Most older women recover baseline functional status following pelvic organ prolapse surgery, Oliphant SS, et al. Int Urogynecol J 25;1425-1432 (2014)

Beth Shelly

Pelvic PT Distance Journal Club Jan 7, 2015

Introduction

POP affects 50% of women over 50 yo

POP surgery is the most common gyn surgery for women over 50 yo - estimated $1 billion per year

40% of women undergoing POP surgery are over 60 yo

Americans are getting older

Elderly women undergoing POP surgery is expected to increase - not if PT has anything to say about it

Other studies have shown persistent post operative loss of function between 3% to 11%

Poor baseline functional status and pre op depression were independent factors in longer time to return to baseline

Subjects

53 consecutive females 65 or older undergoing POP surgery completed the study, table 2

·         Dependant participants are

o   older

o   do not have depression, lower POP stage, less SUI

o   no difference in co-morbidities and meds

o    worse QOL despite no difference in sx index

·         Baseline 31% were dependent in ADL (all but one related to UI), 12% dependent in IADL

·         Was the assignment of patients randomized? No, clinical study, patient received the treatment the MD thought was best

·         Were groups similar at the start of the trial?  unclear

Study design / method

Questionnaires before and after POP surgery, statical analysis of nonrecovery versus recovery patients

Many different surgical procedures, 1 to 2 days in hospital

Very interesting to read complication - can't understand why anyone would jump into this surgery

Aside from the allocated treatment, were the groups treated equally? unclear

·         Quality outcomes measures used - self reported at pre op, 1 week, 2 weeks, 3 months post op  

o   PFDI 46 item self report, validated sx index

o   PFIQ 93 item self reported, validated QOL

o   PHQ-9 score of depression

o   Katz Activities of Daily Living (ADL)- tool developed over 50 yrs ago and is used widely, no validation, authors states is should be observed, measures basic activities. authors reported this measure did not seem to be the best at identifying function of patient

o   Lawton Instrumental Activities of Dailey Living (IADL) - good inter rater reliability by interview administration, measures higher level ADLs

Nonrecovery at 3 months was not reaching pre op level of ADL or IADL

11 point change in PFDI and PFIQ subscales

·         Blinding

o   Subjects - no

o   Treating therapists - unclear

o   Assessors - unclear

Assessing the outcome

Were all patients who entered the trial accounted for – 13 women with missing data were not different from overall study group

Results

3 months - 19% of women failed to return to baseline ADL, 25% failed to return to baseline IADL

6 month - 19% failed ADL, 17% failed IADL

ADL dependence almost entirely attributed to UI - does this mean they have new onset UI?

IADL dependence  due to lack of ability to perform activities outside the home

71% of women who were dependant IADL baseline were still dependant 3 months after -

        ? 29% improved?

Higher BMI and higher baseline CRADI score was associated with nonrecovery

Strengths of study

longitudinal design

length of study

Limitations

self report of function

surgery decision making

Discussion

Assuming no patients had physical therapy after surgery - 17 to 19% fail to return to pre op functional status, could this be improved with PT?

Obesity is associated with many PF dysfunction

Conclusion

17 to 19% fail to return to pre op functional status

Preoperative functional status as a predictor of postoperative morbidly in women undergoing surgery for POP.  Greer JA et al. PP51, International Urogynecology Journal Volume 25 Supplement 1 July 2014

127 women over 60 yo undergoing surgery for POP. Measures - ASA class (American Society of Anesthesiologist), ADL and IADL measures, functional limitation, and recent weight loss. Reassessed at 12 weeks post op.  29% did not return to pre op functional status.  Those not returning to pre op functional ability were more likely to have stage 4 POP, UI, higher # of pre op functional limitations. ASA class 3 was one of the factors predicting longer length of stay - do you have difficulty walking up stairs without stopping. 

The group was charged with educating physicians to screen for functional limitations and consider pre op and or post op functional PT training.