Braekken IH, Majida M, Engh ME, Bo K. Am J Obstet Gynecol 2010;203:170e1-7.
Laura Scheufele PT, DPT, WCS
November 7, 2012
Primary Aim: To
evaluate whether PFMT can (1) reverse and prevent further development of POP
and (2) reduce symptoms related to POP.
Subjects: 109 women at least 1 year post-partum with
POP stages I, II and III as determined by POP-Q regardless of symptoms.
Exclusion criteria as
follows: POP stage 0 or IV, inability to
contract the PFM, breastfeeding, previous POP surgery, radiating back pain,
pelvic cancer, neurologic disorders, psychiatric disorders, untreated urinary
tract infection, planning to become pregnant during the next 6 months, or to be
away for more than 4 weeks during the intervention period.
Study Design: An
assessor-blinded, randomized, controlled, parallel group trial with
stratification on severity of POP.
Stratified into 2 groups by severity of prolapse: (1)
maximal vaginal descent at or above the hymen, and (2) maximal descent below
the hymen. Within each strata randomization proceeded.
Methods:
Procedures
PFMT and control groups both
advised to avoid straining and taught how to perform “the Knack”.
Controls (n=50): Asked not to
start or stop PFMT during intervention period.
PFMT Group ( n=59): Advised
to perform 3 sets of 8-12 close to maximum PFM contractions per day and to
record home training in an exercise diary. Each subject individually supervised
by a PT once a week during the first 3 months and every 2 weeks the last 3
months. Also issued a booklet and DVD showing the exercise program.
Outcome measures (assessed pre-intervention and 6 months post-test)
Stages of POP:
POP-Q
Position of bladder and rectum: Standing ultrasound examination with standing
technique described by Schaer et al and previously found to be reliable. The
positions of the bladder and rectum quantified by locating the urethrovesical
junction (bladder neck) and rectal ampulla.
Frequency and bother of prolapse symptoms: Used a previously validated scale to describe
frequency (daily, weekly, monthly, or less than once per month) and 4-point
scale of prolapse symptoms: feeling of
vaginal bulging and/or heaviness (none, mild, moderate, severe bother).
Frequency and bother of bladder and bowel symptoms: Same validated scale as above to describe frequency
and bother of bladder symptoms (SUI, UUI) and bowel symptoms (flatus, loose,
and solid FI, problems with emptying bowel). In addition, the International
Consultation on Incontinence UI Short Form questionnaire (ICIQ-UI SF) used to
assess UI and impact on quality of life. This is a 4 question validated
incontinence screen with score of 0-21 possible.
PFM function: Evaluated
by vaginal balloon catheter manometry. Strength calculated as the mean of 3
maximal voluntary contractions. Endurance defined as a sustained maximal
contraction and was quantified during the first 10 seconds as the area under
the curve (cmH2O sec). Pelvic floor assessment not blinded.
Results:
Stages of POP: See Table 2. Significantly more women in PFMT compared to control group
improved 1 POP-Q stage (19% vs 8%).
Within
the PFMT group, the number of women improving 1 stage on POP-Q increased with
increasing degree of POP (0% for stage I, 16.7% stage II, 35.7% stage III).
Position of bladder and rectum: Paired ultrasound volumes (pre- and posttest) was 47
each group for position of bladder and 36 of PFMT and 38 controls for position
of rectum.
The
PFMT group had significantly greater cranial elevation of the bladder 2.3 mm vs
-0.6 mm and rectum 4.4 mm vs
-1.1 mm. The effect size calculated was 0.79 for elevation of the bladder and 0.63 for the rectum.
Frequency and bother of prolapse symptoms: See Table 3. Significant improvements with prolapse,
bladder, and bowel (only flatus and loose FI) symptoms and bother for subjects
who were symptomatic at baseline. After adjustment for baseline values, women
in PFMT group had significantly reduced frequency (P=.015) and prolapse bother
(P=.04) compared to controls. Subgroup analyses of the 40 women with prolapse
below the level of hymen demonstrated a reduction in frequency of prolapse
symptoms in 56% of PFMT group as compared with 15% of controls.
PFM function: PFMT group had significantly greater improvement in strength than the
control group(13.1 cmH2O vs 1.1 cmH2O; P<.001) as well
as endurance (107 cmH2O sec vs 8 cmH2O sec, P< .001)
Effect size for muscle
strength and endurance 1.21 and 0.96 respectively.
No change in vaginal resting
pressure between groups.
There were positive
correlations between increased PFM strength and cranial elevation of the
bladder and rectum, but no correlations between increase in PFM strength and
change in POP-Q values or prolapse symptoms.
Strengths. Inclusion of stages I, II and II prolapse.
Randomization. Blinding of primary outcome assessors. Use of POP-Q. Ultrasound
imaging and validated questionnaires. Standardized training protocol. Low
dropout rates. High adherence to training protocol.
Weaknesses: Differences between groups in prolapse symptoms at
baseline: 72.9%of PFMT group vs 52% of controls (may overestimate the
subjective improvement rate). Relatively small sample size. Control subjects
also instructed in “the Knack”.
Conclusion: “Pelvic
floor muscle training is without adverse effects and can be used as treatment
for prolapse.” PFMT can help to reduce prolapse, bladder and some bowel
incontinence symptoms. PFMT can significantly improve pelvic floor muscle
strength, endurance, and cranial position of bladder and rectum.
Impact on practice: This is an important study for PT’s who treat POP. This trial
provides the strongest evidence to date to support supervised PFMT as an
effective treatment for POP symptoms and reduction of anatomic descent of the
prolapse. Article would be excellent choice for marketing.
Food for thought:
1)
If a patient
asked if pelvic exercise could reverse their prolapse, how would you respond?
2)
How does the
6 month intervention time-frame compare to your current standard of care? Does
this study change how long/frequent you will treat your patients?
3)
What
physiological rationale explains why there was no change in resting vaginal
pressure, yet there was a significant increase in pelvic muscle strength and
endurance, and the bladder and rectum were in a more elevated position following
the 6 month training program?
Additional research:
Hagen
S, Stark D. Conservative management of pelvic organ prolapse in women. Cochrane
Database of Systematic Reviews 2011,Issue 12, Art No.:CD003882. DOI:
10.1002/14651858.CD003882.pub4.
Stupp
L, Resende APM, Oliveira E, Castro RA, Girao MJBC, Sartori MGF. Pelvic floor
muscle training for treatment of pelvic organ prolapse: an assessor-blinded
randomized controlled trial. Int Urogynecol J. 2011;22:1233-1239.
Braekken
IH, Majida M, Engh ME, Bo K. Morphological changes after pelvic floor muscle
training measured by 3-dimensional ultrasonography: A randomized controlled
trial. Obstet Gynecol. 2010;115:317-24.
Hagen
S, Stark D, Glazener C, Sinclair L, Ramsay I. A randomized controlled trial of
pelvic floor muscle training for stages I and II pelvic organ prolapse. Int
Urogynecol J.2009;20:45-51.
Ghroubi
S, Kharrat O, Chaari M, Ayed B, Guermazi M, Elleuch MH. Effect of conservative
treatment in the management of low-degree urogenital prolapse. Ann Readapt
Med Phys. 2008;51:96-102.
Piya-Anant
M, Therasakvichya S,Leelaphatanadit C,
Techatrisak K. Integrated health research program for the Thai
elderly:prevalence of genital prolapse and effectiveness of pelvic floor
exercise to prevent worsening of genital prolapse in elderly women. J Med
Assoc Thai. 2003;86(6):509-515.
No comments:
Post a Comment
Note: Only a member of this blog may post a comment.