"You don't know what you don't know": Knowledge, attitudes, and current practice of physiotherapists in recognising and managing metabolic syndrome, a mixed methods study.

OBJECTIVES: To determine the knowledge, attitudes, and current practice of primary care physiotherapists in recognising and managing clients with metabolic syndrome. DESIGN: Mixed-methods research design comprising an online survey and focus groups. PARTICIPANTS: Australian and English physiotherapists (n = 183) working in a primary care setting responded to the survey. Twelve physiotherapists participated in focus groups. RESULTS: Metabolic syndrome was not on physiotherapists radar. They did not screen for metabolic syndrome nor provide management for it in primary care. Although most physiotherapists had some awareness of metabolic syndrome, they were not knowledgeable. Physiotherapists reported a need to focus on their clients' presenting condition, and there was uncertainty on whether metabolic syndrome management was within their scope of practice. Despite this, physiotherapists felt they had an important role to play in exercise and physical activity prescription for chronic disease management and were keen to further their knowledge and skills related to metabolic syndrome. Survey responses and focus group data were convergent. CONCLUSION: Physiotherapists working in primary care settings are well-placed to identify metabolic risk factors in their clients and provide physical activity interventions to enhance management but currently lack knowledge to embed this in clinical practice. Training and resources are required to enable physiotherapists to identify and manage metabolic syndrome within their practice. CONTRIBUTION OF PAPER.

Metabolic syndrome is prevalent and undiagnosed in clients attending private practice physiotherapy: a cross-sectional study.

OBJECTIVES: To determine the prevalence of metabolic syndrome in clients presenting for primary care physiotherapy within private practice settings, and the factors that may be associated with metabolic syndrome. The secondary aim was to determine client's attitudes towards lifestyle change. DESIGN: A cross-sectional study in which self-report and biometric data were collected. The study was conducted in physiotherapy private practices across metropolitan and regional areas, Australia. PARTICIPANTS: 230 clients (mean age 54 (SD18) years, 64% women) presenting for physiotherapy participated. MAIN OUTCOME MEASURES: Participant socio-demographic and lifestyle characteristics were collected. Metabolic syndrome presence was determined by the existence of three or more risk factors on physical examination and capillary blood sample: abdominal obesity, hypertension, elevated random blood glucose, elevated triglycerides and/or reduced HDL cholesterol. RESULTS: Thirty-seven percent of participants had metabolic syndrome, but none knew they had it. Metabolic syndrome was associated with older age and poorer socio-economic status and may have been associated with lower levels of physical activity but not diet. Of those identified as having hypertension and elevated triglycerides, many were undiagnosed (56% and 29% respectively). CONCLUSION: Metabolic syndrome is prevalent and undiagnosed in clients attending private practice physiotherapy. Clients felt lifestyle change was important and they were willing to make changes. This study highlights the need for greater screening of metabolic risk factors in primary care and presents an opportunity for physiotherapists in private practice to identify risk and intervene to improve the overall health of their clients and contribute to chronic disease prevention. CONTRIBUTION OF THE PAPER.

Maternity care during a pandemic: Can a hybrid telehealth model comprising group interdisciplinary education support maternal psychological health?

BACKGROUND: The transition to parenthood is one of the most challenging across the life course, with profound changes that can impact psychological health. In response to the coronavirus disease 2019 (COVID-19), came the rapid implementation of remote antenatal care, i.e., telehealth, with fewer in-person consultations. A change in service delivery in addition to the cancellation of antenatal education represented a potential threat to a woman's experience - with likely adverse effects on mental health and wellbeing. AIM: To explore a hybrid model of pregnancy care, i.e., telehealth and fewer in-person health assessments, coupled with concurrent small group interdisciplinary education delivered via video conferencing, extending into the postnatal period. METHODS: Using a quasi-experimental design with an interrupted time series and a control group, this population-based study recruited low-risk women booking for maternity care at one community health site affiliated with a large public hospital in Victoria, Australia. FINDINGS: Whilst there was no difference in stress and anxiety scores, a significant interactive effect of the hybrid model of care with time was seen in the DASS depression score (-1.17, 95% CI: -1.81, -0.53) and the EPDS (-0.83, 95% CI: -1.5, -0.15). DISCUSSION: The analyses provide important exploratory findings regarding the positive effects of a hybrid model of care with interdisciplinary education in supporting mental health of first-time mothers. CONCLUSION: This study demonstrates that small group online education scheduled in conjunction with individual pregnancy health assessments can be executed within a busy antenatal clinic with promising results and modest but dedicated staff support.

Pelvic floor muscle function in the standing position in women with pelvic floor dysfunction.

INTRODUCTION AND HYPOTHESIS: Clinical assessment of the pelvic floor muscles (PFMs) in a standing position may provide a more valid representation of PFM function experienced by patients in daily life than assessment in the lying position. The primary aim of this study was to examine PFM function in a standing versus a lying position in parous women with any type of urinary incontinence and/or pelvic organ prolapse. METHODS: In this exploratory cross-sectional study, participant symptom status was determined using the Australian Pelvic Floor Questionnaire. Pelvic floor muscle function was assessed in standing and lying positions with a randomised order of testing. The primary outcome measure was vaginal squeeze pressure (VSP) using intra-vaginal manometry. Secondary outcomes included vaginal resting pressure, total PFM work and digital muscle testing. The difference between PFM function in a standing position compared with a lying position was analysed using paired t test or Wilcoxon's signed rank test. RESULTS: Vaginal squeeze pressure assessed with manometry was higher in a standing than in a lying position (p = 0.001): standing (mean [SD]) 24.90 [12.67], lying 21.15 [14.65]. In contrast, PFM strength on digital muscle testing was lower in a standing position than in a lying position. CONCLUSIONS: This study has demonstrated that PFM function in a standing position is different from that in a lying position in women with pelvic floor dysfunction. Whether the higher VSP observed in a standing position reflects a true difference in strength between positions, or a higher pressure reading due to incorrect PFM contraction technique in a standing position is uncertain. Further research with larger cohorts and a measurement tool that can accurately distinguish a rise in intra-vaginal pressure from PFM contraction rather than increasing intra-abdominal pressure is required to confirm this difference, and the clinical significance of any difference.

Attributes of physiotherapy continence clinicians: a qualitative perspective.

OBJECTIVES: To understand the attributes of expert physiotherapy continence clinicians and how they compare to novices in relation to experience, knowledge, capability and skills in pelvic floor rehabilitation. DESIGN: Qualitative methods were used for thematic analysis of data collected from clinician focus groups. PARTICIPANTS: Registered physiotherapists in Melbourne, Australia. Recruitment was through purposive, and "snowball" sampling, and continued until attainment of data adequacy. INTERVENTION: Audio recorded focus groups. RESULTS: Twenty-eight physiotherapists participated in seven focus groups. A key finding was that continence rehabilitation is an area of expert physiotherapy practice. Proficiency is often attained through postgraduate education, mentoring by experienced colleagues, clinical experience and research participation. The 'continence clinician as expert' was identified in three main themes (i) attributes that are important for competent continence practice; (ii) research literacy and the ability to generate and translate research into practice; and (iii) patient-centred care, including managing consumer expectations. Knowledge translation was assisted by research literacy, access to evidence and the use of comprehensively reported research. Proficient clinicians prioritised evidence-informed practice, consumer engagement, peer networks and collaboration. CONCLUSIONS: The main attributes of proficient physiotherapy continence clinicians were high levels of skill, training and experience, enabling an extended scope of practice. Research capability and research co-partnerships were also seen to support implementation of contemporary, evidence-based practice. Therapists new to this field were thought to benefit from structured mentoring, further training and clear career pathways embedded within healthcare systems. Consumer-focussed care was seen as a core skill across all levels of physiotherapy practice.

The impact of pelvic organ prolapse and/or continence surgery on pelvic floor muscle function in women: A systematic review.

AIMS: To systematically review the evidence for the effect of pelvic organ prolapse (POP) and/or continence surgery on pelvic floor muscle (PFM) morphometry and function in women, and to investigate whether a relationship exists between PFM measures and clinician-reported objective pelvic floor outcomes postoperatively. METHODS: Six electronic databases were searched until March 2018. Studies were included if they examined the effect of POP and/or continence surgery on the PFM in women, and reported pre- and postoperative data. Methodological quality was assessed using a modified Downs and Black checklist. Three meta-analyses were planned based on postoperative follow-up time. RESULTS: Twenty-one studies met the inclusion criteria. Varied surgical interventions and 33 different PFM measures were represented. The methodological quality of included studies varied considerably. The 0 to 6 weeks postoperative meta-analysis showed no statistically significant change in PFM function (SMD = 0.04; 95% confidence interval [CI] = -0.26 to 0.33). This was consistent at 3 and 6 or more months (SMD = 1.13; 0.35 95% CI = -0.34 to 2.60, - 0.42 to 1.12 respectively). None of the included studies investigated the relationship between PFM measures and clinician-reported objective outcomes postoperatively. CONCLUSIONS: This review did not show a clear effect of POP and/or continence surgery on PFM morphometry or function in women and was unable to show a relationship with outcomes such as objective prolapse score and urodynamic findings. This could be because surgery does not measurably impact on the PFM or due to the poor quality and heterogeneity of studies. Future well-designed research is needed to specifically investigate change in the PFM following surgery.

Strategies to assist uptake of pelvic floor muscle training for people with urinary incontinence: A clinician viewpoint.

AIMS: The experiences and information needs of clinicians who use pelvic floor muscle training to manage urinary incontinence were explored. METHODS: Qualitative methods were used to conduct thematic analysis of data collected from clinician focus groups and interviews. Participants were registered physiotherapists and continence nurses in Melbourne, Australia. Recruitment was through a combination of purposive and "snowball" sampling and continued until data adequacy was reached. RESULTS: Twenty-eight physiotherapists and one continence nurse participated in seven focus groups and one interview. The main finding communicated by the participants was that pelvic floor muscle training requires comprehensive descriptions of program details in order for clinicians to implement evidence-based interventions. The following themes were identified: (1) pelvic floor muscle training tailored to the needs of each individual is essential; (2) training-specific cues and verbal prompts assist patients to learn and engage with exercises; and (3) clinicians can benefit from research summaries and reports that provide explicit and comprehensive descriptions and decision rules about intervention content and progression. The data indicated that some clinicians can have difficulty interpreting and applying research findings because it is not always well reported. CONCLUSIONS: Clinicians who use pelvic floor muscle training to treat urinary incontinence advised can benefit from accessing explicit details of interventions tested in research and reported as effective. They viewed tailoring therapy to individual goals and the use of verbal prompts and visualization cues as important engagement strategies for effective exercise performance. Explicit reporting could be facilitated by using an exercise guideline template, such as the Consensus on Exercise Reporting Template (CERT).