Evidence-Based Physical Therapy for the Pelvic Floor : Bridging Science and Clinical Practice

434 Pages·2007·9.494 MB·English

by  Berghmans, Bary, Bo, Kari, Van Kampen, Marijke, Morkved, Siv

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First published 2007
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vii
Contributors
Paul Abrams md, frcs Espen Berner md
Professor of Urology, Bristol Urological Institute, Bristol, Department of Surgery, Hamar Hospital, Hamar, Norway
UK
Kari Bø pt, msc, phd
Dianne Alewijnse msc, phd Professor, Department of Sports Medicine, Exercise
Patient Education Communication Advisor, Gelre Scientist, Norwegian School of Sports Sciences, Oslo,
Hospitals, Apeldoorn and Zutphen, The Netherlands Norway
Arve Aschehoug msc sports science Richard C. Bump md
Department of Sports Medicine, Norwegian School of Sport Senior Medical Fellow, Lilly Research Laboratories and
Sciences, Oslo, Norway Clinical Professor of Obstetrics and Gynecology, Indiana
University, Indiana, USA
James A. Ashton–Miller phd
Research Professor, Director, Biomechanics Research
Wendy Bower bappsc, phd
Laboratory, Department of Mechanical Engineering,
Associate Professor, Department of Surgery, The Chinese
University of Michigan, Ann Arbor, Michigan, USA
University of Hong Kong, Hong Kong
James Balmforth mrcog
Pauline Chiarelli dip physio, grad dip, h soc sc,
Subspecialty Trainee in Urogynaecology, Department of
m med sc, phd
Urogynaecology, Kings College Hospital, London, UK
Senior Lecturer, School of Health Sciences, University of
Mohammed Belal ma, mrcs Newcastle, New South Wales, Australia
Specialist Registrar in Urology, London Deanery, UK
Jacques Corcos phd
Bary Berghmans phd, msc, pt Department of Urology, McGill University, Montreal,
Health Scientist and Clinical Epidemiologist, Pelvic Care Quebec, Canada
Center Maastricht, University Hospital Maastricht,
Maastricht, The Netherlands Rob de Bie phd, msc, pt
Professor of Physical Therapy Research, Department of
Nol Bernards md Epidemiology and Center of Evidence Based Physiotherapy
Physician, Dutch Institute for Allied Health Care, (CEBP) Maastricht, Maastricht University, Maastricht,
Amersfoort, The Netherlands The Netherlands
FM-F10146.indd vii 5/28/2007 9:52:50 AM
viii CONTRIBUTORS
John O. L. DeLancey md Job F. M. Metsemakers md, phd
Norman F. Miller Professor and Associate Chair for Department Chair and Professor of General Practice/Family
Gynecology, University of Michigan Women’s Hospital, Medicine, University of Maastricht, Maastricht, The
University of Michigan, Ann Arbor, Michigan, USA Netherlands
Hans Peter Dietz md, phd, franzcog, ddu, cu Siv Mørkved pt, msc, phd
Associate Professor, Department of Obstetrics and
Associate Professor, Clinical Service, St Olavs Hospital,
Gynaecology, University of Sydney, Sydney, Australia
Trondheim University Hospital and Department of
Grace Dorey phd, fcsp Community Medicine & General Practice, Norwegian
Professor Faculty of Health and Social Care, University of University of Science and Technology, Trondheim, Norway
West of England, Bristol, UK
Mélanie Morin msc, pt
Chantale Dumoulin phd, pt PhD Student, Montréal Rehabilitation Institute/Research
Assistant Professor, École de Réadaptation, Faculté de Centre, Université de Montréal, Canada
Médecine, Université de Montréal, Canada
Dudley Robinson mrcog
Helena Frawley pt, bappsc, gradcertphysio Consultant Urogynaecologist, Department of
Lecturer, Research Fellow, School of Physiotherapy, The
Urogynaecology, King’s College Hospital, London, UK
University of Melbourne, Australia
Alessandra Graziottin md Ylva Sahlin md, phd
Chief surgeon, Department of Surgery, Hamar Hospital,
Director, Center of Gynecology and Medical Sexology,
Hamar, Norway
H. San Raffaele Resnati, Milano, Italy
Consultant Professor, School of Obstetrics and Gynecology,
Margaret Sherburn pt
University of Florence and University of Parma, Italy
Lecturer and Research Fellow, Rehabilitation Science
Co-director, Postgraduate Course in Medical Sexology,
Research Centre, School of Physiotherapy, The University of
University of Florence, Italy
Melbourne, Melbourne, Australia
Rob Herbert bappsc, mappsc, phd
Associate Professor, School of Physical Therapy and Centre H. W. van den Borne phd
for Evidence-Based Physiotherapy, University of Sydney, Professor of Patient Education, Department of Health
Australia Education and Promotion, University of Maastricht,
Maastricht, The Netherlands
Erik Hendriks phd, msc, pt
Senior Researcher and Lecturer, Department of Marijke Van Kampen pt, msc, phd
Epidemiology, Maastricht University, Maastricht, The Professor in Rehabilitation Science, Katholieke Universiteit
Netherlands Leuven, Faculty of Kinesiology and Rehabilitation Science,
Co-director, Department of Epidemiology and Center of University Hospital GHB, Leuven, Belgium
Evidence Based Physiotherapy (CEBP) Maastricht,
Maastricht University, Maastricht, The Netherlands David B. Vodušek md, phd
Health Scientist and Clinical Epidemiologist, Dutch Professor of Neurology, Medical Faculty, University of
Institute for Allied Health Care, Amersfoort, The Ljubljana, and Medical Director, Division of Neurology,
Netherlands University Medical Centre, Ljubljana, Slovenia
Anders Mattiasson md, phd Jean F. Wyman phd, aprn, bc, faan
Professor, Department of Urology, Clinical Sciences, Lund Professor and Cora Meidl Siehl Chair in Nursing Research,
University, Lund, Sweden School of Nursing, University of Minnesota, USA
Professor, Department of Family Medicine and Community
Ilse E. P. E. Mesters phd Health, School of Medicine, Minneapolis, MN, USA
Associate Professor, Department of Health Education and
Health Promotion, University of Maastricht, Maastricht,
The Netherlands
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ix
Foreword – International
Continence Society
Walter Artibani
Conservative treatment, and namely physical therapy, used are extensively covered including the existing
is one of the mainstays of management of pelvic evidence.
fl oor disorders and urinary incontinence. To transform The editors and authors are to be commended for
clinical practice into science, and vice-versa to elect their efforts. The outcome is remarkable and this book
evidence-based medicine as the ground for clinical prac- is going to become THE reference book in regards with
tice, is a challenge and this is what this wonderful book physical therapy to all those who are involved in pelvic
aims to reach. fl oor disorders.
Every single related topic is comprehensively dealt
with, from anatomy, to neurophysiology, to assess- Walter Artibani
ment, to strategies of treatment. All possible clinical sit- General Secretary
uations in which physical therapy can be effectively International Continence Society
FM-F10146.indd ix 5/28/2007 9:52:51 AM
xi
Foreword – International
Urogynecology Association
Paul A Riss
The science and clinical practice of the diagnosis and textbook on pelvic fl oor disorders, on the other hand it
treatment of pelvic fl oor disorders has changed dramati- shows how concepts of physical therapy are relevant for
cally over the last few years. While previously most all kinds of problems and should be integrated into
researchers and clinicians often focused on a particular therapeutic concepts.
problem and remained within their sometimes small When reading this book one will immediately notice
area of expertise it has become apparent that the study two particularly noteworthy aspects:
of the pelvic fl oor requires a holistic approach. This is Firstly, as the title implies it is evidence-based physi-
true for the different specialties – gynaecology, urology, cal therapy. This means that it is not just the narrative
physiotherapy, physiology – but even more because of and anecdotal evidence of experienced physical thera-
the fact that it is not enough to look at a particular, well- pists and clinicians but the results of studies and trials
circumscribed problem; many different aspects of a which form the basis of what is presented in this book.
pelvic fl oor dysfunction have to be considered. It goes without saying that in this respect special chap-
In this respect the role of physical therapy has become ters of the book are devoted to methodology, to the
increasingly important. Originally physical therapy design and the conduction of trials, and to the evalua-
often was considered a minor adjunct in the treatment tion of data and the results of trials.
of pelvic fl oor disorders for highly motivated women. The second noteworthy feature of the book is the fact
Today, however, the central role of physical therapy in that it covers every aspect of pelvic fl oor dysfunction:
the prevention and treatment of pelvic fl oor disorders male and female, sexual and urinary function, urinary
and lower urinary tract symptoms is recognized. and fecal incontinence, incontinence and prolapse, and
Without doubt it has been the work and experience of of course the role of pregnancy and childbirth.
our colleagues from Scandinavia which has pioneered In this respect it is a very modern textbook. It is based
these developments. on evidence, it brings together physical therapists, clini-
We owe the Scandinavians a great debt: they not only cians and researchers, and it focuses on what really
popularized and implemented physical therapy in their matters – namely the problem of the patient which
countries but they also put physical therapy on a solid impacts on her or his quality of life. Dr Kari Bø, Dr Bary
scientifi c basis. They addressed the questions of epide- Berghmans, Dr Siv Morkved and Dr Marijke Van
miology, they conducted trials, and several reviews – for Kampen are to be congratulated on having brought
example in the Cochrane database – demonstrate the together such a distinguished list of contributors. They
usefulness and effectiveness of physical therapy. will open our eyes and give us a new understanding of
What has been lacking, however, is an overview physical therapy of the pelvic fl oor.
bringing together the different aspects of physical
therapy and putting them in context with medical and Professor Dr Paul A Riss
physiological research. This is what Professor Kari Bø Past President
and her colleagues from Norway and Belgium have International Urogynecology Association
done with this book. On one hand it almost feels like a
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xiii
Foreword – World Confederation
of Physical Therapy
Sandra Mercer Moore
The World Confederation for Physical Therapy (WCPT) the practitioner must have detailed knowledge of rele-
postulates that physical therapists have a duty and vant sciences such as anatomy, physiology, pathology
responsibility to use evidence to inform practice and to and measurement as well as a good understanding of
ensure that the care of clients, their carers and communi- critical appraisal and review of the effects of physical
ties is based on the best available evidence. WCPT also therapy interventions. The book contains an eclectic mix
believes that evidence should be integrated with clinical of physical therapy assessment and intervention for a
experience, taking into consideration beliefs and values range of conditions from childhood to older age and I
and the cultural context of the local environment. In am pleased to note that attention is given to both male
addition, physical therapists have a duty and responsi- and female patients.
bility not to use techniques and technologies that have On behalf of WCPT, I congratulate the authors and
been shown to be ineffective or unsafe. editors of Evidence-Based Physical Therapy for the Pelvic
It therefore follows that physical therapists should be Floor – Bridging Science and Clinical Practice and commend
prepared to critically evaluate their practice. In addition them for their efforts in contributing to the body of
they need to be able to identify questions arising in knowledge in this important discipline.
practice, access and critically appraise the best evidence,
and implement and evaluate outcomes of their actions Sandra Mercer Moore DBA MPhty
(WCPT 2003). President
Evidence-Based Physical Therapy for the Pelvic Floor World Confederation of Physical Therapy
takes us on a wonderful journey where three core themes
of synthesizing, accessing and implementing evidence WCPT Declarations of Principle – Evidence Based Practice
are intertwined. Throughout the wealth of information Approved at the 15th General Meeting of WCPT, June
in the book is the constant reminder that in order to 2003
provide quality care using the best available evidence,
FM-F10146.indd xiii 5/28/2007 9:52:51 AM
xv
Preface
Kari Bø, Bary Berghmans, Siv Mørkved and
Marijke Van Kampen
It is with great pleasure and excitement that we present refl ected in the readership, serving nurses and other
this new textbook! We hope it will attract all physical health professionals working in conservative treatment
therapists interested in the broad area of function and and pelvic fl oor muscle training, as well as those in the
dysfunction of the pelvic fl oor. The editors of this book physical therapy fi eld.
have more than 20 years’ experience in clinical practice As in the medical profession, clinical practice of
and research in the prevention and treatment of symp- physical therapy in pelvic fl oor has built up from a base
toms of pelvic fl oor dysfunction. Between us our experi- of clinical experience, through small experimental
ence covers most areas of physical therapy for the pelvic studies to clinical trials. Today clinicians can build on
fl oor, from children, women and men, to special groups protocols from high-quality randomized clinical trials
such as pregnant and postpartum women, athletes, the (RCTs) showing suffi cient effect size (the difference
elderly and patients with special health problems. In between the change in the intervention group and the
addition, we also have extensive background in other change in the control group). A quick search on PEDro
areas of physical therapy such as sports physiotherapy, (the Physiotherapy Evidence Database, Sydney, Aus-
neurology, rehabilitation, musculoskeletal, ergonomics, tralia, www.pedro.fhs.usyd.edu.au) shows that physical
exercise science, health promotion, biomechanics, motor therapy is changing rapidly from being a non-scientifi c
control and learning and implementation of guidelines. fi eld to a profession with a strong scientifi c platform. In
Prevention and treatment of pelvic fl oor dysfunction February 2007 there were 8859 RCTs, 1478 systematic
is truly a multidisciplinary fi eld in which every profes- reviews and 461 evidence-based clinical practice guide-
sion should play its own evidence-based role for the lines in different areas of physical therapy listed in the
highest benefi t of the patients. With this in mind, we are database. While this book recognizes that much more
very proud that so many leading international clini- research is needed into the prevention and treatment of
cians, researchers and opinion leaders from different many conditions in the pelvic fl oor area, there are
professions have participated in the realization of this already more than 50 RCTs evaluating the effect of
book. Our sincere and warmest thanks to all of you for pelvic fl oor muscle training for stress and mixed incon-
your unique contribution and the time and effort you tinence. Hence, in good clinical practice the physical
have put in to making this book a truly evidence-based therapist should adapt individual patient training pro-
and up-to-date textbook. grammes according to the protocols from these studies
We sincerely hope to have created a special and rather than using theories or models which are not
important book for the physical therapy profession for backed by clinical data. In addition, good clinical prac-
pelvic fl oor dysfunction. We anticipate that it will be tice always should be individualized and should be
useful for physical therapy schools and will be found in based on a combination of clinical experience, knowl-
scientifi c libraries worldwide. Moreover, we hope this edge from high-quality RCTs and patient preferences.
book will become the base for postgraduate studies in Next to this, good clinical practice should always be
pelvic fl oor physical therapy. We hope that the multidis- based on respect, empathy and strong ethical
ciplinary nature of the authorship of this book will be grounding.
FM-F10146.indd xv 5/28/2007 9:52:51 AM
xvi PREFACE
In 2001, Lewis Wall, Professor of Urogynecology, based on high-quality studies, but only on the best avail-
wrote an editorial in the International Urogynecology able knowledge at that time. The profession should
Journal describing 7 stages in the life of medical never confuse statements, clinical experience and theo-
innovations: ries with evidence from high-quality RCTs, and opti-
mally, we should not use new modalities in regular
1. Promising report, clinical observation, case report,
clinical practice until they have proved to be effective in
short clinical series
RCTs. In this book we have tried our best to differentiate
2. Professional and organizational adoption of the
between the different levels of knowledge and evidence
innovation
and to be very clear about the limitations of the research
3. The public accepts the innovation – state or third
underlying the recommendations for practice. In line
party pays for it
with this, we have left out those areas that were not
4. Standard procedure – into textbooks (still no critical
convincing because of lack of evidence. These areas
evaluation)
include:
5. RCT !
6. Professional denunciation
• The role or effect of PFMT on core stability to prevent/
7. Erosion of professional support, discredit.
treat low back and pelvic girdle pain
He stated that by the time stage 7 is concluded, or • The effect of ‘functional training’
even before the RCT has started, the procedure may • The role of motor control training as the sole treat-
already have given way to a new procedure or method ment of pelvic fl oor dysfunction
which has grown in its wake. This cycle continues with • The defi nition, assessment and treatment for ‘hyper-
these new methods and procedures being prescribed to tone pelvic fl oor’
patients without patients being informed about the • The effect of body posture on the pelvic fl oor
effect, risk factors or complications. It is also noteworthy • The effect of respiration on the pelvic fl oor and vice
that, in most cases, patients are unaware of the fact that versa.
there is no scientifi c base for the proposed treatment.
While Wall’s description of the lifecycle applies specifi - Our aim is to continue updating the evidence in all
cally to medical innovations, we are subject to the same areas of research in pelvic fl oor physical therapy. There-
scrutiny and criticism in physical therapy. fore, we hope that the next edition will already include
Although physical therapy modalities, in compari- more areas because of the continuing growth of knowl-
son with surgery, rarely produce serious side effects or edge based on high-quality research.
complications, we suggest that Wall’s 7 stages also may The evidence presented in this book is based on
be very useful to show how different theories, and not reviews from the Cochrane Library, the three Interna-
science, impact on physical therapy practice. We are tional Consensus Meetings on Incontinence, other sys-
keenly aware and concerned that in the long run such tematic reviews and updated searches on newer RCTs.
un-scientifi c evolution of practice will damage patients, However, the conclusions of these high-quality system-
the physical therapy profession itself and parties respon- atic reviews can differ because they are a product of how
sible for compensation. In particular, the use of such the authors have posed their research questions, what
untested models and theories as a background for type of studies they have included, what choice of
implementing new interventions when there is in fact outcome measures they have made, and how they have
evidence available for alternative and proven treatment classifi ed the studies. Therefore, not all conclusions in
strategies, must be considered bad clinical practice, this book are in line with other conclusions. The goal of
and may even be considered unethical. Hence, it is our the editors of this book is to evaluate only clinically rel-
hope that this book will be a big step towards evidence- evant research questions. Moreover, our selection pro-
based practice in all symptom areas of pelvic fl oor cedure and strategy for the in- and exclusion of studies
dysfunction. should be transparent and easy to understand for the
This does not mean that we should not treat condi- readers of the book.
tions for which there are no or only few/weak control- Active exercise is the core of physical therapy inter-
led studies to support clinical practice. However, we ventions. Passive treatments may be used to stimulate
sincerely believe that all physical therapists should be non-functioning muscles and to manage pain so that
aware of the different level and value of statements, active exercise becomes possible. The following is a
theories, clinical experience, knowledge from research quote from Hippocrates which elegantly lends itself to
designs other than RCTs and knowledge from high- the philosophy of physical therapy:
quality research. It is a duty to openly explain to patients ‘All parts of the body which have a function, if used
and other parties that the proposed treatment is not in moderation and exercised in labours in which each is
FM-F10146.indd xvi 5/28/2007 9:52:51 AM
PREFACE xvii
accustomed, become thereby healthy, well-developed Hopefully, you will enjoy reading the book just as much
and age more slowly, but if unused and left idle they as we have enjoyed working with it. Through working
become liable to disease, defective in growth, and age on the book we have certainly become aware of many
quickly.’ It is the role of the physical therapist to moti- unanswered questions, and have identifi ed many new
vate patients and to facilitate exercise and adapted research areas that need to be addressed in this challeng-
physical activity throughout the lifespan. ing area. We encourage the readers interested in research
We hope that new students in this exciting and inter- to continue with formal education in research methodol-
esting fi eld will fi nd enough guidance in this book to ogy (MSc and PhD programs) and join us in trying to
begin to prevent, assess and treat pelvic fl oor dysfunc- make high-quality clinical research in the future. We
tion effectively in their clients/patients, but they must appreciate any constructive feedback for chapters to be
also learn to be critical of new theories and modalities changed or included for the next edition.
that have not yet been tested suffi ciently. For experi-
enced physical therapists we hope that providing con- Kari Bø, Professor, PhD, MSc PT
temporary scientifi c evidence to support or contradict Bary Berghmans, Researcher, PhD, MSc PT
clinical practice will effect changes in practice and will Marijke Van Kampen, Professor, PhD, MSc PT
push for more high-quality clinical research projects. Siv Mørkved, Associate Professor, PhD, MSc PT
FM-F10146.indd xvii 5/28/2007 9:52:51 AM
1
1
Chapter
Overview of physical therapy for
pelvic fl oor dysfunction
Kari Bø
PELVIC FLOOR DYSFUNCTION
CHAPTER CONTENTS
The framework of this book is based on the ap p roach to
Pelvic fl oor dysfunction 1
disorders of the pelvic fl oor in women described by
Wall & DeLancey (1991). Wall & DeLancey (1991) stated
Physical therapy for the pelvic fl oor 3
that ‘pelvic fl oor dysfunction, particularly as manifested
Role of the physical therapist in pelvic fl oor by genital prolapse and urinary or fecal incontinence,
dysfunction 7 remains one of the largest unaddressed issues in
women’s health care today’ (p. 486). In their opinion
References 8 lack of success in treating patients with pelvic fl oor dys-
function is due to a professional ‘compartmentalization’
of the pelvic fl oor.
Each of the three outlets in the pelvis has had its own
doctor and medical specialty, with the urethra and
bladder belonging to the urologist, the vagina and
female genital organs belonging to the gynaecologist,
and the colon and rectum belonging to the gastroenter-
ologist and the colorectal surgeon (Fig. 1.1).
Wall & DeLancey (1991) argue that instead of con-
centrating on the three ‘holes’ in the pelvis, one should
look at the ‘whole pelvis’ with the pelvic fl oor muscles
(PFM), ligaments and fasciae as the common supportive
system for all the pelvic viscera.
The interaction between the PFM and the supportive
ligaments was later elaborated by DeLancey (1993) and
Norton (1993) as the ‘boat in dry dock theory’. The ship
is analogous to the pelvic organs, the ropes to the liga-
ments and fasciae and the water to the supportive layer
of the PFM (Fig. 1.2).
DeLancey (1993) argues that as long as the PFM or
levator ani muscles function normally, the pelvic fl oor
is supportive and the ligaments and fascia are under
normal tension.
When the PFM relax or are damaged, the pelvic
organs must be held in place by the ligaments and
Ch001-F10146.indd 1 5/28/2007 9:53:34 AM