Self induced plantar flexion objectively reduces wave amplitude of detrussor overactivity and subjectively improve urinary urgency" a pilot study. Stav K, et al. Neurourol and Urodynam 33:1247-1250 (2014).

 Beth Shelly

Pelvic PT Distance Journal Club Jan 7, 2015

Background

Pathophysiology of urgency is not fully understood

Previous studies have shown decrease in urgency by:

·         repetitive swallowing

·        anal stimulation

·         penile squeeze

·         crouching

Authors state that patient have decreased urgency by standing on their toes

Subjects

22 consecutive patients (men and women) dx with DO by multichannel urodynamics, one group of patients. table 1

Study design / method

Patients were asked to stop bladder medications 7 days before the study

A second urodynamic study was done per ICS standards in sitting

DO = rise in vesicle pressure with urgency or UUI

Patients were randomized to perform plantar flexion "pushing tiptoes against the floor" at the beginning  of the 2nd or 3rd DO wave, patients started PF when they began feeling the urgency

Patient was asked to grade the severity of the urge sensation 0-10

·         Outcomes measures

o   Urodynamics which has been shown to be the gold standard although not perfect

o   Urgency scale 1-10 is not a standard scale but used to ensure a quick response

·         Aside from the allocated treatment, were the groups treated equally? Yes

·         Blinding

o   Subjects -  No

o   Assessors -  No

Results

Mean peak detrussor pressure was sig less during PF (0.001) in all pts

Mean peak pressure was not different among urges without PF

All pts reported decreased urgency during PF from 9.3 to 4.4 (0.0001)

 Limitations

Small sample size

Visual analog for urgency instead of validated scale

Bladder outlet integrity was not measured

Strengths of study

Real time measure of bladder function during maneuver

Variety of patient types

Statically and clinically significant results

Discussion

PF muscles (gastroc and solues primarily) are innervated by tibial nerve (L4-S3)

PTNS has been shown to be very helpful in decreasing urgency

Loss of central inhibitory control may contribute to urgency

Stimulation of somatic afferent nerves may block visceral afferent signal to the pontine micturition

         center and decreasing the involuntary reflex micturition thus calming bladder

Other theories - co activation of PFM, abd, leg, thigh and simple distraction

Conclusion

PF in sitting decreases DO and urgency

Points brought up during the call

·         Toes curls have been used by several to decrease urgency

·         January 2014 journal club included a presentation showing plantar flexion may be the optimal position for PFM contraction - journal club recording available at http://rs2386.freeconferencecall.com:80/fcc/cgi-bin/play.mp3/2096471000-436790-38.mp3

·         Discussion of pediatric patient who had increase PFM activity on EMG without increased glut contraction during standing plantar flexion

·         Possibly increasing PF may increase PFM spasm in those with overactive PFM

• Study showed recumbent DF facilitated transversus abdominus contraction