Transcript cps-ii-intervention-final

Clinical Problem Solving II
Anouk Speek
3 October, 2016
Examine
the
evidence
---
Describe
my patient
Case
---
Pelvic
floor
anatomy
and
function
---
---
Objectives
Clinical
application
of the
evidence
to my
patient
case
Pelvic floor
anatomy and
function
43 y/o female
Vulvovaginal pain, burning (<1 yr)
Urinary frequency/urgency
Subjective
Incontinence since birth of two children
Incontinence with cough/sneeze,
running (SUI)
Sx worse when feeling stressed
Not having intercourse due to sx
Objective
Observation:
Lumbar spine:
Increased anterior pelvic tilt
FFT fingertips 4” from floor
with minimal curve reversal,
pain-free
Symmetrical pelvis in
standing/supine
Breathing from accessory muscles
(UT with sternal elevation)
Hip
Left*
Right
ROM
WNL
WNL
Hamstrings
Mod restriction
Mod restriction
Piriformis
Mild restriction
Mild restriction
Iliopsoas
Mod restriction
Mod restriction
Pubic Symphysis
negative
negative
Stork
+, unlocking mid range
+, unlocking mid range
Diaphragmatic breathing
Able to perform with min VC
Pelvic floor exam
G2P2, vaginal deliveries, uncomplicated
External Exam
Skin integrity: pale, no redness or striations, gapping perineal body
Contract/Relax response: able to isolate TrA with VC for gentle PF
contraction, weak voluntary contraction, incomplete voluntary relaxation,
absent involuntary contraction, present involuntary relaxation
Pelvic floor exam
Tone: asymmetric, low
Strength: 2 / 5
Internal Exam
Relax after contraction: slow, inconsistent
Trigger points and myofascial
restriction L Levator Ani
Prolapse: moderate anterior vaginal laxity
L Pubococcygeus
Overactive and TTP
L Iliococcygeus
WNL tone and TTP
R Pubococcygeus
WNL
R Iliococcygeus
Moderate atrophy, no tenderness
PT Diagnosis/ICF Model
Health Condition: Stress urinary incontinence, pelvic floor dysfunction
Body Structure & Function: PFM atrophy (R) and over-activity (L), hip muscle
weakness and flexibility restriction, pain/burning, trigger points Levator Ani m.
Activities: coughing, sneezing, functional/transitional activities, running
Participation: track coaching duties, social activities, intercourse
Environmental factors: stressful job, family demands
Personal Factors: supportive family, lack of good stress management
Patient Goals
In two weeks, patient will demonstrate improved neuromuscular recruitment of
pelvic floor muscles in order to decrease stress urinary incontinence.
In four weeks, patient will demonstrate increased PFM strength and mobility in
order to decrease stress urinary incontinence.
In four weeks, patient will demonstrate independence with PFM-specific HEP to
manage over-activity.
Clinical Question
For a 43 year old female patient, is pelvic floor muscle training
(PFMT) an effective intervention for stress urinary
incontinence, and is there a specific protocol used?
Pelvic floor muscle
training versus no
treatment, or inactive
control treatments, for
urinary incontinence in
women.
Dumoulin, et al., 2014
• Systematic Review
Objective: To determine the effects
of pelvic floor muscle training
(PFMT) for women with urinary
incontinence in comparison to no
treatment, placebo or sham
treatments, or other inactive control
treatments.
Cochrane Incontinence Group Specialised Register, MEDLINE, MEDLINE InProcess, journals, conference proceedings, and reference list of relevant articles
using GRADE approach
Randomised or quasi-randomized
controlled trials in women with stress,
urgency, or mixed urinary incontinence
Pelvic floor muscle
training (PFMT)
No treatment, placebo, sham,
or other inactive control
treatment
Inclusion:
- SUI, MUI, UUI
- Studies with men, but data reported
separately
- All types of PFMT programs
Strengthening
Urge suppression
Different ways of teaching PFMT
Types of contractions
Number of contractions
Dumoulin 2014
Exclusion:
- Sx due to other significant factors:
neurological disorders, cognitive
impairments, lack of independent
mobility, cancer, and
radiotherapy
- Nocturnal enuresis
- Antenatal/postnatal women
- PFMT as prevention for leakage
- PFMT + active treatment
Article Selection, Dumoulin 2014
704 articles
54
potentially
eligible
21 trials
included
(N=1281)
• 18 contributed to
forest plots
• 12 contributed to
primary outcomes
Outcome Measures, Dumoulin 2014
Primary:
1.Patient reported measures:
a. Symptomatic cure of UI at the end of treatment
b. Symptomatic cure or improvement of UI at the end of treatment
c. Symptom and condition specific health measures (I-QOL)
Secondary: Patient-reported quantification of sx, Clinician’s measures, Quality of
Life, Adverse effects, Socioeconomic measures, Measures of likely moderator
variables
Results,
Dumoulin
2014
Illustrative comparative risks*
(95% CI)
Assumed risk
Corresponding
risk
Control
PFMT versus no
treatment, placebo
or control
Outcomes
No of
Quality of
Relative effect
Participants the evidence
(95% CI)
(studies)
(GRADE)
Study population
60 per 1000
505 per 1000
(222 to 1000)
Participant perceived cure stress urinary incontinence Moderate
62 per 1000
RR 8.38
165
(3.68 to 19.07) (4 studies)
⊕⊕⊕⊕
high 1
RR 17
121
(4.25 to 67.95) (2 studies)
⊕⊕⊕⊝
moderate 1,2
520 per 1000
(228 to 1000)
Study population
Participant perceived cure
or improvement after
treatment - stress urinary
incontinence
32 per 1000
540 per 1000
(135 to 1000)
Moderate
32 per 1000
544 per 1000
(136 to 1000)
Results, Dumoulin 2014
Conclusions, Dumoulin 2014
• PFMT is better than no treatment, placebo drug, or inactive control treatments
for women with stress urinary incontinence
• PFMT group were more likely to report cure or improvement, report better
quality of life, have fewer leakage episodes per day, and have less urine leakage
on short office-based pad tests than controls
• Women were also more satisfied with the active treatment, and their sexual
outcomes were better
Study Limitations, Dumoulin 2014
PFMT protocols not detailed
Small – moderate size trials
Poor reporting on adherence
Lack of long term follow up (<1 year)
Some secondary outcomes not reported
Inability to blind either party
Diagnosis did not include imaging
Pelvic floor muscle
activation and strength
components influencing
female urinary
continence and stress
incontinence: A
systematic review.
Luginbuehl, et al., 2015
• Systematic Review
Objective: To summarize and
evaluate existing studies
investigating PFM activation and
strength components influencing
female continence and SUI.
PubMed, EMBASE, Cochrane using PRISMA guidelines
Heterogeneity in protocols seen in studies, meta-analysis not possible
January 1980-November 2013
Intervention studies patients
with SUI
Cross-sectional studies PFM
activation/strength components
Patients with SUI
PFM activation
Healthy controls
PFM strength
Urine loss
Article Selection, Luginbuehl 2015
2,630
abstracts
121 eligible
records
• 345 duplicates
14 final
articles
• 107 excluded
• 2,164 excluded • 9 compare SUI to
healthy controls
• 5 intervention
articles
5 intervention articles, Luginbuehl 2015
- PFM component varied (strength, pelvic muscle pressure, endurance,
squeezing pressure)
- Measurement methods varied
- All studies performed strength (strength/force/pressure) measurements
- Only 1/5 articles looked at endurance
Conclusions, Luginbuehl 2015
• All intervention studies showed an improvement of PFM strength and
decrease in urine loss in SUI patients after pelvic floor physical therapy
• Higher PFM activation and strength components influence female
continence positively
• Higher maximal, mean, endured and increase of PFM strength, and
earlier onset of PFM activation were positively associated with female
urinary continence
Study Limitations, Luginbuehl 2015
Small number of trials/subjects
Heterogeneity of terminology, testing procedures, and
outcomes
Lack of information on the exact intervention given to study
participants
Application to my patient case
Article 1: Dumoulin, 2014
Article 2: Luginbuehl, 2015
•Female
•SUI
•43 y/o
•Patient-reported measures
•Female
•SUI
•43 y/o
•Patient-reported measures
PFMT is better than no
treatment, sham, placebo or
inactive treatment
PFM protocol cannot be established
Clinical Question
For a 43 year old female patient, is pelvic floor muscle
strengthening (PFMT) an effective intervention for stress
urinary incontinence, and is there a specific protocol used?
Yes! It is safe, and effective. As for the protocol go back
to basics…
- PFM strength
- Too much TrA activation
- PFM volume/ muscle bulk
- Compensation by oblique
muscles
- PFM endurance
- PFM coordination
- PFM mobility
- Improper breathing
patterns
Patient
Education
Plan of Care
Relaxation/
Breathing
training
Indirect PF
mobilisation
Stretch/
strengthen hip
stabilisers
Patient
X
Posture
correction
PFMT
Internal
myofascial
release
Dumoulin C, Hay-Smith EJC, Mac Habée-Séguin G. Pelvic
floor muscle training versus no treatment, or inactive control
treatments, for urinary incontinence in women. Cochrane
Database of Systematic Reviews 2014, Issue 5. Art. No.:
CD005654. DOI: 10.1002/14651858.CD005654.pub3.
References
Luginbuehl, H., Baeyens, J.-P., Taeymans, J., Maeder, I.-M.,
Kuhn, A. and Radlinger, L. (2015), Pelvic floor muscle
activation and strength components influencing female urinary
continence and stress incontinence: A systematic review.
Neurourol. Urodynam., 34: 498–506. doi:10.1002/nau.2261
https://www.google.com/search?q=pelvic+floor&espv=2&bi
w=1024&bih=433&source=lnms&tbm=isch&sa=X&ved=
0ahUKEwjMhbk7JvPAhWBmR4KHfLKB7IQ_AUIBigB&gws_rd=ssl#gws_
rd=ssl&imgrc=2jpyVWkme5W73M%3A
https://www.google.com/search?q=pelvic+floor&espv=2&bi
w=1024&bih=433&source=lnms&tbm=isch&sa=X&ved=
0ahUKEwjMhbk7JvPAhWBmR4KHfLKB7IQ_AUIBigB#tbm=isch&q=pelv
ic+floor+urinary+incontinence&imgrc=7Fqnf5CytQlvnM%3
A
Thank you!
Any Questions?
5 articles
•
After 6 months of PFMT, positive correlation between ↑ of PFM strength and better pad-test (r = 0.23,P = 0.05) and PFM strength and
leakage index (r = 0.34,P < 0.01)*. “ mean of 10 MVC of PFM as hard as possible. Balloon catheter.
•
After 16 weeks graded PFMT: Actual pressure (P = 0.0009) (18.9 ± 10.4 < 29.5 ± 12.9) and rate of rise pressure (P = 0.004)
(32.9 ± 16.6 < 49.0 ± 18.9); urine loss (P = 0.03) (14.1 ± 14.1 > 2.4 ± 1.4)** Usdpelvic muscle pres. Intravaginal balloon device;
hr bladder diary, 24-hr home pad-tes
24-
9 comparison articles
-All studies in favour of continent women in:
muscle strength
contraction duration
anteroposterior active strength (sagittal)
left-right active strength (frontal)
Closure pressure
Forces in all 4 directions
resting activity of PFM
PFM timing
Outcome Measures according to SCICS
1. Woman’s observation (symptoms)
2. Quantification of symptoms (ex. urine loss)
3. Clinician’s observation (anatomical and functional)
4. Quality of life
5. Socioeconomic measures
Quality of Evidence
GRADE Approach - 7 main outcomes
1. Symptomatic cure of urinary incontinence (reported by the woman and not the clinician);
2. symptoms of cure or improvement of urinary incontinence (reported by the woman and not the
clinician);
3. symptom and condition specific quality of life assessment (e.g. Incontinence Impact Questionnaire,
King's Health Questionnaire);
4. number of urinary leakage episodes;
5. pad and paper towel testing short (up to one hour) or long (24 hours) urine loss (grams of urine
lost);
6. treatment adherence;
Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary
incontinence in women
Cochrane Database of Systematic Reviews
14 MAY 2014 DOI: 10.1002/14651858.CD005654.pub3
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005654.pub3/full#CD005654-fig-00101
Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary
incontinence in women
Cochrane Database of Systematic Reviews
14 MAY 2014 DOI: 10.1002/14651858.CD005654.pub3
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005654.pub3/full#CD005654-fig-00102
Is a protocol available?
PFM components:
maximal strength
power
hypertrophy
strength-endurance
muscle action (eccentric/concentric/isometric)
Protocol components:
frequency
intensity
type of contraction
Article 3: TrA activation alone or in combination
with PFMT to treat female urinary incontinence?
No additional benefit in adding TrA training to PFMT
http://onlinelibrary.wiley.com/doi/10.1002/nau.20700/epdf