A good first try. After two rocky spots in the beginning we did manage to get through a stimulating discussion of the two listed articles. We had 18 total callers. Just a reminder that we are not taking attendance. We are happy for all who can join in the discussion or just listen and hope others will access the recording at a later time. The following is an outline of the two articles. Please see the end of this post for information on listening to the recordings and future journal club meetings.
This month’s articles
Results
Delphi in 5 rounds to reach expert consensus on protocol for PFM examination based on ICS standards. 15 articles were also used to determine exam techniques. After a pilot another Delphi round was completed. When face validity had been determined they examined subjects in random order and compared results.
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This month’s articles
Hendriks, EJM et al. Prognostic indicators of poor short term outcome of physiotherapy intervention in women with stress urinary incontinence. Neurourol and Urodynam. 2010, 29:336-343.
Slieker-ten Hove MCP et al. Face validity and reliability of the first digital assessment scheme of pelvic floor muscle function conform the new standard terminology of the international continence society. Neurourol and Urodynam 2009, 28:295-300.
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Prognostic indicators of poor short term outcome of physiotherapy intervention in women with SUI
Hendriks E et al, Neurourol and Urodynam 29:336-343 (2010)
Introduction
Cure rates in the literature 50 to 97% with PFMT
Government guidelines say “continence was achieved in one of every three women with SUI treated with PFMT.
Paragraph 3 pg 336-337 lists risk factors for UI which are more important for prevention and wellness. This study looked at prognosis.
Method
Prospective study of 267 women
PT treatments where not controlled and left up to the PT. Based on the Netherlands
Exclusions | Inclusions |
|
|
Intake questionnaire including the items in table 1 and 2 questions – self health assessment and psychological distress.
Some variables where combined
Outcomes measures – Leak Severity Scale, Global Perceived Effectiveness Score
Completed at initial eval, 12 weeks and end of treatment (see blog post on this scale)
Results
Ave 9.5 rx sessions – no difference in outcome vs number of sessions
88% ended rx by 12 weeks
Ave length 30 to 40 minutes – a little shorter than our treatment times?
Types of treatments
94% PFMT
92% pt ed
54% posture ex and PFMT with ADLs
8% BF and ES
43% recovered based on LS scale
59% recovered based on GPE scale
Poor prognostic indicators
11 LS scale, 8 GPE scale – 7 shared indicators
- Severe
SUI POP Q stage greater than 2- Poor outcome in previous PT
- Prolonged second stage labor – longer than 90 minutes
BMI greater than 30- High psychological distress
- Poor physical health – by self report
Page 339 – preparation for prognostic analysis
Linear relation with poor outcome - 45 yo or older AND 3 or more vaginal deliveries
Possible role of menopause – group wonders if onset of menopause is the correlation with changes occurring at 45 yo
Not associated with poor outcomes
· Age
· Perineal laceration up to grade 3
· Forceps or vacuum delivery
Limitations
- Not included – smoking and family history
- Few patients under 30 yo and over 60 yo – this indicators might not apply to those populations
- No data on compliance and attendance in PT although I have heard the
Netherlands - Remember this does not apply to those groups of patients excluded from the data collection.
Conclusion and application to practice
- Risk factors for UI do not always predict those who will have poor outcome with our treatment
- Patients with conditions listed above may not have “success” or “cure” with PT.
- This means you might decrease your goals and make sure the patient knows this at the initial eval but I would still treat them.
- It is possible to use this list to educate MDs in making good choices for PT referral.
- These might also be patients you decide to send back to the MD after one month if they have made very little progress.
Face validity and reliability of the first digital assessment scheme of pelvic floor muscle function conform the new standard terminology of the international continence society.
Slieker-ten Hove MCP et al. Neurourol and Urodynam 2009, 28:295-300.
Introduction
Methods of PFM examination manually – Laycock, Brink, Devreese
Method
Subjects
41 women age 18 to 85 without PF disorders and no neurological disease.
Results -
Substantial intra-observer reliability
· Pain
· Symmetry left right
· Symmetry anterior posterior
· Voluntary contraction
· Endurance
· Voluntary relaxation
· Palpation during cough – involuntary contraction
· Palpation during cough - perineal movement
Substantial intra observer reliability
· Visual inspection of relaxation
· UI
· Digital assessment of voluntary contraction
Test | Intra - observer | Inter – observer |
External observation | ------------------- | --------------------- |
Inward movement with contraction (yes, no, downward) | 100% of patient | 100% of patients |
Co contraction visable (yes, no) | Moderate | Moderate |
Relaxation (yes, no) | Substantial | |
Perineal movement during cough (yes, no, inward) | Moderate | |
UI (yes, no) | Substantial | |
Perineal movement during straining (yes, no, inward) | ||
Palpation | ------------------- | --------------------- |
Pain (yes, no) | Substantial | Substantial |
Urethral lift (yes, no) | ||
Levator closure (yes, no) | Moderate | |
Symmetry Left to Right (yes, no) | Substantial | |
Voluntary contraction (absent, weak, moderate, strong) | Substantial | Substantial |
Endurance - # of seconds | Substantial | |
Fast twitch - # to max of 15 | Moderate | |
Voluntary relaxation (complete, partly, absent) | Substantial | |
Palpation during cough - Movement of perineum (yes, no) | Substantial | |
Palpation during straining - relaxation (yes, no, inward) | Moderate |
Stats
· Good use of random, blinded testing with a good number of subjects.
· This study looked at the terminology and tests not how they work in the clinic on patients.
· Subjects were fairly homogenous but this was OK for the purpose.
· Method of eval well described and some addition was given by Beth from several personal communications with the first author.
· Interpretation of results is a point of discussion and in some cases results in a significant change in usage of the information (see fast twitch discussion below).
Visual inspection – the articles says there was “close agreement” but it did not come out in kappa??? This is an example of how data can be interpreted differently.
Our own Alison Sadowy and her PTs at Mayo evaluated external visualization of PFM function with a slightly different scale but found good reproducibility of some of the tests as noted below.
A Sadowy, et al. J of Women’s Health PT 34(3) December 2010, pages 81-88.
20 subjects with PF dysfunction where evaluated by 5 PTs simultaneously
Several visual inspection measures were tested and showed good reproducibility including
- PFM contraction
- Overflow activity
- Involuntary relaxation (during bearing down)
- Involuntary contraction (during cough)
Inward movement - “lift and squeeze your pelvic floor, try to avoid loss of urine or flatus”
- Yes – any inward movement, good
- No – no inward movement, unable to determine
- Downward - any downward movement, incorrect contraction
Co-contraction visible – this refers to contact of overflow muscles and is not desirable. I would call it overflow activity as the word “co-contraction” is usually related to the desirable contraction of the TrA and the PFM)
- Yes – any co-activity other than TrA (TrA is palpated at medial ASIS)
- No – co-activity of other muscle was visible, this is desirable
Relaxation
- Yes – relaxation visible directly after instruction
- No – absent, partial, or hesitant relaxation, any dysfunction is listed as “no”
Perineal movement during coughing
- Yes – any downward movement, failure of PF to support
- No – no downward movement, good support
- Inward – any visible inward movement, reflex contraction, good support
Incontinence
- Yes - any UI
- No – no UI
Perineal movement during straining (perineal descent is not in this evaluation structure)
- Yes – any downward movement, good ability to relax PFM on command
- No – no downward movement, inability to relax
- Inward – inward movement during straining, paradoxical contraction during straining
Palpation
Pain
- Yes – any pain, any location, L, R, Ant, Post – would then be further clarified by amount and location
- No – no pain on palpation
Urethral lift – finger palpating at the bladder base, looking for cranial or ventral movement of the urethra, this is not a measure of lift of the PFM (that is included in strength grade) This test did not reach even moderate reproducibility and may not be a good test.
- Yes – any urethral lift palpable, this would be normal
- No – no urethral lift palpable
Lavator closure – only measure completed with 2 fingers, place fingers apart on each PFM side wall
- Yes- any levator closure movement palpable, this would be normal
- No – no levator closure movement palpable
Symmetry left, right – during contraction, this applies to size or strength and would be further clarified as needed.
- Yes – complete symmetry between right and left PFM, this would be normal
- No – asymmetry between right and left PFM, this could be related to avulsion or muscle trauma, or other causes
Symmetry ant, post – despite the reliability of this measure the author (in personal communication) has subsequently stopped using this measure.
- Yes – complete symmetry between anterior and posterior PFM
- No – no complete symmetry between anterior and posterior PFM
Voluntary contraction “lift and squeeze your PFM as hard as possible”
Definitions in this article
- Strong – strong closing and lifting cranio-anterior movement palpable
Normal - Weak – short contraction, no closure palpable
- Absent – no contraction
MMT of the PFM
SOWH CAPP 2010 courses
Laycock 2008 | Messelink 2005 |
0 - no contraction | Absent |
1 - flicker | |
2 - weak squeeze, no lift | Weak |
3 - fair squeeze, definite lift (grades 3-5 are generally discernible on visual perineal inspection) | Moderate/normal |
4 - good squeeze, good lift, able to hold against resistance | |
5 - strong squeeze, against strong resistance | Strong |
Endurance ‘make a steady but firm contraction and hold as long as you can while repeating ‘hold, hold, hold’”
- Number of seconds up to 10
Fast twitch “make fast, short and strong contractions while repeating ‘contract, contract, contract’” This test seems to look only at fast twitch muscle recruitment. Journal club participants (including myself) agree that the test could also be used to document inability to relax quickly. I would clarify by making sure the patient is relaxing fully between – I prefer in my practice to ask for number of fast twitch contractions in 10 seconds.
- Number up till 15
Voluntary relaxation – I do not like these categories.
- Complete – direct beyond rest level – this is confusing to me and seems like the involuntary relaxation measure
- Partly – direct relaxation until rest level, in this measure indicated overactive PFM, form me it would be normal
- Absent – no relaxation palpable, indicates overactive PFM
Palpating during cough “cough forcefully”
Involuntary contraction – this author subsequently has stopped taking this measurer as it is very difficult to know if the muscle is contracting or the finger is moving due to internal force.
- Yes – any contraction of PFM
- No – no contraction of PFM
Movement of perineum
- Yes – any downward movement, this would indicate loss of support
- No – no downward movement, this would be normal support
Palpating during straining “give a strong push”
Involuntary relaxation
- Yes – PFM relaxation palpable, normal
- No – no PFM relaxation palpable, seems to me it is difficult to asses this, abnormal
- Paradox – PFM contraction, abnormal
In need of further clarification – these tests have been dropped from the suggested tests.
- A and P symmetry
- Palpation of involuntary contraction during coughing
- Urethral lift
Limitation – Very little variability of subjects, no subjects with dysfunction, poor age distribution which is OK for the purpose of the study. This study points out the subjectivity of PFM testing and need for further clarification. This study also does not help the therapist to know if the test is helpful in clinical decision making.
Further research
- How do internal and external cough and straining tests compare. For example if the patient has a positive external test, can you assume they will have a positive internal test?
- We have some evidence as to the clinical applicability of some of these tests but may remain to be tested.
Conclusion and clinical application
This study begins discussion and testing of the new PFM tests and terms proposed by ICS. Having uniform, valid test procedures helps in multi disciplinary communication and research. It is helpful for therapists to practice the tests to make sure their technique is accurate. This is best done in groups with expert consensus as to the proper technique. Please see attached chart for a summary of evaluation results. Pelvic PT Pelvic Floor Muscle Examination Interpretation of test results and applicability to clinical decision making is unclear on some tests. Therapists are encouraged to look at the whole patient in making clinical decisions about the test results.
2011 schedule
April 6 – TO BE DECIDED
May 4 – Jane O’Brien
June 8 – Michelle Spicka
July 6 – Ann Dunbar
August 10 – TO BE DECIDED
September 7 – Pam Downey
October 5 – Jane O’Brien
November 9 – Beth Shelly
December 7 – TO BE DECIDED
Time - for one hour
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Email Beth Shelly at beth@bethshelly.com to be included on future journal club emails including receiving an electronic copy of the articles to be discussed. Or check back on this blog for updates.
The following is an outline of the two articles. Please see the end of this post for information on future journal club meetings.
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