Characteristics of patients seeking outpatient rehabilitation for pelvic-floor dysfunction

Restrictions and distress in daily, social, and sexual functioning, and intimate relationships in women with pelvic floor complaints: A mixed-method study

Women with pelvic floor complaints experience restrictions and distress in their daily, social, and sexual functioning, and their intimate relationships. We interviewed forty-eight women to unravel differences between women receiving and not receiving pelvic physical therapy and between pregnant, parous, and nulliparous women in preparation for theory development. We analyzed data in a mixed-method design using NVivo and Leximancer. Sexual dysfunction, relationship dynamics, the nature and severity of restrictions and distress, and coping strategies appear to vary between women receiving and not receiving therapy. Specific combinations of restrictions and distress are present in pregnant, parous, and nulliparous women, and might influence women's decision to seek help.

Conceptualization and Inventory of the Sexual and Psychological Burden of Women With Pelvic Floor Complaints; A Mixed-Method Study

Introduction

Despite the fact that the literature reports various restrictions and types of distress in women with pelvic floor complaints, a comprehensive overview of women's sexual and psychological burden emerging from these complaints is lacking, which compromises our ability to assess and grasp the impact to women.

Aim

This study was performed to conceptualize women's sexual and psychological burden and create a more comprehensive overview on this topic from both women's and health care providers’ perspectives. Furthermore, this research intended to identify items to populate a to-be-developed instrument to assess sexual and psychological burden.

Methods

In Group Concept Mapping, 125 statements were used about restrictions and distress that women with pelvic floor complaints experienced. Women with, and health care providers with and without pelvic floor complaints (13 women and 3 men) sorted the statements into comprehensive self-labeled clusters and rated their nature and severity. Multidimensional scaling and hierarchical cluster analyses were performed to identify a conceptual model of coherent clusters of statements. Item-total correlations of severity scores were calculated to identify statements that can be used in future research to represent women's sexual and psychological burden.

Main Outcome Measure

A conceptual model emerged, and outcomes of item-total correlations were then examined again using the conceptual model.

Results

Seven distress clusters were identified, namely, loss of control, sexual distress, feeling insecure, feeling wronged, feeling helpless, feeling angry, and feeling disappointed. Feeling insecure appeared more pervasive than other distresses. Furthermore, 33 statements were identified that can be used in future research to develop an instrument to assess sexual and psychological burden representing both women's and health care providers’ perspectives.

Conclusion

The conceptual model and list of statements may concisely represent the sexual and psychological burden of women with pelvic floor complaints from both women's and health care providers’ perspectives on this topic.

Brand AM, Rosas S, Waterink W, et al. Conceptualization and Inventory of the Sexual and Psychological Burden of Women With Pelvic Floor Complaints; A Mixed-Method Study. Sex Med 2022;10:100504.

A directional preference approach for chronic pelvic pain, bladder dysfunction and concurrent musculoskeletal symptoms: a case series

BACKGROUND

Chronic pelvic pain (CPP) with concurrent musculoskeletal and bladder symptoms is a complex and challenging problem. However, clinically the co-existence of these symptoms is not routinely questioned, and their musculoskeletal source is not investigated thoroughly. The purpose of this case series is to present the use of Mechanical Diagnosis and Therapy (MDT) principles in seven patients with concurrent chronic pelvic pain, bladder dysfunction and musculoskeletal symptoms.

CASE DESCRIPTIONS

Seven patients with coexisting pelvic health and musculoskeletal signs and symptoms were retrospectively reviewed. Most common symptoms were urinary frequency, incontinence, pelvic pain, nocturia, dyspareunia, bladder dyssynergia, and lumbar, pelvic or hip pain. All patients failed to recognize the possible interconnectedness of the two sets of symptoms. Each exhibited a directional preference (DP) and subsequent MDT provisional classification of derangement was established; the use of DP forces abolished or dramatically improved both symptoms and mobility impairments. In all cases DP was for sustained sagittal forces initially, but ultimately lateral forces and mobilization were indicated.

OUTCOMES

Changes in Pelvic Floor Impact Questionnaire, Care Connections Pelvic Floor and Lumbar spine were all clinically significant and exceeded minimally Clinical Important Differences several times. Average of 5.8 sessions per patient was noted. Follow-up at an average of 3.3 years revealed ongoing satisfaction and confidence in independent self-management.

DISCUSSION

These case studies highlight the importance of ensuring expansion of intake questions for possible co-existence of symptoms in both pelvic and musculoskeletal patients, possibly suggesting a mechanical intervention is indicated. Provisional subclassification into 'Mechanical Pelvic Syndrome' is proposed. Level of Evidence: 4.

Factors Associated With Nonadherence to Pelvic Floor Physical Therapy Referral for the Treatment of Pelvic Pain in Women

BACKGROUND

Patients with pelvic pain due to pelvic floor myofascial pain syndrome are often referred for pelvic floor physical therapy, the primary treatment option. However, many patients do not adhere to the treatment.

OBJECTIVE

The purpose of this study was to examine the adherence rate and outcomes of patients referred for physical therapy for pelvic floor myofascial pain syndrome and identify risk factors associated with nonadherence.

DESIGN

This was a retrospective cohort study.

METHODS

ICD-9 codes were used to identify a cohort of patients with pelvic floor myofascial pain syndrome during a 2-year time period within a single provider's clinical practice. Medical records were abstracted to obtain information on referral to physical therapy, associated comorbidities and demographics, and clinical outcomes. "Primary outcomes" was defined as attendance of at least 1 visit. Secondary outcomes included attendance of at least 6 physical therapist visits and overall improvement in pain. Statistical analysis was performed using chi-square, Fisher exact, and independent t tests. Nonparametric comparisons were performed using Wilcoxon signed rank test. Multivariate analysis was completed to adjust for confounders.

RESULTS

Of the 205 patients, 140 (68%) attended at least 1 session with physical therapy. At least 6 visits were attended by 68 (33%) patients. Factors associated with poor adherence included parity and a preexisting psychiatric diagnosis. The odds of attending at least 1 visit were 0.75 (95% confidence interval = 0.62-0.90) and 0.44 (95% confidence interval = 0.21-0.90), respectively. Patients who attended ≥ 6 visits were more likely to have private insurance (78%) and travel shorter distances to a therapist (mean = 16 miles vs 22). Patients with an improvement in pain (compared with those who were unchanged) attended an average of 3 extra physical therapist visits (mean = 6.9 vs 3.1).

LIMITATIONS

Limitations include reliance on medical records for data integrity; a patient population derived from a single clinic, reducing the generalizability of the results; the age of the data (2010-2012); and the likely interrelatedness of many of the variables. It is possible that maternal parity and psychiatric diagnoses are partial surrogates for social, logistic, or economic constraints and patient confidence.

CONCLUSIONS

Initial adherence to pelvic floor physical therapy was less likely for multiparous women and women with a history of psychiatric diagnosis. Persistent adherence was more likely with private insurance or if the physical therapist location was closer. Pain improvement correlated with increased number of physical therapist sessions.

An International Classification of Function, Disability and Health (ICF)-based investigation of movement impairment in women with pelvic organ prolapse

Background

There is little evidence on movement impairment of the abdominal and pelvic floor muscles (PFM) in women with pelvic organ prolapse (POP).

Objectives

The aim of this study was to determine the movement impairments and interactions between the PFM and abdominal muscles in POP.

Method

The PFM and abdominal muscles of 100 conveniently sampled South African women with POP were assessed by ultrasonography, electromyography (EMG), the PERFECT scale, Sahrmann scale and a Pressure Biofeedback Unit (PBU). A demographic questionnaire determined contextual factors (exercise and medical history) and Visual Faces Scale pain intensities. Data were analysed descriptively and with Spearman and Pearson correlation coefficients.

Results

Participants (59 ± 9.31 years) were mostly unemployed (80%), physically inactive (85%), with comorbidities, heart or vascular disease, hypothyroidism and depression. The mean levator hiatus at rest (56.38 mm, standard deviation [SD] 9.95), thickness (5.1 mm, SD 1.41), amount of movement (4.28 mm, SD 6.84), strength (level 1.89, SD 1.13) and endurance (4.04 s, SD 3.32) of the PFM indicated dysfunction. Median values of zero were found for the Sahrmann scale (interquartile [IQ] range [0–1]) and PBU (IQ range [0–2]) and 10.95 µV for abdominal EMG (IQ range [7.9–17.8]). Pelvic floor muscle strength, endurance, movement and EMG activity correlation was fair (r > 0.4, p < 0.001), as was PFM strength, endurance and abdominal muscle function (r > 0.4, p < 0.05).

Conclusion

Movement impairment of local and global stability and mobility functions of PFM and abdominal muscles was present, as well as correlations between these functions. Addressing these impairments may affect the identified contextual factors (socio-economic, psychological and lifestyle factors) and the possible activity limitations and participation restrictions in patients with POP. Further research is needed to investigate these interactions.

Clinical implications

The findings suggest that assessment and management of patients with POP might need to be based on a comprehensive neuro-musculoskeletal assessment and a holistic approach. Standardised protocols for patients with pelvic floor dysfunction (PFD) should therefore be used with caution. Randomised controlled trials should investigate patient-specific and holistic intervention approaches.

Age-related alterations in female obturator internus muscle

INTRODUCTION AND HYPOTHESIS

Pelvic floor muscle rehabilitation is a widely utilized, but often challenging therapy for pelvic floor disorders, which are prevalent in older women. Regimens involving the use of appendicular muscles, such as the obturator internus (OI), have been developed for strengthening of the levator ani muscle (LAM). However, changes that lead to potential dysfunction of these alternative targets in older women are not well known. We hypothesized that aging negatively impacts OI architecture, the main determinant of muscle function, and intramuscular extracellular matrix (ECM), paralleling age-related alterations in LAM.

METHODS

OI and LAM were procured from three groups of female cadaveric donors (five per group): younger (20 - 40 years), middle-aged (41 - 60 years), and older (≥60 years). Architectural predictors of the excursional (fiber length, L _f), force-generating (physiological cross-sectional area, PCSA) and sarcomere length (L _s) capacity of the muscles, and ECM collagen content (measure of fibrosis) were determined using validated methods. The data were analyzed using one-way ANOVA and Tukey's post-hoc test with a significance level of 0.05, and linear regression.

RESULTS

The mean ages of the donors in the three groups were 31.2 ± 2.3 years, 47.6 ± 1.2 years, and 74.6 ± 4.2 years (P < 0.005). The groups did not differ with respect to parity or body mass index (P > 0.5). OI L _f and L _s were not affected by aging. Age >60 years was associated with a substantial decrease in OI PCSA and increased collagen content (P < 0.05). Reductions in OI and LAM force-generating capacities with age were highly correlated (r ² = 0.9).

CONCLUSIONS

Our findings of age-related decreases in predicted OI force production and fibrosis suggest that these alterations should be taken into consideration, when designing pelvic floor fitness programs for older women.

Urinary incontinence symptoms and impact on quality of life in patients seeking outpatient physical therapy services

OBJECTIVE

The objective of this study was to examine the frequency and types of urinary incontinence (UI) in patients seeking outpatient physical therapy for neuro-musculoskeletal conditions.

DESIGN

Retrospective cross-sectional analysis.

PATIENTS

A convenience sample of patients that positively responded to a UI screening question was included in this study.

METHODS

Data were collected for age, sex, and primary treatment condition classified into one of the following (i.e., urinary dysfunction, fecal dysfunction, pelvic pain, spine, neurological disorders, or extremity disorders); UI type (i.e., mixed, urge, stress, or insensible); UI symptom severity; and quality of life (QoL) impact.

MAIN OUTCOME MEASURES

Frequency of UI type, symptom severity, health-related quality of life (HRQoL) impact, and pad use were compared between treatment groups.

RESULTS

The mean age of the sample (n = 599) was 49.8 years (SD = 18.5) and 94.7% were female. The urinary dysfunction group comprised 44.2% of the total sample, followed by the spine group with 25.7% and pelvic pain with 17.2%. The urinary dysfunction group scored significantly higher on UI symptom severity and impact on QoL compared to the pelvic pain and spine groups, but not compared to the extremity disorders, fecal dysfunction, or neurological disorder group.

CONCLUSION

These preliminary data indicate that UI is a condition afflicting many individuals who present to outpatient physical therapy beyond those seeking care for UI. We recommend using a simple screening measure for UI and its impact on HRQoL as part of a routine initial evaluation in outpatient physical therapy settings.

The self-report fecal incontinence and constipation questionnaire in patients with pelvic-floor dysfunction seeking outpatient rehabilitation

BACKGROUND

Fecal incontinence and constipation affect men and women of all ages.

OBJECTIVE

The purpose of this study was to psychometrically analyze the Fecal Incontinence and Constipation Questionnaire (FICQ) in patients seeking outpatient rehabilitation services due to pelvic-floor dysfunction (PFD).

DESIGN

This was a retrospective analysis of cross-sectional data from 644 patients (mean age=52 years, SD=16, range=18-91) being treated for PFD in 64 outpatient rehabilitation clinics in 20 states (United States).

METHODS

We assessed the 20-item FICQ for unidimensionality and local independence, differential item functioning (DIF), item fit, item hierarchical structure, and test precision using an item response theory model.

RESULTS

Factor analyses supported the 2-factor subscales as originally defined; items related to severity of leakage or constipation. Removal of 2 leakage items improved unidimensionality and local independence of the leakage scale. Among the remaining items, 2 items were suggestive of adjustment for DIF by age group and by number of PFD comorbid conditions. Item difficulties were suitable for patients with PFD with no ceiling or floor effect. Mean item difficulty parameters for leakage and constipation subscales ranged from 38.8 to 62.3 and 28.1 to 63.3 (0-100 scale), respectively. Endorsed leakage items representing highest difficulty levels were related to delay defecation and confidence to control bowel leakage. Endorsed constipation items representing highest difficulty levels were related to the need to strain during a bowel movement and the frequency of bowel movements.

LIMITATIONS

A limitation of this study was the lack of medical diagnostic criteria to classify patients.

CONCLUSIONS

After removing 2 items and adjusting for DIF, the results supported sound psychometric properties of the FICQ items and its initial use for patients with PFD in outpatient rehabilitation services.

Psychometric properties and practicability of the self-report urinary incontinence questionnaire in patients with pelvic-floor dysfunction seeking outpatient rehabilitation

BACKGROUND

Pelvic-floor dysfunction (PFD) affects a substantial proportion of individuals, mostly women. In responding to the demands in measuring PFD outcomes in outpatient rehabilitation, the Urinary Incontinence Questionnaire (UIQ) was developed by FOTO in collaboration with an experienced physical therapist who has a specialty in treating patients with PFD.

OBJECTIVE

The purpose of this study was to evaluate psychometric properties and practicability of the 21-item UIQ in patients seeking outpatient physical therapy services due to PFD.

DESIGN

This was a retrospective analysis of cross-sectional data from 1,628 patients (mean age=53 years, SD=16, range=18-91) being treated for their PFD in 91 outpatient physical therapy clinics in 24 states (United States).

METHODS

Using a 2-parameter logistic item response theory (IRT) procedure and the graded response model, the UIQ was assessed for unidimensionality and local independence, differential item functioning (DIF), discriminating ability, item hierarchical structure, and test precision.

RESULTS

Four items were dropped to improve unidimensionality and discriminating ability. Remaining UIQ items met IRT assumptions of unidimensionality and local independence. One item was adjusted for DIF by age group. Item difficulties were suitable for patients with PFD with no ceiling or floor effect. Item difficulty parameters ranged from -2.20 to 0.39 logits. Endorsed items representing highest difficulty levels were related to control urine flow, impact of leaking urine on life, and confidence to control the urine leakage problem. Item discrimination parameters ranged from 0.48 to 1.18. Items with higher discriminating abilities were those related to impact on life of leaking urine, confidence to control the urine leakage problem, and the number of protective garments for urine leakage.

LIMITATIONS

Because this study was a secondary analysis of prospectively collected data, missing data might have influenced our results.

CONCLUSIONS

Preliminary analyses supported sound psychometric properties of the UIQ items and their initial use for patients with PFD in outpatient physical therapy services.