Status of the pelvic floor in young primiparous women.

OBJECTIVES: To investigate the postnatal prevalence of sonographically diagnosed pelvic floor trauma, and the correlations with various antenatal/intrapartum predictors in primiparous women. METHODS: This was a prospective cohort study performed in a tertiary hospital with 9000 deliveries per annum. Of those invited, 202 (23.2%) primiparous participants were assessed clinically at least 1 year after delivery by Pelvic Organ Prolapse Quantification (POP-Q), two/three-dimensional transperineal sonography and quantification of serum collagen type III levels. RESULTS: There was a high prevalence of clinically significant pelvic organ prolapse (POP) on POP-Q staging: uterine prolapse, 63%; cystocele, 42%; and rectocele, 23%. Ballooning of the levator ani muscle (LAM) hiatus was detected in 33% and LAM avulsion in 29% of participants, with partial LAM avulsion occurring in 15% and complete avulsion in 14%. Postnatal POP symptoms (odds ratios (ORs) given here for presence of multiple prolapse symptoms) were positively associated with similar prepregnancy symptoms (OR, 7.2 (95% CI, 1.19-44.33)), LAM avulsion (OR, 4.8 (95% CI, 1.99-11.34)) and forceps delivery (borderline significance; OR, 1.8 (95% CI, 0.96-3.25)) and negatively associated with elective (OR, 0.2 (95% CI, 0.09-0.63)) and emergency (OR, 0.3 (95% CI, 0.12-0.83)) Cesarean section. LAM abnormality was associated with forceps delivery (OR, 4.9 (95% CI, 1.44-16.97)) and prolapse (OR, 6.8-11.7 (95% CI, 2.34-78.51)), whereas collagen levels did not play a role (OR, 1.001 (95% CI, 0.99-1.02)). CONCLUSIONS: Clinically significant POP was common in relatively young premenopausal primiparous women. Partial or full levator avulsion was seen in 29% of participants and was associated with POP and related symptoms. Congenital factors seem to play little role in the etiology of LAM trauma, and the main risk factor seems to be forceps delivery. Avoidance of difficult vaginal deliveries may prevent severe pelvic floor trauma.

Prevalence, etiology and risk factors of pelvic organ prolapse in premenopausal primiparous women.

INTRODUCTION: The natural history of pelvic organ prolapse (POP) is poorly understood. We investigated the prevalence and risk factors of postnatal POP in premenopausal primiparous women and the associated effect of mode of delivery. METHODS: We conducted a prospective cohort study in a tertiary teaching hospital attending 9,000 deliveries annually. Collagen-diseases history and clinical assessment was performed in 202 primiparae at ≥ 1 year postnatally. Assessment included Pelvic Organ Prolapse Quantification (POP-Q) system, Beighton mobility score, 2/3D-transperineal ultrasound (US) and quantification of collagen type III levels. Association with POP was assessed using various statistical tests, including logistic regression, where results with p < 0.1 in univariate analysis were included in multivariate analysis. RESULTS: POP had a high prevalence: uterine prolapse 89 %, cystocele 90 %, rectocele 70 % and up to 65 % having grade two on POP-Q staging. The majority had multicompartment involvement, and 80 % were asymptomatic. POP was significantly associated with joint hypermobility, vertebral hernia, varicose veins, asthma and high collagen type III levels (p < 0.05). In multivariate logistic regression, only levator ani muscle (LAM) avulsion was significant in selected cases (p < 0.05). Caesarean section (CS) was significantly protective against cystocele and rectocele but not for uterine prolapse. CONCLUSIONS: Mild to moderate POP has a very high prevalence in premenopausal primiparous women. There is a significant association between POP, collagen levels, history of collagen disease and childbirth-related pelvic floor trauma. These findings support a congenital contribution to POP etiology, especially for uterine prolapse; however, pelvic trauma seems to play paramount role. CS is significantly protective against some types of prolapse only.

Visual information and the control of reaching in children: a comparison between children with and without developmental coordination disorder.

Three experiments were performed on reach and grasp in 9- to 10-year-old children (8 controls and 8 with developmental coordination disorder [DCD]). In normal reaching, children in the DCD group were less responsive to the accuracy demands of the task in controlling the transport component of prehension and spent less time in the deceleration phase of hand transport. When vision was removed as movement began, children in the control group spent more time decelerating and reached peak aperture earlier. Children in the DCD group did not do that, although, like the control group, they did increase grip aperture in the dark. When depth cues were reduced and only the target or only the target and hand were visible, children in the control group used target information to maintain the same grip aperture in all conditions, but DCD children behaved as if the target was not visible. Throughout the studies, the control group of 9- to 10-year-olds did not produce adult-like adaptations to reduced vision, suggesting that they had not yet attained adult-like integration of sensory input. Compared with control children, children with DCD did not exhibit increased dependence on vision but showed less recognition of accuracy demands, less adaptation to the removal of vision, and less use of minimal visual information when it was available.

Use of proprioception in normal and clumsy children.

This study investigates the relation between performance on simple tasks dependent on proprioception, and performance of complex perceptual-motor skills in clumsy children and age-matched control children. One hundred and forty-six right-handed children aged between 5 and 8 years were tested on non-visual aiming, non-visual posture matching, the Kinaesthetic Sensitivity Test (KST), and the Movement Assessment Battery for Children (ABC). Half of the children had scores below the 15th centile on the Movement ABC and were classed into the developmental coordination disorder (clumsiness) group. Scores on the proprioceptive tasks were used to predict performance on complex tasks of the subscales of the Movement ABC (manual dexterity, ball skills, and balance). Specific relations were found between the proprioceptive tasks and the subscales of the Movement ABC, but the KST did not predict differences in motor skills, and no relation was found between tasks carried out without vision. Simple non-visual movement tasks do predict performance in more complex skilled tasks but this is affected by many task features rather than simply the reliance on proprioception for information about movement.

Planning and execution of action in children with and without developmental coordination disorder.

Ninety-five children from six English primary schools were identified on the basis of the Movement Assessment Battery for Children (Movement ABC) as having developmental coordination disorder (DCD) and, together with age- and ability-matched controls, were given three tasks that involved proprioception in the control and discrimination of limb position, and two tasks that involved planning for end state comfort after a bar was grasped and turned. The children in the DCD group performed less well on the majority of the proprioceptive tasks, but did not differ from controls in planning of grip selection. There was an improvement in grip planning with age. The results are contrasted with research indicating that people with autism do have a difficulty with planning grip selection.

Interference with rehearsal in spatial working memory in the absence of eye movements.

We have previously argued that rehearsal in spatial working memory is interfered with by spatial attention shifts rather than simply by movements to locations in space (Smyth & Scholey, 1994). It is possible, however, that the stimuli intended to induce attention shifts in our experiments also induced eye movements and interfered either with an overt eye movement rehearsal strategy or with a covert one. In the first experiment reported here, subjects fixated while they maintained a sequence of spatial items in memory before recalling them in order. Fixation did not affect recall, but auditory spatial stimuli presented during the interval did decrease performance, and it was further decreased if the stimuli were categorized as corning from the right or the left. A second experiment investigated the effects of auditory spatial stimuli to which no response was ever required and found that these did not interfere with performance, indicating that it is the spatial salience of targets that leads to interference. This interference from spatial input in the absence of any overt movement of the eyes or limbs is interpreted in terms of shifts of spatial attention or spatial monitoring, which Morris (1989) has suggested affects spatial encoding and which our findings suggest also affects reactivation in rehearsal.

The relationship between articulation time and memory performance in verbal and visuospatial tasks.

The number of verbal items which can be recalled immediately is related to the rate at which an individual can speak. Subvocal rehearsal, or articulatory recoding in working memory, has been assumed to mediate this relation. For spatial items recalled in order there is also a relationship with articulation rate, which is not related to verbal rehearsal of the items. One reason for this might be that the relationship is mediated by speed of memory scanning for serial position tags in a memory set, which is related to processing speed. Subjects were asked to perform visuospatial memory tasks which involved serial position and visuospatial memory tasks in which serial position was not involved. They also performed a digit span task. The results indicated that the visuospatial memory tasks were highly related, that they were only weakly related to digit span, and that articulation rate was correlated with every measure of memory performance used, whether serial position was involved or not. There is no support for the hypothesis that speed of scanning for serial position information in immediate spatial memory leads to a relationship with articulation rate, nor is there any support for the view that memory span tasks in different domains share resources for dealing with serial order. The results are discussed in relation to Cowan, Keller, Hulme, Roodenrys, McDougall & Rack's (1994) suggestion that the relationship between articulation rate and memory span may be mediated by general processing speed.

Serial order in spatial immediate memory.

Serial order effects in spatial memory are investigated in three experiments. In the first an analysis of errors in recall data suggested that immediate transpositions were the most common error and that order errors over 2 or 3 adjacent items accounted for the majority of errors in recall. The first and last serial positions are less error-prone than is the middle position in sets of six and seven items. A second experiment investigated recognition of transpositions and found that immediate transpositions were hardest to recognize but that a traditional serial position effect was not found. This may be due to the difficulty of maintaining one set of spatial items when another set is presented for comparison. A probe experiment, in which subjects were asked to recognize whether a single item came from a memory set and then to assign it to its position in the set indicated that the first and last positions were remembered more accurately than were central positions. The combination of serial order data in recall and position data suggests that there are similarities between serial order and position effects in the verbal and spatial domains and that serial order in spatial sequences is position-based.

Women's perceptions of their experiences with breast cancer: are their needs being addressed?

Breast cancer is the major cause of female deaths in Western Europe. In the United Kingdom, one woman in 14 is liable to develop this disease. An increasing emphasis on recognizing survival from cancer and remission periods of up to 20 years for breast cancer has important implications for health-care professionals. Care and support should effectively meet patients' needs to enable them to cope with the impact of a breast cancer diagnosis. This paper provides an overview of selected literature on women's experiences of breast cancer. It places particular emphasis on their perceptions of the information they received about the disease and its treatment, and their perceptions of the support available to them. The overview illustrates the problem of inadequacies in the information and support currently available to women with breast cancer. The necessity for a more comprehensive and sensitive assessment of these women's needs is emphasized and suggestions are made for the direction of future research in this area.

Characteristics of spatial memory span: is there an analogy to the word length effect, based on movement time?

In studies of verbal short-term memory it has been shown that the length of words to be remembered affects the size of memory span. This word-length effect is attributed to relationships between the rate of rehearsal of verbal material and the time it takes to speak the words being rehearsed. For spatial memory span there may also be an internal rehearsal system linked to overt responding, and if there is a strong analogy to be drawn between the verbal and spatial domains then movement time between spatial targets should predict the number of spatial locations that can be recalled. In the experiments reported here the time taken to move between spatial targets is varied by altering the size of targets and the distance between them. No difference between span performance on a nine-block spatial span task were found, either on immediate recall or on recall after an interval. When recall is of items from an array of 27, grouped in nine sets of three, with only one location in any set being presented on any trial, there is an effect of display size. This effect is consonant with the argument that movement time is related to spatial rehearsal, but other explanations are also possible. However, if recall in this task is scored over the nine sets rather than over the 27 items, then there is no difference between the displays. The results indicate that performance on the normal nine-block spatial-span task cannot be predicted by movement time.

Interference in immediate spatial memory.

It has been suggested that maintenance in visuospatial immediate memory involves implicit motor processes that are analogous to the articulatory loop in verbal memory. An alternative account, which is explored here, is that maintenance is based on shifts of spatial attention. In four experiments, subjects recalled spatial memory span items after an interval, and in a fifth experiment, digit span was recalled after an interval. The tasks carried out during the interval included touching visual targets, repeating heard words, listening to tones from spatially separated locations, pointing to these tones, pointing to visual targets, and categorizing spatial targets as being from the left or right. Spatial span recall was impaired if subjects saw visual targets or heard tones, and this impairment was increased if either a motor response or a categorical response was made. Repeating words heard in different spatial locations did not impair recall, but reading visually presented words did interfere. For digit span only, the tasks involving a verbal response impaired recall. The results are interpreted within a framework in which active spatial attention is involved in maintaining spatial items in order in memory, and is interfered with by any task (visual, auditory, perceptual, motor) that also makes demands on spatial attention.

Short-term retention of spatial information.

Four experiments investigated the recall of a subspan set of spatial locations over short intervals of 5 and 15 s. The intervals were filled by one of three activities: simple tapping, repeated tapping at spatial targets and backwards counting. Spatial tapping, which decreases spatial memory span, led to further small but significant errors in recall, as did backward counting. These errors were larger than those found with simple tapping over the same intervals. Backwards counting led to further decreases in recall performance if it was also present during encoding, but this was not the case for spatial tapping. Spatial tapping had little effect on recall of three digits, whereas backwards counting had a large effect, which was much larger than that found with spatial memory items in any condition. The results are interpreted in terms of the use of place-keeping functions in spatial memory sequences, which may not be specific to spatial material.

Space and movement in working memory.

Encoding seen movement of another human body requires visuo-spatial processing, and recall involves motor activity. However, encoding whole body movement patterns is affected differently by patterned and spatial secondary tasks, and this difference is reversed for encoding of spatial targets for movement (Smyth, Pearson, & Pendleton, 1988). The experiments reported here investigate the rehearsal of such movement patterns and their recall over unfilled and filled intervals. Performing, watching, or encoding a sequence of spatial positions while carrying a memory load of movement patterns did not affect recall of those movements, whereas performing, watching, or encoding a further set of patterned movements reduced the number recalled from the original set. However, memory for a series of locations in space was not affected by watching patterned movements during the interval, and only order information was affected by watching movement to a series of spatial locations during the interval. The results are discussed in terms of the independence of rehearsal mechanisms for spatial sequencing and movement patterns.

Visual control of movement patterns and the grammar of action.

In this experiment adult subjects copied three types of material (letters, reversed letters and geometric shapes) with and without sight of the hand and the writing trace. Without vision the number of movement segments decreased and the sequence and direction of movements were altered. This means that subjects did not use a fixed stored representation to produce items nor did they obey the rules of Goodnow and Levine's (1973) grammar of action. When spatial location is made more difficult by the removal of vision, movement production is simplified to reduce the number of relocations required. The use of consistent directions of movement depends on the ability to use visual control of spatial location.

A note: Is it a catch or a fumble?

Following Whiting' (1986) comments on Fischman and Schneider (1985) and Smyth and Marriott (1982), this note addresses the questions of expertise in catching, the effects of sight of the hand on timing and positioning, and the difficulties of comparing performance in different experiments on catching.

Orientation and spatial representation within multiple frames of reference.

The maintenance of orientation while walking through an unfamiliar route within a larger familiar environment was investigated by having subjects count backwards while walking, instructing others to attend to orientation and giving no instructions to a third group. Instructions made no difference to accuracy of location of landmarks, but backwards counting led to larger increases in error. After counting, some subjects were able to recognize the shape of a simple route although they could not use this information to help them orient. The results are interpreted in terms of the use of different frames of reference while constructing a representation of a new space and it is suggested that normal orientation within complex real-world environments may not be best understood by studying performance in artificial mazes, or by limiting the frames of reference which can be used.

Vision and proprioception in simple catching.

Articular proprioception is normally considered to provide accurate information about limb position, particularly in ball skills in which the eyes are be occupied with tracking the ball. If this is so, then preventing sight of the catching hand without interfering with visual tracking of the ball should affect the accuracy of catching. The experiment reported here indicates that is not the case. Catching is much less accurate if the hand cannot be seen. The errors made are in positioning of the catching hand, which frequently does not contact the ball. In addition, subjects showed larger changes in the felt length arms after catching without sight of the hand than did those who could hand while catching. Visual information about the position of the hand for catching, and this may be because the proprioceptive system is by vision.