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?