + 2.36 for the RS-shoes and 3.34 + 2.45 for the CR-shoes.)
Conclusions: The results revealed no metabolic differences between the RS-shoes and CR-shoes. However, the data demonstrated significant medial and lateral instability of the RS-shoes during midstance, which can result in prolonged pronation during the standing phase of gait. This finding could increase the potential for various orthopedic injuries in women, including plantar fasciitis, patellofemoral pain syndrome, and trochanteric bursitis, among others.
Clinical Relevance: The RS-shoes did not increase energy expenditure for improving fitness or weight loss. Additionally, these shoes lacked medial and lateral stability in midstance, which may be detrimental by exacerbating preexisting overpronation and potentially increasing the risk of musculoskeletal injuries of the foot, knee, or hip. Physical therapists need to be mindful of discussing footwear when treating women with sports-related musculoskeletal injuries of the lower limb.
TITLE: Cardio-respiratory Response to Treadmill Walking With Rocker Bottom Shoes in Women That Are Sedentary
AUTHORS: Bini Litwin, Andrea Charles, Tyler Love, Ania Szewczyk
INSTITUTION: Nova Southeastern University, Fort Lauderdale, Florida, USA.
CONTACT: Bini Litwin: mailto:[email protected]
ABSTRACT BODY:
Purpose/Hypothesis: Evidence shows sedentary lifestyle is a contributing factor to disease. To promote healthy lifestyles in keeping with Healthy People 2020, physical therapists often develop fitness and wellness programs. Studies indicate that rocker bottom shoes (RBS) decrease energy costs during walking post-ankle arthrodesis and increase muscle activation during walking in trained able-bodied populations. Other evidence suggests that energy costs depend on rocker shoe radius. This study was conducted to determine the cardiorespiratory response to walking with "MBT" RBS in women who are sedentary.
Number of Subjects: Ten females, ranging in age from 27 to 58 years, with body mass index (BMI) of 20 to 43, served as subjects in this pilot study. Four subjects were white, 4 Hispanic, and 2 black. Inclusion criteria stipulated subject's age between 18 and 65 years, sedentary defined as no participation in structured exercise within the past 6 months, or any medical condition or medication affecting participation or response to exercise.
Materials/Methods: Subjects completed a ramp protocol treadmill walk test (TMWT), including 1-minute warm-up, progressing every 2 minutes to 2.5 mph at inclines from 0% to 6%. Two TMWTs were completed by each subject in alternating order; one with RBS and one with standard sneakers (SS). Blood pressure, SpO2, heart rate (HR), respiratory rate (RR), and rate of perceived exertion (RPE) were taken pre- and post-TMWT. The second test followed a return to baseline measures. The HR, SpO2, RPE, and RR were taken at 2-minute intervals. The TMWT was terminated when the subjects reached a THR calculated at 65% to 70% of maximum heart rate. A polar monitor recorded HR via a metabolic cart that also recorded RR; RPE was measured using the Borg 6- to 20-point scale.
Results: All the subjects achieved THR with both the TMWTs. Parametric analysis found no significant difference between the RBS and SS in time needed to reach THR. No significant differences were found in RR, RPE, SpO2, or blood pressure. Spearman r found no correlation between BMI and the time required to reach HR. Average time for completion was 7 minutes 2 seconds for RBS versus 7 minutes 1 second for SS. Subjects reported increased balance awareness and muscle contraction in the buttocks and calves during walking with RBS.
Conclusions: Results indicate that the cardiorespiratory response to TMW is the same for RBS and SS in women who are sedentary. However, the use of the RBS may be an effective means to develop a walking fitness program that may also promote core strengthening for this population. Although the sample size was small, the range of age, ethnicity, and BMI may indicate applicability of these findings to a wider group. Heart rate and RR may have been confounded by anxiety incurred by the ventilatory mask used to record data and/or familiarity with treadmill walking.
Clinical Relevance: These findings may provide physical therapists with an alternate means via use of RBS to promote healthy lifestyles in women who are sedentary. Further research with a larger sample is needed to determine the relationship of the RBS to cardiorespiratory fitness, metabolic energy costs, and core muscle strengthening.
TITLE: Postpartum Depression in Women With Urinary Incontinence: A Case Series
AUTHORS: Elizabeth R. Northrop, Cynthia E. Neville, Jason Beneciuk
INSTITUTION: Brooks Rehabilitation, Jacksonville, Florida, USA.
CONTACT: Elizabeth Northrop: mailto:[email protected]
ABSTRACT BODY:
Background/Purpose: Postpartum depression (PPD) and urinary incontinence (UI) are 2 of the most prevalent complications that occur following childbirth. Previous research indicates that women with symptoms of UI were more than 2 times more likely to have significant depressive symptoms. There is a gap in the literature regarding women who seek and receive treatment for their symptoms of UI and how their PPD symptoms change with treatment. The purpose of this case series was to determine whether symptoms of UI in women seeking physical therapy (PT) treatment for birth-related trauma are associated with PPD symptoms.
Case Description: This case series consists of 5 patients who received PT for pelvic floor symptoms, including UI. All of the patients were within 36 months postpartum and ranged in age from 25 to 38 years.
Physical therapy interventions for UI included the use of a voiding log, pelvic floor muscle exercises, NMES to the pelvic floor muscles, and sEMG biofeedback. Education was provided to these patients about their condition, fluid management, bladder irritants, and normal voiding patterns. Other interventions provided to the patients varied based on their individual impairments.
Outcomes: Although UI was not the primary complaint for 2 of the 5 patients, all of the patients reported symptoms of UI in the 4 weeks before beginning PT, based on IIQ-7 ([mu] = 26.6, [rho] = 32.7) and ICIQ-UI ([mu] = 7.8, [rho] = 5.1) scores. All patients also reported moderate impairment in their sexual function because of their pelvic floor symptoms based on PISQ-12 scores.
At intake, the presence of depressive symptoms was indicated based on Edinburgh Postnatal Depression Scale scores ([mu] = 7.0, [rho] 5 3.3), although varied based on the magnitude of depressive symptoms. Collectively, a score of 7.0 indicates the presence of depressive symptoms without having major functional impairment. One patient was at risk for developing PPD, and 2 patients demonstrated significant depressive symptoms.
Follow-up data was available for 3 patients who completed PT. For these patients, the average score on the Edinburgh Postnatal Depression Scale decreased from 8.3 points at intake to 6.7 points at discharge. The patients' UI symptoms and their impact on their quality of life also improved, based on the decrease in the IIQ-7 and ICIQ-UI scores at discharge. Average IIQ-7 scores decreased from 4.7 points at intake to 1.7 points at discharge. Average ICIQ-UI scores decreased from 4.3 points at intake to 2.3 points at discharge. As average depressive and UI symptoms decreased with PT treatment, so did the patients' reports of sexual dysfunction, pain, and limitation with performing their daily activities.
Discussion: The data from this case series suggest a high incidence of depressive symptoms in women with postpartum UI.
Decreases in depressive symptoms over an episode of PT were on average consistent with improvements in clinical outcomes. These findings indicate that PT screening for depressive symptoms in patients with postpartum UI should be considered, particularly as the profession continues to evolve as direct-access providers.
TITLE: Effectiveness of Pelvic Floor Manual Therapy on Chronic Pelvic Pain: An Evidence-Based Review
AUTHORS: Jessica A. Manley, Amy Selinger, Jeannette Lee
INSTITUTION: University of California, San Francisco/San Francisco State University, San Francisco, California, USA.
CONTACT: Jessica Manley: mailto:[email protected]
ABSTRACT BODY:
Purpose/Hypothesis: Examine the effectiveness of pelvic floor manual therapy on pain in patients, both men and women, with chronic pelvic pain (CPP). The authors' hypothesis is that pelvic floor manual therapy is an effective treatment for pain reduction in patients with CPP.
Number of Subjects: This search revealed 7 articles containing 8 studies, reviewing the effects of interventions on a total number of 138 participants.
Materials/Methods: A search of the current literature was performed using the following databases: PubMed, Cochrane, and CINAHL. Data measuring pain via the visual analog scale were collected from each of the primary articles reviewed. Single- and 2-group effect sizes were calculated using the appropriate model based on the Q statistic for heterogeneity. The 95% confidence intervals were also calculated for each combined effect size.
Results: Combined single-group effect size and 95% confidence interval were -1.28 (-1.93, -0.63), showing large and statistically significant pain reduction following manual therapy in patients with CPP. Results from the 2-group effect size, -0.72 (-1.44, 0.004), show a moderate effect size, although results were not statistically significant in reducing pain when compared with a control group.
Conclusions: The use of pelvic floor manual therapy is a low-risk, effective intervention for physical therapists to treat patients with CPP.
Clinical Relevance: Knowing the effectiveness of pelvic floor manual techniques will provide an additional intervention with few risks and side effects that can be applied as conservative treatment by physical therapists to reduce pain in men and women with CPP.
TITLE: Pelvic Floor and Transverse Abdominus Function in Young, Nulliparous Women With and Without Incontinence
AUTHORS: Patricia R. Nelson, Laura Dwight, Ashley Wilkens
INSTITUTION: Physical Therapy Department, Eastern Washington University, Spokane, Washington, USA.
CONTACT: Patricia Nelson: mailto:[email protected]
ABSTRACT BODY:
Purpose/Hypothesis: Urinary incontinence (UI) is caused by 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. Live viewing of PFM motion during contraction and valsava maneuvers, using transabdominal (TA) real-time ultrasound (RTUS) imaging, allows information on PFM muscle coordination and control to be gathered. The purpose of this study was to describe TA RTUS imaging values for PFM and transverse abdominus (TrA) functioning in young, nulliparous, healthy women, and compare these measures for those with and without UI.
Number of Subjects: Forty-nine healthy, nulliparous women aged 18 to 30 years participated in this study.
Materials/Methods: Subjects completed a survey regarding health, urinary status, and exercise habits while ingesting 500 mL of water. Each then had a physical examination of posture, PFM and TrA muscle activation patterns, and pelvic control. In addition, measure of PFM activity to standardized cues was collected using TA RTUS imaging.
Results: Eleven women (23%) reported UI symptoms. For those without UI, PFM contraction on TA RTUS imaging was 0.35 cm (-0.12 to 0.97 cm +/-0.31) and with UI was 0.30 cm (-0.18 to 1.17 cm +/-0.40). There was no difference in PFM contraction between groups (P = .66). A lifting contraction was shown by 61% of subjects; however, this had no relationship with UI status (P = .248). Clinical tests of isolated PFM and TrA muscle contraction show overflow. With PFM contraction, 49% used 2 or more sites of overflow, 43% to the external oblique and 29% to adductors or to breath holding. For TrA activation, 57% used 2 or more sites of overflow. External oblique (55%) and breath holding (49%) were most common. Overflow scores for women without UI did not differ from those with UI (P = .562 PFM, P = .617 TrA). Use of TA RTUS imaging for biofeedback helped 50% of those unable to perform a lifting PFM contraction to do so after a brief instruction.
Conclusions: The prevalence of UI was smaller than expected in this cross-sectional convenience sample. While the TA RTUS imaging measure of PFM contraction was similar to that reported by others, there was not a difference in the PRM or TrA performance of those with UI versus those without. It remains unclear whether the type of PFM contraction or coordination of PFM and TrA activity is key to UI status. As prior studies have suggested that both the factors are important, this study leaves more questions than it answers. It appears that TA RTUS imaging is a helpful biofeedback tool but may not be reliable enough to detect small changes in PFM function in different populations.
Clinical Relevance: The use of RTUS imaging is helpful in improving contraction quality after a short training period. Measurement of the pelvic floor contraction, using TA RTUS imaging, is variable in nulliparous, young women and appears to show similar results in women with UI and those without UI. Further research is needed to identify factors causing UI in nulliparous, young women.
TITLE: Pelvic Motion During Running Is Increased During and Postpregnancy
AUTHORS: Elizabeth S. Chumanov, Christa Wille, Bryan Heiderscheit
INSTITUTION: Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, Wisconsin, USA.
CONTACT: Elizabeth Chumanov: mailto:[email protected]
ABSTRACT BODY:
Purpose/Hypothesis: Many women continue to exercise throughout their pregnancy, and current guidelines encourage women to maintain an active lifestyle to promote maternal and fetal well-being. Women who were runners before pregnancy often continue to run throughout their pregnancy; however, little is known about how running gait characteristics are altered as a woman progresses through her pregnancy.
The purpose of this case report was to determine if running mechanics change throughout pregnancy and the postpartum period.
Number of Subjects: One subject participated (27-years-old, 59.7 kg postpregnancy, height 172.5 cm). Before pregnancy, the subject ran approximately 24 km per week and maintained this level until she was at 37 weeks' gestation. She successfully returned to running at this same level 6 months postdelivery.
Materials/Methods: Three-dimensional motion was recorded while the subject ran at her preferred speed (2.95 m/s) on a treadmill. Data collections were performed approximately every 4 weeks, starting when the subject was at 24 weeks' gestation. Over the course of the subject's pregnancy, a total of 5 data collections were completed, including one 2 days before the subject went into labor. Data was also collected at 6 months postpartum when the subject had returned successfully to running. A 3-dimensional musculoskeletal model was used to compute joint angles. Average stride length, step rate, and joint angular excursions and peaks were determined for each data collection session.
Results: Pelvis angular excursions in the frontal and sagittal plane increased over the course of the subject's pregnancy by 4.4[degrees] (33.6%) and 4.1[degrees] (44.8%), respectively. At 6 months postdelivery, pelvic frontal angular excursion remained similar to the value at 40 weeks' gestation (12.8[degrees]). Sagittal plane values had reduced closer to values obtained at 24 weeks' gestation (4.5[degrees] at 24 weeks' gestation, 5.3[degrees] at 6 months postdelivery) No consistent trends were present for sagittal plane hip, knee, and ankle angles, with stride length and step rate varying only 1.1% over the course of the pregnancy.
Conclusions: Despite a general similarity in running mechanics during and after pregnancy, an increase in the frontal plane pelvis motion was observed as pregnancy progressed, and this increase persisted at 6 months postpartum. Previously reported differences as small as 38 of pelvic motion are significant between genders; thus, the 48 increase in motion seen over the course of pregnancy is likely relevant.
Clinical Relevance: Maintaining and returning to an active lifestyle following pregnancy are critical to preventing chronic conditions; however, the incidence of lumbopelvic pain in this population may be a barrier. Our findings suggest that increased pelvic motion during and postpregnancy may be a contributing factor to developing lumbopelvic pain. It is likely that the abdominal wall changes and ligamentous laxity that occur during pregnancy are contributing factors to increased pelvic motion, suggesting the value of initiating a lumbopelvic stabilization program.
TITLE: Prevalence of Scoliosis in a Cohort of Patients With Pelvic Pain
AUTHOR: Lisa Tate
INSTITUTION: Good Shepherd Penn Partners-Penn Therapy and Fitness, Woodbury Heights, New Jersey, USA.
CONTACT: Lisa Tate: mailto:[email protected]
ABSTRACT BODY:
Purpose/Hypothesis: Adolescent Idiopathic Scoliosis (AIS) has a reported prevalence of 0.78% to 5.6% in females, with prevalence up to 12.9% reported for adult degenerative scoliosis. The relationship between pelvic pain and back and lower extremity musculoskeletal dysfunction has been identified in the literature. While clinicians have anecdotally reported the presence of scoliosis in patients referred for pelvic pain, this has not been reported in the literature to date. Therefore, the purpose of this pilot study were to determine the prevalence of scoliosis in a cohort of women referred to a specialty physical therapy center for musculoskeletal pelvic pain and report the outcomes.
Number of Subjects: Thirty-three female patients (mean age, 43.4 years) were referred for pelvic pain.
Materials/Methods: A retrospective chart review was performed from December 2010 until February 2012 to identify patients referred for outpatient physical therapy with a diagnosis of pelvic pain, as defined by pain in the suprapubic, perineal, pelvic floor, or deep rectal area. Scoliosis was defined by the presence of an observable spinal deformity in the transverse, frontal, and sagittal planes, including a positive Adam Forward Bend test. All patients were questioned about a history of AIS. Prevalence of scoliosis, pain, and number of therapy sessions were calculated for this cohort.
Results: Diagnoses included interstitial cystitis (9), vulvodynia or vestibulodynia (11), abdominal pain (4), pelvic floor muscle pain related to surgery or childbirth (6), persistent genital arousal disorder (2), and other (low back and coccyx or rectal pain) (1). Eight patients had known AIS, with an additional 5 positive for AIS or adult degenerative scoliosis. The overall prevalence of scoliosis in this cohort was 39%. Patients with scoliosis required 9.9 physical therapy visits on average, as compared with 5.6 for the nonscoliosis group. Pain improved in the entire cohort from a mean of 6.4 at initial evaluation to 1.2 at discharge. No differences in pain existed between the patients with and without scoliosis at initial evaluation or discharge.
Conclusions: The prevalence rate for scoliosis in the population is very low for young people and is known to increase with age because of progression of the AIS curves and degenerative scoliosis. The prevalence in this preliminary small cohort was much higher than predicted for the age groups, even for the possible degenerative group. It is possible that scoliosis contributes to pelvic pain in a similar manner as other musculoskeletal issues, influencing the alignment of pelvic joints, the tone of pelvic muscles, and the relationship of relevant nerves to surrounding tissue, even when there is another underlying pathology.
Clinical Relevance: If scoliosis is associated with pelvic pain, then measures to evaluate for it must be undertaken by physical therapists. Furthermore, future research would be needed to determine whether specific treatment is necessary and the most optimal treatment parameters.
TITLE: A Multimodal Rehabilitation Approach During Pregnancy and Postpartum for a Patient With Developmental Dysplasia of the Hip: A Case Report
AUTHOR: Kathryn Cieslak
INSTITUTION: Mayo Clinic, Rochester, Minnesota, USA.
CONTACT: Kathryn Cieslak: mailto:[email protected]
ABSTRACT BODY:
Background/Purpose: Females make up 80% of all people with developmental dysplasia of the hip (DDH). Pain, osteoarthritis, and difficulty with walking or mobility have been reported by persons with DDH. Increased weight gain during pregnancy presents challenges for women with DDH. The purpose of this case report was to describe the results of a physical therapy program developed to address impairments and functional limitations in a patient with DDH during pregnancy and early postpartum.
Case Description: A 24-year-old female with a previous diagnosis of DDH presented to physical therapy with a chief complaint of bilateral hip pain at 20 weeks' gestation. She participated in a comprehensive physical therapy program that consisted of (1) progressive hip strengthening, (2) lower extremity flexibility training, (3) trunk muscle motor control training, (3) education for lifting and safe body mechanics, and (4) lumbopelvic stabilization exercises. The patient was progressed based on performance from basic- to higher-level exercise and functional activities. Low back pain was reported at week 38. Follow-up was arranged early in the postpartum phase to assess status. Rehabilitative ultrasound imaging was used in the postpartum phase during motor control training of the trunk muscles.
Outcomes: The patient was seen for a total of 9 sessions. She reported continued ability to work as a waitress into late pregnancy upon participation in physical therapy. The Global Rating of Change upon dismissal was "moderately better." Activity limitations identified at the initial session on the Patient Specific Functional Scale included stairs (2), sitting for greater than 30 minutes (3), and walking (4). Upon dismissal, the Patient Specific Functional Scale scores improved to: stairs (10), sitting for greater than 30 minutes (7), and walking (10). Hip abductor strengthening increased from 4 of 5 to 5 of 5 upon dismissal. Patient reported walking approximately 4 miles per day at 4 months after delivery. Transversus abdominis contraction ratio increased from 1.14 to 2.21 at 4 months after delivery. Oswestry Disability Index improved from 8 of 90 at 2 months postpartum to 6 of 90 at 4 months postpartum. Lower Extremity Functional Scale improved from 57 of 80 to 66 of 80. Hip pain rating at initial session ranged from 3 to 9 of 10, and upon dismissal, pain rating at 3 of 10. Low back pain decreased from 3 of 10 to 0 of 10 upon dismissal. The active straight leg raise at 2 months postpartum were as follows: right, 1 of 5; left, 3 of 5, and right, 0 of 5; left, 2 of 5 at 4 months after delivery.
Discussion: Improvement in pain, muscle performance, and function were reported at both short- and long-term periods of time. Physical therapy interventions, including hip strengthening, body mechanics training, motor control training for trunk muscles, and safe progression of exercise and activity level, may play a key role in the rehabilitation of patients with DDH and hip pain during pregnancy. Rehabilitative ultrasound imaging may assist with facilitation of abdominal muscle training at early postpartum.
TITLE: Effectiveness of Manual Therapy for Pelvic Girdle Pain in Pregnant and Postpartum Clients: A Review of the Literature
AUTHORS: Adrienne Simonds, Kimberly Bryant, Allison Gazda, Melissa Hreha, Caitlin Martin, Leiselle Pilgrim
INSTITUTION: Department of Rehabilitation & Movement Science, University of Medicine & Dentistry of New Jersey, Stratford, New Jersey, USA.
CONTACT: Adrienne Simonds: mailto:[email protected]
ABSTRACT BODY:
Purpose/Hypothesis: The purpose of this literature review was to determine the effectiveness of manual therapy interventions for women with pelvic girdle pain (PGP) during pregnancy and postpartum.
Number of Subjects: Not applicable.
Materials/Methods: The literature review was completed from September 2011 to April 2012, using CINAHL, PubMed, and Ovid databases. Inclusion criteria were female subjects during pregnancy or postpartum, English language, and manual therapy as a main intervention. Search terms included PGP, manual therapy, joint mobilization, spinal manipulation, massage, back pain, pregnancy, and postpartum.
Results: Five articles were selected for review based on inclusion criteria. Articles used in the final review were rated by 2 researchers independently using the MacDermid Evaluation of Effectiveness and Study Design Scale. The MacDermid scale ranges from 0 to 48, with 48 being the highest quality. Discrepancies in scoring were discussed until a consensus was reached. Two randomized controlled trials, 2 case studies, and 1 prospective cohort study were reviewed. Four of the 5 studies examined women with PGP during pregnancy. One study examined women with PGP postpartum. All articles included manual therapy as a main intervention. Manual interventions included soft tissue mobilization, massage, muscle energy techniques, and high-velocity thrust technique. Pain reduction and improvements in function after manual therapy interventions were reported in both pregnant and postpartum clients. A reduction in the rate of deterioration of back-specific functioning during pregnancy was also reported.
Conclusions: Evidence supports manual therapy as an effective intervention to reduce pain and improve function in women with PGP during both pregnancy and postpartum. Manual interventions for women with PGP included soft tissue mobilization, massage, muscle energy techniques, and high-velocity thrust technique. Comparisons regarding the effectiveness among types of manual interventions were not possible. A combination of manual therapy and exercise is recommended for women with PGP. Few studies are available examining the efficacy of physical therapy interventions in postpartum women.
Clinical Relevance: Pelvic girdle pain is commonly reported during pregnancy, and in one-third of women with PGP during pregnancy, symptoms persist postpartum. Women with PGP present to physical therapy with severe limitations in functional mobility and performance of childcare tasks because of pain. Manual therapy is one component of PT intervention for women with PGP; however, its effectiveness is not well-known for this population. The selection of manual interventions for clients with PGP warrants consideration because of the complexities of pregnancy and recovery from childbirth. More research on specific manual therapy interventions is needed to provide physical therapists with effective, reliable tools to manage pain and disability in women with PGP.
TITLE: Physical Therapy as a Conservative Treatment for Neurogenic Bowel in Patients With Incomplete Spinal Cord Injury: A Case Report
AUTHORS: Lauren Nohe, Meryl Alappattu
INSTITUTION: Department of Physical Therapy, University of Florida, Gainesville, Florida, USA.
CONTACT: Lauren Nohe: mailto:[email protected]
ABSTRACT BODY:
Background/Purpose: Neurogenic bowel is a condition in which the function of the bowel is hindered or absent as a result of neurological compromise, leading to either constant leakage of bowel or inability to achieve bowel movement. Physical therapy has been studied for the treatment of other continence conditions, including urinary incontinence, but the role of physical therapy has not been reported in the literature for the treatment of neurogenic bowel and its associated impairments. Thus, the purpose of this case report was to assess the efficacy of physical therapy treatment to enhance the ability of a patient with neurogenic bowel to achieve bowel movement following a C3 incomplete spinal cord injury.
Case Description: A 59-year-old male 15 months post-C3 incomplete spinal cord injury attended outpatient pelvic health physical therapy for 6 sessions over 2 months. Interventions included strengthening, manual therapy, and education regarding positioning, nutrition, hydration, and pelvic floor function for both the patient and his son or caregiver.
Outcomes: Outcome measures were assessed, including the Numerical Pain Rating Scale, Neurogenic Bowel Dysfunction Score (NBDS), Autonomic Standards Assessment Form Bowel, fast- and slow-twitch muscle strength of the pelvic floor muscles, Bristol Stool Scale rating, and time for bowel movement. Following treatment, Numerical Pain Rating Scale score decreased from 7-8 of 10 to 6-7 of 10 during manual disimpaction. The patient's NBDS improved from 34 to 24 (though still severely affected). The areas of the NBDS that improved were ability to control flatus, episodes of fecal incontinence, and perianal skin integrity. The patient increased strength of the pelvic floor to perform 10 repetitions of fast- and slow-twitch exercise (an increase from 4) and decreased time for bowel movement from 90 to 75 minutes. Bristol Stool Type remained a type 2 to 3.
Discussion: While the results were not significant, there were some positive effects of treatment, including decreased time of bowel program, decreased pain with bowel movement, and improved ability to perform Kegel exercises. The study was limited by patient compliance and his early, self-initiated discharge from pelvic physical therapy. Further research is needed to determine the effectiveness of physical therapy as a conservative treatment for neurogenic bowel.
TITLE: The Impact of Nutrition and Physical Activity Interventions Based on the Scale Back Alabama and Go Red Programs on Female Employees at the University of South Alabama
AUTHORS: Jean M. Irion, Coral Gubler
INSTITUTION: Physical Therapy, University of South Alabama, Mobile, Alabama, USA.
CONTACT: Jean Irion: mailto:[email protected]
ABSTRACT BODY:
Purpose/Hypothesis: To determine if an 8-week wellness program affects changes in cardiovascular disease (CVD) risk factors in female employees at the University of South Alabama.
Background: Lifestyle interventions, combining dietary change with physical activity, can result in decreases in CVD risk factors. Physical activity is inversely related to CVD risks in women. Comprehensive employee health programs, which include education and physical activity, can reduce CVD risk factors, costs of absenteeism, and overall health care costs.
Number of Subjects: Thirty-seven subjects completed preintervention measurements. Of these 37, 20 completed the study interventions and postintervention measurements.
Materials/Methods: Subjects were solicited via university E; 61 met inclusion criteria. Of these 61, 37 completed the preintervention measurements of weight and height, body mass index, waist circumference, resting heart rate, and blood pressure, and the 1-Mile Walk Test. Subjects also completed questionnaires on current physical activity level (IPAQ), quality of life (SF-36v2), and readiness to change. Interventions included weekly information sessions based on the Scale Back AL Program and the Go Red Web site, physical activity sessions, completion of weekly physical activity logs, and an online educational resource site. A single-group pretest posttest design was used to test the study hypotheses. Statistical analysis included correlations, t tests, and Wilcoxon signed rank test (significance level: P < .05).
Results: Significant decreases in CVD risk factors of body mass index, systolic blood pressure, and 1-Mile Walk Test were observed. Improvements in the IPAQ and Stages of Change questionnaire were also found. Program participation was inversely correlated with changes in systolic blood pressure (r = 0.40).
Conclusions: A wellness program consisting of information and physical activity sessions was successful in reducing measures of CVD risk in female employees in the United States. A study of longer duration is needed to see the full effects of the program. Further investigation into the reasons for subject dropout is needed.
Clinical Relevance: Heart disease ranks as the number 1 killer among women, striking 1 of every 3 women. The role of physical therapists in prevention is growing. Patient or client care should include prevention and/or intervention for preventable diseases such as CVD on an individual basis and in the worksite.