Myotonometry and extended field-of-view ultrasound imaging allow reliable quantification of patellar tendon stiffness and length at rest and during maximal load, whereas several restrictions exist for the Achilles tendon.

Introduction: Stiffness and length are well-established tendon parameters in sports and medicine. Myotonometry and ultrasound imaging are the commonly used methods to quantify these parameters. However, further studies are needed to clarify the reliability of these methods, especially when assessing maximally loaded tendons and when conducted by different experienced investigators. This study aimed to determine the intra- and interrater reliabilities of measuring the stiffness and length of the patellar tendon (PT) and Achilles tendon (AT) using the myotonometry method and the extended field-of-view ultrasound (EFOV-US) technique at rest and maximal load performed by different experienced investigators. Methods: Twenty-seven participants were examined on three different days by one experienced investigator and one novice investigator. Primary outcomes were the intraclass correlation coefficient (ICC) and associated 95% confidence interval (95% CI), coefficient of variation (CV), standard error of measurement (SEM), and minimal detectable change (MDC) across the measurement days and investigators. Results: For PT measurements at rest and maximal load, the estimated ICCs for stiffness and length were ≥.867 and ≥.970, respectively, with 95% CIs ranging from poor (.306) to excellent (.973) and good (.897) to excellent (.999). The CV, SEM, and MDC for PT stiffness and length were ≤5.2% and ≤2.0%, ≤39.3 N/m and ≤0.9 mm, and ≤108.9 N/m and ≤2.6 mm, respectively. For AT measurements, some restrictions were evident for stiffness at rest and both parameters at maximal load. However, regarding AT length at rest, the estimated ICC was ≥.996, with an excellent 95% CI (.987-.999). The CV, SEM, and MDC for AT length at rest were 2.8%, ≤1.1 mm, and ≤2.9 mm, respectively. Conclusion: The estimated ICCs show good to excellent reliability for the myotonometry method and the EFOV-US technique for measuring PT stiffness and length at rest and maximal load for experienced and novice investigators. However, some restrictions are evident for the AT, especially for measurements at maximal load.

Pelvic floor muscle tenderness on digital palpation among women: convergent validity with central sensitization.

BACKGROUND: Tenderness on palpation of the pelvic floor muscles (PFMs) is a clinical assessment tool used alongside other tests to identify PFM involvement in pelvic complaints including pelvic pain. Although reliability of PFM tenderness has been determined, validity has yet to be established. OBJECTIVES: To assess convergent validity of PFM tenderness on digital palpation with the presence of central pain mechanism, as determined by a score of greater than 40 on the Central Sensitization Inventory (CSI). A secondary objective was to assess the agreement between PFM tenderness and self-reported symptoms of PFM sensitivity. METHODS: Participants completed a battery of self-report questions, the CSI, and various physical assessments (blinded assessors). Convergent validity was assessed between tenderness on palpation and the CSI. Kappa statistics were used to determine agreement between tenderness on palpation and self-reported perineal pain, urinary urgency, dyspareunia, and dysmenorrhea. RESULTS: Ninety-nine female participants with hip or back pain and at least one self-reported symptom of pelvic floor dysfunction were included in the study (mean age 40.56±12.72 years). Convergent validity was found between PFM tenderness on palpation and scores greater than 40 on the CSI (X12=4.2,p=0.04). There was poor agreement between tenderness on palpation with dyspareunia (agreement 62.83%, Kappa=0.27), dysmenorrhea (agreement 55.75%, Kappa=0.14), or perineal pain (agreement 53.04%, Kappa=0.10). CONCLUSIONS: PFM tenderness on digital palpation confirmed convergent validity with CSI scores, suggesting central pain mechanisms. Clinicians may need to consider the role of central pain mechanisms in their clinical decision making when treating PFM dysfunction.

Pelvic floor muscle assessment by digital palpation and translabial ultrasound of women with cervical or endometrial cancer after pelvic radiotherapy: a cross-sectional study.

INTRODUCTION AND HYPOTHESIS: We hypothesized that anatomical changes in the pelvic floor muscles (PFM) could be detected using four-dimensional translabial ultrasound (4D TLUS) in patients with cervical (CC) or endometrial cancer (EC) who underwent pelvic radiotherapy (RT) as digital palpation may present sensitivity limitations. METHODS: This was a cross-sectional study that included 64 women (26 with CC and 38 with EC). PFM function was assessed by digital palpation, grading muscle strength according to the Modified Oxford Scale and by 4D TLUS. Ultrasonographic variables were: levator plate angle, hiatal area, puborectalis muscle thickness, puborectalis strain and levator ani muscle integrity. These variables were also correlated with clinical and sociodemographic data from all these patients. A 5% significance level was adopted. RESULTS: When assessed by digital palpation, no significant difference was found in PFM strength between women with CC and those with EC (p = 0.747). However, when assessed by 4D TLUS, women with CC presented greater thickening of the left (p = 0.039) and right (p = 0.014) lower portion of the puborectalis muscle during PFM contraction compared to those with EC. After pooling the groups, higher cancer staging (p = 0.028) was associated with smaller narrowing in the symphysis-levator distance, and shorter RT finishing duration (< 60 months) was associated with higher thickening in the left (p = 0.029) and right (p = 0.013) upper portion of the puborectalis muscle during PFM contraction as well as a shorter menopause duration (p = 0.007 and p = 0.002, respectively). CONCLUSIONS: Anatomical changes in the puborectalis muscle during PFM contraction were detected by 4D TLUS within gynecological cancer patients after pelvic RT.

Aspiration technique-based device is more reliable in cervical stiffness assessment than digital palpation.

BACKGROUND: The purpose of this study was to compare the reliability and reproducibility of the traditional qualitative method of assessing uterine cervical stiffness with those of a quantitative method using a novel device based on the aspiration technique. METHODS: Five silicone models of the uterine cervix were created and used to simulate different cervical stiffnesses throughout gestation. The stiffness of the five cervix models was assessed both by digital palpation (firm, medium and soft) and with the Pregnolia System. Five self-trained participants conducted the device-based assessment, whereas 63 obstetricians and midwives, trained in digital palpation, conducted the cervical palpation. RESULTS: The results of the two methods were analyzed in terms of inter-and intra-observer variability. For digital palpation, there was no common agreement on the assessment of the stiffness, except for the softest cervix. When assessing the same cervix model for a second time, 76% of the obstetricians and midwives disagreed with their previous assessment. In contrast, the maximum standard deviation for the device-based stiffness assessment for intra- and inter-observer variability was 3% and 3.4%, respectively. CONCLUSIONS: This study has shown that a device based on the aspiration technique provides obstetricians and midwives with a method for objectively and repeatably assess uterine cervical stiffness, which can eliminate the need to rely solely on a subjective interpretation, as is the case with digital palpation.

Is it time to rethink using digital palpation for assessment of muscle stiffness?

AIM: Physiotherapists typically use digital palpation to determine residual tension in a muscle, referred to as muscle stiffness or tone. These assessments are subjective, and little is known about their accuracy or repeatability. Despite this, it is standard practice to base clinical treatment on these findings. The aim of this study was to assess physiotherapists' ability to assign a seven-point palpation scale to quantitative stiffness values generated by a novel device. METHODS: Prospective observational study involving 125 musculoskeletal and pelvic floor physiotherapists. A novel device was developed that replicates the haptic feedback that clinicians assess as muscle stiffness. Measurements of displacement, force, and stiffness were recorded. RESULTS: There was wide overlap between each scale category assigned to the stiffness values, from low stiffness at -3 (119 [106, 132] N/m) to moderate stiffness at 0 (462 [435,489] N/m); to high stiffness at +3 (897 [881,913] N/m). Consistency in applying the scale was poor, and the probability of a similar value of stiffness being assigned to the same scale category by different participants was low. CONCLUSIONS: While palpation is used globally by physiotherapists as a readily available and low-cost method of assessing muscle stiffness, these results indicate that it should be used with caution in diagnosing and defining patient care. Clinical assessment of muscle stiffness requires a validated and reliable palpation scale if this metric is to be used to diagnose pathology and develop treatment protocols. Training in this scale should then be recommended to improve reliability in patient assessment.

Four-dimensional translabial ultrasound concordance with digital palpation and surface electromyography during dynamic pelvic floor muscles assessment: A cross-sectional study.

AIM: To investigate whether pelvic floor muscle (PFM) morphological changes obtained through four-dimensional translabial ultrasound (4D TLUS) correlate with a PFM contraction as evaluated by digital palpation and PFM electromyographic activity evaluated by surface electromyography (sEMG). The secondary objective was to investigate which ultrasound parameter is more strongly associated with digital palpation. METHODS: This cross-sectional study included 210 women and their PFMs were evaluated by digital palpation (graded according to the Modified Oxford Scale), sEMG and 4D TLUS. Offline analysis of ultrasound volume datasets was performed for measuring the change in levator plate angle, bladder neck elevation, hiatal area narrowing, puborectalis strain, and puborectalis muscle thickness at rest and during PFM contraction. Statistical analysis included Kruskal-Wallis, Dunn, and Spearman's tests in addition to univariate and multivariate logistic regression, adopting a significance level of 5%. RESULTS: A weak but significant correlation between the change in levator plate angle and sEMG (P = .04; r = 0.14) was found. All 4D TLUS measurements, except the puborectalis muscle thickness, significantly correlated with digital palpation (P < .0001); with the puborectalis strain and the change in levator plate angle having the strongest combined parameters associated with digital palpation (R2 = 21.77%), despite the low coefficient of determination. CONCLUSION: We found that 4D TLUS significantly correlates with digital palpation and sEMG, being the change in the levator plate angle the parameter that best correlates with both methods. While digital palpation is essential during a PFM functional assessment, 4D TLUS is recommended as a beneficial noninvasive clinical tool for a more in-depth evaluation.

Comparisons of Electromyography and Digital Palpation Measurement of Pelvic Floor Muscle Strength in Postpartum Women with Stress Urinary Incontinence and Asymptomatic Parturients: A Cross-Sectional Study.

AIMS: Early evaluation of pelvic floor muscle (PFM) in postpartum women is important for the treatment of stress urinary incontinence (SUI). Digital vaginal palpation and electromyography (EMG) evaluation based on Glazer protocol are widely used for the assessment of PFM. However, the correlation among digital palpation, EMG, and morbidity of postpartum SUI is still unclear. This study aims to investigate the relationship between postpartum SUI and PFM examinations. METHODS: This hospital-based cross-sectional study included 1,380 parturients during September 2016 to January 2018. We collected the clinical characteristics, PFM strength, and EMG variables of parturients 6-8 weeks after birth. Then the correlation among the results of EMG, digital palpation, and the occurrence of SUI was analyzed. RESULTS: There is no significant difference in digital palpation scores of PFM strength between SUI and non-SUI parturients. The EMG values were closely related to SUI: the multivariate logistic regression revealed that the most reliable evaluation indicators of postpartum SUI were pelvic floor contractile amplitude of endurance contraction (B = 0.021, p = 0.019) and pretest resting baseline (B = 0.056, p = 0.019). Correlation analysis demonstrated that the contraction variables of EMG had a significant correlation with the digital palpation PFM strength in postpartum women (r = 0.467-0.545, p < 0.001). CONCLUSION: The EMG proved to be reliable in assessing the PFM function in postpartum women. The decreased PFM activity, according to EMG, was correlated with postpartum SUI. Although digital palpation scores were positively correlated with EMG results, no correlation was observed with SUI incidence.

Virtual reality: a proposal for pelvic floor muscle training.

INTRODUCTION AND HYPOTHESIS: This video's proposal was to present one of the pelvic floor muscle (PFM) training programs, used in our research, that we designed as a virtual reality intervention protocol and investigated its effects on PFM contractility. METHODS: Two clinical, controlled and prospective studies were conducted, one with 19 nulliparous women without urinary symptoms, who were evaluated by both electromyography and digital palpation (DP) and another with 27 postmenopausal women with mixed urinary symptoms (assessed by both ICIQ UI-SF and ICIQ-OAB), evaluated by vaginal dynamometry and DP, with a total of 46 women in both studies. This protocol was designed so that the participant would play a video game, seated on a pressure base platform, while commanding it through her pelvic movements. Using a virtual reality game, five activities were performed during 30 min, twice a week, with a total of 10 sessions. RESULTS: A significant increase in PFM strength was found in both the nulliparous (p = 0.0001) and the postmenopausal (p = 0.0001) groups of women, as ascertained by DP. A significant increase in postmenopausal women's muscle strength and endurance assessed by dynamometry (p = 0.05) and a concomitant decrease in their urinary symptoms, were observed. CONCLUSION: This virtual reality program promoted an increase in PFM contractility and a decrease in postmenopausal urinary symptoms.

Abdominopelvic kinesiotherapy for pelvic floor muscle training: a tested proposal in different groups.

INTRODUCTION AND HYPOTHESIS: This video's proposal was to present one of the pelvic floor muscle (PFM) training programs used in our research, and to study the effects of abdominopelvic kinesiotherapy on female PFM function. METHODS: A total of 82 women participated in this study, 11 nulliparous, 13 primiparous pregnant, 20 primiparous postpartum and 38 postmenopausal women, who were evaluated first by digital palpation, then by either electromyography or vaginal dynamometry to investigate their PFM strength, followed by ICIQ UI-SF and ICIQ-OAB to evaluate urinary symptoms. This intervention protocol lasted for 60 min, three times a week, with a total of 10 sessions, and was supervised by a physiotherapist, using a gym ball, according to Marques and collaborators. RESULTS: A significant increase in PFM strength was observed by digital palpation in all groups. This finding was confirmed by electromyography in both pregnant (p = 0.0001) and postpartum (p = 0.0001) groups, as well as in 20 of the 38 women from the postmenopausal group (p = 0.003) then by vaginal dynamometry (p = 0.02) in the rest of the women (18) from the same group, with a concomitant decrease in urinary symptoms (p < 0.05). CONCLUSION: The abdominopelvic kinesiotherapy program promotes an increase in pelvic floor muscle strength and a decrease in urinary symptoms.

Pre- and postoperative evaluation of pelvic floor muscle function in POP patients using surface electromyography and digital palpation.

AIMS: The study aims to evaluate the pelvic floor muscle (PFM) function in patients with pelvic organ prolapse (POP) pre- and postoperatively using digital palpation and surface electromyography. METHODS: In this non-randomized prospective study, two groups of patients were recruited for assessment. The surgical group included 74 POP patients receiving the modified pelvic reconstructive surgery and the control group consisted of 30 non-POP patients. One physiotherapist conducted the digital palpation and SEMG evaluation. The scale of PFM strength, the duration and voltage of maximum voluntary contraction (MVC) as well as numbers and voltage of short, fast contractions (SFC) by SEMG were documented and compared in both groups. For statistical analysis, t-test, Mann-Whitney U test and Wilcoxon test were used with a significant level 0.05. RESULTS: A total of 68 POP patients finished the two follow-ups. Sixty-four patients were objectively cured with a 94.1% cure rate. Mesh erosions happened in three patients (4.8%). By digital palpation, the PFM strength increased significantly in POP patients after surgery but still lower than non-POP patients (P<0.001). By SEMG, the electrical activity of PFM increased significantly in the surgical group postoperatively (P 0.001). CONCLUSION: The PFM function was improved 3 months after the modified pelvic reconstructive surgery in POP patients based on digital palpation and SEMG. The evaluation of PFM function should be included in the overall assessment of pelvic reconstructive surgeries.

Métodos de avaliação do assoalho pélvico / Methods of evaluation of pelvic floor

O assoalho pélvico é formado por um grupo de músculos e ligamentos que têm a função básica de sustentar os órgãos pélvicos e abdominais. O objetivo da pesquisa foi verificar e discutir os métodos de avaliação do assoalho pélvico existentes na literatura nos últimos 20 anos. A pesquisa se deu a partir de uma revisão bibliográfica da literatura nas bases de dados SciELO, Medline, Lilacs, Pubmed e em livros de Uroginecologia entre setembro e novembro de 2011. Várias são as maneiras de avaliar a função dos músculos do assoalho pélvico e, nos últimos 20 anos, as técnicas foram aperfeiçoadas para um melhor conforto, tanto do paciente como do terapeuta. Palpação bidigital, cones vaginais, perineometria, eletromiografia são técnicas importantes, por promoverem feedback sensorial ao paciente. Ultrassom e ressonância magnética também são métodos louváveis por avaliar dinamicamente o assoalho pélvico, porém são utilizados experimentalmente, pelo grande dispêndio de dinheiro...

Evaluation of a teaching tool to increase the accuracy of pilot balloon palpation for measuring tracheostomy tube cuff pressure.

OBJECTIVES/HYPOTHESIS: The purpose of this study was to evaluate the efficacy of a novel teaching tool to improve health care providers' ability to inflate tracheostomy tube cuffs to the appropriate pressure. STUDY DESIGN: Single-blinded, randomized, controlled trial. METHODS: Subjects were randomized to a control and study group. The control group viewed a video about inflating tracheostomy tube cuffs to safe pressure levels. The study group viewed the same video and also got to palpate the pilot balloons of tracheostomy tube cuffs inflated to three different pressures. All subjects inflated tracheostomy tube cuffs to pressures they believed to be appropriate based on palpation of the pilot balloon preintervention, and immediately, 2 weeks, and 3 months postintervention. RESULTS: Forty-nine health care providers participated in the study. There was no significant difference in the mean preintervention cuff inflation pressures between the two groups (36 cm H2 O vs. 38 cm H2 O, P = 0.4888), with both initially overinflating. Postintervention, the study group inflated the cuffs to significantly lower pressures than the control group, closer to the ideal of 25 cm H2 O (26 cm H2 O vs. 35 cm H2 O, P = 0.0001). This difference was also observed 2 weeks (28 cm H2 O vs. 37 cm H2 O P <0.0001) and 3 months (28 cm H2 O vs. 36 cm H2 O, P = 0.0002) postintervention. CONCLUSIONS: The novel teaching tool evaluated in this study is simple, easily reproducible, and low-cost. Its use leads to long-lasting improvement in health care providers' ability to more accurately inflate tracheostomy tube cuffs to safe pressures.

Correlation of digital palpation and transabdominal ultrasound for assessment of pelvic floor muscle contraction.

Pelvic floor muscle (PFM) dysfunction has been commonly associated with urinary disorders and lumbo-pelvic pain. Transabdominal (TA) ultrasound is currently used by physical therapists to assess PFM function. Controversy exists regarding the correlation between TA ultrasound measurement and vaginal palpation for assessment of PFM contraction, and this relationship has not yet been examined concurrently during the same contraction. The purpose of this study was to determine the correlation of digital palpation and TA ultrasound to assess PFM contraction when recorded 1) simultaneous to digital palpation during one contraction and 2) following digital palpation testing in another contraction. A descriptive correlational design was used to describe the relationship between variables. A total of 19 women (both asymptomatic women and those with incontinence or lumbo-pelvic pain) participated in the study. The modified Oxford scale was used to grade PFM contraction in digital palpation testing. The amount of bladder base movement on ultrasound was measured and considered as an indicator of PFM activity. Two trials were performed for TA ultrasound measurement: 1) simultaneous to digital palpation during one contraction, and 2) following digital palpation testing in another contraction. Spearman's correlation coefficient was used for analysis. There was a significant correlation between digital palpation and TA ultrasound for PFM assessment when measured simultaneously in one contraction (rho=0.62, p=0.01) and separately in a different contraction (rho=0.52, p=0.02), with a stronger correlation found in simultaneous testing. In conclusion, digital palpation and TA ultrasound measurement are significantly correlated and measure comparable parameters in evaluation of PFM contraction.