Is adding pelvic floor muscle training to an exercise intervention more effective at improving pain in patients with non-specific low back pain? A systematic review of randomized controlled trials.

BACKGROUND: Pelvic floor muscles (PFM) contribute to optimal control of the lumbopelvic spine. PFM function appears altered in some people with nonspecific low back pain (LBP). OBJECTIVE: To systematically review if adding PFM training (PFMT) to another exercise intervention can be more effective at improving pain and function in people with nonspecific LBP than without PFMT. DATA SOURCES: The authors conducted a literature search on Medline, Embase, CINAHL, Cochrane Central and Web of Sciences up to October 2018. ELIGIBILITY CRITERIA: (1) Participants with nonspecific LBP; (2) additional PFMT to an exercise intervention; (3) comparison to the same intervention without PFMT; (4) included minimally one planned outcome; and (5) a randomized controlled trial. Two reviewers performed screening, data extraction (primary outcome; pain severity, secondary outcome; physical function) and risk of bias assessment. SYNTHESIS METHODS: Meta-analysis was performed using mean difference and 95% confidence intervals. RESULTS: Six studies were included (n=200 participants). Participants with PFMT had lower pain severity in comparison with the group without PFMT (mean difference: -0.61, 95%CI [-0.91, -0.31], P<0.0001 and low heterogeneity: I2=0%). Subgroup analysis shows significant effect for interventions lasting longer than 8-weeks. No difference was found for function. Overall risk of bias was unclear. LIMITATIONS: Small groups and high heterogenicity limit our findings. CONCLUSION: There is very low-quality evidence that there is a small benefit of adding PFMT to another exercise intervention on pain severity in nonspecific LBP. Longer duration for an integrated lumbopelvic exercise program including PFMT is likely to impact pain outcomes positively. PROSPERO REGISTRATION: CRD42018114601.

Pelvic floor ultrasound imaging: are physiotherapists interchangeable in the assessment of levator hiatal biometry?

PURPOSE: To evaluate inter-examiner reliability in the ultrasound (US) assessment of levator hiatal dimensions when different physiotherapists perform independent data acquisition and analysis. METHODS: In this cross-sectional observational study, 14 asymptomatic nulliparous women were imaged at rest, during pelvic floor muscle contraction, and during Valsalva manoeuvre by two physiotherapists using three-dimensional (3D) and four-dimensional (4D) transperineal US. Examiners each measured the dimensions of the levator hiatus (area and antero-posterior and transverse diameters) from the US volumes they respectively acquired. Inter-examiner reliability was determined using intra-class correlation coefficients (ICCs), and inter-examiner agreement was determined using Bland-Altman analyses. RESULTS: The ICC results demonstrated very good inter-examiner reliability (ICC=0.84-0.98); Bland-Altman results showed high inter-examiner agreement across all measurements. CONCLUSIONS: Trained examiners may be considered interchangeable in the US assessment of levator hiatal biometry. Overall, trained physiotherapists using transperineal US imaging to assess levator hiatal biometry can be confident when comparing their own clinical findings to those of their colleagues and to findings published in the literature.

Objectif : Examiner la fiabilité entre examinateurs de l'évaluation échographique des dimensions hiatales du muscle releveur de l'anus lorsque des physiothérapeutes différents procèdent à l'acquisition et à l'analyse indépendante de données. Méthodes : Au cours de cette étude par observation transversale, 14 femmes nullipares asymptomatiques ont subi un examen d'imagerie au repos, au cours d'une contraction des muscles du plancher pelvien et durant une manœuvre de Valsalva, effectué par deux physiothérapeutes utilisant l'échographie transpérinéale tridimensionnelle (3D) et quadridimensionnelle (4D). Chaque examinateur a mesuré les dimensions du hiatus du muscle releveur (superficie et diamètre antéropostérieur et transversal) à partir des volumes échographiques qu'ils ont acquis respectivement. On a déterminé la fiabilité entre examinateurs à partir des coefficients de corrélation intra-classe (CCI) et déterminé l'uniformité entre examinateur au moyen des analyses de Bland et d'Altman. Résultats : Les résultats de l'application des CCI ont révélé une très bonne fiabilité entre examinateurs pour toutes les mesures. (CCI=0.84­0.98); les résultats de Bland et Altman ont révélé une grande uniformité entre examinateurs pour toutes les mesures. Conclusions : Les examinateurs qui ont reçu une formation peuvent être considérés comme interchangeables dans l'évaluation échographique de la biométrie hiatale du muscle releveur. Dans l'ensemble, les physiothérapeutes qui ont suivi une formation et utilisent l'imagerie échographique transpérinéale pour évaluer la biométrie hiatale du muscle releveur peuvent comparer en toute confiance leurs constatations cliniques à celles de leurs collègues et à celles des publications.

Pelvic floor muscle training in women with stress urinary incontinence causes hypertrophy of the urethral sphincters and reduces bladder neck mobility during coughing.

AIMS: The purpose of this study was to determine the effect of a 12-week pelvic floor muscle (PFM) training program on urethral morphology and mobility in women with stress urinary incontinence (SUI). METHODS: Forty women with SUI were randomly assigned to one of two groups: the treatment group received 12 weekly physiotherapy sessions during which they learned how to properly contract their pelvic floor muscles (PFMs) and a home exercise program was prescribed, reviewed, and progressed; the control group received no treatment. Before and after the 12-week study period, ultrasound imaging was used to evaluate bladder neck position and mobility during coughing and Valsalva maneuver in supine and in standing, as well as urethral morphology. Secondary outcome measures included a 3-day bladder diary, 30-min pad test, the Incontinence Impact Questionnaire (IIQ-7) and the Urogenital Distress Inventory (UDI-6). RESULTS: The women in the treatment group demonstrated reduced bladder neck mobility during coughing and increased cross-sectional area of their urethra after as compared to before the training. These changes were not evident in the control group. No differences in the resting position of the bladder neck or in bladder neck excursion during Valsalva maneuver were noted in either group. Concomitantly the women in the treatment group demonstrated significant improvements in the 3-day bladder diary and IIQ-7 after the PFM training and improved significantly more than the control group. CONCLUSION: Physiotherapist-supervised PFM training reduces bladder neck motion during coughing, and results in hypertrophy of the urethral sphincter in women who present with SUI.

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.

Pelvic floor muscle assessment outcomes in women with and without provoked vestibulodynia and the impact of a physical therapy program.

INTRODUCTION: Physical therapy (PT) may reduce the pain associated with provoked vestibulodynia (PVD) based on previous findings that pelvic floor muscle dysfunction (PFMD) is associated with PVD symptoms. AIMS: The goals of this study were: (i) to determine whether women with and without PVD differ on measures of pelvic floor muscle (PFM) behavior; and (ii) to assess the impact of PT treatment for women with PVD on these measures. METHODS: Eleven women with PVD and 11 control women completed an assessment evaluating PFM behavior using surface electromyography (SEMG) recordings and a digital intravaginal assessment. Women with PVD repeated the assessment after they had undergone eight PT treatment sessions of manual therapy, biofeedback, electrical stimulation, dilator insertions, and home exercises. MAIN OUTCOME MEASURES: Superficial and deep PFM SEMG tonic activity and phasic activity in response to a painful pressure stimulus, PFM digital assessment variables (tone, flexibility, relaxation capacity, and strength). RESULTS: At pretreatment, women with PVD had higher tonic SEMG activity in their superficial PFMs compared with the control group, whereas no differences were found in the deep PFMs. Both groups demonstrated contractile responses to the painful pressure stimulus that were significantly higher in the superficial as compared with the deep PFMs, with the responses in the PVD group being higher than those in control women. Women with PVD had higher PFM tone, decreased PFM flexibility and lower PFM relaxation capacity compared with control women. Posttreatment improvements included less PFM responsiveness to pain, less PFM tone, improved vaginal flexibility, and improved PFM relaxation capacity, such that women with PVD no longer differed from controls on these measures. CONCLUSION: Women with PVD demonstrated altered PFM behavior when compared with controls, providing empirical evidence of PFMD, especially at the superficial layer. A PT rehabilitation program specifically targeting PFMD normalized PFM behavior in women with PVD.

A prospective study of pelvic floor physical therapy: pain and psychosexual outcomes in provoked vestibulodynia.

INTRODUCTION: Research suggests that increased tension in the pelvic floor muscles of women with provoked vestibulodynia (PVD, the most common form of chronic vulvar pain) may play an important role in maintaining and exacerbating their pain. However, no prospective studies of pelvic floor physical therapy (PFPT) for PVD have been carried out. AIM: This study prospectively examined the effectiveness of a PFPT intervention in treating the pain and sexual and psychological components of PVD, and determined predictors of greater treatment success. METHODS: Thirteen women with PVD completed eight sessions of PFPT. Participants were assessed at pre- and post-treatment via gynecological examinations, vestibular pain threshold testing, structured interviews, and standardized questionnaires. A 3-month follow-up interview assessed any further changes. MAIN OUTCOME MEASURES: Outcome measures included: vestibular pain thresholds, gynecological examination and intercourse pain ratings, sexual function and intercourse frequency, mental health, negative pain cognitions, and success rates. RESULTS: Following treatment, participants had significantly higher vestibular pain thresholds and significantly lower pain ratings during the gynecological examination. Participants reported significant reductions in pain intensity during intercourse and were able to engage in significantly more pain-free activities. Although overall sexual function significantly improved, various components of sexual function and frequency of intercourse did not. Participants' mental health did not significantly improve; however, pain catastrophizing and pain-related anxiety significantly decreased. The treatment was considered to be successful for 10 of the 13 participants, and predictors of greater treatment success included greater reductions in helplessness and a longer period of time in treatment. CONCLUSIONS: Results provide preliminary support for the effectiveness of PFPT in treating the pain of PVD, as well as some of the sexual and cognitive correlates of PVD. The results also indicate the need for large-scale, randomized studies of the effectiveness of PFPT in comparison and in conjunction with other treatment options.