Sonja Soeder - IUGA 38th Annual Meeting

Transcription

IUGA 2013 – Dublin: Physiotherapy Seminar
Scientific-based Clinical Practice of Pelvic Floor Rehabilitation
Post-Partum Prevention
Sonja Soeder, PT, MT, cand. MSc
German Pelvic Floor Center, St. Hedwig Hospital, Berlin, Germany
Introduction I:
INTRODUCTION:
Pregnancy and vaginal delivery are considered to be the main risk factors for
development of pelvic floor dysfunction
Int Urogynecol J. 2011 Dec;22(12):1497-503. doi: 10.1007/s00192-011-1518-9. Epub
2011 Jul 26.
Pelvic floor muscle function before and after first childbirth
Sigurdardottir T, Steingrimsdottir T, Arnason A, Bø K.
SourceDepartment of Physiotherapy, School of Health Sciences, University of
Iceland, Stapi, Hringbraut 31, 101, Reykjavik, Iceland.
th.sigurdardottir@gmail.com
HYPOTHESIS:
 pelvic floor muscle (PFM) strength and endurance is significantly reduced by
first delivery in general
 changes in PFM strength and endurance are influenced by mode of delivery
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27.05.2013
Introduction I:
Methods:
 Prospective repeated measures observational study
 Thirty-six women completed the study
 PFM function was measured as vaginal squeeze pressure
 Paired t-test was used to compare PFM function before and after first childbirth for all
participants as a group
 One-way ANOVA was used to compare changes between different modes of delivery
RESULTS:
 A significant reduction in PFM strength (p < 0.0001) and endurance (p < 0.0001)
 The reduction in strength was 20.1 hPa (CI:16.2; 24.1), 31.4 hPa (CI: 7.4; 55.2) 5.2
hPa (CI: -6.6; 17.0) in the normal vaginal, instrumental vaginal and acute cesarean
groups, respectively
 The difference was significant between normal vaginal and acute cesarean birth (p =
0.028) and instrumental vaginal and acute cesarean birth (p = 0.003)
CONCLUSION:
 PFM strength is significantly reduced after vaginal delivery, both normal and
instrumental, 6 to 12 weeks postpartum
 Acute cesarean section resulted in significantly less muscle strength reduction
PMID: 21789656 [PubMed - indexed for MEDLINE
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What do we need to know?
...about our clients?
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Primi Para
Multi Para
twin babies or more….
closely spaced pregnancies
moms of handicapped babies
each period of life
different histories of miscarriage, stillbirth,
threatened abortion…medical history …
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Social Network:
Who are the people around our clients?
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5
husband/partner
children
Grandparents/family members
Gynecologist
Midwife
Physician/Physios…/Specialists
Fitnesstrainer/ Personal Trainer
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Living Conditions:
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6
Financially
Working / Parental leave
Single family house/apartment building
Commitments
Time schedule
breastfeeding
Fitness and health situation
Postpartal depression?
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Diagnosis:
1. Prevention
2. Urinary incontinence
3. Fecal incontinence
4. Pelvic Pain:
4.1.Dyspareunia
4.2.Pelvic Girdle Pain (PGP)
4.3.Pelvic Instability
5. Postnatal Depression
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Treatment Regime I:
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Interdisciplinary: PT, Gynecologist, Urologist,
Surgeon, Neurologist..... Urogynecologist,
Midwife, Dietitian,
and
Physiotherapy
evidenced based
and individually for every woman
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Treatment Regime II:
 Interdisciplinary
and
 Physiotherapy:
evidenced based and
individually for every woman
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1. Biofeedback:
1.1. digital palpation
1.2. superficial EMG
1.3. Rehabilitative Ultrasound
2. Electrical Stimulation
3. Behaviour education
4. Devices, splints
5. Training for pelvic floor
muscle awareness, volitional
contraction, endurance,27.05.2013
power
Treatment Regime III:
1. Biofeedback:
1.1.digital vaginal palpation in supine or standing
position with PERFECT Scheme from J. Laycock
Observation of the genital area: redness, scar,
eczema, contraction, position of perineum, sensibility
P: Power: Oxford Grading or ICS, E: Endurance,
R: Repetition F: fast contractions , E: Elevation,
C: Couph response, T: Timing und Tonus
Digital anorectal palpation in standing position
or lying on side:
Observation from skin and contraction, reflexibility
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Treatment Regime IV:
1.1. superficial EMG:
 volitional local contraction
 watching of different muscles
 coordination
 proprioception
 external or internal
 combination with electrical
stimulation possible
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Treatment Regime V:
1.3. Rehabilitative Ultrasound / Real Time Ultrasound:
 non invasiv
 visuell and real time Biofeedback
 Observation in different settings possible
Teyhen 2006, Whittaker et al 2007:
 Evaluate the morphology and function
of muscles and their influence on related
soft-tissues, during various physical tasks
 Assist in the restauration of neuromuscular
function by serving as a source of biofeedback
to the patient and physiotherapist
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Treatment Regime VI:
Examples for Real Time Ultrasound Imaging:
:
M. Transversus thoracis
Perineal Imaging
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suprapubisch
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Treatment Regime VII:
2. Electrical Stimulation:
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low frequent current
detonus: 10 Hz
contraction: 35-50 Hz
Home device
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Treatment Regime VIII:
3. Behaviour Education:
 Teaching how to lift
 explain the act of urination and defaecation
 Showing different positions for breastfeeding
 Correct standing
 How to integrate exercises in daily life
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Treatment Regime IX:
4. Devices / Splints / Kinesiotapes:
Maternitybelt
ISJ-Belt
Kinesiotape
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Sacroloc
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Treatment Regime X:
5. Training for pelvic floor muscle awareness, volitional contraction,
endurance and power:
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It is depending on the evaluation of symptoms and medical
history / diagnosis
It has to be “SMART”
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Diagnosis I:
1. Prevention:
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Neurourol Urodyn. 2012 Jun;31(5):683-7. doi:
10.1002/nau.21251. Epub 2012 Mar 6.
Continuous versus intermittent stochastic resonance whole
body vibration and its effect on pelvic floor muscle activity.
Luginbuehl H, Lehmann C, Gerber R, Kuhn A, Hilfiker R,
Baeyens JP, Radlinger L.SourceBern University of Applied
Sciences, Health, Bern, Switzerland. helena.luginbuehl@bfh.ch
27.05.2013
Diagnosis II:
1. Prevention:
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AIMS: To determine the optimal stochastic whole body vibration (SR-WBV) load modality
regarding pelvic floor muscle (PFM) activity in order to complete the SR-WBV training
methodology for future PFM training with SR-WBV.
METHODS: The continuous and the intermittent SR-WBV modalities were tested by means of
electromyography in two independent groups (27 women 8 weeks to 1-year postpartum and 23
women nulliparae or >1-year postpartum) with self-reported stress urinary incontinence. The
change in the PFM activity within a single set and over three sets were calculated for both SRWBV modalities together (time effect) and for both SR-WBV modalities separately (modality-time
interaction).
RESULTS: There was no statistically significant or clinically relevant change in PFM activity over
time or PFM fatigue in either SR-WBV modality within one or three sets and no difference
between the modalities or the groups.
CONCLUSIONS: The lack of change in PFM activity could be due to a no more than moderate to
submaximal PFM activity during SR-WBV, the maintenance of reflexive PFM activity despite
PFM fatigue or a compensation of slow red PFM fiber fatigue by an increase of innervation
frequency and motor unit recruitment of the fast white fibers. As there is no SR-WBV modality
dependent difference regarding PFM activity, the continuous modality is recommended in clinical
practice as it is easier to apply and less time consuming.
Copyright © 2012 Wiley Periodicals, Inc
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Diagnosis III:
1. Prevention:
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Int Urogynecol J. 2012 Jul;23(7):899-906. doi: 10.1007/s00192-0121681-7. Epub 2012 Mar 1.
Pelvic floor muscle strength predicts stress urinary
incontinence in primiparous women after vaginal delivery.
Baracho SM, Barbosa da Silva L, Baracho E, Lopes da Silva Filho
A, Sampaio RF, Mello de Figueiredo E.Source Movement and
Rehabilitation Sciences Program, Federal University of Minas
Gerais, Belo Horizonte, Minas Gerais, Brazil.
27.05.2013
Diagnosis IV:
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INTRODUCTION AND HYPOTHESIS: This study aimed to investigate obstetrical,
neonatal, and clinical predictors of stress urinary incontinence (SUI) focusing on
pelvic floor muscle (PFM) strength after vaginal delivery.
METHODS: A cross-sectional study was used, and potential predictors of SUI were
collected 5-7 months postpartum on 192 primiparous women. Predictors that
reached significance in the bivariate analysis were entered into the Classification and
Regression Tree that identified interactions among them and cutoff points to orient
clinical practice.
RESULTS: PFM strength was the strongest predictor of SUI. A combination of PFM
strength ≤ 35.5 cmH(2)O, prior SUI, newborn weight > 2.988 g, and new onset of
SUI in pregnancy predicted SUI. The model's accuracy was high (84%; p = 0.00).
CONCLUSIONS: From the four predictors identified, three are modifiable by
physical therapy. This could be offered to women targeting at PFM strength >35.5
cmH(2)O at the postpartum as well as at the prevention of SUI before and during
pregnancy.
PMID: 22382655 [PubMed - indexed for MEDLINE]
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Diagnosis V:
1. Prevention:
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Eur J Obstet Gynecol Reprod Biol. 2011 Mar;155(1):27-30. doi:
10.1016/j.ejogrb.2010.11.012. Epub 2010 Dec 24.
Waterbirth and pelvic floor injury: a retrospective study and
postal survey using ICIQ modular long form questionnaires.
Cortes E, Basra R, Kelleher CJ.SourceGuy's & St Thomas' Hospital
NHS Foundation Trust, Women's Health Department, Obstetrics &
Gynaecology, London, United Kingdom.
eduard@doctors.org.ukAbstract
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Diagnosis VI:
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OBJECTIVE: Waterbirth (WB) include a shorter second stage of labour and
reduction of perineal trauma. The aim of this study is to assess the incidence of
perineal trauma and pelvic floor function following WB compared to land birth
 STUDY DESIGN: retrospective analysis on the incidence of perineal trauma
following a spontaneous WB (n=160) or a Land birth (LB) (n=623). Data were
collected using the hospital's healthcare database, which codes information on
pregnancy outcomes and related variables. ICIQ-VS for vaginal symptoms, and the
ICIQ-KH Long Form (KHQ)
 RESULTS: Length of 2nd stage was significantly shorter in the WB group. Although
this did not translate into less perineal trauma, the incidence of 3rd degree tears
appeared to be doubled in the WB group. 77 (38.5%) women from the WB group
and 54 (22%) from the LB group answered the postal questionnaires. A significant
number of women reported vaginal and urinary symptoms, however the difference
between both groups was not statistically significant.
 CONCLUSION: Waterbirth results in a shorter 2nd stage of labour. This does not
lead to less overall perineal trauma or better pelvic floor performance postpartum.
Physical limitations in protecting the perineum during the expulsion phase may be
associated with an increase in the incidence of 3rd degree tears in the WB
population
Copyright © 2010 Elsevier Ireland Ltd. All rights reserved
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Diagnosis VII:
2. Urinary Incontinence:
Eur. Spine J. 2013 Feb 21. [Epub ahead of print]
Predictors of success for physiotherapy treatment in women with
persistent postpartum stress urinary incontinence.
Dumoulin C, Bourbonnais D, Morin M, Gravel D, Lemieux
MC.SourceSchool of Rehabilitation, Faculty of Medicine, University of
Montréal, Montréal, QC, Canada.
chantal.dumoulin@umontreal.caAbstract
 OBJECTIVE:To identify predictors of success for physiotherapy
treatment in women with persistent postpartum stress urinary
incontinence (SUI).
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Diagnosis VIII:
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INTRODUCTION AND HYPOTHESIS:This study aimed to investigate obstetrical,
neonatal, and clinical predictors of stress urinary incontinence (SUI) focusing on
pelvic floor muscle (PFM) strength after vaginal delivery.
METHODS:A cross-sectional study was used, and potential predictors of SUI were
collected 5-7 months postpartum on 192 primiparous women. Predictors that
reached significance in the bivariate analysis were entered into the Classification and
Regression Tree that identified interactions among them and cutoff points to orient
clinical practice.
RESULTS:PFM strength was the strongest predictor of SUI. A combination of PFM
strength ≤ 35.5 cmH(2)O, prior SUI, newborn weight > 2.988 g, and new onset of
SUI in pregnancy predicted SUI. The model's accuracy was high (84%; p = 0.00).
CONCLUSIONS: From the four predictors identified, three are modifiable by
physical therapy. This could be offered to women targeting at PFM strength
>35.5 cmH(2)O at the postpartum as well as at the prevention of SUI before
and during pregnancy.
PMID: 22382655 [PubMed - indexed for MEDLINE]
27.05.2013
Diagnosis IX:
Eur. Spine J. 2013 Feb 21. [Epub ahead of print]
Predictors of success for physiotherapy treatment in women with
persistent postpartum stress urinary incontinence.
Dumoulin C, Bourbonnais D, Morin M, Gravel D, Lemieux MC.SourceSchool of
Rehabilitation, Faculty of Medicine, University of Montréal, Montréal, QC, Canada.
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Design: Secondary analysis of data from a single-blind randomized
controlled trial comparing 2 physiotherapy intervention programs for
persistent SUI in postpartum women.
Setting: Obstetric clinic of a mother and children's university hospital.
Participants: Women, ages 23 to 39 (N=57), were randomized to 1 of 2
pelvic floor muscle (PFM) training programs, 1 with and 1 without
abdominal muscle training.
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Diagnosis X:
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INTERVENTION: Over 8 weeks, participants in each group followed a
specific home exercise program once a day, 5 days a week. In addition,
participants attended individual weekly pt.
MAIN OUTCOME MEASURES:Treatment success was defined as a pad
weight gain of less than 2 g on a 20-minute pad test. The relationship
between potential predictive PFM function variables as measured by a
PFM dynamometer and success of physiotherapy was studied using
forward stepwise multivariate logistic regression analyses.
RESULTS: 42 women (74%) were classified as treatment successes,
15 (26%) were not. Treatment success was associated with lower
pretreatment PFM passive force and greater PFM endurance
pretreatment, the later association was barely statistically significant.
CONCLUSIONS:The results contribute new information on predictors of
success for physiotherapy treatment in women with persistent postpartum
SUI.
27.05.2013
Diagnosis XI:
2. Urinary incontinence:
Neurourol Urodyn. 2013 Mar 28. doi: 10.1002/nau.22330. [Epub ahead of print]
Randomized controlled trial of physiotherapy for postpartum
stress incontinence: 7-year follow-up
Dumoulin C, Martin C, Elliott V, Bourbonnais D, Morin M, Lemieux MC, Gauthier
R.SourceFaculty of Medicine, School of Rehabilitation, University of Montreal, Montreal,
Québec, Canada; Research Centre of the Institut Universitaire de Gériatrie de Montréal,
Montreal, Québec, Canada. chantal.dumoulin@umontreal.ca
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OBJECTIVE: To estimate the long-term effect of intensive, 6-week physiotherapy
programs, with and without deep abdominal muscle (TrA) training, on persistent
postpartum stress urinary incontinence (SUI)
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Diagnosis XII:
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METHODS: Single-blind randomized controlled trial. 57 postnatal women with
clinically demonstrated persistent SUI 3 months after delivery participated in 8 weeks
of either pelvic floor muscle training (PFMT) (28) or PFMT with deep abdominal
muscle training (PFMT + TrA) (29).
Seven years post-treatment, 35 (61.4%) participants agreed to the follow-up; they
were asked to complete a 20-min pad test and three incontinence-specific
questionnaires with an assessor blinded to each participant's group assignment.
RESULTS: follow-up: 26 (45.6%) took the 20-min pad test (12 PFMT and 14
PFMT + TrA) and 35 (61.4%) completed the questionnaires (18 PFMT and 17
PFMT + TrA). The baseline clinical characteristics of the follow-up and non-follow-up
participants were not significantly different; nor did they differ between PFMT and
PFMT + TrA participants enrolled in the follow-up study. At 7 years, the pad test
scores for the PFMT group did not differ statistically from those of the PFMT + TrA
group. When combining both treatment groups, a total of 14/26 (53%) follow-up
participants were still continent according to the pad test.
CONCLUSION: The addition of deep abdominal training does not appear to further
improve the outcome of PFM training in the long term. However, benefits of
physiotherapy for postpartum SUI, although not as pronounced as immediately after
the initial intervention, is still present 7 years post-treatment
27.05.2013
Diagnosis XIII:
Clin Rehabil. 2012 Feb;26(2):132-41. doi: 10.1177/0269215511411498. Epub 2011 Aug 17
Pelvic floor muscle exercises utilizing trunk stabilization for
treating postpartum urinary incontinence: randomized controlled
pilot trial of supervised versus unsupervised training
Kim EY, Kim SY, Oh DW.SourceDepartment of Physical Therapy, The Graduate School, Daejeon University, Dong-gu,
Daejeon, Republic of Korea.
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30
OBJECTIVE: To investigate the effect of supervised and unsupervised
pelvic floor muscle exercises utilizing trunk stabilization for treating
postpartum urinary incontinence and to compare the outcomes.
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Diagnosis XIV:
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DESIGN: Randomized, single-blind controlled study.SETTING:Outpatient
rehabilitation hospital.SUBJECTS:Eighteen subjects with postpartum urinary
incontinence.
Interventions: Subjects were randomized to either a supervised training group with
verbal instruction from a physiotherapist, or an unsupervised training group after
undergoing a supervised demonstration session.
MAIN MEASURES: Bristol Female Lower Urinary Tract Symptom questionnaire
(urinary symptoms and quality of life) and vaginal function test (maximal vaginal
squeeze pressure and holding time) using a perineometer.RESULTS:The change
values for urinary symptoms (-27.22 ± 6.20 versus -18.22 ± 5.49), quality of life (5.33 ± 2.96 versus -1.78 ± 3.93), total score (-32.56 ± 8.17 versus -20.00 ±
6.67), maximal vaginal squeeze pressure (18.96 ± 9.08 versus 2.67 ± 3.64
mmHg), and holding time (11.32 ± 3.17 versus 5.72 ± 2.29 seconds) were more
improved in the supervised group than in the unsupervised group (P < 0.05). In the
supervised group, significant differences were found for all variables between preand post-test values (P < 0.01), whereas the unsupervised group showed significant
differences for urinary symptom score, total score and holding time between the preand post-test results (P < 0.05).
CONCLUSIONS:These findings suggest that exercising the pelvic floor muscles by
utilizing trunk stabilization under physiotherapist supervision may be beneficial for
the management of postpartum urinary incontinence.
27.05.2013
Diagnosis XV:
3. Fecal Incontinence:
Cochrane Database Syst Rev. 2012 Oct 17;10:CD007471. doi: 10.1002/14651858.CD007471.pub2.
Pelvic floor muscle training for prevention and treatment of urinary and
faecal incontinence in antenatal and postnatal women.
Boyle R, Hay-Smith EJ, Cody JD, Mørkved
S.Academic Urology Unit, University of Aberdeen, Aberdeen, UK.
jean.hay-smith@otago.ac.nz.Update of Cochrane Database Syst Rev. 2008;(4):CD007471.
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BACKGROUND:About a third of women have urinary incontinence and up to a 10th have
faecal incontinence after childbirth. Pelvic floor muscle training is commonly recommended
during pregnancy and after birth both for prevention and the treatment of incontinence.
OBJECTIVES:To determine the effect of pelvic floor muscle training compared to usual antenatal
and postnatal care on incontinence.
SEARCH METHODS:We searched the Cochrane Incontinence Group Specialised Register,
which includes searches of CENTRAL, MEDLINE, MEDLINE in Process and handsearching
(searched 7 February 2012) and the references of relevant articles.
SELECTION CRITERIA: Randomised or quasi-randomised trials in pregnant or postnatal
women. One arm of the trial needed to include pelvic floor muscle training (PFMT). Another arm
was either no PFMT or usual antenatal or postnatal care
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Diagnosis XVI:
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COLLECTION AND ANALYSIS: Trials were independently assessed for eligibility and
methodological quality. Data were extracted then cross checked. Disagreements were resolved
by discussion. Data were processed as described in the Cochrane Handbook for Systematic
Reviews of Interventions.
Three different populations of women were considered separately, women dry at randomisation
(prevention); women wet at randomisation (treatment); and a mixed population of women who
might be one or the other (prevention or treatment).
Trials were further divided into those which started during pregnancy (antenatal); and those
started after delivery (postnatal).
MAIN RESULTS: Twenty-two trials involving 8485 women (4231 PFMT, 4254 controls) met the
inclusion criteria and contributed to the analysis.Pregnant women without prior urinary
incontinence (prevention) who were randomised to intensive antenatal PFMT were less likely
than women randomised to no PFMT or usual antenatal care to report urinary incontinence up to
six months after delivery (about 30% less; risk ratio (RR) 0.71, 95% CI 0.54 to 0.95, combined
result of 5 trials).
Postnatal women with persistent urinary incontinence (treatment) three months after delivery and
who received PFMT were less likely than women who did not receive treatment or received usual
postnatal care to report urinary incontinence 12 months after delivery (about 40% less; RR 0.60,
95% CI 0.35 to 1.03, combined result of 3 trials)
27.05.2013
Diagnosis XVII:
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It seemed that the more intensive the programme the greater the treatment
effect.The results of seven studies showed a statistically significant result favouring
PFMT in a mixed population (women with and without incontinence symptoms) in
late pregnancy (RR 0.74, 95% CI 0.58 to 0.94, random-effects model). Based on the
trial data to date, the extent to which mixed prevention and treatment approaches to
PFMT in the postnatal period are effective is less clear (that is, offering advice on
PFMT to all pregnant or postpartum women whether they have incontinence
symptoms or not).
It is possible that mixed prevention and treatment approaches might be effective
when the intervention is intensive enough
There was little evidence about long-term effects for either urinary or faecal
incontinence.
AUTHORS' CONCLUSIONS:There is some evidence that for women having their
first baby, PFMT can prevent urinary incontinence up to six months after delivery.
There is support for the widespread recommendation that PFMT is an appropriate
treatment for women with persistent postpartum urinary incontinence. It is possible
that the effects of PFMT might be greater with targeted rather than mixed prevention
and treatment approaches and in certain groups of women (for example primiparous
women; women who had bladder neck hypermobility in early pregnancy, a large
baby, or a forceps delivery).
34
27.05.2013
Diagnosis XVIII:
4. Pelvic Pain:
Effectiveness of physical therapy for pregnancy-related low
back and/or pelvic pain after delivery: A systematic review
Physiother Theory Pract. 2012 Dec 17. [Epub ahead of print] Ferreira CW, Alburquerque-Sendín F. Source
Physiotherapy Department , Universidade Federal de Pernambuco , Recife, PE , Brazil.
The aim of this work was to investigate the effectiveness of physical therapy for the treatment of low
back pain (LBP) and pelvic girdle pain (PGP) related to pregnancy after delivery.
A systematic review of studies published since 1985 in the databases Medline, PEDro, SciELO,
SCOPUS, LILACS, and the Cochrane Library was made. Studies that focused on postpartum LBP or
PGP, without being related to pregnancy or in other non-pregnant patients, were excluded, as were
papers addressing LBP or PGP indicating radiculopathy, rheumatism, or any other serious disease or
pathologic condition. In accordance with the exclusion criteria and duplicate articles, of the 105 articles
retrieved, only six were considered for quality assessment with the PEDro Scale. Among these
six papers, two were follow-ups, such that only four trials were included in this
reviewapproaches. All trials used exercise for motor control and stability of the lumbopelvic
region, but with different intervention The study affording the best evidence used individual
guidance and adjustments given by the physiotherapists.
Nevertheless, this systematic review was inconclusive and showed that more randomized clinical trials,
with good quality, are needed.
35
27.05.2013
Diagnosis XX:
4. Pelvic Pain:
Low back and hip pain in a postpartum runner: applying ultrasound
imaging and running analysis
J Orthop Sports Phys Ther. 2012;42(7):615-24. doi: 10.2519/jospt.2012.3941. Epub 2012 Mar 23
Thein-Nissenbaum JM, Thompson EF, Chumanov ES, Heiderscheit BC.SourceDepartment of Orthopedics and
Rehabilitation, University of Wisconsin, 1300 University Avenue, Room 5195 MSC, Madison, WI 53706, USA.
 BACKGROUND:Postpartum low back and hip dysfunction may be caused by an incomplete recovery of
abdominal musculature and impaired neuromuscular control.)
 CASE DESCRIPTION:A postpartum runner with hip and low back pain underwent dynamic lumbar stabilization
training with USI biofeedback and running-form modification to reduce mechanical loading
 OUTCOMES:The patient's pain with running decreased from a constant 9/10 (0, no pain; 10, worst pain) to an
occasional 3/10 posttreatment. Transversus abdominis muscle thickness increased 6.3% during the abdominal
drawing-in maneuver and 27.0% during the abdominal drawing-in maneuver with straight leg raise. Changes
were also noted in the internal oblique.
 These findings corresponded to improved lumbopelvic control: pelvic list and axial rotation during running
decreased 38% and 36%, respectively. The patient's running volume returned to preinjury levels (8.1-9.7 km, 3
days per week) with no hip pain and minimal low back pain, and she successfully completed her goal of running a
half-marathon.
 DISCUSSION:The successful outcomes of this case support the consideration of dynamic lumbar stabilization
exercises, USI biofeedback, and running-form modification in postpartum runners with lumbopelvic dysfunction.
LEVEL OF EVIDENCE:Therapy, level 4.
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Diagnosis XXI:
37
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Diagnosis XXII:
38
27.05.2013
Diagnosis XXIII:
4.1. Pain / Instability:
Clin Rehabil. 2012 Feb;26(2):132-41. doi: 10.1177/0269215511411498. Epub 2011 Aug 17.
Pelvic floor muscle exercises utilizing trunk stabilization for treating postpartum urinary incontinence:
randomized controlled pilot trial of supervised versus unsupervised training
Kim EY, Kim SY, Oh DW.SourceDepartment of Physical Therapy, The Graduate School, Daejeon University, Dong-gu,
Daejeon, Republic of Korea.
 OBJECTIVE:To investigate the effect of supervised and unsupervised pelvic floor muscle exercises utilizing trunk
stabilization for treating postpartum urinary incontinence and to compare the outcomes.
 DESIGN: Randomized, single-blind controlled study.SETTING:Outpatient rehabilitation hospital.
 SUBJECTS:Eighteen subjects with postpartum urinary incontinence. Interventions: Subjects were randomized to
either a supervised training group with verbal instruction from a physiotherapist, or an unsupervised training
group after undergoing a supervised demonstration session.
 MAIN MEASURES:Bristol Female Lower Urinary Tract Symptom questionnaire (urinary symptoms and quality of
life) and vaginal function test (maximal vaginal squeeze pressure and holding time) using a
perineometer.RESULTS:The change values for urinary symptoms (-27.22 ± 6.20 versus -18.22 ± 5.49), quality
of life (-5.33 ± 2.96 versus -1.78 ± 3.93), total score (-32.56 ± 8.17 versus -20.00 ± 6.67), maximal vaginal
squeeze pressure (18.96 ± 9.08 versus 2.67 ± 3.64 mmHg), and holding time (11.32 ± 3.17 versus 5.72 ±
2.29 seconds) were more improved in the supervised group than in the unsupervised group (P < 0.05). In the
supervised group, significant differences were found for all variables between pre- and post-test values (P <
0.01), whereas the unsupervised group showed significant differences for urinary symptom score, total score and
holding time between the pre- and post-test results (P < 0.05).
 CONCLUSIONS:These findings suggest that exercising the pelvic floor muscles by utilizing trunk stabilization
under physiotherapist supervision may be beneficial for the management of postpartum urinary incontinence.
39
27.05.2013
Diagnosis XXIV:
Pelvic Tests:
Pelvic girdle instability :
1. Ileosacraler Schmerz (SIJ)
2. Posterior – Pelvic – Pain – Provokation - Test (P4)
3. Patricks – Faber - Test
4. Palpation of Ligamentum longissimus dorsae
5. Gaenslen - Test
6. Active Straight Leg Raise Test
7. Symphysis palpation pain
8. Modified Trendelenburg, Shifting
Quelle: The Pelvic Girdle, Diane Lee,2011
40
27.05.2013
Diagnosis XXV:
4.2. Pelvic Girdle Pain:
Physiother Theory Pract. 2011 Nov;27(8):557-65. doi: 10.3109/09593985.2010.551802. Epub 2011 Jun 18.
Evidence and individualization: Important elements in treatment for women with postpartum
pelvic girdle pain.
Stuge B, Bergland A.SourceSenior Researcher, Oslo University Hospital, Department of Orthopaedics, Oslo, Norway.
britt.stuge@medisin.uio.no




41
Aim: to elucidate patients' experiences of a treatment program for postpartum pelvic girdle pain.
The written information given by 47 women regarding their experiences with the treatment
program was analyzed by qualitative content analysis.
Three categories were identified from the patients' experiences: 1) "Treatment means
involvement"; 2) "The interchange of knowledge and experience"; and 3) "Perceived change and
meaning."
The treatment required the participants' involvement, individual adaptation, and focusing on the
importance of building their capacity to master daily activities. The therapists were skilled,
interested in each patient, and listened attentively. The program was evidence based and put into
practice on a personalized basis. The dialogs of the therapist and patient were experienced as
meaningful, creating insight, knowledge, and hope. The treatment facilitated a feeling of being in
charge of their own bodies. The dialog and the individualized guidance seemed to be
experienced as positive for the women's coping of their daily life. By being active agents in
managing their pelvic girdle pain and therapy, they learned to set proximal goals. Perceived hope
and self-efficacy appeared to be essential for developing a capacity for self-management and an
enhanced ability to benefit from appropriate learning experiences.
27.05.2013
Diagnosis XXVI
4.2. Pelvic girdle pain:
Eur Spine J. 2013 Feb 21. [Epub ahead of print
Predictors for long-term disability in women with
persistent postpartum pelvic girdle pain
Sjödahl J, Gutke A, Oberg B. Source Division of Physiotherapy, Department of Medical
and Health Sciences, Linköping University, 581 83, Linköping
42
27.05.2013
Diagnosis XXVII:




43
PURPOSE: The majority of prognostic studies on postpartum lumbopelvic pain have
investigated factors during pregnancy. Since the majority of women recover within
the first few months of delivery, it is unknown if the same predictors are valid for
long-term consequences. It is also important to investigate predictors within
subgroups of patients with pregnancy-related lumbopelvic pain due to their different
clinical courses. The aim of this study was to identify predictors for disability 15
months postpartum in women with persistent postpartum pelvic girdle pain (PGP).
METHODS: Data were obtained by clinical tests and questionnaires 3 months
postpartum. The outcome 15 months postpartum was disability measured with the
Oswestry Disability Index.
RESULTS: A multiple linear regression analysis identified two significant two-way
interaction effects that were predictive of disability 15 months postpartum: (a) age +
trunk flexor endurance, and (b) disability + hip extensor strength.
CONCLUSIONS: Age, muscle function and disability seem to influence the long-term
outcome on disability in women with persistent postpartum PGP. It may be important
to consider the possibility of different variables impact on each other when predicting
long-term disability. In addition, further studies are needed to investigate the impact
of interaction effects on long-term consequences in women with persistent
postpartum PGP.
27.05.2013
Diagnosis XXVIII:
Diagnosis and treatment of pelvic girdle pain].[Article in Norwegian]
Tidsskr Nor Laegeforen. 2010 Nov 4;130(21):2141-5. doi: 10.4045/tidsskr.09.0702.
Stuge B.SourceSeksjon for operativ forskningsstøtte, Oslo universitetssykehus, Ullevål, Kirkeveien 166, 0407 Oslo,
Norway




44
BACKGROUND: Pelvic girdle pain (PGP) usually presents during pregnancy. About 25% of all
pregnant women and 5% of all women suffer from postpartum lumbopelvic pain causing them to
seek medical help. This article discusses possible causes, diagnostic aspects and treatment of
PGP.
MATERIAL AND METHOD: The paper is based on literature identified through non-systematic
searches in PubMed, Medline, Embase, Cinahl and Cochrane. Only randomized controlled trials
were considered for effect of treatment.
RESULTS: Possible underlying mechanisms are hormonal, biomechanical, inadequate motor
control and stress of ligament structures. The diagnosis should be based on pain location and
several clinical tests. Characteristic signs are problems with walking, standing and sitting. There
is evidence for the existence of PGP subgroups that require different treatment. It is well
documented that individualized physiotherapy focused on body awareness and specific
functional training, has a good and long-lasting effect. Patients with PGP may benefit from
reassuring information based on medical history and clinical examination. When needed, patients
may be referred to targeted individualized physiotherapy which is continuously evaluated. Few
seem to have effect of general or stabilizing exercises.
INTERPRETATION: General or stabilizing exercises seem to have miner effect
27.05.2013
Diagnosis XXXIX:
Spinal mobilization of postpartum low back and pelvic girdle pain: an evidencebased clinical rule for predicting responders and nonresponders.
PM R. 2010 Nov;2(11):995-1005. doi: 10.1016/j.pmrj.2010.07.481
Al-Sayegh NA, George SE, Boninger ML, Rogers JC, Whitney SL, Delitto A.SourceDepartment of Physical Therapy,
Kuwait University, Faculty of Allied Health Sciences, PO Box 31470, Sulaibikhat 90805, Kuwait
 OBJECTIVE: To develop a clinical prediction rule (CPR) for identifying postpartum women with low back pain
(LBP) and/or pelvic girdle pain (PGP) whose functional disability scores improve with a high-velocity thrust
technique (HVTT) conducted by a physical therapist.
 DESIGN: Prospective cohort.SETTING:Outpatient physical therapy departments.PARTICIPANTS:Sixty-nine
postpartum women referred to physical therapy with the complaint of LBP and/or PGP.
 METHODS:Subjects underwent a physical examination and a HVTT to the lumbopelvic region.
 MAIN OUTCOME MEASURES:Success was determined by the use of percent changes in disability scores and
served as the reference standard for determining accuracy of the examination variables. Variables with univariate
prediction of success and nonsuccess were combined into multivariate CPRs.
 RESULTS:Fifty-five subjects (80%) had success with the HVTT. A CPR for success with 4 criteria was identified.
The presence of 2 of 4 criteria (positive likelihood ratio=3.05) increased the probability of success from 80% to
92%. A CPR for treatment failure with 3 criteria was identified. The presence of 2 of 3 criteria (positive likelihood
ratio=11.79) increased the probability of treatment failure from 20% to 75%.
 CONCLUSIONS:The pretest probability of success (80%) is sufficient to reassure the clinician about the decision
to use a HVTT to the lumbopelvic region in postpartum women with LBP and/or PGP. If 2 of 3 criteria for
treatment failure are met in the CPR, an alternative approach is warranted. An intervention such as the HVTT is
compelling, given the need to minimize pharmaceutical remedies in women who are potentially breast-feeding
post partum.
Copyright © 2010 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved
45
27.05.2013
Diagnosis XXX:
4.3. Pain – Dyspareunia:

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
46
J Obstet Gynaecol Res. 2011 Jul;37(7):750-3. doi: 10.1111/j.1447-0756.2010.01425.x.
Epub 2011 Mar 13.
Effect of transcutaneous electrical nerve stimulation on the
postpartum dyspareunia treatment
Dionisi B, Senatori R.
SourceOutpatient Department of Pelvic Floor Rehabilitation and Vulvar Disease,
Nursing Home Holy Family, Rome, Italy.
b.dionisi@tiscali.itAbstract
27.05.2013
Diagnosis XXXI:
4.3. Pain – Dyspareunia:




AIM:This article will evaluate the safety and efficacy of intravaginal transcutaneous electrical
nerve stimulation (TENS) for the treatment of vulvar pain and dyspareunia during the postpartum
period related to perineal trauma caused by episiotomy.
METHODS: January 2007 to January 2009, 45 women presenting with postpartum dyspareunia
related to perineal trauma after a vaginal delivery were educated on the importance of the pelvic
floor and its part in continuing dyspareunia. The treatment consisted of weekly applications of
intravaginal TENS in an outpatient setting and daily home therapy with myofascial stretching and
exercises of the pelvic floor musculature. The results were evaluated using the cotton swab test,
the Marinoff Dyspareunia Scale and the Visual Analog Scale, and the anovulvar distance was
assessed prior to and at the end of the treatment period.
RESULTS:Of the women included in the study, 84.5% reported an improvement of dyspareunia
after only five applications of TENS, with a total remission of symptoms (in 95% of patients) at
the end of the protocol. At follow-up, eight months after the end of treatment, all patients were
pain free.
CONCLUSIONS:Therapy with intravaginal transcutaneous nerve stimulation and pelvic floor
relaxation exercises is safe and effective in the improvement of vulvar pain and dyspareunia in
women with postpartum perineal trauma due to episiorrhaphy, after spontaneous delivery.
© 2011 The Authors. Journal of Obstetrics and Gynaecology Research © 2011 Japan Society of Obstetrics and
Gynecology
47
27.05.2013
Diagnosis XXXII:
5. Postnatal depression, EBM-background:
 Gaynes BN, Gavin N, Melzer-Brody S, Lohr KN, Swinson T,
Gartlehner G, Brody S, Miller WC
Perinatal depression: prevalence, screening accuracy and screening
outcomes. Summary
Evidence Report/Technology Assessment no.119. Prepared by RTIUniversity of North Carolina Evidence based Practice Center under
contract No.290-02-0016.). AHRQ Publication No.05-E006-1.
 O’Hara M, Swain A.
Rates and risk of postpartum depression–a meta analysis
Int Rev Psychol. 1996;8:37–54. doi: 10.3109/09540269609037816.
48
27.05.2013
Diagnosis XXXIII:
5. Postnatal Depression:
The effectiveness of exercise as a treatment for postnatal depression:
study protocol
BMC Pregnancy Childbirth. 2012 Jun 9;12:45.
Daley AJ, Jolly K, Sharp DJ, Turner KM, Blamey RV, Coleman S, McGuinness M, Roalfe AK, Jones MacArthur C
Source Primary Care Clinical Sciences, School of Health and Population Sciences,
University of Birmingham, Birmingham, UK




49
serious problem wich affects across cultures 10 – 15 % of women
some time in the year after giving birth
208 women with ICD-10 diagnosis of depression,recruitment between
April 2010 an January 2012
a pragmatic two arm randomised controlled trial (individual
randomisation) with participants allocated to usual care plus exercise
or usual care only.
There has been an improvement, but the effect has been better with
additional exercises
27.05.2013
Diagnosis XXXIV:
5. Postnatal Depression:
Does exercise during pregnancy prevent postnatal depression? A
randomized controlled trial
Acta Obstet Gynecol Scand. 2012 Jan;91(1):62-7. doi: 10.1111/j.16000412.2011.01262.x. Epub 2011 Oct 24
Songøygard KM, Stafne SN, Evensen KA, Salvesen KÅ, Vik T, Mørkved
S.SourceLaboratory Medicine, Children's and Women's Health Public Health
and General Practice, Norwegian University of Science and Technology,
Trondheim, Norway.
 OBJECTIVE: To study whether exercise during pregnancy reduces the risk
of postnatal depression.
 DESIGN: Randomized controlled trial.
 SETTING: Trondheim and Stavanger University Hospitals, Norway.
 POPULATION AND SAMPLE: Eight hundred and fifty-five pregnant
women were randomized to intervention or control groups.
50
27.05.2013
Diagnosis XXXV:




METHODS: 12 week exercise program, including aerobic and strengthening
exercises, conducted between week 20 and 36 of pregnancy. One weekly group
session was led by physiotherapists, and home exercises were encouraged twice a
week. Control women received regular antenatal care.
MAIN OUTCOME MEASURES: Edinburgh Postnatal Depression Scale (EPDS)
completed three months after birth. Scores of 10 or more and 13 or more suggested
probable minor and major depression, respectively.
RESULTS: Fourteen of 379 (3.7%) women in the intervention group and 17 of 340
(5.0%) in the control group had an EPDS score of ≥10 (p=0.46), and four of 379
(1.2%) women in the intervention group and eight of 340 (2.4%) in the control group
had an EPDS score of ≥13 (p=0.25). Among women who did not exercise prior to
pregnancy, two of 100 (2.0%) women in the intervention group and nine of 95 (9.5%)
in the control group had an EPDS score of ≥10 (p=0.03).
CONCLUSIONS: We did not find a lower prevalence of high EPDS scores
among women randomized to regular exercise during pregnancy compared
with the control group. However, a subgroup of women in the intervention
group who did not exercise regularly prior to pregnancy had a reduced risk of
postnatal depression.
© 2011 The Authors Acta Obstetricia et Gynecologica Scandinavica © 2011 Nordic Federation of Societies of Obstetrics and
Gynecology.
51
27.05.2013
Resumee I:
1. Prevention:
 Should start in pregnancy with Pelvic floor muscle training for
strength
 Watch behaviour in daily life
 Be aware of combination with other functional problems ( f.e.low
back pain, ISJ-problems)
 An important predictor is strength of pelvic floor muscles
 Be aware of instrumental birth or secondary cesarian sectio either
lacerations or perineal tear
 electrical stimulation or biofeedback
 Test the pelvic floor contractability and power in different position of
lumbar spine and hip joint (Outer Rotation)
 Teach how to use the M. Transversus abdominis
52
27.05.2013
Resumee II:



Include motoric / functional learning in your therapy and exercises
Proof training parameters by individual power, strengths and
endurance in different positions
Medical aids > pro Dry vaginal tampons
3. Fecal incontinence:
 Ask for urinary incontinence, too
 Teach coordination, strength and relaxation
 Behaviour training
 Nutrition informations
 Midcurrent electrical stimulation and biofeedback
 Medical aids: anal tampon
 By skin alterations: interdisciplinary work with doctor or midwife
53
27.05.2013
Resumee III:
4. Pain:
 Be empathic
 Give advice o reduce pain or find comfortable positions
 Create together with the patient a time schedule
 To the right tests after anamesis
 Give electrical stimulation first external, and give the option of
internal probe
 If indicated: perineal massage, internal levator muscle mobilisation
 belts, Interdisciplinary treatment
5. Postnatal depression:
 Be empathic
 Work interdisciplinary
 Easy work out
54
27.05.2013
Postpregnancy treatment regime:
1. Medical and social history
2. Individually Evaluation of the
Dysfunction
3. Physiotherapy treatment
4. Behaviour modification
5. Interdisciplinary networking
55
27.05.2013
Thank you for your attendence!
Any for further questions?
send an email to: s.soeder@alexius.de
56

Sonja Soeder - IUGA 38th Annual Meeting

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