Predictors of success for physiotherapy treatment in women with persistent postpartum stress urinary incontinence.

Dumoulin C, Bourbonnais D, Morin M, Gravel D, Lemieux MC. Arch Phys Med Rehabil 2010;91:1059-1063.

Beth Shelly November 9, 2011

Background

·         Women who continue with UI 3 months post-partum have a significant risk of symptoms persisting 5 years later.

·         Cochrane review – PFM exercises decrease SUI

Error in terminology

“Pelvic floor physiotherapy uses graded muscle training, either alone ….”  This sentence (written by physiotherapists) creates and contributes to the confusion other professional have about what we do and what it should be called.  Pelvic floor physiotherapy is a treatment for the pelvic floor provided by physiotherapists.  So can a nurse provide pelvic floor physiotherapy?    Certainly we would say “no” but nurse can provide “graded muscle training, either alone or ….”.  More appropriate alternative would be - “Pelvic floor physiotherapists use graded muscle training, either alone…”

Subjects – 57 women with moderate to severe SUI (without retention or DO) of onset after delivery.

Method – RCT of clinic PT 1x/week for 8 weeks 15 min ES, 25 min PFM ex, with or without 30 min TrA exercises.  Participants did exercises at home 1x/ day for 5 days per week

Measurements – success was measured by pad test of less than 2 g. (5.5 ml = 3g) 7 PFM parameters were taken with the dynamometer.

Results – pad tests sig improved in both groups (P<.001) without significant difference. 

Looking at the other study 70% cure in PFM ex alone, 74% in PFM plus TrA. 

Combining groups – 73% of patients were successful (less than 2 g increase weight in pad test)

Logical regression analysis – 2 predictors reliably distinguished UI or dry

·         Pretreatment lower passive force of PFM

·         Pretreatment higher PFM endurance – 90 second contraction (although the study does admit their exercise program may have favored these subjects and also pointed out this predictor may not have add significantly to the regression)

·         Other factors such as maximum strength of PFM, rate of force development, and number of fast contractions in 15 seconds were not related to outcome

Authors make a case for that fact that PFM training improves passive PFM force and that this improves symptoms. 

Limitations – will consider combination with other pretreatment variables including BMI, intensity and duration of sx, urodynamics parameters and adherence.  I would also add that very few PTs have a dynamometer to measure resting force of the PFM.

The groups discussed ways to apply this to clinical measure without a dynamometer.