The group also discussed the need for more patient education on birth trauma and recovery. It was proposed that the SOWH consider another task force to develop and disseminate such a document.
Unfortunately I was not able to record this month’s call but will work on fixing that for next month. See outlines below. We will be thinking about the schedule for next year. I would like to send out a short survey to all on the journal club list. Please let us know what is working or not working for you. Looking forward to next month’s call.
This month’s discussion
Dietz HP, Simpson JM. Levator trauma is associated with pelvic organ prolapse. BJOG 2008;115:979-984.
Beales DJ, O’Sullivan PB, Briffa NK. Motor control patterns during an active straight leg raise in pain-free subjects. Spine 2008;34(1):E1-E8.
Beales DJ, O’Sullivan PB, Briffa NK. Motor control patterns during an active straight leg raise in chronic pelvic girdle pain subjects. Spine 2009;34(9):861-870.
2011 schedule
May 4 – Jane O’Brien
June 8 – Pam Downey
July 6 – Ann Dunbar
August 10 – Michelle Spicka
September 7 – Pam Downey
October 5 – Jane O’Brien
November 9 – Beth Shelly
December 7 – Michelle Spicka
Study Guides for the September, 2011 Pelvic Floor Think Tank Article Review
Prepared by Pamela Downey, MSPT, DPT, WCS, BCB-PMD
1. Motor Control Patterns During Active Straight Leg Raise in Pain –Free Subjects Beales DJ. O'Sullivan PB. Briffa NK. Spine. 34(1):E1-8, 2009 Jan 1.
2. Motor Control Patterns During Active Straight Leg Raise in Chronic Pelvic Girdle Pain Subjects. Beales DJ. O'Sullivan PB. Briffa NK. Spine. 34(9):861-70, 2009 Apr 20.
These selected articles investigate local muscle control patterns in asymptomatic and symptomatic women with pelvic girdle pain (PGP). I have provided both articles, because the Pain Free study establishes the methodology of the studies and gives a baseline of measured muscle activity during the task of active straight leg raise (ASLR), and adds measures of muscle activity coinciding with respiration, chest wall motion and pelvic floor muscle response to intra-abdominal pressure (IAP).
Summary of (1): Motor Control Patterns During Active Straight Leg Raise in Pain–Free Subjects. Beales DJ. O'Sullivan PB. Briffa NK. Spine. 34(1):E1-8, 2009 Jan 1.
Hypothesis: This was an investigation of motor control strategies (MC) employed by pain free subjects during low level load transfer, the ALSR, through the pelvis. The authors hypothesized that pain free subjects would demonstrate a local motor strategy with minimal change in IAP.
Of interest is the monitoring of both sides of the trunk during ALSR to observe motor control (MC) activation patterns and concurrently monitoring respiration, IAP, and pelvic floor motion, new in presentation of this data at the time.
Subjects: Fourteen nulliparous females recruited in Perth, Australia. Exclusion criteria are clear, and patients were consented under an IRB at Curtin University of Technology.
Methodology:
Use of ALSR: the ALSR is considered reliable and valid in assessing load transfer through the pelvis, with multiple research articles cited.
Respiratory, sEMG and pressure and kinematic data were collected concurrently during ASLR. Well documented and sourced citations for placement of electrodes. Adequate equipment for the study design, with addition of a custom catheter for ITP and IAP. The study is reproduceable per written methodology. I have noted the absence of transverse abdominus monitoring seemingly because of surface patch electrodes used versus fine wire insertion.
Surface EMG data were collected via surface Ag/AgCl patch electrodes from bilateral internal oblique (IO), bilateral external oblique (EO), bilateral rectus abdominus (RA), right chest wall (CW) between 6th and 7th intercostal spaces, bilateral scalenes (Sc) and rectoris femoris for confirmation of leg lifted only. Telemetric units were used, sampled at 100Hz, band of 10 to 500hz, CMRR ratio of >115 dB at 60Hz with preamp and amplification at an overall gain of 2000.
Intrathoracic (ITP) and intraabdominal pressure (IAP) were monitored through a specially built pressure transducer using a naso gastric catheter and recorded while performing ASLR of the ipsilateral and contralateral leg. Confirmation of placement of the catheter was confirmed with opposite pressure changes in both channels during respiration.
To assess compensatory downward pressure on the contralateral heel an inflatable pad was placed linked to a pressure transducer. Ultrasound unit was used to view the bladder, which was used to assess PF movement, and the data was digitally recorded.
Data Collection:
The average root mean square was the metric of the sEMG. Normalization of data: 3 seconds of 3 reps of double leg raise with cervical flexion in the crook lying position for submaximal contraction.
· Data was collected in supine for 60 sec and repeated 3 times for each leg.
· Data collected during ASLR: 5 sec after coughing, the subject raised their leg 10 cm, maintain for 45 sec, then lower leg and data collection was ceased 10 sec later. (Repeat x 2).
· Cough served to produce movement on US to act as marker to synchronize PF video with the rest of the data.
Data was demeaned and then passed through a 4-400 Hz Butterworth filter with zero lag and normalized. (They looked for heartbeat and other artifact.) RMS for 500 milliseconds during the middle of the inspiratory and respiratory phase of 3 breath cycles was used. (The authors were interested in phasic and tonic effects of breath during load transfer.)
IAP and ITP over the 3 cycles was found by subtracting min from max pressure value for that breath. Pressure change related to physical loading was ascertained via baseline shift: average minimum pressure value of 3 breath cycles duirn ASLR minus that of resting supine.
US video frames of max and min PF motion were overlaid during 3 breath cycles and during ASLR.
Data Analysis:
2x2 repeated measures ANOVA was used: L ASLR, R ALSR by inspiration, expiration. Paired t test were used for post hoc analysis for each muscle comparison.
Paired t test was used for comparison of left vs right leg lifting for IAP, ITP, RR, leg pressure and PF motion.
Results:
Please see article.
Discussion:
Authors stated the following findings in their discussion:
· Local muscle activation occurs with a minimal change in IAP (this study confirms finding of previous studies)
· Role of IO as pelvic stabilizer in supine ASLR activity
· Ipsilateral IO and EO activation (in contrast to the sling phenomenon: IO and contralateral EO by Vleeming).
· Phasic to tonic activation of the CW during ipsilateral ASLR in 50% of subjects.
· Subjects could lift their leg without disturbing IAP and ITP fluctuation associated with quiet breathing.
· Small increase only in IAP with ASLR (further confirmation that ASLR may represent a lowload.)
· Most subjects had tonic activation of the abs and chest wall ipsilateral to the side of the ASLR. The body can attend to physical load without affecting respiration.
· Minimal bladder movement during ALSR, indicating PF activation without conscious command is possible in painfree subjects.
Summary of (2): Motor Control Patterns During Active Straight Leg Raise in Chronic Pelvic Girdle Pain Subjects. Beales DJ. O'Sullivan PB. Briffa NK. Spine. 34(9):861-70, 2009 Apr 20.
Hypothesis:
Subjects with Pelvic Girdle Pain (PGP) would demonstrate:
1. Altered muscle patterning when lifting the affected leg
2. Altered patterning would equate to a bracing strategy
3. The changes would be associated with the generation of higher levels of IAP and PF depression.
Subjects:
12 women with unilateral sacroiliac joint (SIJ) symptoms of PGP were consented for study under the IRB of Curtin University of Technology.
Methodology:
Same as previous article. Affected side indicated side with SIJ dysfunction.
Results:
Please see article.
Discussion:
The results indicated the hypothesis proposed by the researchers was supported: subjects with unilateral chronic PGP pain adopt a MC strategy of bracing when performing an ALSR on the affected side, with associated generations of higher levels of IAP and greater PF depression. Also:
1. Increased bilateral IO and EO activation with ASLR
2. Tonic CW activation was noted with performing ASLR on the affected side, but authors noted that it was a small sample size and more study is needed to delineate this further.
3. Over 50% of subjects demonstrated tonic activation of the Scalenes (phasic in pain free subjects), indicating a possible change to accessory breathing patterns.
4. Increase in baseline shift of IAP during ASLR on the affected side (a component of abdominal bracing).
5. Greater depression of the PF was noted during ASLR of symptomatic side leg.
6. Bracing patterns may be provocative in nature, providing a mechanism for ongoing pain.
7. Treatment for PGP that includes a reinforcement of the bracing pattern may worsen symptoms in pts with unilateral SIJ dyfunction.
3. Levator trauma is associated with pelvic organ prolapse. HP Dietz, JM Simpson. BJOG 2008; 115:979-984
This study brings to light the evidence levator ani muscle trauma, specifically the puborectalis, in a sample of women presenting to a uregynecological clinic, were twice as likely to show significant pelvic organ prolapse (POP) Stage II or higher cystocele and uterine prolapse, than those subjects presenting without a trauma. Those women POP showed a four fold higher prevalence of levator injury than those without.
This study also stated that the majority of women studied presented with other dysfunction such as voiding dysfunction, urinary incontinence, or recurrent urinary tract infections rather than POP. Many women, it seems to follow, will suffer the consequences of the POP and decline of muscle function for many years until the POP is diagnosed. As a Women’s Health professional, I then ask, how many of these women are being missed within our own practices? And how can we better as clinicians in helping this population of women?
Guided questions for the group:
1. Do you check for avulsion/tears of the pelvic floor muscles?
2. Do you specifically palpate for the puborectalis insertion at the pubis?
3. If a patient presents with an asymmetric strength pattern, what is your typical plan of care?
4. If the patient does not improve over a given time period, what do you do next?
5. Are physical therapists screening for POP?
a. How do you perform an exam for POP?
b. How do you record it? (tools?)
6. Are physicians screening and sending these patients for surgical repair?
a. Is there any PT follow up at this point post repair?
7. What is there available in the community for patient education?
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