Using focus groups to inform a peer health navigator service for people who are transgender and gender diverse in Saskatchewan, Canada.

BACKGROUND: This study investigated healthcare access and quality for people who are transgender and gender-diverse (PTGD) in Saskatchewan (SK), Canada, to inform a larger project that was piloting two peer health navigators for PTGD. METHODS: Two online focus groups were held. Nineteen participants were recruited to represent a broad range in age, gender and location in SK. Transcripts of the focus groups were analyzed using a thematic approach. RESULTS: The core theme that was identified was participants' desire for culturally safe healthcare. This core theme had two component themes: (1) systemic healthcare factors and (2) individual healthcare provider (HCP) factors. The healthcare system primarily acted as a barrier to culturally safe healthcare. HCPs could be either barriers or facilitators of culturally safe care; however, negative experiences outweighed positive ones. CONCLUSIONS: PTGD in SK face discrimination, with delays and barriers to care at all levels of the healthcare system. Peer health navigators can address some of these discrepancies; however, greater support is required for PTGD to be able to access culturally safe healthcare. PATIENT OR PUBLIC CONTRIBUTION: People with lived experience/PTGD were involved in all stages of this project. They were included on the team as community researchers and co-developed the research project, conducted the focus groups, participated in the analyses and are co-authors. As well, both navigators and all the participants in the focus groups were also PTGD.

A Review of the Effects of Physical Therapy on Self-Esteem in Postpartum Women With Lumbopelvic Dysfunction.

This study sought to determine the impact of physical therapy for lumbopelvic dysfunction on self-esteem in postpartum women. Systematic searches were carried out in CINAHL, Embase, PsycINFO, Medline (OVID), Cochrane, and Web of Science by a health sciences librarian using various combinations of subject headings and key words. A dual review process was used first to assess titles and abstracts and then to examine the full text. Conflicts were resolved through discussion or a third reviewer as needed. Dual data extraction was completed using a standardized collection form. Pairs of reviewers met to discuss conflicts. Data quality was assessed using the Cochrane Collaboration's Risk of Bias Tool, the Joanna Briggs Critical Appraisal Tool, and the Critical Appraisal Skills Programme Checklist. Thirteen articles were included in the review. None of the articles assessed self-esteem specifically; however, each article assessed aspects of self-esteem (self-concept, self-efficacy, self-worth, depression, quality of life, general well-being, or physical function). All articles reported improvements in the selected outcome measures compared with baseline; two studies that compared two different physical therapy interventions found no significant differences between the interventions. To our knowledge, there is no literature explicitly evaluating self-esteem in postpartum women following physical therapy intervention for lumbopelvic dysfunction. Low self-esteem is shown to predict depression and anxiety; therefore, interventions that increase self-esteem may be useful in reducing the risk of depression.

Relationship Between Back Pain and Urinary Incontinence in the Canadian Population.

Background: Back problems and urinary incontinence (UI) have been found to co-occur more frequently than would be predicted by chance. Objective: The aim of this study was to estimate the associations between UI and back problems in the Canadian men and women. Design: This was an observational, cross-sectional study. Methods: The 2011-2012 Statistics Canada Canadian Community Health Survey (CCHS) provided the data. The CCHS surveyed 125,645 adults, providing a representative sample of the Canadian population. Odds ratios (ORs) and 95% confidence intervals (CIs) were used to quantify the strength of the associations among the variables. Results: Having UI increased the risk of also having back problems in both men (OR = 2.45; 95% CI = 2.06-2.91) and women (OR = 2.97; 95% CI = 2.64-3.35) compared with not experiencing UI. Among those participants with UI, men and women were at equal risk of experiencing back problems. Limitations: The CCHS data are cross-sectional and self-reported, which prevents determining causality and carries a risk of response bias. Also, various diagnoses were grouped under the back problems and UI categories, which makes it difficult to propose possible explanations for this pattern of comorbidity. Conclusions: This study provides firm evidence to support clinically observed associations between UI and back problems. The strength of the associations was essentially equal in men and women. These findings reinforce the importance of screening for these frequently coincident conditions.

Pelvic floor morphometry: a predictor of success of pelvic floor muscle training for women with stress and mixed urinary incontinence.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to determine if pelvic floor muscle (PFM) morphometry at baseline, as measured by MRI, can predict response to PFM training in women with stress or mixed urinary incontinence (UI). METHODS: This study was a prospective quasi-experimental pre-test, post-test cohort study of women with UI, aged 60 years and older. All participants completed a baseline assessment of UI severity and impact, using the 72-h bladder diary and the Incontinence Impact Questionnaire. They underwent a pelvic MRI examination to assess the PFM anatomy. Women then participated in a 12-week PFM training program. Finally, they attended a post intervention assessment of UI severity and impact. The association between morphometry and PFM training response was assessed by univariate analysis, multivariate analysis, and receiver operating characteristic (ROC) curve analysis. RESULTS: The urethro-vesical junction height at rest, as measured by MRI before treatment, was associated with response to PFM training both on univariate (p ≤ 0.005) and multivariate analyses (p = 0.007). The area under the ROC curve was 0.82 (95% confidence interval [CI]: 0.67-0.96). Using a cut-off point of 11.4 mm, participants' response to PFM training was predicted with a sensitivity of 77% and a specificity of 83%. Incontinent women with a urethro-vesical junction height above this threshold were 35% more likely to respond to PFM training (OR 1.35; 95% CI: 1.08-1.67). CONCLUSION: In older women with UI, a urethro-vesical junction height at rest of at least 11.4 mm appears to be predictive of PFM training response.

Differences in pelvic floor morphology between continent, stress urinary incontinent, and mixed urinary incontinent elderly women: An MRI study.

AIMS: To compare magnetic resonance imaging (MRI) of the pelvic floor musculature (PFM), bladder neck and urethral sphincter morphology under three conditions (rest, PFM maximal voluntary contraction (MVC), and straining) in older women with symptoms of stress (SUI) or mixed urinary incontinence (MUI) or without incontinence. METHODS: This 2008-2012 exploratory observational cohort study was conducted with community-dwelling women aged 60 and over. Sixty six women (22 per group), mean age of 67.7 ± 5.2 years, participated in the study. A 3 T MRI examination was conducted under three conditions: rest, PFM MVC, and straining. ANOVA or Kruskal-Wallis tests (data not normally distributed) were conducted, with Bonferroni correction, to compare anatomical measurements between groups. RESULTS: Women with MUI symptoms had a lower PFM resting position (M-Line P = 0.010 and PC/H-line angle P = 0.026) and lower pelvic organ support (urethrovesical junction height P = 0.013) than both continent and SUI women. Women with SUI symptoms were more likely to exhibit bladder neck funneling and a larger posterior urethrovesical angle at rest than both continent and MUI women (P = 0.026 and P = 0.008, respectively). There were no significant differences between groups on PFM MVC or straining. CONCLUSIONS: Women with SUI and MUI symptoms present different morphological defects at rest. These observations emphasize the need to tailor UI interventions to specific pelvic floor defects and UI type in older women. PATIENT SUMMARY: Older women with UI demonstrate different problems with their pelvic organ support structures depending on the type of UI. These new findings should be taken into consideration for future research into developing new treatment strategies for UI in older women. Neurourol. Urodynam. 35:515-521, 2016. © 2015 Wiley Periodicals, Inc.

Changes in urethral sphincter size following rehabilitation in older women with stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: The purpose of this study was to evaluate the effects of a pelvic floor muscle (PFM) rehabilitation program on the striated urethral sphincter in women over 60 years with stress urinary incontinence (SUI). We hypothesized that the PFM rehabilitation program would also exercise the striated urethral sphincter and that this would be demonstrated by hypertrophy of the sphincter on magnetic resonance imaging (MRI). METHODS: Women with at least weekly episodes of SUI were recruited. Participants were evaluated before and after a 12-week group PFM rehabilitation intervention with T2-weighted fast-spin-echo MRI sequences recorded in the axial plane at rest to assess urethral sphincter size. Data on SUI symptoms and their bother were also collected. No control group was included. RESULTS: Seventeen women participated in the study. The striated urethral sphincter increased significantly in thickness (21%, p < 0.001), cross-sectional area (20%, p = 0.003), and volume (12%, p = 0.003) following the intervention. The reported number of incontinence episodes and their bother also decreased significantly. CONCLUSIONS: This study appears to demonstrate that PFM training for SUI also trains the striated urethral sphincter and that improvement in incontinence signs and symptoms is associated with sphincter hypertrophy in older women with SUI. These findings support previous ultrasound (US) data showing an increase in urethral cross-sectional area following PFM training and extend the previous findings by more specifically assessing the area of hypertrophy and by demonstrating that older women present the same changes as younger women when assessed using MRI data.

Effects of PFM rehabilitation on PFM function and morphology in older women.

AIMS: The purpose of this study was to examine the effect of a pelvic floor muscle (PFM) rehabilitation program on incontinence symptoms, PFM function, and morphology in older women with SUI. METHODS: Women 60 years old and older with at least weekly episodes of SUI were recruited. Participants were evaluated before and after a 12-week group PFM rehabilitation intervention. The evaluations included 3-day bladder diaries, symptom, and quality of life questionnaires, PFM function testing with dynamometry (force) and electromyography (activation) during seven tasks: rest, PFM maximum voluntary contraction (MVC), straining, rapid-repeated PFM contractions, a 60 sec sustained PFM contraction, a single cough and three repeated coughs, and sagittal MRI recorded at rest, during PFM MVCs and during straining to assess PFM morphology. RESULTS: Seventeen women (68.9 ± 5.5 years) participated. Following the intervention the frequency of urine leakage decreased and disease-specific quality of life improved significantly. PFM function improved significantly: the participants were able to perform more rapid-repeated PFM contractions; they activated their PFMs sooner when coughing and they were better able to maintain a PFM contraction between repeated coughs. Pelvic organ support improved significantly: the anorectal angle was decreased and the urethrovescial junction was higher at rest, during contraction and while straining. CONCLUSIONS: This study indicated that improvements in urine leakage were produced along with improvements in PFM co-ordination (demonstrated by the increased number of rapid PFM contractions and the earlier PFM activation when coughing), motor-control, pelvic organ support.

Survey of Canadian Physiotherapists: Entry-Level and Post-professional Education in Women's Health.

PURPOSE: The aims of this study were to identify (1) practice patterns of Canadian physiotherapists who consider themselves women's health providers or educators (WHPTs); (2) WHPTs' perception of the relative importance of entry-level and post-professional education curricular content directed at women's health issues; and (3) WHPTs' patterns and preferences with respect to continuing education. METHOD: A survey link was sent via e-mail to all 429 members of the Women's Health Division of the Canadian Physiotherapy Association and to physiotherapist educators at the 14 Canadian physiotherapy programmes. RESULTS: A total of 114 WHPTs responded (27%), including 16 educators. Of the 114 respondents, 53% spent less than 25% of their practice specifically treating women's health issues. Over half of the 114 respondents felt that entry-level preparation must include aging issues, musculoskeletal dysfunction, osteoporosis, and sports injuries in women. Respondents' stated that post-professional education should also include female anatomy, obstetrics and gynecology, pelvic floor assessment, treatment of urogenital concerns, complications of cancer, wellness and health promotion, and research. Most respondents (63%) showed interest in achieving continuing-education credentials in women's health, preferably using a combined theoretical online and hands-on weekend-based format. CONCLUSIONS: The survey results suggest that WHPTs practising in Canada seek post-professional training with an emphasis on pelvic floor assessment and treatment, obstetrics and gynecology, urogenital concerns, complications of cancer, wellness and health promotion, and research. Future research should focus on the barriers to devoting full-time practice hours to WHPTs.

Objectif : Les objectifs de cette étude étaient de définir (1) les modèles de pratique des physiothérapeutes canadiens qui se considèrent comme des fournisseurs de soins en santé des femmes ou comme des professionnels de l'éducation à la santé pour les femmes ; (2) la perception que les physiothérapeutes en santé des femmes ont de l'importance relative du contenu traitant de la santé des femmes dans les programmes d'enseignement au niveau d'entrée et en formation postprofessionnelle ; et (3) les modèles et les préférences de ces physiothérapeutes en matière de formation continue. Méthode : Un lien Web conduisant à un sondage a été envoyé par courriel aux 429 membres de la division Santé des femmes de l'Association canadienne de physiothérapie et aux enseignants en physiothérapie de 14 programmes d'enseignement de la physiothérapie au Canada. Résultats : Au total, 114 physiothérapeutes en santé des femmes (27 %), parmi lesquels 16 enseignants dont 53 % consacraient moins de 25 % de leur pratique à traiter des problèmes particuliers propres aux femmes, ont répondu au sondage. Plus de la moitié a estimé que la préparation au niveau d'entrée doit aborder des questions telles que le vieillissement, les dysfonctions musculosquelettiques, l'ostéoporose et les blessures sportives chez les femmes. Les répondants se sont dits d'avis que la formation postprofessionnelle devrait aussi couvrir des sujets tels que l'anatomie féminine, l'obstétrique et la gynécologie, l'évaluation du plancher pelvien, le traitement de problèmes urologiques, les complications associées au cancer, la promotion de la santé et du bien-être ainsi que la recherche. La majorité des répondants (63 %) se sont dits intéressés par l'acquisition de compétences supplémentaires dans le cadre de formation sur la santé des femmes, idéalement sous forme théorique en ligne et dans le cadre d'ateliers pratiques qui pourraient se tenir au cours d'une fin de semaine. Conclusions : Le sondage suggère que les physiothérapeutes en santé des femmes qui pratiquent au Canada souhaiteraient bénéficier de formation postprofessionnelle qui porterait principalement sur l'évaluation du plancher pelvien et sur le traitement de troubles qui y sont associés, l'obstétrique et la gynécologie, les problèmes urologiques, les complications associées au cancer, la promotion de la santé et du bien-être ainsi que la recherche. Des recherches ultérieures devraient se concentrer sur les obstacles associés à des heures de pratique entièrement consacrées à la physiothérapie spécifique à la santé des femmes.

Intravaginal pressure generated during voluntary pelvic floor muscle contractions and during coughing: the effect of age and continence status.

AIMS: The purpose of this study was to determine if, compared to continent women, women with stress urinary incontinence (SUI) generate lower intravaginal pressure (IVP) during maximum voluntary pelvic floor muscle contractions (PFM MVCs) or coughing, slower contraction times or less ability to sustain IVP, and if there are reductions in the ability to generate IVP during these tasks associated with increasing age. METHODS: Eighty-seven (35 continent, 35 with mild SUI and 17 with severe SUI) women participated. IVP data were acquired while participants performed PFM MVCs, maximum effort coughs and a sustained PFM contraction. The maximum IVP amplitudes measured during the MVCs and coughs, the time for IVP to reach a peak during coughing and the time for the IVP to drop by 50% during the sustained contraction were compared among the groups using separate analyses of covariance, with age included as a covariate. RESULTS: There were no differences in maximum PFM MVC IVP or in endurance time among the groups. Women with SUI produced higher cough IVP amplitudes than continent women. Age was associated with a reduction in IVP and with longer contraction times during coughing. CONCLUSIONS: The data suggest that PFM weakness may not be an important factor in the pathophysiology of SUI. Women with SUI may intuitively use their PFMs to compensate for urethral sphincter or fascial deficits. The IVP generated during coughing and the speed at which peak IVP is attained are, however, substantially reduced with increasing age, which might affect continence in older women.

Women with stress urinary incontinence demonstrate motor control differences during coughing.

INTRODUCTION: This study compared the patterns of pelvic floor muscle (PFM) activity during coughing between women with stress urinary incontinence (SUI) and continent women, using surface electromyography (EMG) and posterior vaginal wall (PVW) pressure. METHODS: Twenty-four women participated: eight continent, eight with mild SUI and eight with severe SUI. Volunteers performed three maximum coughs in supine and standing. Maximum PFM EMG and PVW pressure amplitudes and the timing of the EMG peak relative to the PVW pressure peak were determined. Ensemble average PVW pressure versus EMG curves were created. RESULTS: There were no significant differences among the groups in the maximum EMG or PVW pressure amplitudes. The EMG and PVW pressure peaked simultaneously in both positions in the continent group. In the mild SUI group, the EMG and PVW pressure peaked simultaneously in supine, but the EMG peaked before the PVW pressure in standing. In the severe SUI group, the EMG peaked before the PVW pressure in both positions. The shapes of the PVW pressure versus EMG curves were similar among the groups and positions, however the SUI groups displayed higher EMG-intercepts than the continent women. CONCLUSION: These findings suggest that urine leakage during coughing in women with SUI may be related to delays in force generation rather than PFM weakness.

Women with SUI demonstrate motor control differences during voluntary pelvic floor muscle contractions.

INTRODUCTION AND HYPOTHESIS: To compare maximum abdominal and pelvic floor muscle (PFM) electromyographic (EMG) and intravaginal pressure (IVP) amplitudes and muscle activation patterns during voluntary PFM contractions between women with and without stress urinary incontinence (SUI). METHODS: Twenty-eight continent women and 44 women with SUI performed single and repeated PFM contractions in supine. Surface EMG data were recorded simultaneously with IVP. Maximum EMG and IVP amplitudes and ensemble average IVP versus EMG curves were determined from the single contractions. Muscle activation timing was determined with cross-correlation functions from the repeated contractions. RESULTS: The continent group produced higher PFM EMG amplitudes than the SUI group; there were no between group differences in IVP. The women with SUI delayed activating rectus abdominus. The IVP versus EMG curves' shapes were similar between the groups, however the SUI group had higher abdominal muscle y-intercepts than the continent women. CONCLUSIONS: These findings suggest that women with SUI demonstrate altered motor control strategies during voluntary PFM contractions.

Quantification of abdominal and pelvic floor muscle synergies in response to voluntary pelvic floor muscle contractions.

The relative levels of pelvic floor muscle (PFM) activation and pressure generated by maximum voluntary PFM contractions were investigated in healthy continent women. The normal sequence of abdominal and PFM activation was determined. Fifteen women performed single and repeated maximum voluntary PFM contractions in supine, sitting and standing. PFM electromyographic (EMG) signals and associated intra-vaginal pressure data were recorded simultaneously. Surface EMG data were recorded from rectus abdominus (RA), external obliques (EO), internal obliques (IO) and transversus abdominus (TA). Abdominal and PFM EMG and intra-vaginal pressure amplitudes generated during voluntary PFM contractions were not different among the positions. Muscle activation sequence differed by position. In supine, EO activation preceded all other muscles by 27 ms (p = 0.043). In sitting, all of the muscles were activated simultaneously. In standing, RA and EO were activated 11 and 17 ms, respectively, prior to the PFMs and TA and IO were activated 10 and 12 ms, respectively, after the PFMs (p<<0.001). The results suggest that women are able to perform equally strong PFM contractions in supine, sitting and standing, however the pattern of abdominal and PFM activation varies by position. These differences may be related to position-dependent urine leakage in women with stress incontinence.

A contextual model of pelvic floor muscle defects in female stress urinary incontinence: a rationale for physiotherapy treatment.

On the basis of the current literature, we describe a model of structural defects in stress urinary incontinence (SUI) and how physiotherapy for SUI can affect each component of the model with reference to the relevant anatomy and pathophysiology. This model of SUI involves four primary structural defects: (1) increased tonic stress on the pelvic fascia due to pelvic floor muscle (PFM) tears; (2) fascial tearing due to PFM denervation; (3) fascial weakness resulting from tears; and (4) inefficient PFM contraction due to altered motor control. These four components interact to collectively weaken urethral closure and allow urine leakage under conditions of increased intra-abdominal pressure. Physiotherapy can strengthen the PFM and may improve the efficiency and/or timing of PFM contractions to reduce or eliminate SUI. It is worthwhile for motivated women with SUI to try PFM exercise therapy as a first approach to treatment. Women need to be individually instructed to ensure that they correctly perform PFM contractions and that they can monitor their own performance. Long-term, high-intensity exercise, including home exercise, is necessary to achieve maximum effect. Under these conditions the improvement in urinary continence with PFM exercise can be complete and enduring.

Relationship between abdominal and pelvic floor muscle activation and intravaginal pressure during pelvic floor muscle contractions in healthy continent women.

AIM: Activation of the abdominal muscles might contribute to the generation of a strong pelvic floor muscle contraction, and consequently may contribute to the continence mechanism in women. The purpose of this study was to determine the abdominal muscle activation levels and the patterns of muscle activity associated with voluntary pelvic floor muscle (PFM) contractions in urinary continent women. METHODS: Fifteen healthy continent women participated. They performed three maximal contractions of each of the four abdominal muscles and of their PFMs while in supine. Abdominal and PFM activity was recorded using electromyography (EMG), and intravaginal pressure was recorded using a custom modified Femiscan probe. RESULTS: During voluntary maximal PFM contractions, rectus abdominus was activated to 9.61 (+/-7.42)% maximal voluntary electrical activity (MVE), transversus abdominus was activated to 224.30(+/-47.4)% MVE, the external obliques were activated to 18.72(+/-13.33)% MVE, and the internal obliques were activated to 81.47(+/-63.57)% MVE. A clear pattern of activation emerged, whereby the transversus abdominus, internal oblique, and rectus abdominus muscles worked with the PFM in the initial generation of maximal intravaginal pressure. PFM activity predominated in the initial rise in lower vaginal pressure, with later increases in pressure (up to 70% maximum pressure) being associated with the combined activation of the PFM, rectus abdominus, internal obliques, and transverses abdominus. These abdominal muscles were the primary source of intravaginal pressure increases in the latter 30% of the task, whereas there was little increase in PFM activation from this point on. The external oblique muscles showed no clear pattern of activity, but worked at approximately 20% MVE throughout the PFM contractions, suggesting that their role may be predominantly in postural setting prior to the initiation of intravaginal pressure increases. CONCLUSIONS: Defined patterns of abdominal muscle activity were found in response to voluntary PFM contractions in healthy continent women.