Does It Work in the Long Term?—A Systematic Review on Pelvic Floor Muscle Training for Female Stress Urinary Incontinence

BØ K and Hilde G: Neurol and Urodynam 32:215-223 (2013)

Ann Dunbar PT, DPT, MS, WCS

April 9, 2014

Primary Aim:  To present long-term results of pelvic floor muscle training (PFMT) with or without biofeedback on stress urinary incontinence (SUI) and mixed urinary incontinence (MUI) with predominant SUI symptoms (including both RCTs and pre- and post-evaluation studies)

Study Design:  Systematic Review

Methods:

• Inclusion criteria: Pre-and post-test design, non-RCT and RCT’s using PFMT with or without biofeedback to treat SUI and SUI predominant MUI
• Authors completed a computerized search on PubMed
1. Pelvic floor AND (training OR exercise OR physical  activity)AND (urinary incontinence  OR stress urinary incontinence) AND (follow-up OR long-term)
2. Limits: humans, female, clinical trial, English, only adult subjects

Proof of concept: differential effects of Valsalva and straining maneuvers on the pelvic floor

Talasz H, Kremser C, Kofler M, Kalchschmid E, Lechleitner M, Rudisch A:  Eur J Obstet Gynec and Repord Biology 164(2012) 227-233

Ann Dunbar PT, DPT, MS, WCS

April 9, 2014

Introduction: History of Valsalva Maneuver (VM): 

• Named after physician (Antonio Maria Valsalva 1666-1723) whose main interest was in studying the ear. He described use of forceful inflation of air from the oro-nasopharyngeal cavity into Eustachian tubes and then into middle ear with closed mouth and nostrils. Over time, VM became widely used  in medicine including otorhinology, internal medicine (see article for details), and OB/GYN (to assess urinary incontinence, pelvic organ prolapse, to aid diagnosis of intrinsic sphincter deficiency in urodynamic testing, to demonstrate maximum impact of IAP on pelvic organ descent.
• More recently, an article published in 2006, reported on current understanding of VM which demonstrated variance from its original definition thus presenting confusion between 2 different maneuvers.

Systematic review reports the best web sites for Bladder Pain Syndrome

A good resource for patient

Tirlapur SA, Leiu C, Khan KS.  Int Urogynecol 2013;24:1257-1262.

 

www.ic-network.com

www.ichelp.org

www.painful-bladder.org

www.niddk.nih.gov

Recognition of central sensitization in patients with musculoskeletal pain: application of pain neurophysiology in manual therapy practice.

Nijs J, Van Houdenhove B, Oostendrop RAB. Manual Therapy 2010 15:135-141.

Pelvic PT distance journal club 3/5/14

Beth Shelly PT, DPT, WCS, BCB PMD

Mechanism based clinical guidelines using medical diagnosis and history, clinical examination

·         Primary hyperalgesia - acute pain - several days - sensitization of the nociceptors to protect from further damage - local phenomenon

·         Secondary hyperalgesia - chronic pain -  increased responsiveness of dorsal horn neurons in the spinal segments of the primary nociceptors - central sensitization

Central sensitization (CS) - defined by Meyer 1995 - "an augmentation of responsiveness of central neurons to input from unimodal and polymodal receptors."

·         Altered sensory processing in the brain

·         Impaired descending inhibition of pain

·         Overactive ascending pain facilitatory pathways

·         Temporal summation of secondary pain = wind up

·         Long term enhancement of synapses in some areas of the brain

·         Net result

o   Augmented nociceptive signal

o   Increase responsiveness to a variety of peripheral stimuli

o   Decrease tolerance of senses

"How to explain central sensitization to patients with 'unexplained' chronic musculoskeletal pain: Practice guidelines."

Nijs J, et al. (2011)  Manual Therapy  16(5):413-418.

Pelvic PT Distance Journal Club 3/5/14

Beth Shelly PT, DPT, WCS, BCB PMD

Prior to starting rehab

·         Correct maladaptive pain beliefs

·         Reconceptualize pain

·         Affect deep learning

·         Resulting in the perception that pain is less dangerous

RCT - short term pain education alone is more effective for pain relief and improving pain self-efficacy than pain education and group exercise for patients with chronic LBP (Ryan 2010)

Just handing the patient a booklet is not effective in changing beliefs, need to have individually tailored sessions, one on one in person or phone in patients with fibromyalgia. (Van Oosterwijck 2013)