Translate

Friday, February 21, 2014

Sadowy AM, Brouwer HL, Finseth DL, Hagener KM, Lawrence AE, Hollman JH. Development of a Pelvic Floor Muscle Coordination Scale. Journal of Women’s Health Physical Therapy. 2010 September/December; 34 (3): 81-88.


Women’s Health Distance Journal Club 2/12/2014
Pamela Downey, PT, DPT, WCS, BCB-PMD
Esther Levy, SPT

Purpose: Examine the inter-rater reliability and criterion-related validity of a scale developed to quantify pelvic floor muscle (PFM) coordination through observational assessment.

Study Design: Descriptive study.

Participants: 20 women between 23-56 years of age (mean age 40 years) voluntarily responded to advertisements at the Mayo Clinic in Rochester, Minnesota to participate in the study. Both women without and with potential pelvic floor disorders served as subjects. Mean BMI was 27.2, and median parity was 1.5 (range 0-5), with median values of .5 vaginal deliveries (range 0-4) and median value of 0 Cesarean deliveries (range 0-3).

Inclusion Criteria: Proficiency in the English language and ability to ambulate independently.

Exclusion Criteria: Presence of a progressive or non-progressive neuromuscular disease, history of radiation therapy to the pelvis, pelvic reconstructive surgery, complete uterine eversion, prior physical therapy interventions for pelvic floor dysfunction, and/or sexual abuse for which one had not sought counseling.

Pelvic Floor Muscle Coordination Scale (PFMCS) contained five separate scoring systems:

·         Respiration: Investigators observed both the abdominal cavity/chest wall patterns and the pelvic floor during inspiration. During inspiration, as the diaphragm contracts and the abdominal wall expands, the PFM eccentrically lengthen and the perineum moves caudally. This component assessed involuntary relaxation of the PFM during respiration, and was scored the following way:

o   0-consistent diaphragm and PFM expansion during inspiration over a 30-second time period.

o   1-inconsistent diaphragm and pelvic floor expansion.

o   2-absence of diaphragmatic breathing and/or PFM expansion, and/or use of accessory muscles during respiration.

·         Pelvic Floor Muscle Contraction: Perineal elevation (cephalic movement) of the vulva, perineum, and the anus during voluntary contraction of the PFM. It was scored in the following way:

o   0-indicates the presence of cranial movement of the perineum during the first attempted PFM contraction.

o   1-cranial movement only during the second attempted PFM contraction.

o   2-Valsalva-type maneuver during the attempted contraction, or no voluntary contraction was observed.

·         Extrapelvic Muscle Activity During Contraction: contraction of muscles other than the pelvic floor during a voluntary PFM contraction.

o   0-absence of extrapelvic muscle activity during the PFM contraction.

o   1-co-contraction of 1 accessory muscle, either unilateral or bilateral, was observed during PFM contraction.

o   2-co-contraction of 2 or more accessory muscles was observed.

·         Pelvic Floor Muscle Expansion: perineal descent, or caudal movement of the vulva, perineum, and anus, during relaxation of the pelvic floor.

o   0-caudal movement observed during the subject’s first attempt at relaxation of the PFM following verbal cues.

o   1-caudal movement observed only on the second attempt following verbal cues.

o   2-no perineal descent observed and PFM expansion is considered absent.

·         Cough: No perineal descent should be present during a cough. Cephalic movement or involuntary contraction of PFM may also precede a cough.

o   0-Neutral or cephalic movement of the PFM during the first cough.

o   1-Neutral or cephalic movement of the PFM during the second cough only.

o   2-Perineum descends with coughing during both attempts.

·         PFDI-20 questionnaire—served as the criterion standard for this study.

Standardized Procedures: Before testing, each participant gave written consent and filled out the PFDI-20 Questionnaire. Additionally, they answered a standard questionnaire regarding medications used in the 6 months prior to enrollment, surgical history, birth history, and prior treatment of symptoms by a physical therapist (to determine inclusion in the study). One investigator educated the participants about the pelvic floor musculature and function, as well as potential PFM dysfunctions. After participants were educated, they disrobed below the waist and positioned themselves in supine with hips flexed/abducted and feet supported. At this time, 4 other investigators entered the room. A total of 5 investigators participated in this study—1 physical therapist who specialized in women’s health, and 4 student P.T.’s. 1 investigator was placed on each side of the subject to support each knee, and the remaining 3 investigators stood at the foot of the table. All 5 investigators rated each participant on their ability to coordinate their pelvic floor musculature.

Statistical Analysis: Use descriptive statistics. Inter-rater reliability for the PFMCS total score and each subscale score assessed with intra-class correlation coefficient (ICC). Regression analysis used to correlate the PFMCS total score and the PFDI-20 scores. Only scores from the primary author were used in the analysis. Statistical significance classified as α=.05.

Results: Most women performed a PFM contraction correctly, but the majority demonstrated perineal descent during a cough. Few women were able to contract their PFM without extrapelvic muscle activity, and few were able to demonstrate PFM expansion.

·         PFDI-20 scores were positively skewed; 5 participants had a score of 0, and scores ranged from 0-158 with a median score of 12.0. The subscale scores were also positively skewed in a similar fashion.

·         Total PFMCS scores ranged 0-8, median score 5.

o   Frequency of PFM contraction: median score 0

o   Extrapelvic muscle activity: median score 1

o   PFM expansion: median score 0

o   Respiration: median score 1

o   Cough: median score 2

·         Inter-rater reliability for PFMCS total score: ICC=.792 (good reliability)

o   PFMCS Subscale: ICC=.812 (good reliability)

o   PFM Expansion Subscale: ICC=.798 (good reliability)

o   Extrapelvic Muscle Activation Subscale: ICC=.564 (moderate reliability)

o   Respiration Subscale: ICC=.603 (moderate reliability)

o   Cough Subscale: ICC=.642 (moderate reliability)

·         Total score on the PFMCS was not significantly associated with the PFDI-20 total score or with the CRAD-8 subscale. However, total scores on the PFMCS were associated with the POPDI-6 subscale (p=.024) and UDI-6 subscale (p=.046).

Limitations:

·         Small sample size

·         Teaching/learning effect (participants received education prior to the exam, and were also given verbal cues during the exam)

·         Use of 4 student physical therapists without expertise in women’s health may have affected the level of inter-rater reliability. If the co-raters were all physical therapists with women’s health experience, inter-rater reliability may have been higher.

·         Having 5 examiners present at the time of the examination may have affected the results:

o   Visual perspectives of each tester relative to the subject differed

o   Only standardized cues were provided by 1 tester, whether the subject needed a cue or not.

·         Limitations in the subscales (extrapelvic activity, respiration, cough)—required testers to observe multiple areas of the body simultaneously. This may have contributed to low agreement among the investigators.

·         Scoring criteria for the cough subscale needs to be more clearly defined. The authors recommend this subscale to state, “Ventral/cranial movement of perineum observed and sustained during voluntary cough” during first and second trials.

·         No standard approach for interpreting reliability coefficients.

·         Study participants did not likely represent patients who would seek physical therapy services for symptoms of urinary, colorectal, and/or pelvic organ prolapse symptoms. Therefore, the relationship between the PFMCS and the PFDI-20 questionnaire is likely to be negatively skewed.

·         Consideration was not given to the resting tone of each participant’s PFM.

·         Reliability and validity coefficients may have been stronger if subjects had greater levels of PFM dysfunction. The results of this study cannot be generalized to women with symptoms of pelvic floor dysfunction.

Take Home: Based on the evidence presented in this article, the PFMCS holds promise as an instrument that may allow clinicians to provide objective measures of PFM coordination. The evidence for the scale’s total score, as well as PFM contraction and PFM expansion subscales, were strong in terms of inter-rater reliability. There is also evidence that score on the PFMCS had strong associated with components of the PFDI-20. However, due to the extensive limitations of this study, it is important that future studies be conducted in order to strengthen the PFMCS validity, as well as generalize it to a wider population of people with PFM dysfunction.

Discussion Questions:

1.      While this research serves as a good pilot study, how do we as clinicians and researchers add other variables? What are other components of PFM coordination that we could measure in order to strengthen the validity of this scale?

a.       Additional research should be completed, e.g. multicenter randomized control study with experienced women’s health clinicians, in order to obtain better statistics and enhance the scale’s level of reliability/validity.

2.      It is important that we be able to generalize the results of this study to patients with PFM dysfunction, particularly those with PFM hypertonicity and/or weakness that contribute to decreased support.

a.       What are the typical dysfunction patterns that are seen in people who lack PFM coordination?

b.      Are there any other functional outcome measures that we might be able to correlate with the scores obtained from the PFMCS?

3.      How could we relate the results of the PFMCS to the functionality of G-codes?

a.       The scoring in this scale is very distinct, e.g. “0 to 2” offering a black and white picture in terms of a person’s level of PFM coordination.

b.      Is this scale sensitive enough to be tested on people with PFM dysfunction?

c.       Is it a good clinical screening tool to detect people with PFM dysfunction?



Slieker-ten Hove MCP, Pool-Goudzwaard AL,  Eijkemans MJC, Steegers-Theunissen RPM, Burger CW, Vierhout ME.  Face Validity and Reliability of the First Digital Assessment Scheme of Pelvic Floor Muscle Function Conform the New Standardized Terminology of the International Continence Society.  Neurourology and Urodynamics 28:295–300 (2009)

This author agrees that PFM contraction and identification of overflow muscle use are reproducible and that cough test is not reproducible.  They however disagree with this study on the reproducible of the bearing down test and feel it is also not reproducible.  This study did not measure respiration as it is not officially part of the ICS standardization. 

 

Messelink B, Benson T, Bergham B, et al. Standardization of terminology of pelvic floor muscle function and dysfunction: report from the pelvic floor clinical assessment group of the International Continence Society. Neurourol Urodynam. 2005;24:374–380.

This is the standardization document the tests are based on.  The ICS and IUGA conservative management working group is currently working on an updated standardization document with will address these tests as well as terms for treatment.  Stay tuned.

No comments:

Post a Comment

Note: Only a member of this blog may post a comment.