Journal on Women’s Health PT Vol 34 #3, Sept/ Dec 2010

As usual another issue packed with thought provoking, and interesting information.  I have just received the Spring issue and working hard to keep the flow of information timely.  Many a probably way ahead of me and have already read this issue.  I would love to hear your comments.  The major feature is posters and platforms from CSM.  Many good research projects are represented.  I am looking forward to the full papers.

The editorial is on ambiguity and the use of treatments that (in the editor’s opinion) are not evidence based such as visceral mobilization and craniosacral therapy.  I certainly cannot argue with the lack of evidence in these particular areas (and others in women’s health).  And I would suggest therapist continue to PUBLISH some level of evidence on these treatments.  In addition I think that only providing treatments that have been fully studied will limit patient success.  They did not stop using penicillin just because they did not understand how it works.  I believe some of my patients fail orthopedic PT because the therapist only considered treatments with extensive evidence.  My treatment includes some of those treatments and often results in success when others fail.  Certainly I would not charge insurance and keep seeing the patient if my treatments were not changing their symptoms – whether I am using evidence based treatments or those with less evidence.  Variety is good. 

Physical Examination findings by physical therapists compared with physicians of musculoskeletal factors in women with chronic pelvic pain. C Neville, C Fitzgerald, T Mallinson, SA Badillo, CK Hynes. 

This is a great paper and will be discussed on the May 4th Pelvic PT Distance Journal club.  Stay tuned.

Development of a pelvic floor muscle coordination scale. A Sadowy, et al. 

This study provides reliability data on some of the new ICS examinations.  The examinations were completed by one experienced Pelvic PT and 4 trained students.  Each of 5 items is scored and then scores added for one total score.     

·        Scale reads 0 to 2 with 0 being normal – this seems backwards as most scales have 0 as the worst

·        The paper is based on the ICS standardized tests but did not use ICS terms – would have been better to use recommended terms

·        The author added a measurement of PFM relaxation during inhale based on recent literature.  I have never heard this as a PFM test externally, it turned out to be problematic.  I would not include it in my examination

·        The term perineal descent was used in a context of a normal finding.  I would never use this term to describe normal function.

·        This is clearly a modification of the ICS tests.  It would have been nice for the authors to use the pure version of the tests

Results – Most subjects in this study performed the external elevation of the PFM correctly. However, most also had overflow.  Also most subjects had absent involuntary contraction and relaxation.  However in table 1 it looks like many could do what she calls expulsion.  Overall there was moderate to substantial inter rater reliability for most tests.  Correlation to PFDI scores (clinical implications) was less strong but present.  Original interpretation of the ICS PFM test for the CAPP process includes external observation of perienal body mobility.  Further study revealed that these measurements were intended inside the vaginal canal.  (see review of that paper on this blog) The study did a good job of discussing limitation of this study and what might be done differently to make the tests better.  Let’s hope she does make the changes and does another study.

Characteristics of physical therapists reporting high and low skill confidence in examination of the pelvic floor muscles. B Shelly, L Krum.

This reflects part of the research it did for my DPT on education of pelvic PTs.  The results can be easily summarized.  If you want more confidence – practice in the clinic, participate in self study, and continue your course work.  On the job training and mentoring did not increase confidence in my study – I think this is due to limited numbers (203 PTs completed the on line questionnaire).  The examination tools most used were external observation (68.5%) and internal vaginal palpation (73.9%).

 Of note were ten subjects who did not think PFM examination was important in developing the treatment and 7 women who rarely or never complete any examination of the PFM (I listed many options both external and internal) not surprising that most of these subjects expressed low confidence in examining the muscle.  This boggles my mind that PTs would consider treating without testing.  This is a skeletal muscle just like the biceps.  Would you ever consider treating the biceps without some form of testing or palpating?  In addition, ethically, you cannot code “muscle weakness” if you have not tested to document the status of the muscle.  We are experts in muscle dysfunction, it is our responsibility to test the muscle – no one else will do it like us.  If you are concerned or reserved in your ability to examine the PFM internally, you should start with external EMG measurements.  Keep learning and observing others treatments until you feel ready to examine the muscle inside the vaginal canal. 

This issue has reprints of 2 very good articles on ultrasound.  Understanding the lack of evidence in the use of ultrasound is important.  I believe short term, limited use of ultrasound is indicated when its use results in desirable improvements in symptoms.  Good articles to read.

There is also a list of professional conferences in late 2010 and 2011.  This is helpful in planning your calendar, be careful to look at the year to make sure you are looking at a course in 2011.

Glad to hear your comments.