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Common Forms Section on Women’s Health
Section on Women’s Health Certificate of Achievement in Pelvic Physical Therapy Common Forms These files are provided to enhance learning and provide resources for course participants. These files will be reviewed in level 1 and referred to in the other levels. Please print them out and bring them to the courses. Forms may be used by participants in their entirety without changes and with credit to the SOWH. Anatomy Charts Hips PFM – with pelvic nerves Trunk Anal Clinical Forms Bladder record Bladder record assessment sheet Voiding diary Menstrual diary PFM intake questionnaire PFM initial evaluation PFM examination consent Bladder treatment program Pelvic PT Outcomes measures Continence Grading Scale NIH-CPSI Female NIH-CPSI Male Pain Disability Index Patient specific functional scale PFDI 20 o PFDI 20 scoring PFIQ 7 o PFIS 7 scoring PSIQ 12 o PSIQ 12 scoring Urogenital Distress Inventory Vulvar Pain Functional Questionnaire Other Resources Documentation Organizations and resources for Pelvic PT Book list Position statement on internal exam JWHPT instructions for authors Reporting Services to third party payors 1 1 1 Hip Muscles Lower Limb Muscle Piriformis Attachment Attachment Nerve Segmental Innervation Function Round pattern lateral to lower sacrum and posterolateral to hip, posterior buttock, and thigh External rotation of hip when hip extended; internal rotation of hip flexed; assists in hip abduction Medial: ventral surface of sacrum from segments S2-S4; sacrotuberous ligament Lateral: superior aspect of greater trochanter of femur Nerve to piriformis Obturator internus Medial: pelvic cavity margin of obturator foramen and the surface of obturator membrane Lateral: medial aspect of greater trochanter of femur with superior and inferior gemelli Nerve to obturator L5, S1, S2 internus Round pattern around coccyx, upper half of posterior thigh External rotation of femur Femoral Vertical band from L1 to sacroiliac joint along region of transverse processes; upper middle 1/3 of anterior thigh Flexion of hip; flexion and lateral bending of lumbar spine Iliopsoas Iliacus: iliac fossa, Tendon of psoas ala of sacrum, major sacroiliac ligament; anterior inferior iliac spine S1, S2 Referred Pain (Travell and Simons 1992) L2, L3 L2, L3, L4 Psoas major: Lesser trochanter transverse process of femur of L1-L5 2 Anatomy Tables: Hip Muscles Lower Limb Muscle Attachment Attachment Nerve Segmental Innervation Referred Pain (Travell and Simons 1992) Function Gluteus maximus Posterior iliac crest, sacrum, coccyx, sacrotuberous ligament Iliotibial band, Inferior gluteal gluteal tuberosity of femur L5, S1, S2 Round pattern over lower sacrum, lower medial buttock, and ischial tuberosity; curved band from lateral sacrum to ischial tuberosity Extension and external rotation of femur; trunk extension; controls trunk flexion Gluteus medius External ilium below iliac crest and between anterior and posterior gluteal lines Lateral aspect of Superior gluteal greater trochanter of femur L4, L5, S1 Band pattern along posterior iliac crest, lateral sacrum, and lower posterior buttock; round pattern over sacrum, upper lateral thigh, and lower posterior buttock Abduction and internal rotation of femur; lateral stability of pelvis Gluteus minimus External ilium caudal to medius and between anterior and inferior gluteal lines Anterior aspect of Superior gluteal greater trochanter of femur L4, L5, S1 Round pattern in lower posterior buttock Abduction and internal rotation of femur; lateral stability of pelvis 3 Anatomy Tables: Hip Muscles Lower Limb Muscle Attachment Attachment Nerve Segmental Innervation Referred Pain (Travell and Simons 1992) Function Obturator externus External obturator Intertrochanteric foramen and fossa obturator membrane Obturator L2, L3, L4 Band pattern along External rotation upper lateral thigh, of femur upper posterior thigh, lateral and posterior knee, and lateral and posterior lower leg Pectineus Superior pelvic ramus along pectineal line Pectineal line of femur Femoral L2, L3, L4 Round pattern in medial 1/3 of inguinal region extending into upper most anterior thigh Flexion and adduction of hip; assists in medial rotation Adductor longus Body of pelvic bone Middle medial lip Obturator of linea aspera of femur L2, L3, L4 Oval pattern just inferior to inguinal ligament; round pattern to anterior knee just superior to patella Adduction of hip; assists in flexion and medial rotation of hip Adductor brevis Body and inferior Pectineal line, Obturator ramus of pubic proximal medial bone lip of linea aspera L2, L3, L4 Same as adductor longus Adduction of hip; assists in flexion and medial rotation of hip 4 Anatomy Tables: Hip Muscles Lower Limb Muscle Attachment Adductor magnus Inferior pubic ramus, ischial ramus, ischial tuberosity Attachment Nerve Gluteal tuberosity Obturator, L4 of medial linea tibial nerve aspera and supracondylar ridge, adductor tubercle Segmental Innervation Referred Pain (Travell and Simons 1992) Function L2, L3, L4 Band pattern from medial 1/3 of inguinal region along anteromedial thigh; intrapelvic area along anus, rectum, and bladder Adduction of hip; assists in hip extension and medial rotation Gracilis Body and inferior Proximal medial ramus of pubic tibial shaft, pes bone anserine Obturator L2, L3, L4 Band pattern in middle 1/3 of medial thigh Hip adduction; assists in knee flexion and medial tibial rotation Rectus femoris Anterior inferior iliac spine, superior acetabulum Superior patella by quadriceps tendon, tibial tuberosity by patellar ligament Femoral L2, L3, L4 Band pattern in lower 2/3 of middle anterior thigh, anterior patella Extension of knee; flexion of hip Semitendinous Ischial tuberosity of femur Proximal medial tibial shaft, pes anserine Tibial L5, S1, S2 Band pattern along Knee flexion; hip all of extension; medial posteromedial tibial rotation thigh and upper 1/3 of posteromedial lower leg 5 Anatomy Tables: Hip Muscles Lower Limb Muscle Attachment Semimembranous Ischial tuberosity of femur Biceps femoris long head short head Attachment Nerve Segmental Innervation Referred Pain (Travell and Simons 1992) Function Posterior aspect on medial tibial condyle Tibial L5, S1, S2 Same as semitendinous Knee flexion; hip extension; medial tibial rotation Ischial tuberosity, Lateral tibial sacrotuberous condyle, lateral ligament side of fibular head Tibial L5, S1, S2 Lateral lip of linea aspera, lateral supracondylar ridge Common peroneal Band pattern along Knee flexion; hip all of posterolateral extension; lateral thigh and tibia rotation posterolateral popliteal fossa Travell J, Simons D. Myofascial Pain and Dysfunction Trigger Point Manual. 2nd ed. Baltimore, Md: Williams & Wilkins; 1992. Please note: The literature on anatomy varies. Ongoing research and discussion about muscle function, terminology, and innervations sometimes results in conflicting information. The CAPP committee has tried to present the most accepted information. 6 Anatomy Tables: Hip Muscles Pelvic Floor Muscles Muscle Layer Muscle Attachment Pelvic diaphragm Pubococcygeus Levator ani Puboperinealis portion Anterior: pubis Pelvic diaphragm Pubococcygeus Levator ani Pubovaginalis portion Anterior: pubis Pelvic diaphragm Pubococcygeus Levator ani Puboanalis portion Anterior: pubis Attachment Nerve Segmental Innervation Posterior: perineal Nerve to levator body ani Pudendal S3, S4 Medial: midurethral vaginal wall Nerve to levator ani Pudendal S3, S4 Posterior: intersphincteric groove Nerve to levator ani Pudendal S3, S4 Pelvic diaphragm Puborectalis Levator ani Anterior: superior Posterior: right Nerve to levator pubic ramus and left ani puborectalis join Pudendal to form a sling around the anorectal junction S3, S4 Pelvic diaphragm Iliococcygeus Levator ani Medial: coccyx; anococcygeal ligament Nerve to levator ani Pudendal S3, S4 Sacral nerves S3, S4, S5 Lateral: thick tendinous arch from obturator internus fascia; ischial spine Pelvic diaphragm Coccygeus Medial: lower Lateral: ischial Levator ani (ischiococcygeus) lateral sacrum and spine; upper coccyx sacrospinous ligament S2, S3, S4 S2, S3, S4 S2, S3, S4 S2, S3, S4 S2, S3, S4 Function Pulls perineal body toward pubis Elevates midurethral vagina Elevates anal canal Forms the anorectal angle; closes the pelvic floor Elevates pelvic floor; supports pelvic viscera Stabilizes coccyx; supports pelvic viscera Anatomy Tables: Pelvic Floor Muscles and Pelvic Nerves 7 Perineal membrane Sphincter urethrae Anterior: pubic Posterior: trigonal Pudendal arch and upper ⅔ ring of urethra S2, S3, S4 Constricts urethra Perineal membrane Compressor urethrae Anterior: Posterior: urethra Pudendal ischiopubic ramus S2, S3, S4 Compresses urethra Perineal membrane Urethrovaginal sphincter Medial: vaginal wall Posterior: urethra Pudendal S2, S3, S4 Compresses urethra Lateral: ischial tuberosity Medial: perineal body Pudendal S2, S3, S4 Supports perineal body Superficial genital Bulbocavernosus Lateral: fascia of muscles corpus cavernosum Medial: perineal body Pudendal S2, S3, S4 Clitoral erection Superficial genital Ischiocavernosus Anterior: crus of muscles the clitoris Posterior: ischial tuberosity Pudendal S2, S3, S4 Clitoral erection Superficial genital Superficial muscles transverse perineal Ashton-Miller JA, Howard D, DeLancey JO. The functional anatomy of the female pelvic floor and stress continence control system. Scand J Urol Nephrol Suppl. 2001;207:1–125. Kerney R, Sawhney R, DeLancey J. Levator ani muscle anatomy evaluated by origin-insertion pairs. Obstet Gynecol. 2004;104:168– 173. Wei JT, DeLancey JO. Functional anatomy of the pelvic floor and lower urinary tract. Clin Obstet Gynecol. 2004;47:3–17. Please note: The literature on anatomy varies. Ongoing research and discussion about muscle function, terminology, and innervations sometimes results in conflicting information. The CAPP committee has tried to present the most accepted information. Anatomy Tables: Pelvic Floor Muscles and Pelvic Nerves 8 Pelvic Nerves Nerve Spinal Level Pathway Innervation Trauma Iliohypogastric L1 Anterior to quadratus lumborum, Skin above pubic bone pierces internal oblique muscle and Lower abdominal muscles travels between the internal and Posterior gluteal region external oblique muscles to the superior pubic bone Transverse incision with retractors During closure of transverse incisions Sutures of needle urethropexies Ilioinguinal Anterior to quadratus lumborum, Mons pubis inferior to iliohypogastric, pierces External genitalia the transversus muscle and travels Upper medial thigh between the transversus and internal oblique muscles through the inguinal canal to the mons pubis Transverse incision with retractors During closure of transverse incisions Sutures of needle urethropexies Lateral femoral L2, L3 cutaneous Anterior to quadratus lumborum, posterior to psoas, inferior to ilioinguinal, anterior to iliacus, under inguinal ligament Lateral and anterior thigh to the knee Positioning during gynecological surgeries, especially extreme hip flexion Femoral L2, L3, L4 Through psoas, anterior to iliacus, under inguinal ligament Quadriceps, sartorius pectineus, iliacus muscles Cutaneous medial anterior thigh and medial lower leg Knee joint Hyperflexion of hip and knee such as in labor Diabetic neuropathy Deep lateral retractors with transverse gynecological incision Genitofemoral L1, L2 Through psoas, anterior to psoas, under inguinal ligament Upper anterior thigh: femoral Lateral retractors during branch gynecological surgeries Mons pubis: genital branch Harvesting of external iliac lymph nodes L1 Anatomy Tables: Pelvic Floor Muscles and Pelvic Nerves 9 Obturator internus L2, L3, L4 Through psoas, exiting posterior to travel just anterior to the sacroiliac joint, anterior to obturator internus muscle, and through the obturator notch Adductor muscles Cutaneous medial thigh Pelvic node dissection Deep pelvic retractors Dissection in the space of Retzius Pudendal S2, S3, S4 Through the greater sciatic notch, around ischial spine, back in through lesser sciatic notch, behind sacrospinous ligament, curves anterior along the medial ischial tuberosity within Alcock’s canal, turns superior to the ischioanal fossa Superficial perineal and perineal membrane muscles: perineal branch External anal sphincter: inferior rectal branch Cutaneous perineal area and clitoris Pelvic diaphragm (?) Chronic constipation and straining Prolonged and difficult labor and delivery Deep mediolateral episiotomy Nerve to pelvic S3, S4 diaphragm Nerve root directly off sacral plexus Pelvic diaphragm muscles: to muscle levator ani and coccygeus Chronic constipation and straining Prolonged and difficult labor and delivery Possibly deep pelvic surgery Barber M, Bremer R, Thor K, Dolber P, Kuehl T, Coates K. Innervation of the female levator ani muscles. Am J Obstet Gynecol. 2002;187:64–71. Steege J, ed. Chronic Pelvic Pain: An Integrated Approach. Philadelphia, Pa: W B Saunders Co; 1998. Please note: The literature on anatomy varies. Ongoing research and discussion about muscle function, terminology, and innervations sometimes results in conflicting information. The CAPP committee has tried to present the most accepted information. Anatomy Tables: Pelvic Floor Muscles and Pelvic Nerves 10 Trunk Muscles Trunk Muscle Attachment Rectus abdominus Pubic symphysis and pubic crest External abdominal oblique Internal abdominal oblique Attachment Nerve Xiphoid and Intercostal costal cartilage of nerves T6-T11 ribs 5, 6, 7 Segmental Referred Pain Innervation (Travell and Simons 1992*) Function T6-T12 Wide posterior band across ilium, SI joint, sacrum; wide band across lower 4 ribs and thoracic vertebrae; oval pattern between umbilicus and pubic Bilaterally forward trunk flexion; posterior pelvic tilt; stabilization of pelvis and trunk Bodies of ribs 5-12 Linea alba, Intercostal anterior iliac nerves T6-T11, crest, anterior iliohypogastric superior iliac spine, pubic tubercle by inguinal ligament T6-L1 Band pattern from xiphoid to along costal cartilage of lower anterior rib cage and along entire inguinal region Bilaterally forward trunk flexion; unilaterally lateral trunk flexion to same side and rotation to opposite side; posterior pelvic tilt; stabilizes pelvis and trunk; supports the viscera Thoracolumbar fascia, anterior iliac crest, lateral inguinal ligament T6-L1 Same as external abdominal oblique Same as external abdominal oblique Costal surface of ribs 9-12, linea alba, superior pubic ramus along pectineal line Intercostal nerves T6-T11, subcostal, ilioinguinal iliohypogastric Anatomy Tables: Trunk Muscles 11 Transversus abdominus Thoracolumbar fascia, anterior iliac crest, lateral inguinal ligament, costal cartilages of ribs 7-12 into diaphragm Linea alba, aponeurosis fusing with the fascia of the obliques and rectus, pubic crest Intercostal nerves T6-T11, subcostal, ilioinguinal iliohypogastric T6-L1 Same as external abdominal oblique Supports viscera; decreases infrasternal angle with exhale; stabilizes SI and trunk; synergistic with PFM Quadratus lumborum Iliac crest lateral to Medial aspect of Ventral rami of erector spinae, rib 12, transverse L1-L4 iliolumbar ligament processes of L1L4 L1-L4 Band pattern along iliac crest and lower lateral buttock; round pattern over lower posterior buttock and SI joint Bilaterally extends trunk; unilaterally flexes to same side and controls lateral flexion to opposite side Multifidus lumborum Posterior sacrum, Spinous processes Dorsal rami of Lumbar Round pattern over Bilaterally extends posterior superior of vertebrae 1-4 spinal nerves levels lateral ½ of sacrum trunk; unilaterally iliac spine, posterior levels superior to crossed by crossed by and coccyx, SI joint, rotates and controls sacroiliac ligament, first attachment muscle muscle posterior iliac crest lateral flexion to mamillary process opposite side L1-L5 * Travell J, Simons D. Myofascial Pain and Dysfunction Trigger Point Manual. 2nd ed. Baltimore, Md: Williams & Wilkins; 1992. Please note: The literature on anatomy varies. Ongoing research and discussion about muscle function, terminology, and innervations sometimes results in conflicting information. The CAPP committee has tried to present the most accepted information. Anatomy Tables: Trunk Muscles 12 Anal Muscles Muscle Attachment Attachment Nerve Segmental Innervation S2, 3, 4 Function External anal sphincter (EAS) Deep or upper loop EAS Superficial or middle loop Superficial transverse perineal muscle and perineal body Puborectalis muscle Inferior rectal nerve branch of pudendal nerve Tip of coccyx via the anococcygeal ligament Perineal body Inferior rectal nerve branch of pudendal nerve S2, 3, 4 Closure of the anal canal: 20% EAS Subcutaneous or basal loop Internal anal sphincter (IAS) Involuntary Circumferential striated fibers attached to the skin Continuation of rectal smooth muscle Inferior rectal nerve branch of pudendal nerve Inferior hypogastric plexus or pelvic plexus S2, 3, 4 Closure of the anal canal: 20% T12-L2 Provides 80% of resting anal pressure/tone Closure of the anal canal: 20% Please note: The literature on anatomy varies. Ongoing research and discussion about muscle function, terminology, and innervations sometimes results in conflicting information. The CAPP committee has tried to present the most accepted information. Anatomy Tables: Anal Muscles 13 Bladder Record Name: ______________________________________________________________ Date: __________________________ Date: ___________________________ Amount Urinate of leak / in toilet accident Activity during leak Drink type/ amount Amount Urinate of leak / in toilet accident Activity during leak Drink type/ amount 6 AM 6 AM 7 AM 7 AM 8 AM 8 AM 9 AM 9 AM 10 AM 10 AM 11 AM 11 AM 12 AM 12 AM 1 PM 1 PM 2 PM 2 PM 3 PM 3 PM 4 PM 4 PM 5 PM 5 PM 6 PM 6 PM 7 PM 7 PM 8 PM 8 PM 9 PM 9 PM 10 PM 10 PM 11 PM 11 PM 12 PM 12 PM 1 AM 1 AM 2 AM 2 AM 3 AM 3 AM 4 AM 4 AM 5 AM 5 AM Total Total Number of pads used: _____________ Number of pads used: ________________ 2 14 14 Bladder diary assessment sheet Patient name ___________________________________________________________ Date Date Daytime frequency Nocturia 24-hour frequency Average voiding interval Minimum voiding interval Maximum voiding interval Average voided volume Minimum voided volume Maximum voided volume Total incontinence episodes Small leaks Medium leaks Large leaks Cause of leakage Total fluid intake Irritant intake Timing of fluid intake Diagnosis Proposed fluid changes Proposed bladder schedule 3 15 15 Voiding Diary Date: Name: Please keep track of your fluid and food intake and the amount of urine voided, amount of leakage, the activity when the leakage occurred, and if an urge was present. Do this for 4 days. Date / time of day Type and amount of fluid intake Type and amount of food eaten Amount voided (small, medium, large) Amount of leakage (small, medium, large) Activity engaged in when leakage occurred Was an urge present? (Yes or No) Change of pad? 4 16 16 Menstrual diary Patient name __________________________________ Month Month Symptom → Day ↓ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Comments 5 17 17 Pelvic Floor Therapy Questionnaire Patient name __________________________________ Date ______________________ Please fill in the following questionnaire to the best of your ability. The therapist will review the answers with you at your appointment. History Number of pregnancies _______________ Number of vaginal deliveries ____________ Birth weight of largest baby ___________ Number of cesarean deliveries ___________ Number of episiotomies ______________ Date of last pap smear _________________ Did you have any trouble healing after delivery Y N Do you have a history of sexual abuse or trauma Y N Are you having regular periods/ menstrual cycles Y N Do you have frequent urinary tract infections Y N Pain Do you have pain with: Sexual intercourse Y N Pelvic exam Y N Tampon use Y N Back, leg, groin, abdominal pain Y N Test results Urodynamics test Y N Results: _______________________ Cystoscope Y N Results: _______________________ Urine test Y N Results: _______________________ Bowel test Y N Results: _______________________ 6 18 18 Bladder symptoms Do you lose urine when you: Cough/ sneeze/ laugh Y N Lift/ exercise/ dance/ jump Y N On the way to the bathroom Y N Have a strong urge to urinate Y N Hear running water N Other __________________ Y N Y Do you wet the bed Y N Have burning/ pain with urination Y N Difficulty starting a stream of urine Y N Strain to empty your bladder Y N Feel unable to empty bladder fully Y N Have a falling out feeling Y N Have pain with a full bladder Y N Have an urgency of urination (a strong urge to urinate) Y N Urinate more than 7 times/day Y N Strain to have a bowel movement Y N Leak / stain feces Y N Include fiber in your diet Y N Have diarrhea often Y N Take laxatives / enema regularly Y N Leak gas by accident Y N Have pain with bowel movement Y N Bowel symptoms Have a very strong urge to move your bowels Y N How often do you move your bowels: _____________ per day, week Most common stool consistency ____ liquid ___ soft ___ firm ___ pellets ___ other ___________ Thank you for taking the time to fill out this questionnaire. 7 19 19 Pelvic Floor Physical Therapy Evaluation Name: Date: DR: Next visit with DR: Family DR: Medical DX: PT DX: Prescription: HPI: Tests: PMH GYN: PMH OB: PMH: SOC: UI SX: ___ stress sx ___ urge sx ___ retention sx ___ prolapse sx QOL results SX score Bowel SX: ___ constipation ___ leakage ___ pain Pain: ___ dyspareunia Pain: ___ low back, buttock ___ abdomen ___ other Informed consent for internal evaluation consent given External observation: Introitus: Resting position: Voluntary contraction: absent Involuntary contraction: absent Involuntary relaxation: absent Perineal descent: rest absent Perineal descent: bearing absent present present present present present Introitus clock: Skin condition: Scarring: Other: Skin condition: Other: ___________________ scar +++, pain x, skin color /// 8 20 20 Pelvic floor: Vaginal vault size: Muscle volume: PFM tone: decreased decreased decreased increased WNL increased WNL defect WNL Pelvic floor clock: scar +++ pain x Contraction ability: spasm ~ Voluntary contraction: absent weak moderate strong MMT: ____ R, ____ L Voluntary relaxation: absent partial complete Muscle endurance: ______ seconds right, ______seconds left Number of quick contractions in 10 seconds _____ Brink score: time ___ displacement ___ pressure ____ Tissue laxity test: Anterior wall: min mod severe WNL Posterior wall: min mod severe WNL Urethra: min mod severe WNL Quality of contractions: Overflow: Treatment today: __ Evaluation / examination __ Bladder and PFM education Bladder diary results: __ Bladder diary given __ PFM exercises # large leaks / 24 hrs # small leaks / 24 hrs Minimum voided volume Fluid intake / 24 hrs # void / 24 hrs # medium leaks / 24 hrs Minimum voided interval Average voided interval Irritant intake / 24 hrs SEMG evaluation: date uV Resting tone Quality / rest: irregular, elevated, WNL uV 5-second hold uV 10-second hold Quality of: Recruitment: Derecruitment: Holding: Stability of hold: Stability of rest: Baseline b/t contract: Overflow: absent slow slow poor poor poor poor min fair fair fair fair fair fair mod good good good good good good severe Assessment: PFM dysfunction: non-contracting PFM non-relaxing PFM non-contracting, non-relaxing PFM PFM condition: underactive PFM overactive PFM non-functioning PFM Rehabilitation potential: excellent good fair poor Symptoms of abuse: absent present ___________________________________ Learning barriers: absent present ___________________________________ Obstacles to rehabilitation: _______________________________________________________ 9 21 21 Clinical Problem List Joint dysfunction _________________________ Muscle spasm ___________________________ Abdominal / perineal scar adhesion __________ Poor trunk stability Decreased PFM strength Decreased PFM endurance ___ seconds PFM trigger point / pain _________________ Increased PFM resting tone ________________ Initial symptom index ___ Initial QOL index ___ Increased tissue laxity: anterior, posterior, urethra Increased overflow with PFM contraction Decreased relaxation ability Decreased involuntary contraction / relaxation ____________________________________ ____________________________________ Clinical Goals ____________________________________ ____________________________________ Normalize scar mobility Improve trunk stability PFM strength: normal, strong PFM contraction ___ seconds hold with good quality Decrease PFM pain Normalize PFM tone Discharge symptom index: improved ____ points Discharge QOL index: improved ____ points Improved support of the PFM Good isolation of PFM Improved relaxation ability Improved involuntary contraction / relaxation ________________________________________ ________________________________________ Functional problem list Decreased sexual activity due to pain Decreased tolerance for vaginal penetration Limited social activities due to UI or pain Min Decreased sitting ability Min Decreased standing ability pain Decreased sleeping ability Sleep disturbed by nocturia ___ x / night minutes / miles Decreased walking distance Decreased ability for basic ADLs leakage/ pain Functional goals Resume sexual activity with ____ / 10 pain Able to insert # ___ dilator with ___ / 10 pain Social activity not limited by UI or pain Sitting ability minutes for work, travel, social Standing minutes for work, home social Sleeping hours per night Nocturnal voiding ___ x / night for improved sleep Walking minutes / miles Basic ADLs with ___ /10 pain / ___ % decreased leakage Advanced ADLs with ___ /10 pain / ____ % decreased leakage hour work day Able to tolerate ___ hour voiding schedule Good knowledge of PFM contraction Good knowledge of PFM relaxation PFM contraction before increased intra-abdominal pressure Good fluid intake Good knowledge of posture and body mechanics Good knowledge of self-help Discharge functional index / QOL score ___ ______________________________________ ______________________________________ Decreased ability for advanced ADLs leakage/pain Decreased tolerance for work Urinary frequency Poor knowledge of PFM contraction Poor knowledge of PFM relaxation Poor timing of PFM contraction with cough, etc Poor fluid intake and irritant intake Poor knowledge of posture and body mechanics Poor knowledge of self-help Initial functional index / QOL score ___ _____________________________________ _____________________________________ Treatment plan: Frequency: ________________ __ Neuromuscular reeducation __ Manual therapy __ Therapeutic activities __ Other Duration: ___________________ __ Therapeutic exercise __ Education __ Modalities __ Bladder training and fluid education Signature: ____________________________ Date: _____________________________ 10 22 22 PELVIC FLOOR CONSENT FOR EVALUATION AND TREATMENT I acknowledge and understand that I have been referred for evaluation and treatment of pelvic floor dysfunction. Pelvic floor dysfunctions include, but are not limited to, urinary or fecal incontinence; difficulty with bowel, bladder, or sexual functions; painful scars after childbirth or surgery; persistent sacroiliac or low back pain; or pelvic pain conditions. I understand that to evaluate my condition it may be necessary, initially and periodically, to have my therapist perform an internal pelvic floor muscle examination. This examination is performed by observing and/or palpating the perineal region including the vagina and/or rectum. This evaluation will assess skin condition, reflexes, muscle tone, length, strength and endurance, scar mobility, and function of the pelvic floor region. Such evaluation may include vaginal or rectal sensors for muscle biofeedback. Treatment may include, but not be limited to, the following: observation, palpation, use of vaginal weights, vaginal or rectal sensors for biofeedback and/or electrical stimulation, ultrasound, heat, cold, stretching and strengthening exercises, soft tissue and/or joint mobilization, and educational instruction. I understand that in order for therapy to be effective, I must come as scheduled unless there are unusual circumstances that prevent me from attending therapy. I agree to cooperate with and carry out the home program assigned to me. If I have difficulty with any part of my treatment program, I will discuss it with my therapist. 1. The purpose, risks, and benefits of this evaluation have been explained to me. 2. I understand that I can terminate the procedure at any time. 3. I understand that I am responsible for immediately telling the examiner if I am having any discomfort or unusual symptoms during the evaluation. 4. I have the option of having a second person present in the room during the procedure and _____ choose _____ refuse this option. Date: Patient Name: Patient Signature Signature of Parent or Guardian (if applicable) Witness Signature 11 23 23 Date Name BLADDER TREATMENT PROGRAM Voiding Schedule Fluid Intake Increase intake of: Decrease intake of: Pelvic floor muscle exercises / Kegels Short: hold ___ seconds relax ____ seconds repeat ___ times Long: hold ___ seconds relax ____ seconds repeat ___ times Other Biofeedback / Electrical stimulation / Vaginal weights Abdominal muscle exercises Other 12 24 24 Continence Grading Scale: A Symptom Index (Jorge 1993) Never Incontinence for solid stool Incontinence for liquid stool Incontinence for gas Alteration in lifestyle Rarely 0 0 0 0 1 1 1 1 Sometimes Weekly 2 2 2 2 3 3 3 3 No 0 0 0 Need to wear pad or plug Taking constipation medicines Lacking the ability to defer defecation for 15 minutes Daily 4 4 4 4 Yes 2 2 4 Never = no episodes in the past 4 weeks Rarely = 1 episode in the past 4 weeks Sometimes = more than 1 episode in the past 4 weeks but less than once per week Weekly = 1 or more episodes per week but less than daily Daily = 1 or more episodes per day Scoring: add one score from each row Minimum score: 0 = perfect continence Maximum score: 24 = totally incontinent Jorge JM, Wexner SD. Etiology and management of fecal incontinence. Dis Colon Rectum. 1993;36(1):77-97. 13 25 25 Female NIH-Chronic Prostatitis Symptom Index (NIH-CPSI) Center for Urologic and Pelvic Pain Name: ____________________________ Date: _____________________________ Pain or Discomfort 1. In the last week, have you experienced any pain or discomfort in the following areas? Yes No a. Area between rectum and 1 0 vagina (perineum) b. Labia 1 0 c. Clitoris (not related to urination) 1 0 d. Below your waist in your pubic area 1 0 e. Below your waist in your rectal area 1 0 2. In the last week, have you experienced: a. Pain or burning during urination? b. Pain or discomfort during or after sexual climax? Yes No 1 0 1 0 6. How often have you had to urinate again less than two hours after you finished urinating, over the last week? 0 Not at all 1 Less than 1 time in 5 2 Less than half the time 3 About half the time 4 More than half the time 5 Almost always Impact of Symptoms 7. How much have your symptoms kept you from doing the kinds of things you would usually do, over the last week? 0 None 1 Only a little 2 Some 3 A lot 8. How much did you think about your symptoms, over the last week? 0 None 1 Only a little 2 Some 3 A lot 3. How often have you had pain or discomfort in any of these areas over the last week? 0 1 2 3 4 5 Never Rarely Sometimes Often Usually Always Quality of Life 9. If you were to spend the rest of your life with your symptoms just the way they have been during the last week, how would you feel about that? 0 Delighted 1 Pleased 2 Mostly satisfied 3 Mixed (about equally satisfied and dissatisfied) 4 Mostly dissatisfied 5 Unhappy 6 Terrible 4. Which number best describes your AVERAGE pain or discomfort on the days that you had it, over the last week? 0 1 2 3 4 5 6 7 8 9 10 NO PAIN PAIN AS BAD AS YOU CAN IMAGINE Urination 5. How often have you had a sensation of not emptying your bladder completely after you finished urinating, over the last week? 0 Not at all 1 Less than 1 time in 5 2 Less than half the time 3 About half the time 4 More than half the time 5 Almost always or always Scoring the NIH-Chronic Prostatitis Symptom Index Domains Pain: Total of items 1a, 1b, 1c, 1d, 1e, 2a, 2b, 3, and 4 =____ Urinary Symptoms: Total of items 5 and 6 =____ Quality of Life Impact: Total of items 7, 8, and 9 =____ Adapted from Litwin et al. J Urol. 1999;162:369-375 26 26 NIH-Chronic Prostatitis Symptom Index (NIH-CPSI) (for males) Center for Urologic and Pelvic Pain Name: ____________________________ Date: _____________________________ Pain or Discomfort 6. How often have you had to urinate again less than two hours after you finished urinating, over the last week? 0 Not at all 1 Less than 1 time in 5 2 Less than half the time 3 About half the time 4 More than half the time 5 Almost always 1. In the last week, have you experienced any pain or discomfort in the following areas? Yes No a. Area between rectum and 1 0 testicles (perineum) b. Testicles 1 0 c. Tip of the penis (not related to urination) 1 0 d. Below your waist, in your pubic or bladder area 1 0 2. In the last week, have you experienced: Yes a. Pain or burning during urination? 1 b. Pain or discomfort during or after sexual climax (ejaculation)? 1 Impact of Symptoms 7. How much have your symptoms kept you from doing the kinds of things you would usually do, over the last week? 0 None 1 Only a little 2 Some 3 A lot No 0 0 8. How much did you think about your symptoms, over the last week? 0 None 1 Only a little 2 Some 3 A lot 3. How often have you had pain or discomfort in any of these areas over the last week? 0 Never 1 Rarely 2 Sometimes 3 Often 4 Usually 5 Always Quality of Life 9. If you were to spend the rest of your life with your symptoms just the way they have been during the last week, how would you feel about that? 0 Delighted 1 Pleased 2 Mostly satisfied 3 Mixed (about equally satisfied and dissatisfied) 4 Mostly dissatisfied 5 Unhappy 6 Terrible 4. Which number best describes your AVERAGE pain or discomfort on the days that you had it, over the last week? 0 1 2 3 4 5 6 7 8 9 10 NO PAIN PAIN AS BAD AS YOU CAN IMAGINE Urination 5. How often have you had a sensation of not emptying your bladder completely after you finished urinating, over the last week? 0 Not at all 1 Less than 1 time in 5 2 Less than half the time 3 About half the time 4 More than half the time 5 Almost always Scoring the NIH-Chronic Prostatitis Symptom Index Domains Pain: Total of items 1a, 1b, 1c,1d, 2a, 2b, 3, and 4 =____ Urinary Symptom s: Total of items 5 and 6 =____ Quality of Life & Impact: Total of items 7, 8, and 9 =____ Adapted from Litwin et al. J Urol. 1999;162:369-375 . 27 27 Name: __________________________________ Date: ________________________ Pain Disability Index In order to determine how effective your treatment is, we need to know how much pain is interfering in your normal activities. For the 7 areas listed below, please circle the number on the scale which describes the level of disability you have experienced in each area OVER THE PAST WEEK. A score of “0” means no disability at all, and a score of “10” indicates that all of the activities which you would normally do have been totally disrupted or prevented by your pain over the past week. Circle “0” if a category does not apply to you. Family/Home Responsibilities: This category refers to activities related to the home or family. It includes chores or duties performed around the house (e.g. yard work, house cleaning) and errands or favors for other family members (e.g. driving the children to school. 0 1 No Disability 2 3 4 Mild 5 6 Moderate 7 8 Severe 9 10 Total Disability Recreation: This category includes hobbies, sports, and other similar leisure time activities. 0 1 No Disability 2 3 4 Mild 5 6 Moderate 7 8 Severe 9 10 Total Disability Social Activity: This category refers to activities which involve participation with friends and acquaintances other than family members. It includes parties, theater, concerts, dining out, and other social functions. 0 1 No Disability 2 3 4 Mild 5 6 Moderate 7 8 Severe 9 10 Total Disability Occupation: This category refers to activities that are a part of or directly related to one’s job. This includes non-paying jobs as well, such as housewife or volunteer worker. 0 1 No Disability 2 3 4 Mild 5 6 Moderate 7 8 Severe 9 10 Total Disability Sexual Behavior: This category refers to the frequency and quality of one’s sex life. 0 1 No Disability 2 3 4 Mild 5 6 Moderate 7 8 Severe 9 10 Total Disability Self-Care: This category includes activities which involve personal maintenance and independent daily living (e.g. taking a shower, driving, getting dressed). 0 1 No Disability 2 3 4 Mild 5 6 Moderate 7 8 Severe 9 10 Total Disability Life-Support Activity: This category refers to basic life-supporting behaviors such as eating and sleeping. 0 1 No Disability 2 3 Mild Total Score: _____________________ 4 5 6 Moderate 28 28 7 8 Severe 9 10 Total Disability Pain Disability Index 03-07 PDI Scoring: Scores for each item are summed. Higher score = higher disability. Tait RC, Pollard CA, Margolis RB, Duchro PN, Krause SJ. The pain disability index: psychometric and validity data. Arch Phys Med Rehabil. 1987;68:438-441. 15 30 29 Patient Specific Functional Scale (PSFS) Read at Baseline Assessment I’m going to ask you to identify up to 3 important activities that you are unable to do or are having difficulty with as a result of your _____________ problem. Today, are there any activities that you are unable to do or have difficulty with because of your ________________ problem. Try to be specific and descriptive eg. I have difficulty sitting for 15 minutes Activity #1 Activity #2 Activity #3 Patient Specific Activity Scoring Scheme (Point to a number): 10 9 8 7 6 5 4 3 2 1 0 Able Minimal difficulty Moderate difficulty Severe difficulty Unable to to perform activity to perform activity to perform activity to perform perform activity This is not a pain rating scale. The key is “how much difficulty”. This does not work with urinary incontinence, fecal incontinence, or constipation. It is best to administer the PSFS following the history but prior to the physical examination. It appears that when the PSFS is administered following the physical exam, patients often select activities which are of more (perceived) interest to the therapist rather than the patient. (trying to please) Minimal clinical significant change is 3 points on any one activity scale. For example: I have difficulty sitting for 15 minutes o Initial rating 6 - This would mean I can sit for 15 minutes but it is moderately difficult. o Discharge rating 9 – I can sit for 15 minutes with minimal difficulty I have difficulty lifting 25 pounds from the floor o Initial rating 0 – This would mean I am currently unable to perform this task o Progress rating 3 – I can lift 25 pounds from the floor but it is severely difficult o Discharge rating 10 – I can lift 25 pounds form the floor without limitation or difficulty I have difficulty with intercourse o Intial rating 3 – I can have intercourse but it is severely difficult o Discharge rating 8 – I can have intercourse with minimal difficulty – even if I do not have desire for it (that would be another goal for another professional) 16 31 30 Read at Follow-up Visits and Discharge Visit When I assessed you on (state previous date), you told me that you had difficulty with ________ (Read all activities from the Functional Goals) Today, how would you rate your difficulty with those activities? (Have the patient score each item and record on the Functional Goals) Depledge J, McNair PJ, Keal-Smith C, Williams M. Management of symphysis pubis dysfunction during pregnancy using exercise and pelvic support belts. Phys Ther. 2005 Dec;85(12):1290-300. Jolles BM, Buchbinder R, Beaton DE. A study compared nine patient-specific indices for musculoskeletal disorders. J Clin Epidemiol. 2005 Aug;58(8):791-801. Pengel LH, Refshauge KM, Maher CG. Responsiveness of pain, disability, and physical impairment outcomes in patients with low back pain. Spine. 2004 Apr 15;29(8):879-83. Donnelly C, Carswell A. Individualized outcome measures: a review of the literature. Can J Occup Ther. 2002 Apr;69(2):84-94. Review. Pietrobon R, Coeytaux RR, Carey TS, Richardson WJ, DeVellis RF. Standard scales for measurement of functional outcome for cervical pain or dysfunction: a systematic review. Spine. 2002 Mar 1;27(5):515-22. Review. Westaway MD, Stratford PW, Binkley JM. The patient-specific functional scale: validation of its use in persons with neck dysfunction. J Orthop Sports Phys Ther.1998 May;27:331-8. Chatman AB, Hyams SP, Neel JM, Binkley JM, Stratford PW, Schomberg A, Stabler M. The Patient-Specific Functional Scale: measurement properties in patients with knee dysfunction. Phys Ther. 1997 Aug;77(8):820-9. 17 32 31 18 33 32 Scoring of PFDI-20 (POPDI-6 + CRADI-8 + UDI-6) POPDI-6 # no = 0 1 2 3 4 5 6 not at all = 1 somewhat = 2 moderately = 3 quite a bit = 4 Total scores = ____ divide by 6 = _____ x 25 = _____ CRADI-8 # no = 0 7 8 9 10 11 12 13 14 not at all = 1 somewhat = 2 moderately = 3 quite a bit = 4 Total scores = ____ divide by 8 = _____ x 25 = _____ UDI-6 # no = 0 15 16 17 18 19 20 not at all = 1 somewhat = 2 moderately = 3 quite a bit = 4 Total scores = ____ divide by 6 = ____ x 25 = ____ POPDI-6 score _____ CRADI-8 score _____ UDI-6 score ______ Add all scores for PFDI-20 score = _________ Higher = more dysfunction Barber MD, Kuchibhatla M, Pieper CF, Bump RC. Psychometric evaluation of 2 comprehensive condition-specific quality of life instruments for women with pelvic floor disorders. American Journal of Obstetric and Gynecology Volume 185; Number 6, 2001 19 34 33 20 35 34 Scoring of PFIQ-7 (UQI + CRAIQ + POPQ) UIQ-7 (bladder) Question # Not at all = 0 1 2 3 4 5 6 7 somewhat = 1 moderately = 2 quite a bit = 3 Total scores = ____ divide by 7 = ____ x 33.3 = ____ CRAIQ-7 (bowel) Question # 1 2 3 4 5 6 7 Not at all = 0 somewhat = 1 moderately = 2 quite a bit = 3 moderately = 2 quite a bit = 3 Total scores = ____ divide by 7 = ____ x 33.3 = ____ POPIQ-7 (vagina) Question # Not at all = 0 1 2 3 4 5 6 7 somewhat = 1 Total scores = ____ divide by 7 = ____ x 33.3 = ____ UIQ-7 score ______ CRAIQ score _____ POPIQ-7 score ____ Add all score for PFIQ-7 score = ______ Higher = more dysfunction Barber MD, Kuchibhatla M, Pieper CF, Bump RC. Psychometric evaluation of 2 comprehensive condition-specific quality of life instruments for women with pelvic floor disorders. American Journal of Obstetric and Gynecology Volume 185; Number 6, 2001 21 36 35 22 37 36 Pelvic Organ Prolapse / Urinary Incontinence Sexual Function Questionnaire (PISQ-12) Question # 1 2 3 4 Always = 0 Usually = 1 Sometimes = 2 Seldom = 3 Never = 4 Question # 5 6 7 8 9 10 11 Always = 4 Usually = 3 Sometimes = 2 Seldom = 1 Never = 0 Total scores = ____ divide by 11 = ____ x 10 = ____ Normal is high score – 44 Higher is better 37 Urogenital Distress Inventory (UDI-6 Short Form): UDI-6 Yes No 1) Do you usually experience frequent urination? Not at all Somewhat Moderately Quite a bit If yes, how much does this bother you? 2) Do you usually experience urine leakage associated with a feeling of urgency; that is, a strong sensation of needing to go to the bathroom? Yes No Not at all Somewhat Moderately Quite a bit If yes, how much does this bother you? 3) Do you usually experience urine leakage related to coughing, sneezing, or laughing? Yes No If yes, how much does this bother you? Not at all Somewhat Moderately Quite a bit 4) Do you experience small amounts of urine leakage (that is, drops)? Yes No Not at all Somewhat Moderately Quite a bit If yes, how much does this bother you? 5) Do you experience difficulty emptying your bladder? Yes No Not at all Somewhat Moderately Quite a bit If yes, how much does this bother you? 6) Do you usually experience pain or discomfort in the lower abdomen or genital region? Yes No If yes, how much does this bother you? Not at all Somewhat Moderately Quite a bit If yes, then is your pain relieved after emptying your bladder? Yes No No= 0, Not at all= 1, Somewhat= 2, Moderately= 3, Quite a bit= 4 Add all scores and multiply by 6 then multiply by 25 for the scale score Missing items are dealt with by using the mean from the answered items only Higher score = higher disability Also see scoring of PFDI-20. Uebersax JS, Wyman JF, Shumaker SA, McClish DK, Fantl AJ. Short forms to assess life quality and symptom distress for urinary incontinence in women: the incontinence impact questionnaire and the urogenital distress inventory. Neurourol and Urodynam 1995;14:131-139. Grade A rating for symptoms of UI for women Donavan J, et al Symptom and quality of life assessment. In Incontinence vol 1 Basics and Evaluation eds Abrams P, Cardozo L, Khoury S, Wein A. Health Publications Ltd Paris France 2005. 24 39 38 VULVAR PAIN FUNCTIONAL QUESTIONNAIRE (VQ) These are statements about how your pelvic pain affects your everyday life. Please check one box for each item below, choosing the one that best describes your situation. Some of the statements deal with personal subjects. These statements are included because they will help your health care provider design the best treatment for you and measure your progress during treatment. Your responses will be kept completely confidential at all times. 1. Because of my pelvic pain 3 I can’t wear tight-fitting clothing like pantyhose that puts any pressure over my painful area. 2 I can wear closer fitting clothing as long as it only puts a little bit of pressure over my painful area. 1 I can wear whatever I like most of the time, but every now and then I feel pelvic pain caused by pressure from my clothing. 0 I can wear whatever I like; I never have pelvic pain because of clothing. 2. My pelvic pain 3 Gets worse when I walk, so I can only walk far enough to move around in my house, no further. 2 Gets worse when I walk. I can walk a short distance outside the house, but it is very painful to walk far enough to get a full load of groceries in a grocery store. 1 Gets a little worse when I walk. I can walk far enough to do my errands, like grocery shopping, but it would be very painful to walk longer distances for fun or exercise. 0 My pain does not get worse with walking; I can walk as far as I want to 3. 0 I have trouble sitting for very long because of another medical problem, but pelvic pain doesn’t make it hard to sit. Because of pain pills I take for my pelvic pain 3 I am sleepy and I have trouble concentrating at work or while I do housework. 2 I can concentrate just enough to do my work, but I can’t do more, like go out in the evenings. 1 I can do all of my work, and go out in the evening if I want, but I feel out of sorts. 0 I don’t have any problems with the pills that I take for pelvic pain. 5. I have a hard time walking because of another medical problem, but pelvic pain doesn’t make it hard to walk. My pelvic pain 3 Gets worse when I sit, so it hurts too much to sit any longer than 30 minutes at a time. 2 Gets worse when I sit. I can sit for longer than 30 minutes at a time, but it is so painful that it is difficult to do my job or sit long enough to watch a movie. 1 Occasionally gets worse when I sit, but most of the time sitting is comfortable. 0 My pain does not get worse with sitting, I can sit as long as I want to. 4. 0 0 I don’t take pain pills for my pelvic pain. Because of my pelvic pain 3 I have very bad pain when I try to have a bowel movement, and it keeps hurting for at least 5 minutes after I am finished. 2 It hurts when I try to have a bowel movement, but the pain goes away when I am finished. 1 Most of the time it does not hurt when I have a bowel movement, but every now and then it does. 0 It never hurts from my pelvic pain when I have a bowel movement. 39 6. Because of my pelvic pain 3 I don’t get together with my friends or go out to parties or events. 2 I only get together with my friends or go out to parties or events every now and then. 1 I usually will go out with friends or to events if I want to, but every now and then I don’t because of the pain. 0 I get together with friends or go to events whenever I want, pelvic pain does not get in the way 7. Because of my pelvic pain 3 I can’t stand for the doctor to insert the speculum when I go to the gynecologist. 2 I can stand it when the doctor inserts the speculum if they are very careful, but most of the time it really hurts. 1 It usually doesn’t hurt when the doctor inserts the speculum, but every now and then it does hurt. 0 It never hurts for the doctor to insert the speculum when I go to the gynecologist. 8. Because of my pelvic pain 3 I cannot use tampons at all, because they make my pain much worse. 2 I can only use tampons if I put them in very carefully. 1 It usually doesn’t hurt to use tampons, but occasionally it does hurt. 0 It never hurts to use tampons. 9. 0 This question doesn’t apply to me, because I don’t need to use tampons, or I wouldn’t choose to use them whether they hurt or not. Because of my pelvic pain 3 I can’t let my partner put a finger or penis in my vagina during sex at all. 2 My partner can put a finger or penis in my vagina very carefully, but it still hurts. 1 It usually doesn’t hurt if my partner puts a finger or penis in my vagina, but every now and then it does hurt. 0 It doesn’t hurt to have my partner put a finger or penis in my vagina at all. 0 This question does not apply to me because I don’t have a sexual partner. 0 Specifically, I won’t get involved with a partner because I worry about pelvic pain during sex. 10. Because of my pelvic pain 3 It hurts too much for my partner to touch me sexually even if the touching doesn’t go in my vagina. 2 My partner can touch me sexually outside the vagina if we are very careful 1 It doesn’t usually hurt for my partner to touch me sexually outside the vagina, but every now and then it does hurt 0 It never hurts for my partner to touch me sexually outside the vagina 0 This question does not apply to me because I don’t have a sexual partner. 0 Specifically, I won’t get involved with a partner because I worry about pelvic pain during sex. 11. Because of my pelvic pain 3 It is too painful to touch myself for sexual pleasure. 2 I can touch myself for sexual pleasure if I am very careful. 1 It usually doesn’t hurt to touch myself for sexual pleasure, but every now and then it does hurt. 0 It never hurts to touch myself for sexual pleasure. 0 I don’t touch myself for sexual pleasure, but that is by choice, not because of pelvic pain. For scorers (patient should not see these directions): To score the VQ, add numerical values assigned to each response. These appear next to the check-boxes. The higher the score the greater the functional limitation. A diminishing score represents improvement. Hummel-Berry K, Wallace K, Herman H. Reliability and validity of the Vulvar Functional Status Questionnaire. JWHPT. 2007; 31:3. 40 Documentation and Forms Types (Samples of these are available for down load on the SOWH web site) Pre-evaluation questionnaire Consent for PFM exam and treatment Evaluation form Bladder diary QOL index Symptoms index General Recommendations for PT Documentation and Sample Goal Writing: Initial Assessment / Plan of Care Summarize the patient’s main problems: eg, underactive PFM with weakness and impaired endurance contributes to symptoms of UI Summarize patient’s history, symptoms, pertinent surgical history, chief complaints Document objective findings (see examination section), goals, and plan Use validated measures to report outcomes Emphasize functional limitations caused by impairments Critical Elements in Writing FUNCTIONAL Goals PERSON ACTIVE VERB CONDITION CRITERIA Short-term Goals: Sample Documentation Patient will verbalize an understanding of pelvic anatomy and causes of incontinence Patient will verbalize rationale and purposes for exercises Patient will be independent in the performance of a home program of PFM exercises on a daily basis Patient will demonstrate decreased overflow muscle activity during PFM contraction Patient will demonstrate an increase in PFM contraction to normal grade as measured by MMT Patient will demonstrate an increase in PFM endurance from 3-second hold to 8second hold x 10 repetitions as measured by EMG Patient will demonstrate use of functional PFM contraction by performing a precontraction (“knack”) to eliminate UI during a cough Patient will incorporate a voiding schedule and urge strategies into his/her daily routine to manage urgency, frequency, and incontinence with a goal of ____ minutes of delay 27 42 41 Organizations and resources for Pelvic PT Organizations: Support Groups Arthritis Foundation PO Box 7669 Atlanta, GA 30357-0669 www.arthritis.org Continence Restored, Inc. 407 Strawberry Hill Stamford, CT 06902 1-914-285-1470 1-203-348-0601 (evenings) E-mail: annevyoung@aol.com Endometriosis Assoc., Inc 8585 North 76th Place Milwaukee, WI 53223 1-800-992-ENDO www.endometriosisassn.org Enu-Care Foundation Inc 100 Main-Sumner Coos Bay, OR 97420 1-800-437-9233 www.essentialcontrol.com Hysterectomy Education Resources & Services (HERS) 422 Bryn Mawr Avenue Bala Cynwyd, PA 19004 1-610-667-7757 www.hersfoundation.com International Adhesions Society David Wiseman, PhD Synechion, Inc. 6757 Arapaho Road, Suite 711 #238 Dallas, TX 75248 1-972-931-5596 www.adhesions.org International Foundation for Functional Gastrointestinal Disorders (IFFGD) PO Box 170864 Milwaukee, WI 53217-8076 1-888-964-2001 www.iffgd.org International Paruresis Association www.paruresis.org The Interstitial Cystitis Network www.ic-network.org Interstitial Cystitis Association PO Box 1553 Madison Square Station New York, NY 10159 1-212-979-6057 www.ichelp.org 28 43 42 Intestinal Disease Foundation (IDF) 1323 Forbes Avenue, Suite 200 Pittsburgh, PA 15219 www.intestinalfoundation.org National Association for Continence PO Box 1019 Charleston, SC 29402-1019 1-800-BLADDER www.nafc.org National Fibromyalgia Association 2200 N. Glassell St., Suite A Orange, CA 92865 1-714-921-0150 Fax: 1-714-921-6920 www.fmaware.org National Organization for Rare Disorders (NORD) PO Box 8923 New Fairfield, CT 06812 1-800-999-6673 www.rarediseases.org National Vulvodynia Association (NVA) PO Box 4491 Silver Spring, MD 20914 1-301-299-0775 www.nva.org Share National Kidney Foundation of Texas 1919 Oakwell Farms Pkwy, Suite 135 San Antonio, TX 78218-1725 1-888- 829-299 www.kidneytx.org The American Fibromyalgia Syndrome Association PO Box 9699 Bakersfield, CA 93389 www.afsafund.org The International Pelvic Pain Society 2006 Brookwood Medical Center Dr, Suite 402 Birmingham, AL 35209 1-205-877-2950 www.pelvicpain.org The Fibromyalgia Network Newsletter PO Box 31750 Tucson, AZ 85751 www.fmnetnews.com/ The Simon Foundation PO Box 815 Wilmette, IL 60091 1-800-23SIMON www.simonfoundation.org The Vulvar Pain Foundation PO Box 177 Graham, NC 27253 1-910-226-0704 www.vulvarpainfoundation.org United Ostomy Association 19772 MacArthur Blvd, #200 Irvine, CA 927612-2405 1-800-826-0826 www.uoa.org 29 44 43 Support for Men Impotence Information Center 10700 Bren Rd West Minnetonka, MN 55343 1-800-843-4315 Impotence Institute of America, Inc. 2020 Pennsylvania Ave NW Washington, DC 20006 1-800-669-1603 Man to Man 24600 Northwestern Hwy Southfield, MI 48075 1-313-356-8870 The Prostatitis Foundation 1063 30th St, Box 8 Smithshire, IL 61478 1-888-891-4200 www.prostate.org Us Too Prostate Cancer Survivor Support Group 5003 Fairview Ave Downers Grove, IL 60515 1-800-808-7866 www.ustoo.com Professional Education Texas Women’s University, School of PT PO Box 425589 Denton, TX 76204 1-940-898-2460 Long-distance women’s health education www.twu.edu/pt Rosalind Franklin University Interprofessional Healthcare Studies 3333 Green Bay Rd North Chicago, IL 60064 1-847-578-3310 Master of Science in Women’s Health www.rosalindfranklin.edu 30 45 44 Professional Groups ACOG 409 12th St. SW PO Box 96920 Washington, DC 20090-6920 1-202-638-5577 www.acog.org Alliance for Aging Research 2021 K Street NW, Suite 305 Washington, DC 20006 1-202-293-2856 www.agingresource.org American Association of Sex Education Counselors & Therapists 435 North Michigan Avenue, Suite 1717 Chicago, IL 60611-4067 1-312-644-0828 www.aasect.org American Gastroenterology Assoc. 4930 Del Ray Ave Bethesda, MD 20814 1-301-654-2055 www.gastro.org American Medical Association (AMA) 515 North State St. Chicago, IL 60610 1-312-464-5000 www.ama-assn.org American Pain Foundation 201 North Charles St, Suite 710 Baltimore, MD 21201-4111 1-888-615-PAIN www.painfoundation.org American Urological Association www.urologyhealth.org American Urogynecologic Society 401 North Michigan Ave Chicago, IL 60611 1-312-644-6610 x4739 www.augs.org American Urological Society 1120 North Charles St. Baltimore, MD 21201 1-410-727-1100 www.auanet.org APTA/ Section on Women’s Health PO Box 327 Alexandria, VA 22313 1-800-999-APTA www.womenshealthapta.org Association for Rehabilitation Nurses ARN Publications Orders 5700 Old Orchard Rd, 1st Floor Skokie, IL 60077-1057 1-708-966-3433 www.rehabnurse.org International Association for the Study of Pain 111 Queen Anne Avenue North, #501 Seattle, WA 98109-4955 1-206-283-0311 www.iasp-pain.org 31 46 45 International Continence Society (ICS) Dr. Werner Schaefer Southmead Hospital Bristol BS10 5NB United Kingdom +44 0 117 950 3510 www.continet.org International Organization of Physical Therapists in Women’s Health www.ioptwh.org National Institute on Aging Building 31, Room 5C27 31 Center Drive, MSC 2292 Bethesda, MD 20892 1-800-222-4225 www.nia.nih.gov National Fibromyalgia Association 2200 North Glassell St, Suite A Orange, CA 92865 1-714-921-0150 www.fmaware.org The National Foundation for the Treatment of Pain 1330 Skyline Dr, 21 Monterey, CA 93940 1-831-655-8812 www.paincare.org National Kidney Foundation 30 East 33rd St New York, NY 10016 1-800-622-9010 www.kidney.org National Kidney and Urologic Diseases Information Clearinghouse Box NKUDIC 3 Information Way Bethesda, MD 20892-3580 1-800-891-5390 www.kidney.niddk.nih.gov/index.htm Prostate Health Council/ American Foundation for Urologic Disease 1128 N. Charles St. Baltimore, MD 21201 1-800-242-2383 www.afud.org Society for Urologic Nurses and Assoc. (SUNA) East Holly Avenue, Box 56 Pittman, NJ 08071 1-888-827-7862 www.suna.org Society for Pudendal Neuralgia 3 Shepherds Lane North Hampton, New Hampshire 03862 www.spuninfo.org Subgroup of World Physical Therapy www.wcpt.org 32 47 46 Additional Information and Links Clearinghouse for health information from a variety of sources – Diane Newman RN www.seekwellness.com/phase/phase_data base.htm Dr. Howard Glazer 340 East 63rd St, Suite 1A New York, NY 10021 www.vulvodynia.com www.coccyx.org Pelvic floor disorders and biofeedback – Dr John Perry www.incontinet.com March of Dimes Education and Health Promotion Dept. 1275 Mamaroneck Avenue White Plains, NY 10605 1-914-997-4456 1-800-367-6630 www.marchofdimes.com OSHA Publication Office Room N3101 2000 Constitution Ave, NW Washington, DC 20210 US Dept of Health and Human Services, Public Health Service Agency for Health Care Policy and Research Publications Clearinghouse PO Box 8547 Silver Spring, MD 20907 1-800-358-9295 Publications 96-0684, 96-0682: Urinary Incontinence in Adults guidelines) www.os.dhhs.gov 3M Center St. Paul, MN 55144-100 1-800-228-3957 Preventing transmission of infectious agents www.3m.com/us/healthcare/professionals/i nfectionprevention 33 48 47 Pelvic Floor Physical Therapy Booklist Patient Books: Urinary Incontinence Beyond Kegels, Janet Hulme; Phoenix Publishing Co, 1997 Drips, Leaks and Low Spirits: A Women’s Guide to Bladder Control, Infections and Depression, Andre Alexander Kulisz; Bookstand Publishing, 2001 Geriatric Incontinence: A Behavioral and Exercise Approach to Treatment, Janet Hulme; Phoenix Publishing, 1999 I laughed so hard I peed my pants, Kelli Berzuk; IPPC Publisher, Winnipeg, Canada. 2002 Managing and Treating Urinary Incontinence, Diane Newman; Health Professions Press 2002 Managing Incontinence: A Guide to Living with Loss of Bladder Control, Cheryle B. Gartley; The Simon Foundation, www.simonfoundation.org Overcoming Overactive Bladder: Your Complete Self-Care Guide., Diane K. Newman and Alan J. Wein; Oakland, CA: New Harbinger Publications, 2004. Overcoming Bladder Disorders, Rebecca Chalker and Kristine E. Whitmore; available from NAFC, 1-800-BLADDER Pelvic Power for Men and Women, Eric Franklin; Princeton Book Company, 2002 Staying Dry, Kathryn Burgio; Johns Hopkins University Press, Baltimore, MD, 1989 The Bottom Line on Kegels, Woman’s Hospital, Baton Rouge, LA, www.womans.org/for_health_professionals/resources.pdf, 1997 The Female Pelvis Anatomy and Exercises, Blandine Calais-Germain; Eastland Press, Seattle, 2003 The Shy Bladder Syndrome: Your Step-By-Step Guide to Overcoming Paruresis, Steven Soifer; www.paruresis.org Women's Waterworks, Pauline Chiarelli; Health Books www.womenswaterworks.com Patient Books: Bowel Breaking the Bonds of Irritable Bowel Syndrome, Barbara Bradley Bolen; New Harbinger Publications, 2000 34 49 48 Conquering Irritable Bowel Syndrome: A Guide To Liberating Those Suffering With Chronic Stomach or Bowel Problems, Nicholas J. Talley; Empowering Press, 2005 Continence With Biofeedback, Susan Trunnell; Advantage Publications, available from NAFC, 1991 Keeping Control: Understanding and Overcoming Fecal Incontinence, Marvin Schuster and Jacqueline Wehmueller; Johns Hopkins Press, 1994 Prevent it! A Guide for Men and Women With Leakage From the Back Passage, Grace Dorey; Mobilis Healthcare Group, 2004 No More Digestive Problems: A Leading Gastroenterologist Provides the Answers Every Woman Needs--Real Solutions to Stop the Pain and Achieve Lasting Digestive Health, Cynthia Yoshida; Bantam, 2005 The Good Bowel Habit: pelvic floor function and the bowel - managing constipation and incontinence, 3rd Ed., Robyn Nagel and Shirley Owen; Beaconsfield Publishers Ltd, 2007 Patient Books: Male Conquering Incontinence: A new and physical approach to a freer lifestyle. Peter Dornan; Allen and Unwin, Australia, 2003. Conservative Treatment Of Male Urinary Incontinence and Erectile Dysfunction, Grace Dorey; www.desmitmedical.com, 2001 Living and loving after prostate surgery. Dorey Grace; www.desmitmedical.com, 2005 Pelvic Dysfunction in Men: Diagnosis and Treatment of Male Incontinence and Erectile Dysfunction, Grace Dorey; Wiley 2006 Pelvic Floor Exercises for Erectile Dysfunction, Grace Dorey; Wiley 2005 The Prostate Book: Sound Advice on Symptoms and Treatment, Stephen Rous, W.W. Norton & Company, Inc, 2002 Patient Books: Bed Wetting Dry All Night, Allison Mack; Little Brown and Co, 1989 Waking up Dry: How to End Bedwetting Forever. Martin Scharf; Writer’s Digest Book, 1986 35 50 49 Patient Books: Pelvic Pain A Headache in the Pelvis: A new understanding and treatment for prostatitis and chronic pelvic pain syndromes, 4th Ed. David Wise and Rodney Anderson; Center for Pelvic Pain Research, 2008 Fibromyalgia: A Handbook for Self Care and Treatment, Janet Hulme; Phoenix Publishing Co, 1995 Hysterectomy: Before and After, Winnifred Culter; Harper and Row Publishers, 1988 IC and Pain: Taking Control-A Handbook for People with IC and their Caregivers; Interstitial Cystitis Association, 2004 Managing Pain Before it Manages You, Margaret Caudill, Rev ed., Guilford Press, 2002 Pelvic Pain and Low Back Pain: A Handbook for Self Care and Treatment, Janet Hulme; Phoenix Publishing Co, 2002 Private Pain - It's About Life, Not Just Sex: Understanding Vaginismus and Dyspareunia 2nd ed., Ditza Katz and Ross Lynn Tabisel; Katz-Tabi Publication, 2005 The Endometriosis Sourcebook, Mary Lou Ballweg, The Endometriosis Association; McGraw-Hill Professional, 1995 The Core Program, Peggy Brill; Bantam Books, 2003 The IC Survival Guide The Interstitial Cystitis Survival Guide: Your Guide to the Latest Treatment Options and Coping Strategies. Robert Moldwin; New Harbinger Publishers, 2000 The Vulvodynia Survival Guide, Howard Glazer and Gae Rodke; New Harbinger Publishers, 2002 The Yeast Connection, William Crook; Professional Books Inc., 2002 When Movement Hurts: A Self-Help Manual for Treating Trigger Points 2nd Ed, Barbara J. Headley; Innovative Systems for Rehabilitation, 1997 You Don’t Have to Live with Cystitis, Larrian Gillespie; Avon Books, NY, 1996. 10 Steps to Completely Overcome Vaginismus: Books 1 and 2, Mark and Lisa Carter; www.vaginismus.com 36 51 50 Patient Books: Gynecological How to Give her Absolute Pleasure: Total Explicit Techniques Every Women Wants her Man to Know, Lou Paget; Broadway Books, 2000 For Yourself: The Fulfillment of Female Sexuality, Lonnie Garfield Barbach; Doubleday, 1975 For Women Only, Jennifer Berman and Laura Berman; Henry Holt and Co, NY, 2001 Screaming to be Heard: Hormonal Connections that Women Suspect and Doctors Ignore, Elizabeth Lee Vliet; M. Evans and Co. Inc., NY, 1995 Seven Weeks to Better Sex, Domeena Renshaw; Westcom Press, CA, 2004 The Five Love Languages, Gary Chapman; Lifeway Press, 2000. The Sex-Starved Marriage: A Couple’s Guide to Boosting Their Marriage Libido, Michele Weiner-Davis; Simon & Schuster, 2003 The V Book, Elizabeth Stewart; Bantam Books, NY, 2002 Physical Therapy Books Clinical Application in Surface EMG: Chronic Musculoskeletal Pain, Glen Kasman, Jeffrey Cram and Steven Wolf; Aspen Publishers, 1998 Diagnosis and Treatment of Movement Impairment Syndromes, Shirley Sahrmann; Mosby, 2002 Diagnosis Specific Orthopedic Management of the Hip. Omer Matthijs, Didi vanParidon, Phillip S. Sizer, Jean-Michel Brismée, Valerie Phelps; International Academy of Orthopedic Medicine, IAOM, US 2007 Examination in Physical Therapy Practice: Screening for Medical Disease, William G. Boissonault, Ed.; Churchill Livingston, 1995 Evidence-based Physical Therapy for the Pelvic Floor, Kari Bo, Bary Berghmans, Siv Morkved, Marijke Van Kampen; Elsevier Ltd, 2007 Fitness for the Pelvic Floor, Beate Carriere; Thieme, 2002 Introduction to Surface Electromyography, Jeffrey Cram and Glen Kasman; Aspen Publications, 1998 37 52 51 Low Back Disorders: Evidence Based Prevention and Rehabilitation, Stuart McGill; Human Kinetics, 2002 Myofascial Pain and Dysfunction: The Trigger Point Manual, Vol 2, Janet Travell and David Simons; Williams & Wilkins, Baltimore, MD, 1992 Obstetric and Gynecologic Care in Physical Therapy, Linda O’Connor and Rebecca Stephenson; Slack Inc., 2000 Pelvic Floor Disorders, Alain Bourcier, Edward McGuire and Paul Abrams; Saunders, 2004 Pelvic Power, Elizabeth Noble; available from New Life Images Physiotherapy in Obstetrics and Gynecology, Margaret Polden and Jill Mantle; ButterworthHeinemann Publishers, Stoneham, MA, 1990 The Gynecological Manual, Elaine Wilder, editor, Section on Women’s Health APTA, 2002 The Pelvic Floor, Beate Carriere, Cynthia Markel-Feldt and Oliver French; Thieme, 2006 The Pelvic Girdle 3rd Ed., Diane Lee; Churchill Livingstone, 2004 Therapeutic Exercise for Spinal Segmental Stabilization in Low Back Pain, Carolyn Richardson, Gwendolen Jull, Paul Hodges, and Julie Hides; Churchill Livingston, 1999 Therapeutic Exercise: Moving Towards Function, Carrie Hall and Lori Thein Brody; Lippincott Williams & Wilkins, 2005 Therapeutic Management of Incontinence and Pelvic Pain, Jo Laycock and Jeanette Haslam; Springer Verlag, 2008 Ultrasound Imaging for Rehabilitation of the Lumbopelvic Region: A Clinical Approach, Jackie L. Whittaker; Elsevier Publishers, 2007 Women’s Health: A Textbook for Physiotherapists, Ruth Sapsford, Joanne Bullock-Saxton and Sue Markwell; WB Saunders, 1998 Other Professional Books Atlas of Human Anatomy, 3rd Ed. Frank Netter; Ciba-Geigy Corporation, 1994 Biofeedback: A Practitioner’s Guide, Mark Schwartz; Guilford Press, 1995 Cognitive Behavioral Treatment of IBS, Brenda Toner, Zindel Segal, Shelagh Emmott, and David Myran; Guilford Press, 2000 38 53 52 Essentials of Health Care Marketing, Eric Berkowitz; Aspen Publishers, 1996 Irritable Bowel Syndrome and the Mind, Body, Brain, Gut Connection, William Salt; Parkview Publishers, 1997 Masters and Johnson on Sex and Human Loving, Masters and Johnson; Little Brown Books, Boston, MA, 1987 Marketing Public Health, Michael Siegel and Lynne Doner; Aspen Publishers, 1998 Strain/Counterstrain, Lawrence Jones, American Academy of Osteopathy, 1127 Mt Vernon Road, Newark, OH 43055, available from the Upledger Institute, 1981 Textbook of Prostatitis, J. Curtis Nickel; ISIS Medical Media, 1999 Urogenital Manipulation, Jean-Pierre Barral; Eastland Press, 2003 Visceral Manipulation, Jean-Pierre Barral & Pierre Mercier; Eastland Press, 2003 Physician and Nursing Books Clinical Urogynecology, Mark Walters and Mickey Karram; Mosby, 1993 Chronic Pelvic Pain: An Integrated Approach, John Steege, Deborah Metzger, and Barbara Levy; WB Saunders Co, Philadelphia, 1998 Chronic Pelvic Pain: Evaluation and Management, Richard E. Blackwell and David L. Olive; Springer-Verlag, New York,. 1998 Female Pelvic Floor Disorders, J. Thomas Benson, ed.; Norton Medical Books, 1992 Handbook of Pediatric Urology, LS Baskin, BA Kogan, and LW Duckett, Lippincott Raven, 1997 Incontinence: Volumes 1 and 2, Paul Abrams, Linda Cardozo, Saad Khoury, Alan Wein, eds.; Health Publications Ltd, editions21@wanadoo.fr, 2005 Multidisciplinary Management of Female Pelvic Floor Disorders, Chapple CR, Zimmern PE, Brubaker L, Smith ARB, Bo K, eds.; Churchill Livingstone, Elsevier, Edinburgh, 2006 Netter’s Obstetrics and Gynecology and Women’s Health, Roger P Smith; Icon Learning Systems, NJ, 2002 39 54 53 Pelvic Floor Re-Education, Bernhard Schussler, Jo Laycock, Peggy Norton, and Stuart Stanton; Springer-Verlag Publishers, New York, 1995 Pelvic Pain: Diagnosis & Management, Fred Howard and Paul Perry; Lippincott Williams & Wilkins, Philadelphia, 2000 The Female Pelvic Floor: Disorders of Function and Support, Linda Brubacker and Theodore Saclarides; FA Davis Co., 1996 The Pelvic Floor: Its Function and Disorders, John Pemberton, Michael Swash, Michael M. Henry, eds; Harcourt, 2002 Urinary and Fecal Incontinence: Nursing Management 2nd ed, DB Doughty, ed; Mosby, 2000. Urodynamics Made Easy, Christopher Chapple and Scott A. MacDiarmid; Elsevier Health Sciences, 2000 Voiding Function and Dysfunction, Allen Wein and David Barrett; Year Book Medical Publishers Inc, 1988 40 55 54 41 56 55 Instructions for Authors GENERAL INFORMATION The Journal of Women’s Health Physical Therapy (JWHPT) is the official publication of the Section on Women’s Health (SOWH) of the American Physical Therapy Association. JWHPT is a peer-reviewed publication that is focused on the clinical interests of physical therapists practicing in women’s health, as well as those of other health care workers who interface with physical therapists in the healthcare of women. SUBMISSION REQUIREMENTS Original manuscripts submitted for review must be accompanied by a cover letter with original signatures of all authors. The cover letter must address copyright release, conflict of interest disclosures, photographic releases, author(s) statement that written permission has been obtained from persons named in the acknowledgment, subject protection, research or project support/funding, and reprint permission for tables or figures. Contact information for all authors must include mailing addresses, fax and phone numbers, and electronic mail addresses. These must be updated as necessary during the review process. Manuscripts must be submitted in triplicate along with one original and 3 copies of photographs and figures. An electronic version of each manuscript is required on the initial submission, and additional electronic files may be requested later in the review process. The Editor-in-Chief reserves the right to return manuscripts without review that do not meet minimal submission requirements. The Editorial Board adheres to the “Uniform Requirements for Manuscripts (URM) submitted to biomedical journals. These are available from the International committee of Medical Journal Editors (ICJME) at http://www.icmje.org/index.html Authors should consult the most current edition (at this writing this is the 9th edition) of the American Medical Association (AMA) Manual of Style, available from Lippincott, Williams and Wilkins, 351 West Camden Street, Baltimore, MD 21201-2436, USA for detailed descriptions of acceptable style and format, as well as specifics related to the preparation and submission of manuscripts. Clarification of submission requirements can be obtained by contacting the Editorin-chief. Manuscripts previously published or currently under review for publication should not be submitted. Authors who submit manuscripts that contain substantially similar content that has been published or is currently being considered elsewhere for publication, must inform the Editor-in-Chief of this and must provide the Editor-in-Chief with a copy of the other article. The Editor-in-Chief will make the determination of the duplicative nature of the submitted manuscript and may decide that the submitted manuscript is unacceptable for publication in JWHPT. Published abstracts of oral presentations at scientific conferences or meetings will not be considered duplicative. All manuscripts accepted for review undergo blinded peer review. The Editor will assist authors as necessary to make manuscripts acceptable for publication. Submissions that do not meet essential requirements will be returned to the author without review. The Editorial staff reserve the right to make literary and copyediting changes to manuscripts as necessary to meet publication criteria and standards. 42 57 56 Submit manuscripts (original, 3 copies, and electronic copy) to: Nancy Rich, Editor-in-Chief Journal of Women’s Health Physical Therapy c/o Kathie St. Clair, Editorial Assistant American Physical Therapy Association 1111 North Fairfax Street Alexandria, Virginia 22314 SOWHmanuscript@apta.org MANUSCRIPT CATEGORIES Research Report A report of original research relevant to women's health research studies utilizing qualitative, quantitative, and single subject design methods are all included in this category. A research report must contain: Abstract containing a maximum of 250 words divided into 6 sections with the following bolded headings: Objective (specific purpose or research question, or hypothesis of the investigation), Study Design (randomized controlled, blinded, case series, etc.) Background (rationale for the study), Methods and Measures (subject/participants, setting, outcome measures, interventions), Results (Main results with statistical significance), Conclusions (those that are supported by the data, along with implications for physical therapist practice). All abstracts must end with a Key Words section containing 3 to 5 key words that are not contained in the manuscript title. Manuscript text – the body of the manuscript must contain the following bolded headings: Introduction (The purpose of the study as well as a rationale, with background from the literature, for the importance of the research question, and the significance to physical therapists) , Methods and Measures (selection and description of participants, including inclusion and exclusion criteria, intervention(s), outcome measures, methods of data collection, reduction and analysis in enough detail that would allow others to replicate the study, statistical analyses), Results (most important findings relevant to the research hypothesis), Comment (critical explanation for the findings, comparison to previous studies, limitations and generalizability of the study), Conclusion (Brief summary of the main findings, implications for clinicians, researchers, educators, or others involved in women’s health physical therapy, possible directions for future research). There may be any number of sub-headings that are appropriate to make the manuscript easier to read. Acknowledgements are placed after the Conclusion Section. References must be cited numerically in the text, tables, or figures with superscript numbers. The entire reference is listed in numerical order at the end of the manuscript. The reference format must that which is outlined in the American Medical Association (AMA) Manual of Style. 43 58 57 Literature Review A literature review is s comprehensive review and critical analysis of previously published literature. The review should focus on a particular topic in women's health and include justifiable conclusions and recommendations that are relevant to the practice of physical therapy in women's health. The purpose of the literature review may be to provide readers a summary of what is currently supported by the literature. It may be that there are several competing theories about your topic and you wish to complete a critical review to determine if there is support for one particular theory, or to identify gaps in the literature. They may also be systematic reviews or meta-analyses. Manuscripts in this category must be invited by the Editor-in-chief. Selfnominations for an invitation to submit a literature report for review are welcome. Literature review proposals must be sent to the Editor-in-Chief. A current curriculum vitae must also be enclosed. The format for a literature report submission is as follows: Title page Abstract with the identical guidelines as for research reports Manuscript text with the identical guidelines as for research reports References as outlined above Clinical Commentary A scholarly paper addressing a specific clinical approach or intervention of relevance to the practice of physical therapy in women's health. Clinical experiences may be reported to support rationales and approaches, however, references from the published research literature must also be utilized. The format of a clinical commentary is as follows: Title Page An abstract of no more than 250 words. The abstract for a clinical commentary is unstructured. The abstract ends with a Key Words Section, containing 3 to 5 key words that are not contained in the manuscript title. Following the Introduction Section, the text is separated into relevant sections with appropriate bolded headings. 44 59 58 Case Report Brief reports describing evaluation and treatment of one to three patients that illustrate or critique an approach or aspect of the clinical management relevant to women's health. References must be utilized to support rationale and approaches. The format of a case report is as follows: Title Page Abstract of no more than 250 words with the following bolded headings: Background, Study Design, Case Description, Outcomes, Discussion. The text must have the following bolded headings: Introduction or Background, Study Design, Case Description (Examination (History, Systems Review, Tests and Measures, including Outcome Assessment tools) Evaluation/Diagnosis, Intervention, Outcome, Discussion, Conclusions. Tables Each table must be organized and formatted according to the AMA Manual of Style, section 2.13 Figures Each figure must be prepared according to the AMA Manual of Style, section 2.14 Additional Documents Required For Submitted Manuscripts: 1. Photograph Release Statement. This statement must contain the manuscript title, names of all authors, a statement granting the Journal of Women’s Health Physical Therapy the royalty-free right to publish the photographs and/or videos of the participant for the JWHPT and the manuscript in which the participant appears, as well as on the journal’s website (http://www.womenshealthapta.org/). The statement must be signed by the participant who is on the photograph and/or video. 2. Protection of Human Subjects. The name of the Institutional Review Board that approved the research protocol must be placed on the title page. In addition, The Methods section must contain a statement that informed consent was obtained and that the rights of the subjects were protected. 45 60 59 Reporting Services to Third Party Payers Medical billing is complex and variable. It is important to contact each payer’s provider service representatives for specific payment policies and benefit language related to the services that will be provided. The following is a general list and should not be considered a substitute for the full narratives included in CPT. 97001 PT evaluation 97530 Therapeutic activities 97110 Therapeutic exercise 97112 Neuromuscular re-education 97140 Manual therapy 97014 Electrical stimulation – unattended Medicare: G0283 unattended electrical stimulation 97032 Electrical stimulation – attended Includes the cost of a vaginal or rectal electrode Must document that patient has tried and failed pelvic floor muscle exercises for 4 weeks before Medicare will reimburse for e-stim Must use a modifier code to charge for both NMES and BFB in the same treatment session Check with local fiscal intermediary and it’s interpretation of Medicare guidelines 97535 Self care home management 97010 Hot / cold pack 97035 Ultrasound 64550 TENS 90911 Biofeedback training Addresses the sphincter specifically Not a timed code Includes the cost of a vaginal or rectal electrode Must document that the patient has tried and failed pelvic floor muscle exercise for 4 weeks before Medicare will reimburse for biofeedback or electrical stimulation. 46 61 60 Medicare Ruling on Report Services Related to: HCFA (CMS) ruling on biofeedback for urinary incontinence October 6, 2000 (effective 7/01) “Biofeedback therapy is covered for the treatment of stress and/or urge incontinence in patients who fail a documented trail of pelvic muscle training or who are unable to perform pelvic muscle exercise. Contractors may decide whether or not to cover biofeedback as an initial treatment modality.” HCFA (CMS) defines a failed trail for pelvic muscle exercise: “A failed trail of pelvic muscle training is defined as not clinically significant improvement in urinary continence after completing 4 weeks of an ordered plan of pelvic muscle exercise designed to increase periurethral muscle strength.” HCFA (CMS) ruling on electrical stim for urinary incontinence Oct 6, 2000 (effective 7/01) “Pelvic floor electrical stimulators, inserted into the vaginal canal or rectum, are covered as reasonable and necessary as a treatment for stress and/or urge urinary incontinence. The patient must have first undergone and failed a documented trail of pelvic muscle exercise training. There devices are not covered as an initial treatment modality for SUI or UI.” Coverage of Electrodes Electrodes are considered part of the practice expense for the procedure. Separate reporting of electrodes would be considered “unbundling” and is not permitted. It is recommended that you contact other insurance companies regarding payment policy before attempting to report the following HCPCS codes. E0740 – Incontinence treatment system, pelvic floor stimulator, monitor sensor and or trainer (home units are listed here) A4335 – Incontinence supply and miscellaneous Out of Pocket Patient Expenses Co-payment(s) and Deductibles – make sure you collect these at the time of the visit. Equipment: CPT code 99070 – supplies and materials provided by the provider over and above those utilized during an office visit or other services rendered. Do not under any circumstances charge Medicare patients for electrode(s) as it is considered an essential supply for the performance of the procedures of BF or ES. Check payers for payment policy, i.e., if a payer pays on an RBRVS system, then any supply used in the office cannot be unbundled from the procedure charge. For other insurances, single patient use vaginal or anal electrodes: depending on the number ordered Surface electrical stimulation electrodes Individual snap leads for surface EMG Pressure EMG insert Vaginal weight set Dilators 47 62 61 Most Common ICD 9 Codes 728.2 Muscle Dysfunction / disuse atrophy / Muscle weakness – PFM, abdominal this code is currently being recommended for best reimbursement and Medicare coverage for pelvic floor weakness 781.3 Muscle incoordination – PFM, abdominal 728.85 Muscle spasm – PFM, abdominal, trunk, hip 724.2 Back pain 724.3 Sciatic pain 729.1 Myofascial pain syndrome, myalgia, muscle pain 847.3 Sacrococcygeal strain – coccygodynia Other ICD 9 Codes Included in Pattern C 564.0 constipation 569.42 anal and rectal pain 618 genital prolapse 623 non-inflammatory disorders of vagina 624 non-inflammatory disorders of the vulva and perineum 625 pain associated with female genital organs 625.6 stress incontinence – female Miscellaneous ICD 9 Codes 596.51 hypertonicity of bladder (overactive bladder – OAB) 618.8 relaxation of vaginal outlet 623.4 old vaginal laceration 624.4 old laceration or scaring of vulva 625.0 dyspareunia 625.1 vaginismus 788.2 retention of urine (733.21 – incomplete bladder emptying) 788.3 incontinence of urine 788.31 urge incontinence 788.32 stress incontinence – male 788.33 mixed incontinence 788.41 urinary frequency 788.43 nocturia 617 endometriosis 787.6 fecal incontinence 724.7 disorders of the coccyx 724.79 coccygodynia 709.2 adherent scar 789.0 abdominal pain Also check the “Practice” page on the web site of the Section on Women’s Health for more information on billing and coding. 48 63 62
