Physiotherapeutic diagnostic consultation and evaluation in antenatal & post-

partum women IUGA 2015, Nice

Kari Bø Professor, Ph.D, PT,

Exercise scientist

Norwegian School of Sport Sciences

Dept of Sports Medicine

Akershus University Hospital

Dept of Obstet Gynecol

Diagnosis WCPT 1999

Arises from the examination and evaluation and represents the outcome of the process of clinical reasoning

ICIDH/ICF : impairment, disability (activity) and handicap (participation)

Main tool: History taking

Often need for additional information from other professionals: urology, gynecology, neurology, radiology etc.

WHO: ICF 2001

International Classification of Functioning, Disability and Health

Unified and standard language and framework for discription of health and health-related states

BODY, INDIVIDUAL, SOCIETY 1. Body functions and structures

2. Activities and participation

Overview of ICF health components WHO, ICF 2001

Body functions: physiological and psycological functions of body systems

Body structures: anatomical parts

Impairments: problems in body function or structure such as significant deviation or loss

Activity: execution of a task or action by an individual

Participation: involvement in a life situation

SUI

Pathophysiology? Nerve damage, rupture, weak connective tissue

Impairment: Pelvic floor?

Disability: Urinary leakage

Handicap/

participation: QoL, dropout PA

Outcome measures

Pathophysiology: MRI, ultrasound, urodynamics (?)

Impairment: PFM squeeze pressure, MRI, ultrasound, EMG

Disability: leakage episodes, leakage index, pad test, cough stress test

Handicap/partici.: QoL questionnaires

Ethical issues

Information

Informed concent?

PT should be well trained

During pregnancy and after childbirth?

Ability to perform a voluntary correct PFM contraction >30% not able to

contract Benvenuti et al -87, Bø et

al -88, Hesse et al -90, Bump et al -91, Talasz et al-08

Only 49% increased urethral pressure during contraction Bump et al 1991

25% straining instead of contracting Bump et al -91

32% not able during pregnancy Dinc et al 2009

4% not able at GW 21 after thororugh instruction Hilde et al 2012

Erroneous contractions

Gluteal muscles

Hip adductor

Abdominal muscles

Stop breathing/ enhanced inspiration

↓STRAINING↓

We need to be good clinicians!

Ability to contract: squeeze and inward/forward lift

Methods

Observation

Palpation

EMG

Ultrasound

MRI

Digital palpation ICS Clinical Assessment

Group 2004

Voluntary contraction Absent Weak Normal Strong

Voluntary relaxation (able to relax after a contraction has been performed at least to resting state) Absent Partial Complete

Observation /palpation agreement ICS Clinical Asessment Group Slieker et al Neurourol Urodyn -09

Intra-observer Kw

Inter-observer Kw

Visible inward movement (100% agreement)

Visible co-contr .48 .52

Visible relaxation (97.6% agreement)

Palp MVC .67 .64

Palp levator closure .39 .45

Palp symmetry .64 .16

Palp voluntary relax .76 .17

EMG Fowler et al 2002 (in Abrams et al, ICI, Paris 2001), Vodusek

2007 (in Bø et al, Elsevier 2007)

Measures:

Muscle activation

Differenciate normal /abnormal striated muscle

Electrodes

Surface (artifacts,cross-talks)

Intra-muscular (invasive)

Wire

Concentric needle

TEST-RETEST of surface EMG Grape et al, Neurourol Urodyn -09

17 nullipara, healthy women age 20-35 years able to contract PFM correctly

Results

ICC: 0.83-0.96

Reliablity somewhat higher in same day compared to 26-30 days inbetween test-retest

Somewhat higher in peak compared to mean of 3 contractions

VALIDITY - CROSS-TALK?

Why measure PFM strength (MVC)?

Strength (independent variable)

Has the program worked? Proxi for

Neural adaptation

Cross sectional area

Stiffness Position Hiatus

Methods to measure PFM strength

Digital palpation

Manometers (vaginal squeeze pressure)

Dynamometers

Ultrasound/MRI

Modified Oxford Grading System (Laycock 1989)

0 = no contraction

1 = flicker

2 = weak

3 = moderate

4 = good

5 = strong

Oxford Grading Scale Inter-rater 0.82-0.95 Jeyaseelan et al -99

Inter-rater

K= 0.37, agreement in 45%

No difference between weak, moderate, good and strong Bø & Finckenhagen -01

Inter-rater K=0.80 Dietz & Shek -08

Unacceptably poor levels of agreement between and within rater Jean-Michel et al-10

Not reliable and sensitive enough for measurement of strength for scientific purpose?

Perineometer/Manometers Kegel

1947

The term ”Perineometer” is misleading

Vaginal squeeze pressure cmH2O

mmHg

hPa

Pressure measurement

Vaginal squeeze pressure (Kegel,

Dougherty, Bø, Hahn, Laycock, Pescher, Kerschan-Schindl)

Urethral (Benvenuti, Bernstein, Lose)

Anal (Burgio)

Found to be reliable (Bø et al, Frawley et al,

Sigurdardottir et al, Ferreira et al)

Validity of pressure measurement has been questioned

Abdominal muscles and PFM contraction

Dougherty et al 1986

Bø et al 1990

Bø and Stien 1992

Sapsford et al 2001

Neumann and Gill 2002

Madill & McLean 2006

Always co-contraction of abdominals with max PFM contraction

Validity of manometers

Main problems Straining Use of additional muscles

Palpation Simultaneous observation of

inward movement Allow some ”indrawing” of

abdominals

Minor problems: Placement of the device Device size Position of patient

INSTRUCTION

CANNOT BE USED TO MEASURE AUTOMATIC FUNCTION!!!

Dynamometers

Measures force directly in Newton (N)

Caufriez 1993, -98

Rowe -95

Sampselle et al -98 (Miller et al -07)

Dumoulin et al -01 (Dumoulin et al -04)

Verelst & Leivseth-04

Challenges of dynamometry

They also measure contraction of other muscles and straining

Not yet commericially available?

Question Validity of opening force Pain?

Φ=20mm

150mm

Constantinou C et al -05

Measurement of PFM contraction gives a lot of information

Ultrasound for morphology assessment

Automatic function?

Visual observation

EMG

Ambulatory urodynamics

Ultrasound/MRI

Observation /palpation agreement Slieker (Phd thesis 2009), Neurourol Urodyn

Intra-observer Kw

Inter-observer Kw

Obs:Perineal movement cough

.54 .33

Obs:Perineal move. strain

.33 .01

Palp during cough (automatic PFM con)

.66 .33

Palp cough: movement of perineum

.77 .03

Palp strain: invol relax

.60 .15

Bø & Sherburn: Evaluation of female pelvic –floor muscle

function and strength. Physical Therapy, 85, 3: 269-282, 2005,

Messelink et al Neurourol Urodyn, 24:374-380, 2005

Agreement Pressure measurement

needs simultaneous observation of inward movement to be valid

Need for thorough training

Ultrasound and MRI as gold standards

Controversies The role of digital

palpation and visual observation for quantification of PFM function

Automatic function?