Margaret Sherburn

Reliability of pelvic floor muscle strength assessment using different test positions and tools

AIMS The aims of this study were to determine the intra-therapist reliability for digital muscle testing and vaginal manometry on maximum voluntary contraction strength and endurance. In addition, we assessed how reliability varied with different tools and different testing positions. METHODS Subjects included 20 female physiotherapists. The modified Oxford scale was used for the digital muscle testing, and the Peritron perineometer was used for the vaginal resting pressure and vaginal squeeze pressure assessments. Strength and endurance testing were performed. The highest of the maximum voluntary contraction scores was used in strength analysis, and a fatigue index value was calculated from the endurance repetitions. Bent-knee lying, supine, sitting, and standing positions were used. The time interval for between-session reliability was 2-6 weeks. RESULTS Kappa values for the between-session reliability of digital muscle testing were 0.69, 0.69, 0.86, and 0.79 for the four test positions, respectively. Intra-class correlation coefficient (ICC) values for squeeze pressure readings for the four positions were 0.95, 0.91, 0.96, and 0.92 for maximum voluntary contraction, and 0.05, 0.42, 0.13, and 0.35 for endurance testing. ICC values for resting pressure were 0.74, 0.77, 0.47, and 0.29. CONCLUSIONS Reliability of digital muscle testing was very good in sitting and good in the other three positions. vaginal resting pressure demonstrated very good reliability in all four positions for maximum voluntary contraction, but was unreliable for endurance testing. Vaginal resting pressure was not reliable in upright positions. Both measurement tools are reliable in certain positions, with manometry demonstrating higher reliability coefficients.

Is incontinence associated with menopause

OBJECTIVES To estimate (1) the prevalence of urinary incontinence in a population‐based sample of Australian women aged 45–55 and to identify the factors associated with urinary incontinence; (2) the incidence of urinary incontinence over a 7‐year follow‐up period and to identify whether the transition from pre‐ to postmenopause is associated with the development of urinary incontinence. METHODS This was a cross‐sectional study of 1897 women and a 7‐year longitudinal follow‐up of 373 of these women who were premenopausal at baseline. Annual interviews and physical measurements were taken in their homes. RESULTS Cross‐sectional: the prevalence of urinary incontinence was 15%; multivariate analysis found that urinary incontinence patients were significantly more likely than those without incontinence to have higher body mass index (odds ratio [OR] 1.50, 95% confidence interval [CI] 1.15, 1.95), have had gynecologic surgery (OR 2.17, 95% CI 1.42, 3.32), report urinary tract infections (OR 4.75, 95% CI 2.28, 9.90), diarrhea or constipation (OR 1.95, 95% CI 1.27, 3.00), and have had three or more children (OR 1.47, 95% CI 1.06, 2.05). Longitudinal: during the 7‐year follow‐up, the average prevalence of urinary incontinence was 18% and the overall incidence 35%. Women who experienced a hysterectomy during the follow‐up period had a higher incidence. CONCLUSION Urinary incontinence in middle‐aged women is more closely associated with mechanical factors than with menopausal transition.

An Exercise and Education Program Improves Well-Being of New Mothers: A Randomized Controlled Trial

Objective The purpose of this study was to evaluate the effect of a physical therapy exercise and health care education program on the psychological well-being of new mothers. Design This was a randomized controlled trial. Participants Primiparous and multiparous English-speaking women ready for discharge from The Angliss Hospital postnatal ward were eligible for this study. Women who were receiving psychiatric care were excluded. One hundred sixty-one women were randomized into the trial. Intervention The experimental group (n=62) received an 8-week “Mother and Baby” (M&B) program, including specialized exercise provided by a womens health physical therapist combined with parenting education. The other group (education only [EO], n=73) received only the same educational material as the experimental group. Main Outcome Measures Psychological well-being (Positive Affect Balance Scale), depressive symptoms (Edinburgh Postnatal Depression Scale), and physical activity levels were assessed at baseline, after 8 weeks (post-program), and then 4 weeks later. Results There was significant improvement in well-being scores and depressive symptoms of the M&B group compared with the EO group over the study period. More specifically, there was a significant positive effect on well-being scores and depressive symptoms at 8 weeks, and this effect was maintained 4 weeks after completion of the program. The number of women identified as “at risk” for postnatal depression pre-intervention was reduced by 50% by the end of the intervention. Limitations Although this study provides promising short-term (4-week) outcomes, further work is needed to explore whether the intervention effects are maintained as sustained psychological and behavioral benefits at 6 months. Conclusions A physical therapy exercise and health education program is effective in improving postnatal well-being. Routine use of this program may reduce longer-term problems such as postnatal depression.

Evidence for benefit of transversus abdominis training alone or in combination with pelvic floor muscle training to treat female urinary incontinence: A systematic review.

Pelvic floor muscle training (PFMT) has Level A evidence to treat female urinary incontinence (UI). Recently, indirect training of the pelvic floor muscles (PFM) via the transversus abdominis muscle (TrA) has been suggested as a new method to treat UI. The aim of this article is to discuss whether there is evidence for a synergistic co‐contraction between TrA and PFM in women with UI, whether TrA contraction is as effective, or more effective than PFMT in treating UI and whether there is evidence to recommend TrA training as an intervention strategy.

Investigation of transabdominal real-time ultrasound to visualise the muscles of the pelvic floor

Clinical measurement of pelvic floor muscle activity commonly involves techniques that are both physically and psychologically invasive. This study investigated transabdominal application of ultrasound to measure pelvic floor muscle action. The specific aims were to establish the face validity of ultrasound measures of displacement of the posterior bladder wall as a reflection of pelvic floor muscle contraction, and the reliability of measurement between raters and between testing occasions. Non-pregnant adult female subjects aged 24 to 57 years were tested in lying with a 3.5 MHz 35 mm curved array ultrasound transducer over the lower abdomen. Posterior bladder wall displacement was observed in both sagittal and transverse planes. Digital vaginal palpation and transabdominal ultrasound were undertaken simultaneously during pelvic floor muscle contractions to confirm that pelvic floor contractions were performed correctly and to grade pelvic floor muscle strength. Displacement (mm) was measured using electronic calipers on the ultrasound monitor screen. In all subjects, a correct pelvic floor muscle contraction was confirmed on digital palpation, and consistent anterior and cephalic movement was observed on screen. Digital strength grading did not correlate with ultrasound measures in either transverse or sagittal planes (r = 0.21 and -0.13). Average intra-class correlation coefficients for within session inter-rater reliability ranged between 0.86 and 0.88 (95% CI 0.68 to 0.97), and for inter session intra-rater reliability between 0.81 and 0.89 (95% CI 0.51 to 0.96). Transabdominal application of diagnostic ultrasound is a personally non-invasive method for imaging and assessing pelvic floor muscle activity and is both valid and reliable.

Incontinence improves in older women after intensive pelvic floor muscle training: an assessor-blinded randomized controlled trial.

To test the hypotheses that high intensity pelvic floor muscle training (PFMT) is effective in relief of stress urinary incontinence in community dwelling older women, and that intense PFMT improves stress urinary incontinence more than bladder training (BT) in this population.

Effect of test position on pelvic floor muscle assessment

The aims of this study were to analyse the effect of different body positions on pelvic floor muscle (PFM) assessment using digital muscle testing, manometry and transabdominal ultrasound. In addition, subject acceptance of each testing position was recorded. Subjects were 20 womens health physiotherapists. The testing protocol included the best of three maximum voluntary contractions tested in each of four positions (crook lying, supine, sitting and standing). Significant differences in muscle strength and subject acceptance between positions were found with each tool, most often between lying and upright positions. Digital muscle testing and vaginal squeeze-pressure scores were highest in the lying position, and vaginal resting pressure and transabdominal ultrasound scores were highest in the standing position. Subjects preferred the lying positions for internal examinations. The clinical significance of these differences and the reasons for these variations require further investigation.

Managing perineal trauma after childbirth

#### The bottom line Every year millions of women worldwide sustain trauma to the perineum when giving birth. Around 6% of these women will have short term wound complications such as infection and dehiscence.1 Some are also at risk of long term problems such as dyspareunia, pain, urinary and faecal incontinence, pelvic organ prolapse, and psychosocial problems. Correct assessment and repair of this trauma is therefore essential to help reduce long term complications. In this review we focus on the management of childbirth related perineal trauma that does not involve injury to the anal sphincter complex (this has been dealt with previously2)—that is, first and second degree perineal trauma. We provide healthcare professionals caring for women during childbirth and the postnatal period with an overview of the current best evidence for the assessment, repair, and postnatal management of perineal trauma to reduce the incidence of complications in the short and long term. #### Sources and selection criteria We searched Medline and Embase from 1980 to date, limited to publications in English and to studies in women. Our search strategy used a combination of MeSH, textwords, and appropriate word variants of “perineal” or “trauma” and “obstetric” or “labour”. We supplemented these …

Pregnant women maintain body temperatures within safe limits during moderate-intensity aqua-aerobic classes conducted in pools heated up to 33 degrees Celsius: an observational study

QUESTION What is the body temperature response of healthy pregnant women exercising at moderate intensity in an aqua-aerobics class where the water temperature is in the range of 28 to 33 degrees Celsius, as typically found in community swimming pools? DESIGN An observational study. PARTICIPANTS One hundred and nine women in the second and third trimester of pregnancy who were enrolled in a standardised aqua-aerobics class. OUTCOME MEASURES Tympanic temperature was measured at rest pre-immersion (T1), after 35minutes of moderate-intensity aqua-aerobic exercise (T2), after a further 10minutes of light exercise while still in the water (T3) and finally on departure from the facility (T4). The range of water temperatures in seven indoor community pools was 28.8 to 33.4 degrees Celsius. RESULTS Body temperature increased by a mean of 0.16 degrees Celsius (SD 0.35, p<0.001) at T2, was maintained at this level at T3 and had returned to pre-immersion resting values at T4. Regression analysis demonstrated that the temperature response was not related to the water temperature (T2 r = -0.01, p = 0.9; T3 r = -0.02, p=0.9; T4 r=0.03, p=0.8). Analysis of variance demonstrated no difference in body temperature response between participants when grouped in the cooler, medium and warmer water temperatures (T2 F=0.94, p=0.40; T3 F=0.93, p=0.40; T4 F=0.70, p=0.50). CONCLUSIONS Healthy pregnant women maintain body temperatures within safe limits during moderate-intensity aqua-aerobic exercise conducted in pools heated up to 33 degrees Celsius. The study provides evidence to inform guidelines for safe water temperatures for aqua-aerobic exercise during pregnancy.

Prevalence and impact of urinary incontinence in men with chronic obstructive pulmonary disease: a questionnaire survey

OBJECTIVES To identify urinary incontinence and its impact on men with stable chronic obstructive pulmonary disease (COPD) and men without lung disease. DESIGN Prospective questionnaire study. SETTING Outpatients attending a public metropolitan hospital. PARTICIPANTS Men with COPD (n=49) and age-matched men without lung disease (n=36). INTERVENTIONS Validated questionnaires to identify the prevalence and impact of urinary incontinence. MAIN OUTCOME MEASURES Prevalence of urinary incontinence and relationship with disease-specific factors, and relationship of urinary incontinence with anxiety and depression. RESULTS The prevalence of urinary incontinence was higher in men with COPD (n=19/49) compared with men without lung disease (n=6/36; P=0.027). In men with COPD, symptoms of urgency were more prevalent in men with urinary incontinence (P=0.005), but this was not evident in men without lung disease (P=0.101). Only men with COPD reported symptoms of urgency associated with dyspnoea, and this did not vary between men with and without urinary incontinence (P=0.138). In men with COPD, forced expiratory volume in 1 second (FEV1) was lower in those with urinary incontinence compared with those without urinary incontinence {mean 38 [standard deviation (SD) 14] % predicted vs 61 (SD 24) % predicted; P=0.002}. The impact of urinary incontinence did not differ between the two groups (P=0.333). CONCLUSIONS Incontinence is more prevalent in men with COPD than in men without lung disease. The prevalence of urinary incontinence increases with greater disease severity, as reflected by lower FEV1. Screening for urinary incontinence should be considered in men with COPD and compromised lung function.