A survey of prolapse practice in UK women's health physiotherapists: what has changed in the last decade?

Accessibility of Pelvic Floor Physiotherapy for Treating Urinary Incontinence in Older Women in Quebec: An Online Survey

Purpose

This cross-sectional descriptive study describes available pelvic floor physiotherapy (PT) services for older women with urinary incontinence (UI) in Quebec, Canada, and identifies possible affordability barriers.

Methods

From September to December 2019, Quebec physiotherapists practising pelvic floor PT were invited to complete a survey on their clinical practice and perceptions of the affordability of UI treatment for older women.

Results

Eighty-four of the 225 registered pelvic floor physiotherapists (37.3%) filled out the online survey. They worked a median of 32 hours/week in PT, with 15 of those hours (46.9%) in pelvic floor PT and three hours (9.8%) treating UI in older women. Only 13.0% of them offered group treatment, while 84.3% were interested in it. Most of the physiotherapists (92.2%) had met older women in their practice who had reported financial barriers to completing their pelvic floor PT treatment.

Conclusions

The accessibility of UI care in Quebec appears hampered by the limited availability of pelvic floor PT treatments, mainly in public settings, and potential financial constraints. Providing pelvic floor PT to groups could constitute a promising avenue to tackle both issues. Future studies should look at ways of implementing this option.

Pelvic organ prolapse: Women's experiences of Accessing Care & Recommendations for improvement

Up to 50% of women will develop pelvic organ prolapse (POP) over their lifetime. Symptoms include pain, bulge, urinary, bowel and sexual symptoms affecting all aspects of a woman's life.Many women with POP symptoms present initially to primary care settings. Research has shown these interactions are often unsatisfactory, with women reporting their health care professional (HCP) trivialized their symptoms or appeared to have poor knowledge about pelvic floor dysfunction (PFD).Aim The aim of this qualitative study was to explore experiences of younger women seeking treatment for POP and their recommendations for improvements.Methods Ethics approval was obtained (LS-21-01-Carroll-Ful). Women with POP were recruited from an online support group (n = 930 members). Inclusion criteria: adult women, diagnosed with POP and aware of their POP stage. Following informed consent, a demographic questionnaire, interview questions and the Central Sensitization Inventory (CSI) were forwarded. Semi-structured zoom audio-recorded interviews were conducted. Thematic analysis was undertaken; transcripts coded, and themes identified.Results Fourteen women aged 32-41, parity 1-3, with POP Grade 1-3 participated. Many women reported HCPs as dismissive or not appreciative of the impact of their condition. Others described interactions with HCPs who they felt listened, understood the impact of their POP, gave simple explanations, a positive prognosis and outlined a realistic treatment plan.Current antenatal education, post-partum care and primary HCP screening for PFD were identified by women as deficient. Many highlighted delays in accessing specialist care for POP. Women made several recommendations for improvements to the current model of care.Conclusions Increased focus on person-centred care, particularly emotional support, information and education may improve younger women's experiences when seeking care for POP.

Validation of the Sinhala translations of the Pelvic Floor Distress Inventory and the Pelvic Floor Impact Questionnaire in a Sri Lankan population

INTRODUCTION AND HYPOTHESIS

This study was to translate and validate self-reported questionnaires, the Pelvic Floor Distress Inventory (PFDI-20) and the Pelvic Floor Impact Questionnaire (PFIQ-7) into Sinhala, the language spoken by the majority of Sri Lankans.

METHODS

A total of 270 patients were enrolled in this study. Two groups were selected with pelvic organ prolapse (POP)-cases and without POP-controls in a ratio of 1:2 respectively. Psychometric properties of the questionnaires were assessed using content validity, face validity, convergent validity, construct validity, internal consistency, and reliability. Pelvic Organ Prolapse Quantification (POP-Q) was used as the test to quantify POP.

RESULTS

Excellent content validity was demonstrated by a content validity ratio for all items by experts. Face validity was confirmed by non-experts using a five-point Likert scale and Mann-Whitney U test for all items. Internal consistency was found to be high for both questionnaires (Cronbach's alpha >0.8) in all items. Construct validity was assessed by receiver-operating characteristic curves and the area under the curve is above 0.5 in all items in both questionnaires. Convergent validity was assessed using Pearson coefficient correlation, which was above 0.8 for all subscales. Reliability was low for all subscales in the paired t test.

CONCLUSIONS

The Sinhala versions of PFDI-20 and PFIQ-7 were valid, consistent, responsive, but have low reliability in the Sri Lankan setting.

Can effective supervised pelvic floor muscle training be provided by primary care nurses? A randomized controlled trial

INTRODUCTION AND HYPOTHESIS

To determine whether primary care nurses with no prior experience can, after training, provide effective supervised pelvic floor muscle training (PFMT) by a three-group parallel randomized controlled trial (RCT): primary care nurse, urogynaecology nurse specialist and controls undertaken in 11 primary care/general practices, covering urban and rural settings in SW England. The sample consisted of 337 women with weak pelvic floor muscles (Modified Oxford Score 2 or less) in a randomly sampled survey.

METHODS

Following detailed instruction and training, primary care nurses recruited patients who were randomized to PFMT provided by them, a urogynaecology nurse specialist or a 'no training' control group. The primary outcome measure to assess the effectiveness of training was pelvic floor muscle strength as measured by perineometry.

RESULTS

Two hundred forty women aged 19 to 76 (median 49) years were recruited. After 3 months there was an increase in strength in both intervention groups compared with controls: median differences (95% CI) were 3.0 (0.3, 6.0) cmH₂O higher for the primary care nurse group (n = 50) compared to the control group (n = 56; p = 0.02) and 4.3 (1.0, 7.3) cmH₂O for the urogynaecology nurse specialist group (n = 53) compared to control (p < 0.01); there was no difference between the primary care nurse and urogynaecology nurse specialist groups [1.3 (-2.0,4.7; p = 0.70].

CONCLUSIONS

PFMT provided by trained primary care nurses achieved improvements in pelvic floor muscle strength compared with controls (and comparable to that of a urogynaecology nurse specialist). This could have implications for the provision of PFMT for all women and potentially help in the prevention of pelvic floor dysfunction.

TRIAL REGISTRATION

Registered with ClinicalTrials.gov; Identifier NCT01635894. This was done retrospectively to conform to current registration requirements. When the trial commenced (2003), there was no requirement to register; this was introduced in 2005. The International Committee of Medical Journal Editors (ICMJE) decided that from July 1, 2005, no trials would be considered for publication unless they are included on a clinical trials registry, hence the retrospective registration.

Pelvic floor muscle training for women with pelvic organ prolapse: the PROPEL realist evaluation

Background

Pelvic organ prolapse is estimated to affect 41–50% of women aged > 40 years. A multicentre randomised controlled trial of individualised pelvic floor muscle training found that pelvic floor muscle training was effective in reducing symptoms of prolapse, improved quality of life and showed clear potential to be cost-effective. Provision of pelvic floor muscle training for prolapse has continued to vary across the UK, with limited availability of specialist physiotherapists to deliver it.

Objectives

This project aimed to study the implementation and outcomes of different models of delivery to increase the service provision of pelvic floor muscle training, and to follow up treatment outcomes for the original trial participants.

Design

A realist evaluation of pelvic floor muscle training implementation conducted within three full case study sites and two partial case study sites; an observational prospective cohort study comparing patient-reported outcomes pre and post intervention in all five sites; and a long-term follow-up study linking previous trial participants to routine NHS hospital data.

Setting

The setting for the realist evaluation was pelvic floor muscle training service delivery models in three NHS sites. The setting for the patient-reported outcome measures study was pelvic floor muscle training services in five NHS sites.

Methods

Realist evaluation qualitative data were collected at four time points in three case study sites to understand the implementation models, uptake, adherence and impact. Interviews involved service managers/leads, consultants, staff delivering pelvic floor muscle training and women receiving pelvic floor muscle training.

Main outcomes measures

Patient-reported outcomes were collected at baseline and at 6 and 12 months across five sites, including the Pelvic Organ Prolapse Symptom Score, health-related quality of life (measured using the EuroQol-5 Dimensions, five-level version, questionnaire), prolapse severity (measured using the Pelvic Organ Prolapse Quantification System), urinary incontinence (measured using International Consultation on Incontinence Questionnaire – Urinary Incontinence Short Form) and need for further treatment.

Results

A total of 102 women were recruited to the patient-reported outcome measures cohort study (target, n = 120), and 65 women had matched baseline and 6-month Pelvic Organ Prolapse Symptom Scores. The mean Pelvic Organ Prolapse Symptom Score was 10.18 (standard deviation 5.63) at baseline and 6.98 (standard deviation 5.23) at 6 months, representing a statistically significant and clinically meaningful difference. There was no statistically significant difference between the outcomes obtained from delivery by specialist physiotherapists and the outcomes obtained from delivery by other health-care professionals (mean change in Pelvic Organ Prolapse Symptom Score: –3.95 vs. –2.81, respectively). Services delivered using higher-band physiotherapists only were more costly than services delivered using other staff mixes. The effect of the original pelvic floor muscle training intervention, over a post-intervention period of > 10 years, was a reduction in the odds of any treatment during follow-up (odds ratio 0.61, 95% confidence interval 0.37 to 0.99). The realist evaluation revealed stark differences in implementation. The site with a specialist physiotherapy service resisted change because of perceived threats to the specialist role and concerns about care quality. Pelvic floor muscle training delivery by other health-care staff was easier when there was a lack of any existing specialist service; staff had prior training and interest in pelvic health; staff had support, autonomy, time and resources to deliver pelvic floor muscle training as part of their core role; and surrounding services supported a flow of pelvic floor muscle training referrals.

Limitations

The number of available matched pre and post outcomes for women and the lack of Pelvic Organ Prolapse Quantification System examinations were limitations of this study.

Conclusions

It is possible to train different staff to effectively deliver pelvic floor muscle training to women. Women’s self-reported outcomes significantly improved across all service models. Training should be adequately tailored to differential skill mix needs.

Future work

Future work should include further implementation of pelvic floor muscle training and should include pre- and post-outcome data collection using the Pelvic Organ Prolapse Symptom Score.

Study registration

This study is registered as Research Registry 4919.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 47. See the NIHR Journals Library website for further project information.

Efficacy of bio-assisted pelvic floor muscle training in women with pelvic floor dysfunction

OBJECTIVES

To evaluate the efficacy of 12-week pelvic floor muscle training (PFMT) using bio-assisted surface electromyography (EMG) feedback in women with complex pelvic floor dysfunction (PFD); to further differentiate the effect of exercise adherence from the biofeedback per se; and to assess and compare the severities of overactive bladder (OAB) symptoms, stress urinary incontinence (SUI), and stage of prolapse with the women's perception of symptom cure or improvement following the program.

STUDY DESIGN

This prospective observational study was conducted between December 2015 and November 2018 at a medical center in Taiwan. It included 83 women with PFD, manifesting solely as either OAB or SUI with (group 1) or without (group 2) concomitant stages I and II pelvic organ prolapse (POP). All women underwent a 12-week bio-assisted PFMT. The main outcome was the electromyographic activity of the pelvic floor muscles (PFMs). The severities of OAB symptoms, SUI, and stage of POP were assessed both subjectively and objectively before and after the intervention.

RESULTS

A notable improvement of PFM function was identified after 12 weeks of training in all women with PFD. The number of effective PFM contractions achieved during bio-assisted PFMT was positively correlated with the improvement of PFM function in both groups of women in different body positions, except in the standing position in group 2. Exercise adherence, however, had no significant impact on the efficacy of the training. There was a significant improvement over time and high consistency between subjective and objective improvements of OAB symptoms and SUI severity after the completion of PFMT. Nonetheless, only the Ba point of the POP-Quantification system in women with POP showed a significant improvement after the intervention.

CONCLUSION

PFMT using surface EMG biofeedback significantly improves PFM function in women with complex PFD, and thus, has a significant therapeutic effect on OAB, SUI, and bladder prolapse.

Development of a biotensegrity focused therapy for the treatment of pelvic organ prolapse: A retrospective case series

INTRODUCTION

Pelvic organ prolapse (POP), the bulging of pelvic organs into the vagina, is a common condition thought to be caused by weak pelvic tissue. There is a paucity of evidence supporting current treatment approaches. This case series proposes a new biotensegrity-focused hypothesis that POP is caused by taut pelvic tissue and that releasing pelvic tension will improve POP.

METHODS

Three retrospective patient cohorts are presented illustrating the development of the new biotensegrity-focused therapy (BFT) approach. All women received: postural assessment; pelvic tissue examination; and myofascial release of taut pelvic tissue, trigger points, and scar tissue. A standard assessment protocol (SOTAP) recorded patients' Subjective experience, the therapist's Objective assessment, the Treatment plan, Assessment of treatment outcomes, and subsequent treatment and self-care Plans. Cohort three additionally self-reported symptoms using the short-form PDFI-20 questionnaire at baseline and after final treatment.

RESULTS

Twenty-three women participated (Cohort 1 n = 7; Cohort 2 n = 7; Cohort 3 n = 9). Fourteen (61%) presented with cystocele, 10 (44%) urethracele, 7 (30%), cervical descent, and 17 (74%) rectocele. Seven (30%) presented with single prolapse, 8 (35%) double, 6 (26%) triple, and 2 (9%) quadruple. Median treatments received was 5 (range 3-8). All women reported improved prolapse symptoms. Cohort 3 (n = 9) reported clinically meaningful reductions (mean 56%) in PFDI-20 total after final treatment.

CONCLUSIONS

This case series offers preliminary evidence for the association between POP and pelvic tissue tension. Further research is needed to explore these findings and to determine the efficacy of BFT for treating POP in a wider sample.

All Levels of Providers Can Effectively and Efficiently Teach Pelvic Floor Strength Assessment at Time of Pelvic Examination

OBJECTIVE

In women who undergo provider-guided vaginal biofeedback of pelvic floor muscle strength, we sought to determine whether the level of the provider correlates with the patient's ability to achieve adequate pelvic floor muscle contractions (PFMCs).

METHODS

From August 2017 to April 2018, patients from 2 urogynecology clinics were recruited to participate in an institutional review board-approved, prospective study examining PFMCs. Pelvic examination and teaching session were done by providers who had specific training on how to assess pelvic floor muscle strength using the validated, modified Oxford scale. Patients were asked to perform a baseline PFMC during a 2-digit pelvic examination. Thereafter, patients were counseled to relax their muscles, identify the levator ani muscles during provider teaching, and perform 3 consecutive provider-guided PFMCs. The strength of each PFMC was measured, and the time-to-teach (TTT) was recorded. The level of provider and TTT were correlated with PFMC1 to PFMC3 using Spearman correlation coefficient.

RESULTS

One hundred women participated. Obstetrics/gynecology (OB/GYN) residents (post-graduate years 1-4) evaluated 20 patients; female pelvic medicine and reconstructive surgery fellowship trainees (post-graduate years 5-7), 38 patients; OB/GYN nurse practitioners, 18 patients; generalist OB/GYN faculty, 9 patients; and female pelvic medicine and reconstructive surgery faculty, 15 patients. There was no correlation between level of provider and TTT or between level of provider and strength of PFMC1, PFMC2, or PFMC3.

CONCLUSIONS

At the time of pelvic floor muscle assessment, the level of provider does not impact teaching time or PFMC1 to PFMC3. Teaching pelvic floor muscle exercise is a cost-effective, low-resource tool to improve patient care, and providers of any level should be encouraged to teach pelvic floor muscle exercise to patients at the time of office examination.

Now Anyone Can Kegel: One-Time Office Teaching of Pelvic Floor Muscle Exercises

OBJECTIVE

In women with pelvic floor disorders, we sought to determine time-to-teach (TTT) correct pelvic floor muscle (PFM) contraction, prevalence of inappropriate muscle contractions, and the association between TTT with PFM strength (PFMS).

METHODS

From August 2017 to April 2018, patients from 2 pelvic floor disorder clinics participated in a prospective study examining PFMS. Assessment of PFMS was performed to obtain TTT, inappropriate accessory muscle, and Modified Oxford Grading Scale scores for pelvic floor muscle contractions 1 to pelvic floor muscle contractions 2.

RESULTS

Of 100 women, 77 were from low-resource setting and 23 from high-resource setting. Mean TTT overall was 64.1 seconds (±26.0; range, 9-160 seconds), and mean TTT between settings was not significant. Mean overall TTT was significantly less than 90 seconds. Seventy-one women (71%) demonstrated at least 1 inappropriate accessory muscle, and of those, up to 50% of patients contracting 2 accessory muscle groups with abdominal muscles most frequently contracted at baseline. Thirty-nine percent of patients had a PFM contraction of at least 3 at baseline compared with 82% of patients upon completion of teaching, with 60% of women with scores of 4 or 5. The mean difference overall between baseline and pelvic floor muscle contractions 3 was 1.27 (confidence interval, 1.08-1.46; P < 0.001), and this increase was significant.

CONCLUSIONS

One-time PFMS teaching can be done in a time-proficient fashion and is translatable across high-resource and low-resource settings. Most patients show improvement in PFMS immediately and can quickly acquire this learned skill for proper home practice.

PROPEL: implementation of an evidence based pelvic floor muscle training intervention for women with pelvic organ prolapse: a realist evaluation and outcomes study protocol

Background

Pelvic Organ Prolapse (POP) is estimated to affect 41%–50% of women aged over 40. Findings from the multi-centre randomised controlled “Pelvic Organ Prolapse PhysiotherapY” (POPPY) trial showed that individualised pelvic floor muscle training (PFMT) was effective in reducing symptoms of prolapse, improved quality of life and showed clear potential to be cost-effective. However, provision of PFMT for prolapse continues to vary across the UK, with limited numbers of women’s health physiotherapists specialising in its delivery. Implementation of this robust evidence from the POPPY trial will require attention to different models of delivery (e.g. staff skill mix) to fit with differing care environments.

Methods

A Realist Evaluation (RE) of implementation and outcomes of PFMT delivery in contrasting NHS settings will be conducted using multiple case study sites. Involving substantial local stakeholder engagement will permit a detailed exploration of how local sites make decisions on how to deliver PFMT and how these lead to service change. The RE will track how implementation is working; identify what influences outcomes; and, guided by the RE-AIM framework, will collect robust outcomes data. This will require mixed methods data collection and analysis.

Qualitative data will be collected at four time-points across each site to understand local contexts and decisions regarding options for intervention delivery and to monitor implementation, uptake, adherence and outcomes. Patient outcome data will be collected at baseline, six months and one year follow-up for 120 women. Primary outcome will be the Pelvic Organ Prolapse Symptom Score (POP-SS). An economic evaluation will assess the costs and benefits associated with different delivery models taking account of further health care resource use by the women. Cost data will be combined with the primary outcome in a cost effectiveness analysis, and the EQ-5D-5L data in a cost utility analysis for each of the different models of delivery.

Discussion

Study of the implementation of varying models of service delivery of PFMT across contrasting sites combined with outcomes data and a cost effectiveness analysis will provide insight into the implementation and value of different models of PFMT service delivery and the cost benefits to the NHS in the longer term.