Dutch guidelines for physiotherapy in patients with stress urinary incontinence: an update.

Bernards  et al.  Int Urogynecol Journal October 2013

 Journal Club discussion November 6, 2013; Trisha Jenkyns PT, DPT, WCS, BCB-PMD

Primary Aim: To update the existing Dutch evidence-based clinical practice guidelines (CPGs) for physiotherapy management of patients with SUI and to support decision making, improve efficacy and uniformity of care.

Introduction includes: definitions of SUI (according to ICS & IUGA), SUI etiology & prognostic factors and a description of the biopsychosocial model

·         Biopsychosocial model: there is a decrease in the resilience of the PFM, which may lead to impairments of physical & mental function, restrictions in activities and participation. The model also includes consequences of SUI and prognostic factors

·         SUI etiology: intrinsic closure mechanism & extrinsic support mechanism

Materials & Methods:

·         A computerized literature search of what they thought to be relevant databases was performed.  They searched for information regarding etiology, prognosis, and physiotherapy assessment and management in patients with SUI.  

o   Literature search was done from 1998 - 2012 from the following data-bases: PubMed, MEDLINE, Embase, CINAHL, PEDro, and the Cochrane Database, searching for publications on SUI nature, severity, physiotherapeutic diagnostic procedures, and preventive and therapeutic interventions

o   Studies and their methodological quality were graded according to Evidence-Based Guideline Development (EBRO) criteria.  In Table 1, the classification of the levels of evidence is listed; followed by the level of evidence for the conclusions made (Level of conclusion).  As you read the article you will see the level of conclusions in parentheses.

§ Level 1- Study at A1 level or at least 2 independent A2-level studies

§ Level 2- One study at A2 level or at least 2 independent B-level studies

§ Level 3- One B-level or C-level study

§ Level 4- Expert opinion

·         Establishment of Consensus

o   Where no evidence was available, recommendations were based on consensus

o   Consensus was established after discussion of explicit clinical reasoning and expertise by the team/authors

·         Diagnostic Process presented

o   Based on systematic reviews from Staskin et al.  (2005) Initial Assessment of Incontinence in Abrams et al Incontinence 3^rd International consultation on Incontinence and other Dutch Guidelines

§  This dx process is used to:

·         Formulate the treatment plan, determine the nature of the underlying disorder and SUI severity (based on ICF), identify any unfavorable prognostic factors modifiable by PT.

·         Recommend using the 3IQ test for assessing type of UI (Brown et al. The sensitivity and specificity of a simple test to distinguish between urge and stress UI. 2006)…Level 1

·         Physical assessment: inspection at rest and during PFM movement, PFM palpation…Level 2

·         Functional assessment: level of voluntary & involuntary, coordination & synergistic activity, quantification & symmetry, endurance, fatigue, any musculoskeletal issue hampering PFM function, voiding posture, breath holding…Level 3

·         Any unfavorable prognostic factors, i.e. obesity  …Level 3

·         ICS Pelvic Floor Clinical Assessment has opted for a summary description as being a condition: normal, overactive or underactive

Measurement Instruments… Level 1 &2

·         The Protection, Amount, Frequency, Adjustment Body Image (PRAFAB) questionnaire for assessment of UI severity…Level 2

·         PRotection use of absorptive products, Amount volume of leakage, Frequency, Adjustment: impact & patient’s coping, Body Image: perceived impact scale,

·         24 hour Pad Test…Level 3

·         Patient-Specific Complaints (PSC) instrument: patient can indicate the activities they feel restricted in and helps illustrate subjective functional status before and after treatment…Level 2

·         Global Perceived Effect (GPE) instrument: indicates general perception of health status improvement…Level 2

·         3-day micturition diary, followed with specific feedback & advice on timing and toileting behavior …Level 1

·         PT Problem categories (7) are then discussed, based on the above analysis;

o   Example: “The tone of the PFM is measurably too high, and the patient is unable to reduce this on demand (with or without voluntary tightening and with or without effective involuntary contraction associated with increased abdominal pressure)”

 Problem definition- Identify etiology

·         PT should assess the nature of the dysfunction of the continence mechanism...Level 4

Treatment plan

·         PFMT to improve and maintain PFM function requiring lifestyle changes

·         General physical condition must be optimized

·         Patient specific education on anatomy and physiology must be a standard component to enhance understanding and motivation

Therapeutic Process & Interventions Aim to:

·         Provide information & advice, risk & prognostic factors, lifestyle advice, use of diagrams and pelvic models…Level 4

·         Improve general physical condition…Level 4

·         Improve PFM function:

o   Daily PFMT:  with sufficient intensity and duration with correct performance and integration in ADL…Level 1

§  Design of training program needs to be practical to help promote compliance.  PMFT effect is determined by training frequency & duration …Level 2

§  PFMT needs to be integrated into daily life activities…Level 4

o   Biofeedback…may speed up initial improvement and may support motivation to keep exercising… Level 4

o   Electrical Stimulation

§  Goal to make PFM contract, but authors state there is insufficient evidence that estim alone is an effective treatment for SUI…Level 1

·         It may be helpful for increasing awareness… “this statement needs further research”

o   Vaginal Cones

§  VC compared with no treatment or combined with PFMT & estim remains unclear …Level 1

§  Effectiveness is unclear, however authors state that combining PFMT with VC may be effective …Level 3

§  Women find VC difficult and uncomfortable…Level 1

Preventing SUI

·         Continent primiparous women should be offered a supervised and intensive PFMT program to prevent postpartum UI…Level 1

 Evaluation

·         If there has been no progress after six sessions on the PRAFAB and/or GPE, pt should be referred for further investigation, such as surgery

·         “ Good physical condition of the pelvic floor is a favorable prognostic factor for postoperative recovery after surgical intervention, physiotherapy can be regarded as useful”

Interaction between PT and other health-care providers

·         Necessary for communication about etiology & prognosis

·         Referral back to MD if no improvement or if dx is unclear  

Discussion: The CPG’s are based on state-of-the-art evidence and serve to assist PT’s in diagnosing & treating, improve quality of care, provide uniformity in care and make physiotherapy treatment more transparent to physicians and patients.

Results:  Scientific evidence supporting assessment and management of SUI is strong

Conclusions: The CPGs reflect the current state of knowledge of effective and tailor-made intervention in SUI patients.  Guidelines should be followed, but okay to deviate if good reasons to do so

·         Intervention recommendations are mostly derived from systematic reviews

·         “Because not all guidelines are evidence based, these guidelines may contain some bias” !!!