The official quarterly publication of the APTA Academy of Pelvic Health (formerly called the Section on Women’s Health), an academy of the American Physical Therapy Association, publishes scholarly work to advance women’s and pelvic health practice.
The journal provides a forum for scientific and professional exchange among researchers and practitioners throughout the world. High standards of quality are maintained through a rigorous, double-blinded, peer-review process and adherence to standards recommended by the International Committee of Medical Journal Editors.
With the editorial board comprised of a panel of preeminent researchers and clinical scholars, JWHPT publishes original research articles, systematic reviews and metaanalyses, clinical practice guidelines, case studies, and clinical commentaries promoting the integration of evidence into theory, education and research. In support for the evidenced-based practice of physical therapy for women’s health and the pelvic health of children and adults, articles encompass multiple systems, with an emphasis on musculoskeletal, urological, gynecological systems as well biomechanical foundations and psychosocial aspects of this practice.
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More than 3,500 PTs, PTAs and students belong to the Academy of Pelvic Health Physical Therapy.
APTA sections are your link to the resources that you need to stay current in expertise areas and the best way to connect with others who share your interests — including some of the profession’s most influential thought leaders.
APTA sections, some also referred to as academies, focus on a wide range of areas, from specific types of physical therapy to broader policy areas and patient populations. No matter what your interest is there’s probably a section for you.
Each month we will highlight one of the 18 APTA sections, giving information on the specialty, involvement opportunities, and even sharing an experience from a current member.
Abstract ID: 31516
TITLE: Gender-Based Violence Against Women: Trauma-Informed Obstetric and Gynecologic Physical Therapy Programs
AUTHORS/AFFILIATIONS: Lori M. Walton, DPT, PhD, MScPT, MPH(s), Department of Physical Therapy University of Scranton, Scranton, Pennsylvania, UNITED STATES; Veena Laxman Raigangar, PT, PhD(c), MSc, MEd, Department of Physiotherapy, University of Sharjah, Sharjah, United Arab Emirates; Fahmida Akter, MScPT, UNHCR, Ukhiya Cox’s Bazaar, Bangladesh; S. J. M. Ummul Ambia, PT, MSc, Bangladesh Health Professions Institute, University of Dhaka, Savaar, Bangladesh; Bassima Schbley, PhD, LMSW, Department of Social Work, Washburn University, Topeka, Kansas, UNITED STATES; Renee Hakim, Department of Physical Therapy, University of Scranton, Scranton Pennsylvania, UNITED STATES.
Purpose: To assess obstetric and gynecologic physical therapy health services, particularly for girls and women who are subjected to any form of gender-based violence (GBV) and provide recommendations to physical therapists for specific public health screening mechanisms for GBV and treatment of underlying related trauma.
Description: The World Health Organization (WHO) Global and Regional Estimates of Violence Against Women Report indicates a prevalence of 25% for GBV in the North American region. The global prevalence of GBV was reported at 30% (95% CI, 27.8-32.2), with high-income regions reporting 23% to 58% globally. Women who identify as racial or ethnic minorities may suffer even greater systemic bias against them within the local host country health system and create another level of power and privilege pivoted against physical therapy services in an already vulnerable population. Furthermore, subpopulations by ethnicity and region have individual needs that are directly related to GBV risk and protective factors that should be considered when creating any evidence-informed obstetric and gynecologic physical therapy program that seeks to effectively reduce GBV, ensure safe spaces for women, and engage survivors at all levels of intervention. It is essential that any obstetric and gynecologic physical therapy program planning for GBV prevention and survivorship for women be culturally and linguistically appropriate, participatory of the local subpopulation community on all levels (societal, community, family, and individual) of program development and implementation to be successful. Nineteen novel recommendations have been created from this evidence-based model, with focus on efficient and effective screening mechanisms and addressing trauma for women who have experienced GBV. Content validity by 3 content experts in GBV was to be excellent for the 19 recommendations provided in this research.
Summary of Use: This may be used by physical therapists in the clinic or community to screen and address GBV at the clinical level more efficiently and effectively and contribute positively to prevention of GBV nationwide.
Importance to Members: Consideration of a dynamic, collaborative, and participatory-driven model must be central to any obstetric and gynecologic physical therapy program that seeks to reduce GBV for vulnerable groups of women and may also be immediately useful in working with other vulnerable women who have experienced GBV across the United States.
Abstract ID: 32641
TITLE: A Short Story in Stimulating Awareness of the Pelvic Floor
AUTHOR/AFFILIATION: Ruth Maher, PT, PhD, Philadelphia College of Osteopathic Medicine-Georgia, Suwanee, Georgia, UNITED STATES.
Purpose/Hypothesis: Neuromuscular electrical stimulation (NMES) is used clinically as an adjuvant intervention to facilitate pelvic floor muscle (PFM) contractions that may enhance proprioception. Neural imaging shows that NMES contractions activate similar cortical and subcortical structures to volitional ones. Proprioception is fundamental to motor learning, and sensorimotor afferents may facilitate changes in motor control. This study aimed to determine if NMES delivered in a pair of shorts (INNOVO) provided a proprioceptive stimulus to enhance PFM function.
Number of subjects: Ten women aged 23 to 57 years.
Materials and Methods: A bladder-filling protocol facilitated delineation of structures during transabdominal ultrasound imaging (TAUS) of bladder base displacement (BBD) in centimeters (cm) under 3 conditions in standing: pre-NMES volitional contractions, INNOVO NMES contractions, and post-NMES volitional contractions with at least a 5-minute washout period between conditions. INNOVO shorts consist of 8 embedded electrodes, with a cumulative stimulating surface area of 1200 cm2. The electrodes are positioned bilaterally around the pelvis and anterior and posterior thighs. INNOVO delivered a biphasic symmetrical waveform at 50 Hz, with a pulse duration of 620 µs for 5 minutes (on:off time of 5:5 seconds), resulting in 30 PFM contractions. Participants were blinded to TAUS and verbally cued to perform volitional PFM contractions pre- and post-INNOVO NMES. No verbal cues were given during INNOVO NMES, delivered at each participant’s maximum tolerable amplitude (mA) to elicit a PFM contraction confirmed by a cranial displacement of the BBD observed with TAUS.
Results: One-way repeated-measures analysis of variance revealed a significant difference and large effect (P = .001, partial η2 = 0.78). Post hoc analysis with a Bonferroni adjustment revealed INNOVO NMES contraction with BBD = 1.31 cm was significantly different from baseline contraction with BBD = 0.42 cm (P < .001) and post-NMES volitional contraction with BBD = 1.1 cm (P = .011), while post-NMES volitional contraction with BBD = 1.1 cm was significantly different (P = .001) from baseline volitional contraction with BBD = 0.42 cm.
Conclusions: The findings suggest a very short bout with INNOVO NMES provided a proprioceptive sensorimotor stimulus that significantly enhanced function. All PFM contractions post-NMES showed a greater magnitude of BBD than that at baseline. Studies report that NMES-elicited muscle contraction plays a role in proprioception by stimulating muscle spindles and Golgi tendon organs that send afferent information to the somatosensory cortex. High NMES amplitude, which elicits a motor response, has been associated with inducing a cortical facilitatory effect. In contrast, low amplitudes are associated with a cortical inhibitory effect, thus showing an amplitude-based dose effect. Consequently, the presence or lack of a contraction directly impacts the somatosensory cortex and, ultimately, cortical excitability as determined by motor evoked potentials (MEPs).
Clinical Relevance: A 5-minute bout of INNOVO-elicited contractions resulted in significantly improved PFM function compared with pre-INNOVO function. Since the improvement cannot be explained by increased strength, it is plausible that INNOVO stimulated a large number of proprioceptive receptors and sensory afferents, which led to the immediate change in motor response. Since numerous studies have shown that NMES can induce neural plasticity, future studies should look at the longevity of these effects and their impact on pelvic floor function, morphology, and incontinence symptoms.
Abstract ID: 30891
TITLE: Does Game Therapy Decrease Urinary Incontinence in Middle to Older Aged Women? A Systematic Review
AUTHORS/AFFILIATION: Connie R. Matheny, PT, PhD; Emily Brown, SPT; Sara Martin, SPT; Jordan Puvogel, SPT; Maggie G. Sanders, SPT; Southwest Baptist University Blue Springs, MO.
Purpose/Hypothesis: Urinary incontinence (UI) is a common condition that involves the involuntary loss of urine. While this is an issue that can impact women of any age, middle-aged and older women tend to have an increased risk of developing UI based on age, the number of vaginal births, anatomy, and obesity. Urinary incontinence is an epidemic often treated with conservative treatment such as pelvic floor muscle training (PFMT). Urinary incontinence can have a substantial impact on the affected patient’s quality of life. Women with UI experience limitations in physical, social, sexual, and occupational activities. The purpose of this systematic review is to determine whether game therapy (GT) or virtual reality training (VRT) combined with traditional PFMT reduces the incidence of UI in middle-aged and older women.
Number of Subjects: 162
Materials and Methods: The researchers utilized EBSCOhost database system and Google Scholar for articles that supported the hypothesis. The search terms included pelvic floor muscle training and virtual reality or game therapy and urinary incontinence and women. Peer-reviewed literature published in English between 2015 and 2021 focusing on game therapy for treating UI in middle-aged and older women was chosen for this review. The initial search yielded 560 articles. After removing duplicates, 241 studies remained for evaluation. Twenty-one studies qualified for eligibility assessment. Three researchers individually determined the power and eligibility of the articles using the Modified Downs and Black Checklist. A fourth, neutral researcher settled any score discrepancies.
Results: The original search resulted in 560 records. Four of these studies were eligible for this review, 3 randomized controlled trials, and one feasibility study. These studies had participants ranging in number from 24 to 60. The Modified Downs and Black Checklist determined the quality of each of the 4 studies. This tool classifies studies with a score of 26 to 28 as excellent, 20 to 25 as good, 15 to 19 as fair, and less than 15 as poor. Two of the 4 articles were rated excellent, while 2 were rated good.
Conclusions: The literature shows a decrease in UI when game therapy, virtual reality, and traditional pelvic floor muscle training are combined. This decrease is due to an increase in the strength and endurance of the pelvic floor musculature. Additional benefits of game therapy included an overall improvement in quality of life and increased patient compliance.
Clinical Relevance: Game therapy in combination with traditional PFMT is a valid, simple, and low-cost intervention, which decreases UI. Game therapy is another option allowing clinicians to provide an engaging treatment protocol that promotes patient compliance. While the evidence supports this topic, there is limited research, and further studies are needed.
Abstract ID: 31025
TITLE: Assessing Construct Validity of a Pelvic Floor Symptom Scale in Females Undergoing Total Hip Arthroplasty
AUTHORS/AFFILIATIONS: Jenny LaCross, PT, DPT, PhD(c), ATC Texas Woman’s University T. Boone Pickens Institute of Health Sciences-Dallas, School of Physical Therapy, Dallas, TX; Kelli Brizzolara, PT, DPT, PhD, Texas Woman’s University T. Boone Pickens Institute of Health Sciences-Dallas, School of Physical Therapy, Dallas, TX; Amisha Mehta, MD student, University of Texas at Southwestern Medical School, Dallas, TX; Joel Wells, MD, MPH, University of Texas Southwestern Medical School, Dallas, TX.
Purpose/Hypothesis: Hip osteoarthritis (OA) and pelvic floor dysfunction are common conditions occurring in the aging female population. Total hip arthroplasty (THA) is the most common surgical intervention for the management of hip OA. Studies are beginning to demonstrate the impact of THA on pelvic floor function. There is currently no pelvic floor patient-reported outcome measure validated in this patient population. The purpose was to determine the construct validity of the Pelvic Floor Distress Inventory-Short Form 20 (PFDI-SF20) in females presenting with hip OA undergoing THA. It was predicted that scores on the PFDI-SF20 would have a moderate to high positive correlation, r > 0.50, with those on the International Incontinence Questionnaire Short Form (ICIQ-UI) postoperatively indicating convergent validity, and would have a low to no correlation, r < 0.25, with scores on each of the Hip Disability and Osteoarthritis Outcome Score (HOOS) subscales post-operatively, indicating discriminant validity.
Number of Subjects: Thirty-one females with hip OA, ranging from 45 to 83 years of age (mean = 64.8) and living independently, were recruited via consecutive convenience sampling. All underwent unilateral total hip arthroplasty (16 [51.6%] left-sided, 15 [48.4%] right-sided; 21 [67.7%] anterior approach, 10 [32.2%] posterior approach).
Materials and Methods: Construct validity of the PFDI-SF20 was evaluated via hypothesis testing at a hospital-based orthopedic surgery practice. Convergent and discriminant validity of the PFDI-SF20 were investigated using the ICIQ-UI SF and the HOOS, respectively. The Shapiro-Wilk test was used to determine normality. Convergent validity was assessed utilizing Spearman correlations between scores on the PFDI-SF20 and scores on the ICIQ-UI SF. Discriminant validity was assessed using Spearman correlations between scores on the PFDI-SF20 and scores on the 5 subscales of the HOOS.
Results: For convergent validity testing, the Spearman’s rho correlation coefficient was significant for the PFDI-SF20 and ICIQ-UI SF, ρ = 0.46 (P = .013). For discriminant validity testing, there were no significant correlations between the PFDI-SF20 and any of the HOOS subscales: symptom, ρ = −0.133 (P = .64); pain, ρ = 0.24 (P = .41); activities of daily living, ρ = −0.252 (P = .36); recreation, ρ = 0.078 (P = .79); quality of life, ρ = 0.075 (P = .78).
Conclusions: The PFDI-SF20 demonstrated fair convergent validity in our small sample of females with hip OA undergoing THA. While not statistically significant, it also demonstrated good discriminant validity. Evaluation of construct validity suggests the PFDI-SF20 measures the construct of pelvic floor dysfunction symptom-related quality of life in this specialized population. However, additional studies with larger more diverse samples are needed.
Clinical Relevance: This is the first study to examine the validity of a pelvic floor symptom scale in females with hip OA undergoing THA.
Abstract ID: 31047
TITLE: Don’t Forget the Hip! Analysis of Femoracetabular Movement Faults in Patients With Coccydynia
AUTHOR/AFFILIATION: Megan Burgess, DPT, OCS; Washington University in St Louis.
Background and Purpose: The coccyx serves as an attachment site for many muscles and ligamentous structures. Its contribution to optimal movement cannot be understated. Pain in this region, termed coccydynia, is more common in females. Regardless of the cause of the symptoms, conservative interventions for coccydynia are effective for reducing pain and improving function in 90% of patient cases. While interventions by a physical therapist such as manual therapies, biofeedback, ergonomic/sitting changes (effecting spine and sacrococcygeal complex), massage, TENS, and downtraining of the pelvic floor have been proposed to be first-line treatments for coccydynia, it is even more imperative to consider more global hip implications on the musculature within the pelvic girdle. Therefore, the purpose of this case study is to describe hip movement impairment considerations for pain reduction and sitting tolerance in an adolescent with chronic coccydynia.
Case Description: A 14-year-old patient presented with 6-month duration of coccyx pain sitting more than 1 hour and with quick sit to stand. Her pain at worst was 7/10 on the NPRS. At first visit, examination revealed rear- and mid-foot pronation and femoral medial rotation (MR) bilaterally in standing, and slumped sitting. These lower extremity faults were exaggerated with double-leg and single-leg squats but symptoms were only improved with cues to reduce femoral MR/add during single-leg activity. Gluteus medius and deep lateral rotator strength was deficient bilaterally. Craig testing and passive range of motion of the hip favored an anteverted hip structure. Palpation of the obturator internus bilaterally reproduced her symptoms. Initial interventions included education on findings, deep lateral rotator strengthening, and cuing for minimization of movement faults, namely hip adduction/MR during sit to stand. Interventions for visits 2 and 3 consisted of progressive strengthening for hip lateral rotators and abductors, and correction of faults in novel and advanced situations (eg, unstable support, upper limb movements, single-leg activities, and eyes closed). By the end of care, the patient reported no pain, was able to maintain appropriate frontal and transverse plane femoral alignment during dynamic tasks, and was adherent with movement modifications.
Outcomes: Over the course of 4 visits spanning 23 days’ duration, the patient’s pain improved from 7/10 at worst to 0/10 at worst. Oswestry Disability Index (ODI) values decreased from 18% to 0%, which is clinically relevant. While 18% correlates with low disability, no disability is clearly improved from 18% disability, particularly as domains with greatest change in score occurred during common movements.
Discussion: This case study demonstrates the essentiality of assessing femoral-acetabular movement faults in a female patient with coccyx pain. No localized pelvic floor nor lumbar spine interventions were performed, which are more standard interventions for this region. I propose that precision movement assessment of the hip be considered routine for this patient population.
Abstract ID: 31196
TITLE: Post-Partum Back Pain to Pregnancy and Lactation Associated Osteoporosis and Vertebral Fractures: A Case Report
AUTHORS/AFFILIATIONS: Payal Sahni, PT, MPT, DPT, NY Osteoporosis Prevention and Education Program Helen Hayes Hospital, Haverstraw, NY; Ayse Edeer, PT, MSc, PhD, Doctoral Programs in Physical Therapy Dominican College, Orangeburg, NY; Robert Lindsay, MD, NYOsteoporosis Prevention and Education Program, Helen Hayes Hospital, Haverstraw, NY.
Background/Purpose: The physiological demands of pregnancy and lactation greatly affect bone metabolism, requiring the maternal body to exceed daily requirements of calcium and phosphates. Coupled with reduced maternal absorption of calcium, this period creates the perfect scene for a condition called as Pregnancy & Lactation Associated Osteoporosis (PLO). PLO is a rare and transient osteoporosis, characterized by severe lower back or hip pain and vertebral fractures in late pregnancy or early postpartum period. The purpose of this report is to present a case of PLO with thoracic and lumbar vertebral fractures developed 3 months post-partum.
Case Description: A 34-year-old woman was admitted for in-patient care with a diagnosis of spontaneous vertebral fractures at Thoracic 8, 10, 11 and Lumbar 2. The patient was nonambulatory at the time of admission. Besides being in severe pain, she required moderate assistance from one person for wheelchair to bed transfers and was unable to roll from supine to side-lying in bed. Patient’s rehabilitation consisted of an intense and multidimensional approach in in-patient and outpatient settings. The 2-week in-patient management consisted of a regimen of Tymlos, pain medication, and functional rehabilitation for the basic activities of daily living. Outpatient rehabilitation lasted a total of 18 months and included Strong Bones Exercise Program, Tai Chi, Aquatic Therapy, and Nutrition Education. After first 4 months of continuous rehabilitation, patient was followed up with home exercises and an Osteoporosis Wellness Program. Patient was seen for 2 more rounds of physical therapy, twice a week each for 6 and 8 weeks, respectively, focusing on functional progression.
Outcomes: Outcome measures utilized to evaluate and measure progress were bone densitometry for bone mineral density (BMD), blood C-Telopeptide (CTX) levels to assess bone turnover, visual analog scale (VAS) for pain, lower extremity functional scale (LEFS) for ambulatory functional assessment, Timed Up & Go for functional mobility, and Back Index for pain and disability. BMD and CTX testing were performed at the time of admission, 3 months, 6 months, 1 year, and 2 years. All other outcome measure testing was performed at admission, 1 month, 6 months, 1 year and 2 years from then. Patient showed significant improvement in lumbar spine Z-scores (from −2.9 to −1.6), CTX levels (from 373 to 147 pg/mL), LEFS score (from 4/80 to 67/80), Back Index score (from 80% to 12%), Timed Up and Go test (from 15 to 8 seconds), and pain scale (from 9/10 to 0/10), from admission as in-patient to final discharge from outpatient rehabilitation.
Discussion: Patients with PLO often present to outpatient clinics with a complaint of back pain. It is easy to label this as postpartum back pain and weakness due to the clinical presentation. Differential diagnosis to rule out vertebral fractures secondary to PLO is necessary. It is also valuable for physical therapists to know that BMD, bone turnover, vitamin D, and calcium levels can be affected postpregnancy and that patient education about this rare diagnosis can greatly improve the quality of their services.
Abstract ID: 31459
TITLE: The Effectiveness of Complementary/Alternative Medicine for Pain Management in Postpartum Women: A Systematic Review
AUTHORS/AFFILIATIONS: Colleen R. Berry, SPT; Nicholas Anthony Capobianco, SPT; Bryan Gorczyca, SPT; Jamie Hreniuk, SPT; Lori Marie Walton, PT, DPT, PhD, University of Scranton, Scranton, PA; Renee M. Hakim, PT, PhD, Dallas, PA.
Purpose/Hypothesis: The purpose of this systematic review was to determine the impact of complementary/alternative medicine (CAM) on pain in postpartum women.
Number of Subjects: N/A
Materials and Methods: A literature search of ProQuest, PubMed, Cochrane, and CINAHL was conducted with search terms: (“postpartum” OR “postnatal”) AND (“pain”) AND (“RCT” OR “random* control* trial” OR “random* clinical trial”). Selection criteria: RCT, women (>18 years) with postpartum pain (PP) up to 3 years, CAM as defined by the National Center for Complementary and Integrative Health, and at least one pain outcome measure. Two reviewers independently assessed each study for methodological quality and came to consensus using PEDro guidelines.
Results: A total of 483 studies were screened for eligibility and 22 RCTs met the selection criteria. PEDro scores ranged from 5/10 to 10/10 (average = 7.5). Samples ranged from 11 to 500 (N = 2952) adult women with PP. Intervention protocols varied widely. Primary pain outcome measures were Visual Analog Scale (VAS) and Numeric Rating Scale (NRS) (11-point scale). There were 7 pain categories that emerged with statistically significant between-group reduction of pain in CAM groups versus controls (VAS/NRS for 14 CAM groups, mean difference (MD) = −3.66 points, 95% confidence interval (CI) [−4.75, −2.57]) including: breast/nipple pain (3/5 statistically significant), perineal pain (5/7), pelvic girdle pain (0/1), low back pain (LBP, 3/3), general PP (2/3), and postcesarean pain (PCP, 2/2). CAM included lanolin, herbal compresses/ointment, cabbage leaves, cinnamon, lavender, acupressure, acupuncture, dry cupping, mobilization, massage, Turkish classical music (TCM), and abdominal binders (AB). Statistically significant pain reduction was reported for AB on PCP (n = 1, −7 points), massage on LBP and PCP (n = 2, −2.1, −2.0 points), lumbar mobilization on LBP (n = 2, −5.1 points), acupressure on perineal and PP (n = 2, −2.4, −0.2 points), acupuncture (n = 1, −1.5 points), and cinnamon ointment (n = 1, −2.4 points) on perineal pain, cabbage leaves (n = 1, −3.1 points), TCM (n = 1, −4.28 points), and herbal compresses (n = 1, −5.9 points) on breast pain. Adverse events reported in 4 studies included: hemorrhage, removal of AB, tenderness with chiropractic treatment, and mild skin irritation for herbal compresses and lanolin.
Conclusions: Strong evidence supports CAM to decrease pain in postpartum women, with greater pain reduction than usual care in some cases. Limitations included small samples, lack of blinding, long-term follow-up, and adherence. Further research is needed to determine optimal treatment parameters, long-term, and co-intervention effects of CAM for PP.
Clinical Relevance: For optimal clinical management, physical therapists (PTs) should review evidence of CAM in the PT scope of practice including mobilization, massage, and acupressure. Meaningful clinical improvements were found for AB, lumbar mobilization, cabbage leaves, and herbal compresses, which exceeded the NRS Minimal Clinically Important Difference (MCID) value (−3.0 points). Clinicians should be prepared to educate and refer as needed for women with PP who are considering or already using CAM as part of holistic clinical management.
Abstract ID: 31537
TITLE: Breathing for Pelvic Floor Muscle Relaxation and Rectoabdominal Muscle Coordination to Optimize Defecation
AUTHORS/AFFILIATION: Victoria Lynn Faulkner, PT, DPT; Stephanie Jane Bush, PT, DPT; Brooks Rehabilitation, Jacksonville, FL.
Background and Purpose: One type of obstructed defecation, insufficient recto-abdominal coordination, is the inability to coordinate intra-abdominal pressure with pelvic floor muscle (PFM) relaxation in order to have a bowel movement. Patients may contract PFM instead of relax when asked to bear down as if having a bowel movement, which can lead to the inability to completely evacuate stool. With inhalation, the respiratory diaphragm and the pelvic diaphragm move caudally as the PFM relax. During exhalation, the respiratory diaphragm and pelvic diaphragm move cephalically as the PFM contract. Therefore, the purpose of this case report was to investigate the effects of breathing strategy to optimize pelvic floor muscle relaxation and recto-abdominal muscle coordination to facilitate complete defecation.
Case Description: A 38-year-old male patient presented to outpatient physical therapy with a referral for dyssynergic defecation and primary complaints of inability to empty his bowels completely with increased time needed to defecate, as well as, increased fecal frequency 3 to 4 times a day. The patient also reported urinary leakage, urinary frequency of 15 times per day, and nocturia twice per night. Past medical history included grade III internal hemorrhoids, hemorrhoidectomy about 6 years ago, a history of opioid addiction 10 years ago, and constipation. Key examination findings included postural abnormality and asymmetry, gluteus maximus and pelvic floor muscle weakness, and pelvic floor muscle incoordination leading to a clinical impression of insufficient recto-abdominal coordination. Primary interventions implemented included neuromuscular re-education for breath training to assist with pelvic floor muscle relaxation via biofeedback, patient education on healthy bowel and bladder habits, therapeutic exercises for core and PFM strengthening, and manual therapy to promote pelvic alignment and postural correction.
Outcomes: The patient reported decreased fecal frequency to one complete bowel movement within 10 minutes; decreased urinary frequency to every 3 hours during the day and once at night; and he no longer experienced postmicturition dribble. Positive changes of improvement were demonstrated for the following functional outcome measures: the ICIQ-UI by 3 points, PUF improved by 10 points; ICIQ-B domains for bowel pattern by 17 points, bowel control by 7 points, and quality of life by 34 points.
Discussion: The purpose of this case report was to investigate the effects of breathing on incomplete defecation. This case report demonstrates positive results similar to previous research that biofeedback is a preferred method of treating dyssynergic defecation. Surface electromyography (sEMG) biofeedback-assisted pelvic floor muscle training was successful for this patient in facilitating pelvic floor relaxation with inhalation while generating appropriate intra-abdominal pressure to improve the ability to have a bowel movement. Emphasis on correct breathing strategy could improve the effectiveness of sEMG biofeedback-assisted pelvic floor muscle training.
Abstract ID: 31563
TITLE: The Relative Activation of Pelvic Floor Muscles During Selected Yoga Poses
AUTHORS/AFFILIATION: Margaret Blagg, PT, DPT; Lori Bolgla, PT, PhD; Kathryn Aronica, SPT; Christina Cruipe, SPT; Jasmine Green, SPT; Jessica Litavec, SPT; Olivia McTeer, SPT; Tamara Price, SPT; Augusta University, Augusta, GA.
Purpose/Hypothesis: Core stabilization is important when treating patients with low back pain (LBP). Moreover, yoga is a popular treatment strategy that can promote core stabilization. Emerging data have shown moderate to high levels of trunk activation during many yoga poses. The pelvic floor muscles (PFM) also are important stabilizers that receive minimal attention. PFM dysfunction can disrupt trunk stability and contribute to both LBP and genitourinary complications. Patients who perform traditional core and PFM stabilization exercises have shown greater improvements in pain and function than those who only perform traditional core exercises. Yoga also can improve PFM strength; however, no data exist regarding PFM activation during yoga poses. Understanding PFM activation during poses will provide an evidence-based approach for exercise prescription. The purpose of this study was to determine the relative activation of the PFM during select yoga poses. We hypothesized that there would be no difference in PFM activation between poses.
Subjects: Thirteen females participated.
Materials and Methods: Surface electromyography (EMG) sensors were placed perianally to capture levator ani (LA) activation. Subjects performed 3 maximum voluntary isometric contractions (MVIC) by contracting as if to stop the flow of urine or the escape of gas. Peak activity represented 100% activation. Subjects performed 4 yoga poses: locust (LOC); modified side plank (MSP); side angle (SA); and hands-clasped front plank (FP). These poses emulate exercises typically prescribed in physical therapy practice. For testing, subjects held each pose for 30 seconds. EMG data were sampled at 2000 Hz; band passed-filtered (20-450 Hz); root-mean-squared over a 125-millisecond window; and expressed as 100% MVIC (% MVIC). Average EMG activity from 5 to 25 seconds of each pose was analyzed. A 1-way analysis of variance with repeated measures was used to compare amplitudes across the poses. The P value was .05 and adjusted for multiple comparisons using the Bonferroni-Holm correction.
Results: Subjects generated very high (70.2% MVIC) activity during the LOC. They had moderate-to-high activity during the SA (39.9% MVIC) and MSP (37.9% MVIC), and moderate activity during the FP (28.1% MVIC). LOC activity was significantly greater (P < .02) than all poses; SA activity was significantly greater (P = .009) than the FP. No other significant differences existed.
Conclusions: LA activation during the LOC was very high and sufficient for strength gains. LA activation for SA, FP, and MSP indicated that these poses will likely increase endurance and neuromuscular control of the pelvic floor.
Clinical Relevance: Findings from this study showed differing levels of PFM activation across yoga poses that may benefit patients with LBP or genitourinary dysfunction. Data also showed adequate activation to promote PFM endurance/neuromuscular reeducation or strength gains. Clinicians initially should consider prescribing the FP and MSP for patients requiring endurance training of the PFM. The LOC would be appropriate for patients who may benefit from greater strengthening of the PFM.
Abstract ID: 31639
TITLE: The Female Athlete: Return to Sport Postpartum
AUTHORS/AFFILIATION: Kelli Crisp MS, SPT; Abigail Measells, SPT; Audra Sadler, MEd, SPT; Amber Terry, SPT; University of North Texas Health Science Center, Fort Worth, TX.
Purpose: Several top-level female athletes are returning to their careers in sport after childbirth. The purpose of this review examines the existing literature regarding postpartum return to sport and guidelines that are in place to protect athlete safety while increasing performance and recovery during the time period following pregnancy.
Description: A literature search was performed using PubMed and American Physical Therapy Association (APTA) databases. Search terms included “postpartum,” “return to sport,” and “elite athlete.” Articles were included if they were written in the previous 30 years, were written in English, and included a postpartum population or an intervention related to elite or recreational athletes. A total of 18 studies with 2450 participants were analyzed. Of the 18 articles, there were 3 case reports, 2 randomized clinical trials, 1 cohort study, 7 guidelines/clinical reports, 2 systematic reviews/meta-analyses, and 3 nonexperimental studies. The range of participants included elite athletes, recreational athletes, and sedentary females postpartum with various outcome assessments, interventions, and activity recommendations. Factors found that contribute to return to sport outcomes include but are not limited to: pelvic health, musculoskeletal injuries, method of delivery, pregnancy complications, number of births, time between multiple births, breastfeeding, prior level of function, exercise modulation during pregnancy, nutrition, level of competitiveness, patient goals, level of social support, sleep hygiene, pain, and depression. There is a low quantity of evidence available to support guidelines and recommendations for the appropriate management of the female athlete returning to sport postpartum and minimal research specifically addressing the elite athlete. Low-quality studies support the use of exercise to decrease pain, decrease risk for cardiovascular complications and gestational diabetes, promote weight loss, and improve recovery. However, there is currently no multidisciplinary consensus regarding outcome measures or exercise prescription specifically regarding return to sport postpartum.
Summary of Use: The research is widely variable and limited in this population, but all signs point to pregnancy not being a death sentence for these athlete’s careers as previously thought. It is extremely important for us as physical therapists to advocate on behalf of these women to their coaches and other support personnel. Not only is it possible for them to return to their previous level of performance but they can surpass their previous performance. Collaborating with physicians and other professionals to create standardized terminology in this patient population can create more cohesive, collaborative, and comprehensive plans for return to sport. High-quality research studies are needed in this specific population to develop appropriate evidence-based guidelines and recommendations for the assessment, treatment, and health of postpartum athletes.
Abstract ID: 31926
TITLE: Pudendal Neuralgia of Insidious Onset in a Male Subject: A Retrospective Case Study
AUTHOR/AFFILIATION: Christine Eddow, PT, PhD; Western University of Health Sciences, Corona, CA.
Purpose: Evaluating and addressing pelvic pain is complex due to the combined musculoskeletal, neurological, and psychological considerations. Because pelvic health is such an intimate part of an individual’s quality of life, patients are often reluctant to disclose important facts and background information that may lead a therapist to best direct their plan of care. The purpose of this retrospective case study is to demonstrate the value of applying differential diagnostic skills in a male subject with chronic pelvic pain who was initially mismanaged combined with administering unique treatment interventions to achieve an optimal outcome.
Case Description: A 65-year-old male referred to physical therapy presented with a 2-year history of left testicular, penile, ischial, and anal region pain. He had been treated by a general orthopedic therapist for 18 months. He had undergone arthroscopic knee surgery with catheterization, which was the only precursor to his pelvic pain. The patient was seen for 18 months at a facility where the focus of treatment was on his lumbar spine without resolution of symptoms. A physician specializing in pain referred the patient to the primary investigator who discovered the origination of symptoms was associated with catheterization due to a routine arthroscopic knee surgery. The inflammatory sequelae of events resulted in pudendal neuralgia as confirmed with neural tension testing. He was unable to sit for greater than 30 minutes and rated his pain at 7 to 10/10 on a visual analog scale (VAS). The patient was treated with a combination of neural glides, pelvic floor manual therapy, instrument assisted soft tissue mobilization (IASTM), and a home exercise program to promote gains achieved in clinical interventions.
Outcomes: Following 8 weeks of clinical pelvic health intervention, the patient presented with an improved Male NIH Symptom Index scores decreasing from 12, 6, and 10 for pain, urinary symptoms, and quality of life, respectively, to 9, 4, and 5. He was able to sit for 4 hours without exacerbation of symptoms and actually resumed a hobby of bicycling with proper seat selection.
Discussion: Skilled differential diagnosis and appropriate referral to colleagues with practice specialization is essential in ensuring quality outcomes for patients with pelvic pain. Additionally, thorough investigation regarding the etiology of pain is essential in understanding the sequelae of events that may result in atypical symptoms. The patient in this case study responded swiftly and positively to appropriately targeted interventions including manual therapies and guided neural tension techniques. The positive outcomes of this case warrant further education among health care professionals who may encounter pelvic pain to expedite referral to a skilled pelvic health specialist.
Abstract ID: 32279
TITLE: Esophageal “Para”stalsis: Describing Motility in the Distal Esophagus Created by the Diaphragm During Esophageal Manometry
AUTHOR/AFFILIATION: C. Joseph Yelvington, DPT; Mayo Clinic Jacksonville, FL.
Purpose: To describe the diaphragm’s effect on the esophagus, the “abdominal roof’s” contribution to controlling reflux, how this mirrors the pelvic floor effect on incontinence, and how it may lend itself to training and rehabilitation.
Description: Peristalsis is the progressive wave of contraction and relaxation of a tubular muscular system, especially the alimentary canal, by which the contents are forced through the system. Esophageal peristalsis can be visualized in select images via esophageal high-resolution manometry. Manometry is performed by placing a thin catheter with up to 36 pressure sensors every 1 cm at a predetermined length to the level of the stomach, encompassing both upper and lower sphincters. Peristalsis is displayed as a temporal, downward wave descending the entire length of the esophagus, terminating at the stomach. This wave increases and decreases in pressure as the circular contraction moves distally toward the stomach and is seen through color change as muscular pressure increases and increases when the bolus moves down the length esophagus. This covers the manometer readings from 20 to 45 cm from the nares, to the junction of the stomach. The esophagogastric junction, near the distal end of the esophagus, has a separate isolated “wave,” which is unrelated to the esophageal musculature and is created by the diaphragmatic crus. There are 2 portions of the diaphragm: the respiratory diaphragm and the much lesser known diaphragmatic crura. The diaphragmatic crus encircles the lower esophagus near the level of the lower esophageal sphincter (LES). Some resting pressure exists inside the esophagus, which increases proportionally with deep breathing as both portions of the diaphragm contract. Pressure can increase several-fold during deep breathing (source) and can be visualized during manometry. However, closer examination reveals a dynamic “mini” peristaltic wave during manometry. This occurs closer to the 45-cm mark, at the LES on manometry. Like the primary esophageal wave, this is a “progressive wave through a tubular system” and may represent an unrecognized extra-esophageal “para”stalsis coming from outside of the esophageal body from the diaphragmatic crus, hence “parastalsis” designation. A “milking” motion is evident around the lower esophagus and can be accentuated during forced diaphragmatic breathing. This “milking” may function to control refluxate coming from the stomach. Being under voluntary control, this mechanism could be further enhanced with training.
Summary of Use: Studies have consistently demonstrated that a diaphragmatic breathing program can reduce symptoms of reflux. This enhanced “parastaltic” milking action of the diaphragm may help explain these positive results. The ability of an individual to be trained to control pressure at the lower esophagus or “the abdominal roof,” like Kegels exercises for the pelvic floor, may represent an evolving, inexpensive new treatment for a very common disorder. This opens a new realm discovery for physical therapy.
Abstract ID: 32461
TITLE: Effect of Exercise on Lumbopelvic Pain During Pregnancy: A Systematic Review and Meta-Analysis
AUTHORS/AFFILIATIONS: Nicole Tombers, PT, DPT; Margaret Grob, SPT; Kathryn Ollenburg, SPT; Christine A. Cabelka, PT, PhD; College of St Scholastica Duluth, MN.
Purpose: At least 50% of women experience lumbopelvic pain during pregnancy. Physical activity has moderate health benefits and no adverse outcomes for women with uncomplicated pregnancies. Physically active pregnant women have lower pain intensities than sedentary women. It is not clear whether all exercise types are equally beneficial for the management of lumbopelvic pain during pregnancy. This study aims to investigate the question: Are all exercise types equally beneficial in reducing lumbopelvic pain during pregnancy?
Subjects: Seventeen studies included 1911 subjects (959 in control groups and 952 in intervention groups).
Methods: Seven databases (CINAHL, Medline, ScienceDirect, SportDiscus, Proquest, Google Scholar, and Cochrane) were searched between October 2020 and April 2021. Studies investigating the effect of exercise on low back or pelvic pain in pregnant women were included, with no limitation on publication date. Participants were at least 18 years old with uncomplicated pregnancies, any number of past pregnancies, and carrying any number of fetuses. Studies including women with histories of lumbopelvic pain or that did not compare the intervention against a control were excluded. Two reviewers were used to screen, extract data and determine risk of bias from all studies, with a third reviewer resolving disputes. Data collected for quantitative analysis included pain score, functional outcome measures, age, number of weeks of pregnancy, and duration of intervention. Bias was assessed using the Cochrane Bias Tool. Quantitative analysis was performed on included studies using Comprehensive Meta-Analysis software (version 3.0) with significance P < .05.
Results: After duplicates were removed, 608 studies were evaluated and 17 studies were included. Exercise types reported are as follows: core stability (n = 7), mobility (n = 4), aquatic (n = 3), aerobic (n = 1), foot strengthening (n = 1), and relaxation (n = 1). Visual analog scale was the primary method for reporting pain, with some studies alternatively using the Quebec Back Pain Questionnaire or Smith’s Pregnancy Discomfort Index. Six studies were found to have high risk of bias primarily due to randomization effects. The remaining 11 studies had moderate risk due to outcomes being self-reported by participants. The main finding of the meta-analysis was significant (P = .00) with a large effect size of 1.33, indicating that exercise, regardless of type, is beneficial in reducing pain. Heterogeneity was high, with I2 value of 94.99 (P = .00).
Conclusions: Exercise is effective in decreasing intensity of lumbopelvic pain among pregnant women. The heterogeneity of studies makes comparison between exercise types difficult. However, our literature review suggests mobility exercise may have a greater effect on pain reduction than other exercise types.
Clinical Relevance: Exercise is safe and effective in reducing lumbopelvic pain during pregnancy. Clinicians should recommend exercise to pregnant women as a strategy to reduce pain. Further research is needed to determine the most beneficial exercise frequency and intensity.
Abstract ID: 32469
TITLE: The Impact of Educational Level on Incidence and Awareness of Pelvic Floor Dysfunction
AUTHORS/AFFILIATIONS: Ashlie Crewe, PT, DPT; Alida Steenkamer, SPT; Tianna Yanoscak, SPT; Lillian Zenner, SPT; Lindsey Zulkosky, SPT; Kathryn N. Oriel, PT, EdD; Lebanon Valley College Annville, PA.
Purpose/Hypothesis: Pelvic floor physical therapy (PT) is an underutilized service for the management of pelvic floor dysfunction (PFD). This underutilization may be impacted by lack of awareness of PFD, which may be more prevalent in lower socioeconomic groups. The purpose of this study was to examine the impact of educational level on incidence and awareness of PFD.
Subjects: Participants included 454 individuals (415 females, 37 males, 2 nonbinary), 18 and older, who were recruited from social media platforms. The majority of participants were between the ages of 18 and 29 (35%), while 24% were between the ages of 30 and 39 (24%), 40 and 55 (25%), and more than 55 (17%). Participants represented 28 states and 2 countries.
Materials/Methods: A survey was developed by the researchers to explore awareness of PFD. The Cozean screening tool was used to identify possible PFD among participants. Descriptive statistics, including frequencies and corresponding percentages, were used to describe survey responses, while a 1-way analysis of variance (ANOVA) with post hoc testing was used to determine if differences in awareness and incidence existed between educational groups. Statistical package for social sciences (SPSS) 26 was used to perform all statistical analyses.
Results: Educational levels of participants included high school only (7%), some college (27%), Bachelor’s degree (39%), and graduate degree (27%). Over half (53%) of respondents were employed full-time. Survey responses indicated that 63% of participants were aware of PFD. Out of all respondents, 28% reported that PFD only affects females, and 6% indicated that PFD only affects people who have given birth. Majority of participants (81%) had never received information about pelvic health from a health care provider. Out of respondents, 14% had been treated for PFD, yet 49% did not know there are various treatment options available. Of the 454 participants, 61.81% said “yes” to 3 or more questions on the Cozean screening tool indicative of pelvic floor dysfunction. Statistically significant differences existed between education levels and awareness of PFD (P = .001). Tukey’s post hoc test indicated that awareness of PFD was decreased in the high school group in comparison to all other levels of education (P = .004, P = .001, and P = .001, respectively). There was no difference between educational levels and incidence of PFD (P = .387).
Conclusions: Results of this study suggested that individuals with only a high school education were less aware of PFD than those with higher levels of education. While differences in educational levels and awareness of PFD existed, there were no differences in incidence of PFD and educational levels. The disparity identified related to awareness of PFD among individuals with lower educational levels should help direct primary prevention efforts.
Clinical Relevance: Physical therapists have a role in assisting to educate individuals on PFD and evidence-based treatment options. Lack of awareness among individuals may lead to a lack of services that may negatively impact quality of life. Results of this study suggest that individuals with lower levels of education should be targeted in efforts to improve awareness of PFD and ensure access to services for all individuals.
Abstract ID: 32504
TITLE: Physical Therapy Interventions to Reduce Pain and Improve Outcomes for Post-Cesarean Section Recovery: A Literature Review
AUTHORS/AFFILIATION: Erika Hall, DPT; Heather Lynn Disney-Polman, PT, DPT; University of St Augustine for Health Sciences, San Marcos, CA.
Background: Cesarean section (c-section) is one of the most common surgeries performed in the United States. In 2019, over 1.19 million c-sections were performed, equating to 31.7% of all US births. Women with c-sections require both postpartum and postoperative surgical care to prevent surgical complications and return to prior level of function. Complications from c-sections include bowel and bladder dysfunction, low back, pelvic, and sacroiliac joint pain, and reduced mobility and quality of life. There is little research on rehabilitation protocols for postcesarean section recovery.
Purpose: The purpose of this literature review is to identify when to initiate physical therapy (PT) and what interventions to include to improve patient outcomes following a c-section.
Methods: A literature review of 10 studies was conducted. Search refinement included peer-reviewed articles from 2016 to 2021. Inclusion criteria included healthy women between the ages of 18 and 45 who had undergone a successful cesarean section. Exclusion criteria included women who were pregnant and contraindicated medical conditions.
Results: Results from the literature review indicate that PT for c-section deliveries can decrease postoperative complications, pain, and disabilities associated with pain while increasing core strength and endurance. Three of the 10 studies demonstrated adding PT interventions immediately post-surgery decreased common complications, time to ambulation, getting in/out of bed, and length of hospital stay. Seven out of 10 studies revealed that physical therapy was primarily initiated 2 to 6 months after c-section allowing for scar tissue healing. Three studies showed soft tissue interventions increased scar mobility in all directions by up to 200% and increased pain tolerance by up to 79%. Two studies showed a structured core strengthening program decreased pain and disabilities associated with pain while increasing core strength, endurance, and self-efficacy. One core program showed utilizing Kinesio Tape on the abdominal muscles in conjunction with core exercises increased effectiveness of the program. The majority of studies utilized a validated scale. Six used Visual Analog Scale/Numerical Pain Rating Scale and 5 used Oswestry Disability Index and Roland Morris Disability Questionnaire. Physical therapy demonstrated decreased pain by 25% to 100% and a significant decrease in disabilities due to pain.
Discussion: These studies indicate that physical therapy is effective in reducing pain, improving functional activities, increasing core strength, improving scar mobility, and improving self-efficacy. Limitations include small sample size, lack of double-blind studies, and short time frames that were unable to capture the long-term effects of treatment. Additional research is needed to investigate optimal initiation time and which interventions to include to return patients to prior level of function.
Conclusion: Physical therapy offers a variety of inpatient and outpatient treatments that can be successful in promoting return to prior level of function post-c-section.
Abstract ID: 32923
TITLE: Physical Therapy Management for Male Pelvic Pain: A Case Reflection
AUTHOR/AFFILIATION: Taylor Mugnier PT, DPT; University of Pittsburgh Department of Physical Therapy, Pittsburgh, PA.
Background and Purpose: Prostatitis affects 10% to 14% of men in Europe and the United States. The most common category of prostatitis is chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), with 90% of those with prostatitis being diagnosed with CP/CPPS. This category can be considered the most challenging to treat due to its possible etiologies. Such etiologies include infection, inflammation/autoimmunity, dysfunctional voiding, stress, and neurological changes typical for a systemic chronic pain syndrome. Symptoms of CP/CPPS include pelvic pain, voiding difficulties, and ejaculatory pain. Those with CP/CPPS have significantly decreased quality of life and pelvic pain, which is strongly associated with sexual dysfunction. Pelvic floor physical therapy (PFPT) has been shown to be efficacious in patients with CP/CPPS. The purpose of this case reflection is to describe the effectiveness of PFPT intervention for a male with CP/CPPS, pelvic pain, and lower urinary tract symptoms.
Case Description: The patient was a 35-year-old male referred to PFPT for pelvic pain by his urologist. The patient had a medical history of prostatitis, kidney stones, varicocele, and epididymal cyst. He reported symptoms of burning with urination, pain with ejaculation, occasional constipation, and urinary urgency. Additionally, the patient’s symptoms lead to a pattern of urinary frequency, voiding hourly during the day and at least one time a night. Based on these symptoms persisting for greater than 3 months, he fits the criteria for CP/CPPS. PFPT exam revealed gluteus and abdominal muscle weakness, reduced hamstring flexibility, pelvic floor muscle spasm, pelvic floor weakness, and reduced range of motion. PFPT interventions included manual therapy, neuromuscular re-education, and muscle activation training with functional activities.
Outcomes: The patient attended 7 PFPT sessions over a 3-month period. He met all of the PFPT goals including resolution of penile pain with urination and after ejaculation, urinary urgency, and constipation. Additionally, he became independent in managing his pelvic floor muscle spasm, was able to relax his pelvic floor muscles with bear-down, had improved core and hip strength, and was able to return to his activities. The patient met the minimum clinically important difference in pain reduction using the Numeric Pain Scale, as well as met the optimal threshold to detect a clinically perceptible difference on the Male Genitourinary Pain Index.
Conclusion/Discussion: PFPT interventions utilizing manual therapy, neuromuscular re-education, and exercises to improve lumbopelvic motor control were effective in reducing patient’s physical impairments, activity limitations, and participation restrictions. The knowledge gained from this case can be applied to improve outcomes and quality of life for future male patients with pelvic pain, and supports PFPT for males with CP/CPPS.
Abstract ID: 32926
TITLE: Physical Therapy Management for Adolescent Nocturnal Enuresis: A Case Reflection
AUTHOR/AFFILIATION: Mary Roberts PT, DPT; University of Pittsburgh Department of Physical Therapy Pittsburgh, PA.
Background and Purpose: Nocturnal enuresis (NE) is defined as the involuntary loss of urine at night. NE is observed in 10% of children at 7 years, 3.1% at 11 to 12 years, and 0.5% to 1.7% at 16 to 17 years. Children with NE are at higher risk for social, emotional, and behavioral difficulties compared to their peers. The purpose of this case reflection is to describe the effectiveness of pelvic floor physical therapy (PFPT) intervention for a pediatric female patient with lifelong NE.
Case Description: The patient was a 16-year-old female with the diagnosis of NE. She reported episodes of NE 5 to 6 nights per week. This had occurred since the patient had been toilet trained at 2.5 years old. She had previously attempted a variety of interventions including Desmopressin, Ditropan, waking at night to void, and altering her daytime voiding habits. None of these interventions improved her NE. Urodynamics were completed shortly before attending PFPT demonstrating urinary retention and a staccato pattern when voiding. There was also a genetic component, demonstrated by both parents having a past medical history of NE. The patient did not report any daytime symptoms but did have a history of low back and abdominal pain. Both the patient and her mother provided verbal and written consent for an intra-pelvic exam at evaluation. PFPT examination demonstrated decreased postural stability, reduced hamstring length, weakness, and impaired coordination of core and gluteal musculature, abdominal fascial restrictions, and trigger points. The pelvic exam was positive for elevated tone throughout her pelvic floor musculature as well as deficits in pelvic floor muscle coordination, strength, and endurance. PFPT interventions included soft tissue and joint mobilizations, pelvic floor muscle training (PFMT), gluteal and core strengthening, stretching, neuromuscular re-education, activity modification, dietary recommendations, and functional endurance.
Outcomes: The patient attended a total of 17 visits over 23 weeks. At discharge, the patient was experiencing 0 to 2 nights of NE a week with more than 60% decrease in the amount voided during an enuretic episode. The patient met PFPT goals of pelvic symmetry, improved posture, reduction in pelvic and abdominal fascial restrictions, and increased pelvic floor strength and range of motion, as well as decreased pain with a pelvic exam. Outcome measures used with this patient included the Oswestry Disability Index (ODI), Pelvic Floor Distress Inventory-20 (PFDI-20), Pelvic Floor Impact Questionnaire-7 (PFIQ-7), and Numeric Pain Rating Scale. Due to the lack of daytime symptoms, these outcomes did not reflect her NE and her scores remained within normal ranges throughout her care.
Discussion: PFPT interventions utilizing manual therapy, PFMT, dietary education, and functional lumbopelvic stability were effective in reducing this patient’s NE where other medical interventions had failed. The knowledge gained from this case can be applied to improve the quality of life for future patients with nocturnal enuresis and supports PFPT intervention for this patient population.
Abstract ID: 33194
TITLE: The Efficacy of Physical Therapy for Pain Management In Women With Endometriosis: A Systematic Review
AUTHORS/AFFILIATION: Amy Tremback-Ball, PhD, PT; Courtney Portaro, SPT; Kiley Morrison, SPT; Samantha Miller, SPT; Sabrina DiTucci, SPT; Misericordia University, Dallas, PA.
Background: Endometriosis is a disorder in which benign endometrial tissue grows due to atypical endometrial glands that form outside of the uterus. The disorder causes pain, excessive bleeding, dyspareunia, and may affect quality of life. Common medical treatment includes nonsteroidal anti-inflammatory drug or NSAIDs, hormonal therapy, and surgery. Alternative interventions such as physical therapy may also be an option. The purpose of this review is to examine the effectiveness of physical therapy in decreasing pain and improving quality of life for women with endometriosis.
Methods: A review was performed in August/September 2020 using CINAHL Complete, PubMed, PEDro, and Academic Search Ultimate. Search terms included endometriosis, exercise, physical therapy, physiotherapy, and rehabilitation. Inclusion criteria were peer-reviewed randomized controlled trials, meta-analyses, articles published in the last 15 years, and full-text English. A hand search was also conducted.
Results: The search yielded 11 studies that met the inclusion criteria. There were 2 level 1, 2 level 2, and 7 level 3 on the hierarchy of evidence scale included in the study. Articles were grouped into the following categories: modality therapy, physical activity, manual therapy, combined intervention, and meta-analysis.
Conclusion: Research has shown a positive relationship between the use of combined physical therapy interventions as means of pain management for women with endometriosis. The study is inconclusive regarding use of a single intervention. The role of physical therapy for treating endometriosis needs further research to determine the best protocol for endometrial pain management.
Abstract ID: 33272
TITLE: Resistance Training Utilized to Address Postpartum Chronic Pelvic Pain and Fear Avoidance
AUTHORS/AFFILIATION: Emily Durham, PT; Zachary Walton, PT; Lisa Spiker, PT; Solutions Physical Therapy, Atlanta, GA.
Background and Purpose: Pregnancy-related pelvic girdle pain (PPGP) is a multi-factorial condition associated with anxiety, fear avoidance (FA), pain catastrophization, low self-efficacy, and altered body perception. PPGP prevalence is 23% to 65% with 1 in 10 developing chronic pelvic pain (CPP) with severe consequences. Current guidelines for CPP suggest addressing FA with a multidisciplinary approach and an emphasis on conservative interventions. Additionally, per the 2020 ACOG guidelines “Women with uncomplicated pregnancies should be encouraged to engage in aerobic and strength-conditioning exercises.” Yet postpartum women often experience pain and musculoskeletal sequelae, which limit exercise participation. Thus, individuals with PPGP require pelvic floor and orthopedic physical therapy to manage the musculoskeletal sequelae, reduce FA, and return to an active lifestyle. The purpose of this case study is to demonstrate the successful treatment of PPGP and FA with high-quality orthopedic and pelvic floor physical therapy.
Case Description: A 29-year-old mother of 4 had PPGP and feared worsening her pelvic organ prolapse at 18 months postpartum. PMH: 4 vaginal deliveries, dysmenorrhea, back pain, knee pain, hormone sensitivity, headaches, and insomnia. She reported severe pain with carrying her children, dyspareunia, and inability to tolerate a pelvic exam. Objective findings included PERFECT of 4/5/2, poor relaxation during quick flicks, hypertonicity of the right superficial pelvic floor musculature and right obturator internus, grade 2 cystocele, positive active straight leg raise (ASLR) bilaterally, moderate diastasis, functional constipation, gross hip weakness, and poor trunk control. She demonstrated kinesiophobia, FA, and high levels of anxiety surrounding exercise. Interventions included resistance training, graded exposure, downregulation, soft tissue mobilization, lumbar and SIJ mobilization/manipulation, and internal vaginal and rectal manual therapy. Resistance training was progressed to tolerance and modified to accommodate PPGP. Education included pain neuroscience, coping strategies, self-management techniques, and self-progression of exercise.
Outcomes: At discharge, NPRS reduced 8 points with gynecologic examination, 7 points with carrying her child, and 6 points in back pain. The PPIQ, UIQ-7, and POPIQ-7 improved by 82%, 74%, and 57%, respectively. Bladder prolapse reduced to grade 1. ASLR test was negative. She ran without pain, had infrequent dyspareunia, and demonstrated no FA of activity due to her pain or prolapse.
Discussion: Exercise helps women meet the demands of motherhood and active lifestyles. In this case, an educated and active female developed pain, FA, and anxiety regarding exercise after multiple pregnancies. With pelvic floor physical therapy and high-quality orthopedic physical therapy, she was able to recover from 4 deliveries, meet her goals, and improve her quality of life. FA should be screened for and treated throughout postpartum recovery.
Abstract ID: 33297
TITLE: Embedding a Pelvic Therapy Trained Physical Therapist in a VA Women’s Health Clinic and Tracking Outcomes for Quality Improvement
AUTHORS/AFFILIATIONS: Colleen Burke, PT, DPT; VA Quality Scholars Fellowship, Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, VA; Jason Sharpe, PT, DPT, PhD; VA Quality Scholars Fellowship, Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center Physical Therapy, Durham, VA; Mia Talcott, PT, DPT; Durham VA Medical Center Physical Therapy, Durham, VA.
Purpose: Early physical therapist intervention for diagnoses affecting the pelvic floor has been associated with reduced risk of developing chronic pain and disability for patients seeking pelvic therapy care. Early intervention is accomplished in several health systems by co-locating a physical therapist with medical care providers. This abstract describes the process of integrating a pelvic floor physical therapist in the Durham Veteran’s Affairs (VA) Women’s Health clinic to promote direct access for veterans and data tracking using patient-reported outcome measures.
Description: The Durham VA Women’s Health Clinic was awarded the PFPT 20-22 Rural Health Grant to establish pelvic health clinics and to facilitate the integration of pelvic floor therapy, women’s health, and rural health. This funding was applied to coursework to train the physical therapist in pelvic floor care as well as to purchase the equipment needed to provide these services on-site. Due to space constraints, integration of therapy services in the women’s health clinic is only part-time, but this allows the therapist to see pelvic health patients from other specialty referrals such as urology, gastroenterology, and primary care. The physical therapist is available for face-to-face evaluations and treatments on days when the Durham VA gynecologist is in-clinic, so medical and rehabilitation visits are able to occur the same day. Currently, the therapist’s schedule does not have much availability, but the ultimate goal of embedding a physical therapist in the Women’s Health Clinic would be to allow patients to see both their medical provider and physical therapist in the same day. Additionally, this model has the potential to improve quality control by ensuring veterans are treated by specialized therapists, to save the VA money by avoiding outside referrals to care in the community, and anecdotally has been well received by patients utilizing these services.
Summary of Use: After successful integration into the Women’s Health Clinic with the VA gynecologist, the physical therapist partnered with 2 VA Quality Scholars Fellows to track outcomes. Outcomes tracking was implemented using patient-reported outcomes recording use both excel and REDCap depending on collection method (printed or digital surveys). Currently, 5 PROs are utilized: ICIQUI for urinary incontinence, Female NIHCPSI for pelvic pain, Male NIHCPSI for pelvic pain, EPIC-CP for post-proctectomy, and ICIQ-B for bowel health. There are future plans to incorporate a patient satisfaction measure to track program success from the veteran’s perspective.
Importance to Members: Accessible care is critical to the implementation of early intervention for pelvic health. Embedding a physical therapist in a women’s clinic at the VA helps highlight the interdisciplinary nature of health care for patients with pelvic pain or dysfunction. This process has also created a culture of quality improvement data tracking within the women’s health clinic.
Abstract ID: 33340
TITLE: Clinician Perceptions on Physical Therapy Management of Individuals Who Are Pregnant or Postpartum
AUTHORS/AFFILIATIONS: Natalie Turrentine, PT, DPT, MSHA; Lauren Deets, SPT, Cassidy McFarlane, SPT; Alyssa Minnicino, SPT; Matthew Nuciforo, PT, DPT, PhD; Rosalind Franklin University, Chicago, IL.
Purpose/Hypothesis: The purpose of this study was to assess the perceived role of outpatient (OP) physical therapists (PTs) in treating individuals who are pregnant or postpartum. This study sought to identify barriers to physical therapy (PT) management of this patient population and clinicians’ suggested improvements.
Number of Subjects: The study included 606 survey responses from OP PTs.
Materials and Methods: The 42-item survey was distributed via email, academy newsletters, and social media. Participants responded to Likert scale and open-ended questions relating to demographics, PT confidence level in treating individuals who are pregnant or postpartum, and perceived barriers and opportunities in rehabilitative management of this patient population. Demographic data and Likert scale questions were analyzed using descriptive statistics. Thematic analysis was used to examine open-ended responses in which subjects identified potential barriers and opportunities to improve patient management.
Results: Subjects’ credentials included 85 (14%) American Board of Physical Therapy Specialty (ABPTS) in orthopaedics, 93 (15%) ABPTS in women’s health, and 428 (71%) with any other/no ABPTS certification. Participants of all specialty groups agreed that patients did not receive adequate evidence-based education during (87%) and after (96%) pregnancy. Respondents agreed that patients were unaware of PT options during (78%) and after (76%) pregnancy. Subjects agreed that other medical providers were unaware of PT roles during (61%) and after (67%) pregnancy. The most common perceived barriers to PT included lack of awareness of the role of OP PTs in treating individuals who are pregnant or postpartum among patients (16%) and interprofessional (IP) providers (22%), lack of education among PTs (26%), and lack of referrals (19%). Psychosocial factors (13%) including normalized dysfunction, lack of postpartum support, and fear were also reported barriers. Participants identified increased education/educational opportunities for patients and PTs (64%) and greater advocacy for PT services (54%) as opportunities to address patient and provider awareness. Respondents also suggested increased collaboration between PT specialties (6%).
Conclusions: The majority of respondents believed that patients and IP health care providers are unaware of PT as a treatment option during and after pregnancy. The majority of subjects also believed individuals do not receive adequate evidence-based patient education during and after pregnancy. Over half of participants believed education and awareness on physical therapist abilities and roles would improve management of this population.
Clinical Relevance: There is a lack of research regarding PT management of individuals who are pregnant or postpartum. Our findings suggest there is a need for patient, PT, and IP health care provider education on the benefits of PT during pregnancy and postpartum as well as increased advocacy for PT.
Abstract ID: 33350
TITLE: Utilization of a Webinar to Improve Maternal Pelvic Health Knowledge: From Development to Validation
AUTHORS/AFFILIATIONS: Kim Masuda, SPT; Lindsay Shadden, SPT; Kari-Bargstadt-Wilson, PT; Julie Peterson, PT; Kailey Snyder, PhD; Department of Physical Therapy, School of Pharmacy and Health Professions, Creighton University, Omaha, NE; Cara Morrison, PT; Department of Physical Therapy, Creighton Therapy & Wellness Clinic, Creighton University, Omaha, NE.
Purpose/Hypothesis: 1 in 4 women will experience pelvic floor dysfunction in their lifetime. The perinatal period is a vulnerable time for pelvic dysfunction; however, few women are accessing treatment/support before severe disorder has occurred. More cost-effective and accessible education modalities are needed to increase pelvic health knowledge among mothers to improve symptom recognition and earlier onset of treatment. The purpose of this study was to validate an educational webinar designed to improve maternal knowledge of the structure, functions, and muscles of the pelvic floor.
Subjects: Women (n = 12) in their third trimester of pregnancy.
Materials and Methods: A 4-phase approach to develop and validate an education webinar was utilized. The phases included: (1) initial drafting of content, (2) initial testing by patients, (3) validation via the Prolapse Incontinence Knowledge Questionnaire (PIKQ) and semi-structured interviews, and (4) revision/repetition of validation.
Results: This webinar was designed over a 2-year period. Year 1 included the first iteration of the webinar developed by a Women’s Health Resident Physical Therapist. Phases 1 to 4 were conducted with (n = 16) postpartum mothers who completed the PIKQ and a semi-structured interview, viewed the webinar, and completed a follow-up interview/PIKQ 1 week later. Findings showed significant knowledge change based on PIKQ scores (P < .001) and thematic changes like improved specificity of language, enhanced description of pelvic floor muscle exercises, and increased understanding of pelvic organ prolapse. The webinar was re-recorded expanding upon the same content by 2 board-certified Women’s Health Physical Therapists. Phases 1 to 4 were repeated utilizing a longitudinal design. Women (n = 12) in their third trimester of pregnancy completed the PIKQ and semi-structured interview prior to viewing the webinar and again 6 weeks postpartum. Again, PIKQ scores significantly improved (P < .001), and semi-structured interviews identified a theme of increased value/importance for pelvic health in addition to previous themes found. Specific to the webinar itself, participants requested aesthetic changes with more interactive slides, fewer words on slides, and simplified female anatomy wording. These changes were made accordingly, and the webinar was considered complete.
Conclusions: A webinar appears to be a cost-effective and efficient method for increasing maternal knowledge of structures, functions, and muscles of the pelvic floor. Maternal knowledge/perception changes can be seen in the short-term (∼1 week post-viewing) and long-term (∼3 months post-viewing). Future research should assess how these knowledge changes translate to seeking pelvic health support and engaging in pelvic floor muscle strengthening exercises.
Clinical Relevance: Education webinars can be utilized by providers to improve pelvic health knowledge among pregnant/postpartum women. However, providers should consider supplementing the webinar with additional support/resources until the impact webinars have on patient behavior are better established.
Abstract ID: 33488
TITLE: Hyperreflexia in Young Women With Genito-Pelvic Pain/Penetration Disorder
AUTHORS/AFFILIATION: Teresa Smith, PT; Ellen Ward, PT; KORT Physical Therapy, Lexington, KY.
Background and Purpose: The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) recently combined dyspareunia and vaginismus into one diagnostic category called genito-pelvic pain/penetration disorder (GPPPD). These patients often have hypertonic pelvic floor dysfunction resulting in pain or difficulty with urination, defecation, and sexual intercourse. Pelvic floor physical therapy (PFPT) for pelvic muscle overactivity is a successful option for sexual dysfunction. The prevalence of GPPPD in young women has been reported to be as high as 21%. Predisposing factors include a familial history of vaginismus; however, a history of abuse, relational parameters, gynecologic diseases, and hormones do not seem to play a role in the development of GPPPD. The relationship between deep tendon reflexes (DTR) and GPPPD has not been studied, but overactive DTR would be a logical connection. The purpose of this case series is to describe the PFPT treatment of 3 women aged 19 to 30 years with hyperreflexia and GPPPD.
Case Description: Three cisgender nulliparous women presented with secondary onset of GPPPD. Primary clinical findings included hypertonic levator ani and obturator internus muscles. They had no other comorbidities or history of neurologic dysfunction but demonstrated brisk lower extremity DTR. Treatment focused on education about pelvic floor anatomy and stress management, intravaginal manual therapy, and a comprehensive home exercise program for relaxation of the PFM. Each patient used a pelvic wand to target internal myofascial trigger points between sessions.
Outcomes: Patients were seen for 4 to 10 visits. Verbal pain rating decreased by 3 to 10 points. All patients had no tenderness to intravaginal palpation of pelvic floor muscles at the time of discharge. Of the 3 patients, 2 were able to return to pain-free sexual intercourse. The third patient reported 85% improvement but continued to have pain up to 2/10 that required a break before resuming intercourse.
Discussion: Sexual pain disorders are multifactorial. There are multiple physical and psychosocial factors that influence a patient’s condition. These cases demonstrate a relationship between hyperreflexia and GPPD, but more research is needed to determine if this is a pattern within a larger population. Further evaluation could aid health care practitioners in identifying if hyperreflexia is a predisposing factor for GPPPD. It is unknown how hyperreflexia affected these patients’ prognoses, if at all, but all 3 cases had positive outcomes and decreased pain with intercourse after completion of PFPT.
Abstract ID: 33915
TITLE: Webinar’s Impact on Perceptions of Pelvic Health and Help-Seeking Behavior During the Perinatal Period.
AUTHORS/AFFILIATION: Lindsay Shadden, SPT; Kim Masuda, SPT; Julie Peterson, PT; Bargstadt-Wilson, PT; Kailey Snyder, PhD; Department of Physical Therapy, School of Pharmacy and Health Professions, Creighton University, Omaha, NE.
Purpose/Hypothesis: The perinatal period is a particularly vulnerable time for pelvic floor dysfunction; however, many women have limited pelvic health knowledge and avoid seeking treatment until severe disorder occurs. Video-based webinars have been shown to create short-term pelvic knowledge change; however, the influence of these modalities after an extended time period remains unknown. The purpose of this study was to explore the influence of a webinar on perceptions of pelvic health and help-seeking behavior during and after pregnancy.
Methods: This mixed-methods longitudinal study collected data at 3 time points. First, women participated in a survey/interview in the third trimester of pregnancy. After the interview, they received access to an online webinar on the structures, muscles, and functions of the pelvic floor. Second, women were e-mailed an electronic survey link to complete 1 week after the webinar was disseminated. Finally, they were contacted at 6 weeks postpartum to complete an additional survey/interview on pelvic health perceptions. Data collection measures at time points 1 and 2 included an electronic survey that consisted of the Prolapse and Incontinence Knowledge Questionnaire (PIKQ) and Likert-type questions surrounding the likelihood of accessing pelvic health resources. A qualitative interview was also conducted at time points 1 and 3. Interview questions were guided by constructs of the Theory of Planned Behavior. PIKQ scores were analyzed via independent t tests. Likert data were analyzed via Mann-Whitney tests. Qualitative data were analyzed via a recurrent cross-sectional analysis to explore thematic changes from pregnancy to postpartum.
Results: A total of 11 women participated in this study. The majority of participants were White, had a household income less than $75 000 per year, and at least had a bachelor’s degree. PIKQ scores were significantly improved from pre- to post-webinar viewing (P < .001). Likert data revealed participants would prefer to receive online pelvic floor education. Qualitative analysis revealed the webinar produced increased awareness of resources and value for pelvic health. Women reported minimal engagement in pelvic floor muscle exercises and limited discussion of their pelvic health with their obstetrician and gynecologist (OBGYN) at their 6-week postpartum visit despite most reporting symptoms of urinary incontinence.
Conclusion: Knowledge changes were maintained approximately 3 months after viewing the webinar indicating long-term change may be occurring. However, this knowledge change does not seem to be influencing women’s desire to obtain pelvic floor physical therapy or their likelihood of discussing their pelvic health with their OBGYN. Further research is necessary to determine what barriers remain in accessing pelvic health support.
Clinical Relevance: Providers can utilize webinars to provide pelvic health education. However, they should supplement with additional resources/support as webinars to increase the likelihood of addressing pelvic health symptoms like urinary incontinence.
Abstract ID: 34173
TITLE: Exploring the Relationship Between Pelvic Floor Dysfunction and Balance in Community-Dwelling Older Women
AUTHORS/AFFILIATION: Reema Thakkar, PT, DPT; Leah Verebes, PT, DPT; Peninah Friedman, SPT; Elisheva Liberman, SPT; Devora Peikes, SPT; IlianaTokarsky, SPT; Heber Weber, SPT; Ralph Garcia, PT, PhD; Touro College School of Health Sciences, Doctor of Physical Therapy Program, Jersey City, NJ.
Background: Pelvic floor dysfunction (PFD) and balance dysfunction are 2 common problems among community-dwelling older adults. As older women frequently experience both pelvic floor dysfunction and balance dysfunction, it is of interest to explore the connection between the 2. Specifically, previous research has focused on objective measures of balance without looking at women’s perception of their balance or their PFD.
Objectives: To evaluate the correlation between PFD and balance dysfunction in community-dwelling women aged 65+; and to describe the subjective feelings and opinions of older women who experience PFD and balance impairments.
Study Design: Correlational study.
Methods: Eighty-four community-dwelling women aged 65+ were recruited via email with convenience sampling. Seventy-six participants were included in the analysis. This study was granted institutional IRB approval. Participants filled out an online anonymous survey, which included basic demographic information, questions about number of recent falls, subjective questions about pelvic floor symptoms and balance perception, the Activities Specific Balance Confidence Scale-6 (ABC-6), the Tinetti Falls Efficacy Scale (Tinetti FES), the Pelvic Floor Distress Inventory-20 (PFDI-20), and the Pelvic Pain Impact Questionnaire (PPIQ).
Results: Spearman’s rho showed a moderate correlation between scores on the PFDI-20 and ABC-6 (rs = −0.504, P = .000) and between scores on the PFDI-20 and Tinetti FES (rs = 0.413, P = .000), as well as a weak correlation between the PPIQ and ABC-6 (−0.278, P = .015). Spearman’s rho found no significant correlation between the PPIQ and the Tinetti FES. Qualitative data analysis showed themes of embarrassment, anxiety, intimacy concerns, and lack of independence and participation among women with PFD and balance impairments. This supports current research suggesting a multifactorial connection between balance and pelvic floor. Our qualitative data specifically highlight that woman with PFD suffer from decreased participation in physical activity, which may be contributing to decreased balance performance in this population. We found a statistically significant correlation between impact of PFD and decreased subjective balance outcome measure scores. Considering that many of our participants did not report pelvic pain but instead reported other pelvic floor dysfunctions, it is possible that the correlation between the PPIQ and Tinetti FES did not rise to the level of significance due to small sample size. Our study also showed that women with PFD and balance impairments experience physical and emotional ramifications of these conditions that may not yet be fully addressed by the health care community.
Discussion: This shows that there is correlation between all forms of PFD and balance impairments. Our data suggest that there are negative physical as well as emotional effects of these conditions. Clinically, older women with balance impairments should be screened for PFD and treated accordingly. Future studies could examine if this correlation is causative.
Abstract ID: 32038
TITLE: Using Transcranial Direct Current Stimulation (tDCS) to Augment Vaginal Trainer Treatment for Lifelong Vaginismus
AUTHORS/AFFILIATIONS: Darla Cathcart, PT, PhD; University of Arkansas Medical Sciences, Little Rock, AR; Core and Pelvic Physical Therapy, Conway, AR; Mark Mennemeier, PhD, University of Arkansas Medical Sciences, Little Rock, AR; Jeff Thostenson, MS, University of Arkansas Medical Sciences, Little Rock, AR; Kevin Garrison, PT, PhD, University of Central Arkansas, Conway, AR; Chad Lairamore, PT, PhD, FNAP, Western University of Health Sciences, Lebanon, OR.
Purpose/Hypothesis: Lifelong vaginismus affects 6% to 17% of women and involves pelvic floor muscle (PFM) spasm and pain that limits vaginal insertion (eg, intercourse and tampon use). Vaginal trainers (VT) are often used for treatment. Transcranial direct current stimulation (tDCS) is a type of neuromodulation used to treat dystonia, spasm, and pain. The aims of this study were to compare the effect of using sham and active tDCS combined with VT on (1) PFM surface electromyography (sEMG) and (2) secondary measures of vulvar allodynia, muscle tone, VT volume insertion, and self-report questionnaires (Female Sexual Function Index (FSFI), Pain Catastrophizing Scale (PCS), and Beck Depression Inventory (BDI)).
Number of Subjects: 17
Materials and Methods: The study design was a double-blinded, mixed model with participants randomized to sham or active tDCS groups, both receiving the same VT behavioral intervention (with clinician guidance for breathing and PFM contract-relax techniques) 3 times a week for 4 weeks. Comparisons between and within subjects were made before and after treatment, over time and from baseline to a 1-month follow-up. Analyses were performed by a blinded biostatistician using SAS v9.4. Continuous variables were analyzed by the t-test or by the Wilcoxon rank sum test. Categorical variables were analyzed by the Fischer exact test when cell counts were lower than expected. Additional models were used to explore the interactions of group, time, and session.
Results: For the primary measure of pelvic sEMG, within the active tDCS group, there was a significant improvement in the ability to match a square wave with 10-second isometric contractions (P ≤ .0457 at 9th visit and later). Comparing 1st and 12th visits, both groups reported decreased pain at the beginning and end of sessions (P = .0303). Muscle tone significantly improved within sessions in active versus sham tDCS (P = .0118). Over time, muscle tone improved in both groups between earlier and later visits (P ≤ .0258). Both groups improved significantly and equally in terms of VT accommodation over time (comparing between 1st and later visits/follow-up, P ≤ .0312). Both groups also had significant improvements in self-report measures between the 1st visit and follow-up of sexual function (FSFI, P < .0001), pain (FSFI pain domain, P < .0001; and PCS, P < .0001), and depressive symptoms (BDI, P = .0016).
Conclusions: Active tDCS appears to have augmented VT by improving muscle control by reducing muscle tension. The behavioral VT treatment protocol (with breathing coordination and PFM contract-relax techniques) proved effective as a stand-alone treatment for pain, muscle tension, VT accommodation, and outcomes questionnaires. Findings were maintained at 1-month follow-up.
Clinical Relevance: This study’s results indicate that PFM spasm and pain related to vaginismus may involve dysfunction at a supraspinal/cortical level. This study also demonstrates that vaginal trainers can be effective as treatment when combined with contract-relax behavioral intervention, and that tDCS can further augment these results.
Abstract ID: 31480
TITLE: Academy of Pelvic Health Physical Therapy 2022 Combined Sections Meeting Posters and Platforms
AUTHORS/AFFILIATIONS: Kathryn L. Havens, PhD, Sonia Williams, MPH, SPT, Eileen Villanueva Johnson, PT, DPT; Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, California, UNITED STATES; Catherine Starnes, PhD, Department of Mathematics and Computer Science, Belmont University, Nashville, Tennessee, UNITED STATES.
Purpose/Hypothesis: Pelvic floor dysfunction, including urinary incontinence and pelvic organ prolapse, is common among postpartum mothers. Researchers estimate that a third of women suffer from symptoms a year after delivery, which can impact quality of life. The Pelvic Floor Distress Inventory (PFDI-20) is a questionnaire with high reliability, construct validity, and internal consistency that is commonly used to assess the impact pelvic floor disorders have on health-related quality of life. However, without published large normative data sets, interpretation of these scales is difficult. This study’s purpose was to provide a score distribution of subscales of PFDI-20 in the postpartum population to enhance its interpretability. We hypothesized that mothers would report some bothersome symptoms and that these would decrease with age of the youngest child.
Number of Subjects: 3469.
Materials and Methods: A quantitative research design was used. Pelvic floor dysfunction was assessed using subscales of PFDI-20, which asks how bothersome (0-4 scale) symptoms have been over the past 3 months. Questions are averaged and multiplied by 25 (0-100 scale), and larger numbers indicate greater perceived impact on an individual’s life. The Pelvic Organ Prolapse Distress Inventory (POPDI-6) was used to assess prolapse symptoms. Urogenital Distress Inventory (UDI-6) was used to examine incontinence symptoms. Counts and means were used to describe demographics; ranges were used to describe scale scores. One-way analysis of variance and t tests were used to investigate whether differences existed between POPDI-6 and UDI-6 based on the age of the child (SPSS v24).
Results: The surveyed population consisted of biological mothers: 344 were currently pregnant, 1209 primiparous, and 2258 multiparous. Most (n = 3148) identified as White, 271 identified as Hispanic, and 64 as Black. Age was 32.9 ± 4.8 years. Age of the youngest child was 2.5 ± 2.1 years. POPDI-6 score distributions: Min = 0; Q1 = 0; median = 20.8; Q3 = 29.2; Max = 87.5. UDI-6 score distributions: Min = 0; Q1 = 12.5; median = 25.0; Q3 = 37.5; Max = 100. Of the questions asked, the highest score (median = 50) was “Do you usually experience urine leakage related to coughing, sneezing, or laughing?” suggesting that stress urinary incontinence in postpartum mothers is bothersome. POPDI-6 differed on the basis of the child’s age (P = .049), but post hoc tests were not significant. In contrast, UDI-6 also differed (P < .001) and post hoc test revealed larger scores with infants aged 0 to 6 months than those with 1-, 3-, 4-, and 6-year-olds (P < .05).
Conclusions: This study reveals the urinary distress and pelvic organ prolapse symptoms experienced by a large sample of postpartum mothers. It also suggests that symptoms associated with urinary dysfunction alleviate with time following birth.
Clinical Relevance: The score distribution of the PFDI subscales from a large sample of postpartum mothers enhances the interpretability of the scales by supplying reference points to understand bothersome symptoms and their effect on quality of life in this population.
Abstract ID: 31499
TITLE: Community-Based Pelvic Rehabilitation Programs for Women Refugees: Trauma-Informed, Gender-Focused, Intersectional Approach
AUTHORS/AFFILIATONS: Lori Marie Walton, PT, DPT, PhD, University of Scranton, Old Forge, Pennsylvania, UNITED STATES; Renee M. Hakim, PT, PhD, Dallas, Pennsylvania, UNITED STATES; Jennifer Joan Schwartz, PT, DPT, University of Scranton, Scranton, Pennsylvania, UNITED STATES; Veena Laxman Raigangar, PT, PhD(c), MSc, MEd, Department of Physiotherapy, University of Sharjah, Sharjah, United Arab Emirates; Asma Javed, DPT, PhD(c), University of Sharjah, Sharjah, United Arab Emirates; Najah Zaaeed, DrPH, LMSW, SUNY Oswego, New York City, New York, UNITED STATES; S. J. M. Ummul Ambia, PT, MSc, Bangladesh Health Professions Institute, University of Dhaka, Savaar, Bangladesh; Ibrahim Moustafa Moustafa, PT, MSPT, PhD, University of Sharjah, Sharjah, United Arab Emirates.
Purpose: The purpose of this research was to explore the role of community-based pelvic rehabilitation (CBPR) programs for utilization with women refugees and provide a framework for physical therapists to analyze and develop trauma-informed, gender-focused, intersectional CBPR programs.
Description: According to the United Nations High Commissioner for Refugees, more than 65 million people were forced to migrate because of violence, wars, or persecution in 2015. Because of multiple complex experiences and resettlement trauma, toxic stress has been linked to chronic disease onset and chronic disease health outcomes, including chronic pelvic pain, for women refugee populations. Community-based health programs have been shown to be one cost-effective mechanism for reducing chronic pain within the general population and play an important role in access to treatment of trauma-based pelvic pain for vulnerable populations. This research recommends a novel, nuanced approach to CBPR that is trauma-informed, gender-focused, and intersectional in nature to address power and privilege issues and provide the best physical therapy–related outcomes.
Summary of Use: CBPR programs for women refugees are an essential part of increasing accessibility to rehabilitation services and reducing health inequity for vulnerable populations across the world. CBPR programs have both distal and proximal effects on improving health equity and reducing mortality and morbidity for the most vulnerable. Women with refugee status present unique program needs at the societal, community, family, and individual levels and require a trauma-informed, gender-focused, intersectional approach for best physical therapy practice. The CBPR program development for women refugees presented in this analysis may be used by physical therapists as a trauma-informed, gender-based, intersectional framework for work with refugee women populations.
Importance to Members: Participatory intersectional program development enhances participation from the community, builds trust between participants, and provides the nuanced feedback necessary for a successful public health CBPR program that meets the needs of the community and lays the foundation for long-term, sustainable, community-driven pelvic rehabilitation programs.
Abstract ID: 31983
TITLE: Predictive Association of DRA on Pelvic Floor Dysfunction, Sacroiliac Dysfunction, and Health-Related Quality of Life for Chronic Postpartum Women
AUTHORS/AFFILIATIONS: Enas Mohammad Abu Saleh, PT, MSc, University of Sharjah, United Arab Emirates; Lori Marie Walton, PT, DPT, PhD, MSc, MPH(s), University of Scranton, Scranton, Pennsylvania, UNITED STATES; Meeyoung Kim, PT, PhD, University of Sharjah, United Arab Emirates; Veena Laxman Raigangar, PT, PhD(c), MSc, MEd, Department of Physiotherapy, University of Sharjah, Sharjah, United Arab Emirates.
Purpose/Hypothesis: The purpose of this study was to examine the predictive association of diastasis recti abdominis (DRA) on pelvic floor dysfunction, sacroiliac joint (SIJ) dysfunction, and health-related quality of life (HRQoL) for women in the chronic postpartum period.
Number of Subjects: n = 32.
Materials and Methods: A purposive sample of 32 postpartum women between the ages of 18 and 45 years was the focus of this cross-sectional, predictive, correlative study. Research Ethics Committee (REC) approval and written consent were obtained prior to data collection. DRA was defined as a separation of the rectus abdominis muscle greater than 20 mm and was measured with real ultrasound sonographic imaging (RUSI). Pelvic floor dysfunction was determined using the Pelvic Floor Disability Index (PFDI). Long Dorsal Sacral Ligament Test (LDL), Posterior Pelvic Provocation Test (P4), and the Active Straight Leg Raise Test (ASLR) were also used. HRQoL was measured with the Short Form-12 (SF-12) survey.
Results: Mean DRA was reported at the early postpartum period, 12 to 24 weeks, with a mean inter-rectus distance (IRD) of 43.66 ± 19.11, with subjects reporting significantly greater DRA dysfunction at less than 24 weeks compared with subjects between 24 and 36 weeks postpartum. A significant predictive association was found between DRA and pelvic floor dysfunction for the following categories: (1) Pelvic Organ Prolapse Distress Inventory-6 (POPDI-6) (r = 0.51) (ρ = 0.01); (2) Colorectal-Anal Distress Inventory-8 (CRAD-8) (r = 0.494) (ρ = 0.01); (3) Urinary Distress Inventory-6 (UDI-6) (r = 0.59) (ρ = 0.00). No significant association was found between DRA and SIJ dysfunction (r = 0.08) (ρ = 0.80) and pelvic excursion or between DRA and HRQoL, though a negative trend was observed for HRQoL (r = −0.32) (ρ = 0.06).
Conclusions: DRA was found to be a significant predictor of pelvic floor dysfunction, including (1) pelvic prolapse, (2) colorectal-anal dysfunction, and (3) urinary distress. No significant association was found between DRA and SIJ dysfunction or HRQoL.
Clinical Relevance: This research may be utilized to guide physical therapy evidence-based practice in addressing issues related to DRA and pelvic floor intervention and is foundational for future research in this area.
Abstract ID: 32382
TITLE: Integrating Pelvic Health and Orthopedic Programs to Treat Pelvic Floor Dysfunction in Female Runners
AUTHORS/AFFILIATIONS: Jennifer R. Kinder, PT, DPTSc, MS, Victor Cheuy, PhD, University of California, San Francisco, California, UNITED STATES; Todd Eldon Davenport, PT, DPT, MPH, University of the Pacific, Thomas J. Long School of Pharmacy and Health Sciences, Stockton, California, UNITED STATES.
Purpose/Hypothesis: The female athlete population has a high prevalence of pelvic floor dysfunction (PFD), putting them at increased risk for urinary incontinence. Very few studies have investigated the use of a home exercise program (HEP) to prevent PFD in sports, particularly running. While PFD prevalence is high, the advocacy for preventive recommendations is low; most incontinent women irrespective of age report never speaking about their condition to anyone and having no knowledge of preventive measures. This study investigated whether a 1-time educational workshop on pelvic and core health and a generalizable HEP had positive changes in reported PFD at 2-week and 6-month follow-ups for female runners.
Number of Subjects: 22 (age: 44 ± 11 years; BMI: 22 ± 2 kg/m2).
Materials and Methods: A pilot study was conducted where participants attended a workshop comprising education about the pelvic floor and core muscles and about the pelvic health and orthopedic-based HEP of breath work, posture, strengthening, and stretching of the hips, back, trunk, and pelvic floor muscles. A blinded assessor evaluated overall core strength (CoreFirst Strategy, using 0-5 scale) pre- and postworkshop. Questionnaires evaluated the frequency of leakage during jumping, landing from jumping, running, during competition, approaching the finish line, during other sports, coughing, sneezing, heavy lifting, walking to the bathroom, sleeping, and hearing running water. Time points were baseline (ie, preworkshop) and 2-week and 6-month follow-ups. Paired-samples t tests and McNemar’s tests were used for comparisons.
Results: Overall core strength improved after the workshop (right foot forward: +1.4 (1.3); left foot forward: +1.3 (1.4); both Ps < .001). HEP adherence was 86% and 55% through 2 weeks and 6 months, respectively. Results are presented as the percent reporting any instance of leakage baseline to follow-up (ie, a decrease in percentage is symptom improvement). Improvements occurred after 2 weeks for jumping (41% to 5%, P = .021), landing from jumping (46% to 9%, P = .008), coughing (64% to 14%, P = .003), sneezing (59% to 14%, P = .002), and walking to bathroom (59% to 32%, P = .031). Improvements occurred after 6 months for jumping (41% to 14%, P = .031), coughing (64% to 14%, P = .001), and sneezing (59% to 23%, P = .008).
Conclusions: Educating competitive female runners and providing a generalized HEP focused on pelvic health had immediate positive changes in overall core strength and PFD at 2 weeks, which were maintained through 6 months. Future studies are needed with larger cohorts and randomized controlled study designs.
Clinical Relevance: PFD is reported as a barrier to women’s participation in sport and fitness activities and may be a threat to women’s health, self-esteem, and well-being. Currently, there are no standard recommendations or training programs for the prevention of PFD in female athletes. Providing a 1-time in-person workshop focused on pelvic health education and pelvic health and/or orthopedic exercises can have immediate and long-lasting improvements in competitive female runners’ core strength and PFD.
Abstract ID: 32728
TITLE: Telehealth Video Visits in the Fourth Trimester: A Case Report
AUTHOR/AFFILIATION: Jennifer Goss, PT, Ohio State University Wexner Medical Center, Columbus, Ohio, UNITED STATES.
Background and Purpose: This patient case involves the use of telehealth video visits to provide pelvic floor physical therapy (PFPT) treatment for a patient with urinary, abdominal, bowel, and shoulder complaints in postpartum during the coronavirus disease 2019 (COVID-19) global pandemic. Slowing down the transmission of the virus through social distancing is made possible by reduction of person-to-person contact. Natural disasters and epidemics not only pose challenges to the health care system but also allow for the effective use of current technological advances and innovation to provide optimal service delivery and patient satisfaction. Remote care can be beneficial for nonemergency situations. Visual conferencing is satisfactory in providing quality care by avoiding travel and childcare costs while minimizing direct transmission of the virus. However, barriers exist with implementing telehealth, such as safety and quality; moreover, few studies investigate the effectiveness of utilizing telehealth video visits for treatment of stress urinary incontinence (SUI), one of the primary complaints of the patient. The purpose of this case study was to demonstrate the use of video visits for physical therapists as an alternative to in-person care during a global pandemic.
Case Description: A 36-year-old woman was referred to PFPT for routine postpartum care follow-up with primary complaints of SUI, urinary and bowel urgency, and abdominal weakness following a cesarean delivery. At the initial visit, the patient preferred telehealth video visits for the remainder of her care. During her plan of care, we required consistent Internet and video connection to successfully complete sessions. She was able to use gym equipment at home to progress her exercises as needed and utilized a similar environment as the clinic. Communication was key to providing care over telehealth video visits.
Outcomes: Urinary outcomes were measured with the International Consultation on Incontinence Questionnaire–Urinary Incontinence-Short Form (ICIQ-UI SF); functional limitations were assessed by the Patient Specific Functional Score (PSFS); and pelvic floor strength was assessed by the Modified Oxford Scale. ICIQ-UI SF reduced from 5 to 1. PSFS improved from 7.33 to 10. Pelvic floor strength was unable to be reassessed because of discharge over video. These outcomes demonstrated clinical improvement, and the patient verbally reported completion of her initial goals.
Discussion: PFPT was able to utilize a method of care that has been underutilized in the health care system prior to the onset of the COVID-19 pandemic. The patient appreciated our ability to utilize video visits and thankful for the coverage from her health insurance, otherwise she would not have received the appropriate care in her fourth trimester. This case study demonstrates the value of multimodal care for patients who may not have access to in-person clinic environments and at the same time still receive high-quality care from their health care providers.
Abstract ID: 33955
TITLE: Men’s Pelvic Health Content in Entry-Level Doctor of Physical Therapy Curricula: A Physical Therapist Clinician Perspective
AUTHORS/AFFILIATION: Rachel Anderson, SPT, Adam Fischer, SPT, Marissa Hudoba, SPT, Benjamin Peters, SPT, Shani Johnson, PT, DScPT, Concordia University-St Paul, Minnesota, UNITED STATES.
Purpose: Many common diagnoses for which individuals seek physical therapy include low back pain, hip pain, and abdominal and pelvic floor discomfort. As a result, the Academy of Pelvic Health (APH) has recognized the need to increase awareness of pelvic disorders across all gender populations. A recent survey found that approximately a quarter of Doctor of Physical Therapy (DPT) faculty reported spending less than 1 hour teaching content on male pelvic health despite the fact that 16% of males face pelvic floor dysfunction. The purpose of this study was to determine from expert opinion if male pelvic health content should be included in entry-level DPT curricula. In addition, it is hypothesized that key topics identified as important in the faculty survey will be supported by expert clinicians. This research seeks to gain a deeper understanding of curricular material, from the physical therapist clinician perspective, that can be incorporated into entry-level DPT programs to fulfill the need to improve men’s health education.
Subjects: Licensed physical therapy clinicians who are members of the APH.
Methods: A mixed-methods survey was utilized for this study. The survey collected qualitative and quantitative data to explore delivery of content on men’s pelvic health including data on key topics, demographics, and clinician opinions/attitudes concerning male pelvic health curriculum. Survey inquiries were modeled after the recent study performed on educators at CAPTE accredited DPT programs across the United States regarding delivery of men’s pelvic content. Approximately 3500 licensed physical therapy clinicians identified as APH members were included in the study. All APH members received the survey link via e-mail from the American Physical Therapy Association. Responses were received from 199 members.
Results: Responding clinicians were evenly distributed geographically, with 52 (26%) located in the Midwest, 33 (17%) in the northeast, 48 (24%) in the southeast, 22 (11%) in the southwest, and 39 (20%) in the west. Years of experience ranged as follows: 40 (20%), 0-4 years of experience; 51 (27%), 5-10 years; 49 (25%), 10-19 years; 38 (20%), 20-29 years; 39 (6%), 30-39 years; and 4 (2%), at 40 plus years. Of the 199 APH members who participated in the study, 89% agreed/strongly agreed that men’s pelvic health should be included in entry-level DPT programs. In addition, 95% of these clinicians reported that they disagreed/strongly disagreed that, as an entry-level graduate, they felt adequately prepared to treat men’s pelvic health conditions. Eighty of the clinicians were board certified specialists.
Conclusions: Male pelvic health is a basic function of the musculoskeletal system and is an essential piece of physical therapy practice. These data have supported the need for development of curricular guidelines for educators in entry-level DPT programs by both faculty and clinicians.
Clinical Relevance: Imperative findings from APH clinicians support educator perspective on the need to develop and enhance curricular content inclusive of male pelvic health for entry-level DPT CAPTE accredited programs across the United States.