Aims: This paper, the first of four emanating from the International Continence Society's 2011 St... more Aims: This paper, the first of four emanating from the International Continence Society's 2011 State-of-the-Science Seminar on pelvic-floor-muscle training (PFMT) adherence, aimed to summarize the literature on theoretical models to promote PFMT adherence, as identified in the research, or suggested by the seminar's expert panel, and recommends future directions for clinical practice and research. Methods: Existing literature on theories of health behavior were identified through a conventional subject search of electronic databases, reference-list checking, and input from the expert panel. A core eligibility criterion was that the study included a theoretical model to underpin adherence strategies used in an intervention to promote PFM training/exercise. Results: A brief critique of 12 theoretical models/theories is provided and, were appropriate, their use in PFMT adherence strategies identified or examples of possible uses in future studies outlined. Conclusion: A better theoretical-based understanding of interventions to promote PFMT adherence through changes in health behaviors is required. The results of this scoping review and expert opinions identified several promising models. Future research should explicitly map the theories behind interventions that are thought to improve adherence in various populations (e.g., perinatal women to prevent or lessen urinary incontinence). In addition, identified behavioral theories applied to PFMT require a process whereby their impact can be evaluated. Neurourol. Urodynam.
Aims: This review aims to locate and summarize the findings of qualitative studies exploring the ... more Aims: This review aims to locate and summarize the findings of qualitative studies exploring the experience of and adherence to pelvic floor muscle training (PFMT) to recommend future directions for practice and research. Methods: Primary qualitative studies were identified through a conventional subject search of electronic databases, reference-list checking, and expert contact. A core eligibility criterion was the inclusion of verbatim quotes from participants about PFMT experiences. Details of study aims, methods, and participants were extracted and tabulated. Data were inductively grouped into categories describing "modifiers" of adherence (verified by a second author) and systematically displayed with supporting illustrative quotes. Results: Thirteen studies (14 study reports) were included; eight recruited only or predominantly women with urinary incontinence, three recruited postnatal women, and two included women with pelvic organ prolapse. The quality of methodological reporting varied. Six "modifiers" of adherence were described: knowledge; physical skill; feelings about PFMT; cognitive analysis, planning, and attention; prioritization; and service provision. Conclusions: Individuals' experience substantial difficulties with capability (particularly knowledge and skills), motivation (especially associated with the considerable cognitive demands of PFMT), and opportunity (as external factors generate competing priorities) when adopting and maintaining a PFMT program. Expert consensus was that judicious selection and deliberate application of appropriate behavior change strategies directed to the "modifiers" of adherence identified in the review may improve PFMT outcomes. Future research is needed to explore whether the review findings are congruent with the PFMT experiences of antenatal women, men, and adults with fecal incontinence. Neurourol. Urodynam.
Aims: This paper on pelvic-floor-muscle training (PFMT) adherence, the second of four from the In... more Aims: This paper on pelvic-floor-muscle training (PFMT) adherence, the second of four from the International Continence Society's 2011 State-of-the-Science Conference, aims to (1) identify and collate current adherence outcome measures, (2) report the determinants of adherence, (3) report on PFMT adherence strategies, and (4) make actionable clinical and research recommendations. Method: Data were amassed from a literature review and an expert panel (2011 conference), following consensus statement methodology. Experts in pelvic floor dysfunction collated and synthesized the evidence and expert opinions on PFMT adherence for urinary incontinence (UI) and lower bowel dysfunction in men and women and pelvic organ prolapse in women. Results: The literature was scarce for most of the studied populations except for limited research on women with UI. Outcome measures: Exercise diaries were the most widely-used adherence outcome measure, PFMT adherence was inconsistently monitored and inadequately reported. Determinants: Research, mostly secondary analyses of RCTs, suggested that intention to adhere, self-efficacy expectations, attitudes towards the exercises, perceived benefits and a high social pressure to engage in PFMT impacted adherence. Strategies: Few trials studied and compared adherence strategies. A structured PFMT programme, an enthusiastic physiotherapist, audio prompts, use of established theories of behavior change, and user-consultations seem to increase adherence. Conclusion: The literature on adherence outcome measures, determinants and strategies remains scarce for the studied populations with PFM dysfunction, except in women with UI. Although some current adherence findings can be applied to clinical practice, more effective and standardized research is urgently needed across all the sub-populations. Neurourol. Urodynam. # 2015 Wiley Periodicals, Inc.
Aims: There is scant information on pelvic floor muscle training (PFMT) adherence barriers and fa... more Aims: There is scant information on pelvic floor muscle training (PFMT) adherence barriers and facilitators. A web-based survey was conducted (1) to investigate whether responses from health professionals and the public broadly reflected findings in the literature, (2) if responses differed between the two groups, and (3) to identify new research directions. Methods: Health professional and public surveys were posted on the ICS website. PFMT adherence barriers and facilitators were divided into four categories: physical/condition, patient, therapy, and social-economic. Responses were analyzed using descriptive statistics from quantitative data and thematic data analysis for qualitative data. Results: Five hundred and fifteen health professionals and 51 public respondents participated. Both cohorts felt ''patient-related factors'' constituted the most important adherence barrier, but differed in their rankings of short-and long-term barriers. Health professionals rated ''patient-related'' and the public ''therapy-related'' factors as the most important adherence facilitator. Both ranked ''perception of PFMT benefit'' as the most important long-term facilitator. Contrary to published findings, symptom severity was not ranked highly. Neither cohort felt the barriers nor facilitators differed according to PFM condition (urinary/faecal incontinence, pelvic organ prolapse, pelvic pain); however, a large number of health professionals felt differences existed across age, gender, and ethnicity. Half of respondents in both cohorts felt research barriers and facilitators differed from those in clinical practice. Conclusions: An emphasis on ''patient-related'' factors, ahead of ''condition-specific'' and ''therapy-related,'' affecting PFMT adherence barriers was evident. Health professionals need to be aware of the importance of long-term patient perception of PFMT benefits and consider enabling strategies. Neurourol. Urodynam.
Aims: To summarize the findings and ''expert-panel'' consensus of the State-of-the-Science Semina... more Aims: To summarize the findings and ''expert-panel'' consensus of the State-of-the-Science Seminar on pelvic floor muscle training (PFMT) adherence held prior to the 41st International Continence Society scientific meeting, Glasgow, 2011. Methods: Summaries of research and theory about PFMT adherence (based on a comprehensive literature search) were presented by subject experts at the 2011 Seminar to generate discussion and guidance for clinical practice and future research. Supplemental research, post-seminar, resulted in, three review papers summarizing: (1) relevant behavioral theories, (2) adherence measurement, determinants and effectiveness of PFMT adherence interventions, and (3) patients' PFMT experiences. A fourth, reported findings from an online survey of health professionals and the public. Results: Few high-quality studies were found. Paper I summarizes 12 behavioral frameworks relevant to theoretical development of PFMT adherence interventions and strategies. Findings in Paper II suggest both PFMT self-efficacy and intention-to-adhere predict PFMT adherence. Paper III identified six potential adherence modifiers worthy of further investigation. Paper IV found patient-related factors were the biggest adherence barrier to PFMT adherence. Conclusion: Given the lack of high-quality studies, the conclusions were informed by expert opinion. Adherence is central to short-and longer-term PFMT effect. More attention and explicit reporting is needed regarding: (1) applying health behavior theory in PFMT program planning; (2) identifying adherence determinants; (3) developing and implementing interventions targeting known adherence determinants; (4) using patient-centred approaches to evaluating adherence barriers and facilitators; (5) measuring adherence, including refining and testing instruments; and (6) testing the association between adherence and PFMT outcome. Neurourol. Urodynam.
Peer physical examination (PPE) is a method of teaching and learning clinical skills in which stu... more Peer physical examination (PPE) is a method of teaching and learning clinical skills in which students use fellow students as surrogate patients or models. PPE is recognised as useful as an experiential learning method to increase skill development for physiotherapy clinical practice. However students may feel pressured to participate despite discomfort and embarrassment when practising physical examination and treatment skills with their peers. Obtaining students' informed consent to participate in PPE is an important process to address these disadvantages of PPE. This paper proposes a three stage process for obtaining informed consent from postgraduate physiotherapy students learning pelvic floor examination and treatment skills. The process is designed to encourage educators to articulate the ethical issues that are relevant in this area of teaching; to provide information to students to enable them to understand what is involved and to choose to participate, and to offer alternatives to participation through a formalised process of informed consent. These steps mirror students' future obligations and actions when communicating with their patients.
Aims: Pelvic floor muscle training (PFMT) has Level A evidence to treat female urinary incontinen... more Aims: Pelvic floor muscle training (PFMT) has Level A evidence to treat female urinary incontinence (UI). Recently, indirect training of the pelvic floor muscles (PFM) via the transversus abdominis muscle (TrA) has been suggested as a new method to treat UI. The aim of this article is to discuss whether there is evidence for a synergistic co-contraction between TrA and PFM in women with UI, whether TrA contraction is as effective, or more effective than PFMT in treating UI and whether there is evidence to recommend TrA training as an intervention strategy. Methods: A computerized search on PubMed, and hand searching in proceedings from the meetings of the World Confederation of Physical Therapy (1993)(1994)(1995)(1996)(1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007), International Continence Society and International Urogynecology Association (1990Association ( -2007 were performed. Results: While a co-contraction of the TrA normally occurs with PFM contraction, there is evidence that a co-contraction of the PFM with TrA contraction can be lost or altered in women with UI. No randomized controlled trials (RCTs) were found comparing TrA training with untreated controls or sham. Two RCTs have shown no additional effect of adding TrA training to PFMT in the treatment of UI. Conclusions: To date there is insufficient evidence for the use of TrA training instead of or in addition to PFMT for women with UI.
Aims: The aims of this study were to determine the intra-therapist reliability for digital muscle... more Aims: The aims of this study were to determine the intra-therapist reliability for digital muscle testing and vaginal manometry on maximum voluntary contraction strength and endurance. In addition, we assessed how reliability varied with di¡erent tools and di¡erent testing positions. Methods: Subjects included 20 female physiotherapists. The modi¢ed Oxford scale was used for the digital muscle testing, and the Peritron TM perineometer was used for the vaginal resting pressure and vaginal squeeze pressure assessments. Strength and endurance testing were performed. The highest of the maximum voluntary contraction scores was used in strength analysis, and a fatigue index value was calculated from the endurance repetitions. Bent-knee lying, supine, sitting, and standing positions were used. The time interval for between-session reliability was 2^6 weeks. Results: Kappa values for the between-session reliability of digital muscle testing were 0.69, 0.69, 0.86, and 0.79 for the four test positions, respectively. Intra-class correlation coe⁄cient (ICC) values for squeeze pressure readings for the four positions were 0.95, 0.91, 0.96, and 0.92 for maximum voluntary contraction, and 0.05, 0.42, 0.13, and 0.35 for endurance testing. ICC values for resting pressure were 0.74, 0.77, 0.47, and 0.29. Conclusions: Reliability of digital muscle testing was very good in sitting and good in the other three positions. vaginal resting pressure demonstrated very good reliability in all four positions for maximum voluntary contraction, but was unreliable for endurance testing. Vaginal resting pressure was not reliable in upright positions. Both measurement tools are reliable in certain positions, with manometry demonstrating higher reliability coe⁄cients.
Introduction: This assessor-blinded randomized controlled trial investigated the effect of a pre-... more Introduction: This assessor-blinded randomized controlled trial investigated the effect of a pre-and post-operative physiotherapy-supervised pelvic floor muscle (PFM) training program in women undergoing surgery for prolapse or hysterectomy. Methods: Participants were assessed pre-operatively, and at 3, 6, and 12 months post-operatively by a blinded physiotherapy assessor. Following randomization, participants were allocated to a control group (CG) which included ''usual care'' (as provided by the surgeon and the hospital staff), or a treatment group (TG) which included one pre-operative and seven post-operative treatment sessions over 12 months. Primary outcomes were bladder and prolapse symptoms, measured by the Urogenital Distress Inventory (UDI) and the Incontinence Impact Questionnaire (IIQ). Results: Fifty-one participants were randomized. The 12-month post-operative findings showed there was no difference in the prevalence of the primary outcomes (ORs 1.2, 1.3). There were no significant differences between groups on the change scores of the UDI mean: 44.1 [5.1]; 54.0 [5.4], P ¼ 0.20) nor the IIQ (median: 0.0 [9,14]; 10.0 [5,19], P ¼ 0.09). The repeated measures analyses also demonstrated no significant changes. Conclusion: The program tested did not improve bladder or prolapse symptoms in this trial. Reasons may include the effectiveness of surgery alone, wide variance in data, small sample size, insufficient training by the TG, and PFM training by the usual care group. Neurourol. Urodynam. 29:719-725,
Background Pelvic organ prolapse is common and is strongly associated with childbirth and increas... more Background Pelvic organ prolapse is common and is strongly associated with childbirth and increasing age. Women with prolapse are often advised to do pelvic fl oor muscle exercises, but evidence supporting the benefi ts of such exercises is scarce. We aimed to establish the eff ectiveness of one-to-one individualised pelvic fl oor muscle training for reducing prolapse symptoms.
The aims of this study were to analyse the effect of different body positions on pelvic floor mus... more The aims of this study were to analyse the effect of different body positions on pelvic floor muscle (PFM) assessment using digital muscle testing, manometry and transabdominal ultrasound. In addition, subject acceptance of each testing position was recorded. Subjects were 20 women's health physiotherapists. The testing protocol included the best of three maximum voluntary contractions tested in each of four positions (crook lying, supine, sitting and standing). Significant differences in muscle strength and subject acceptance between positions were found with each tool, most often between lying and upright positions. Digital muscle testing and vaginal squeeze-pressure scores were highest in the lying position, and vaginal resting pressure and transabdominal ultrasound scores were highest in the standing position. Subjects preferred the lying positions for internal examinations. The clinical significance of these differences and the reasons for these variations require further investigation.
Introduction and hypothesis There is evidence that in nonsurgical populations, pelvic floor muscl... more Introduction and hypothesis There is evidence that in nonsurgical populations, pelvic floor muscle training (PFMT) and lifestyle advice improves symptoms and stage of pelvic organ prolapse (POP). Some women, however, require surgery, after which de novo symptoms can develop or additional surgery is required due to recurrence. Robust evidence is required as to the benefit of perioperative PFMT in the postsurgery reduction of symptoms and POP recurrence. The aim of this study was to assess the feasibility of and collect pilot data to inform sample size (SS) calculation for a multicentre randomised controlled trial (RCT) of perioperative PFMT following surgical intervention for POP. Methods Fifty-seven participants were recruited and randomised to a treatment group (one pre and six postoperative PFMT sessions) or a control group (usual care). The primary outcome measure was the Pelvic Organ Prolapse Symptom Score (POP-SS) at 12 months; secondary outcome measures included measurement of prolapse, the pelvic floor and questionnaires relating to urinary and bowel incontinence. All outcomes were measured at 0, 6 and 12 months. Results Information on recruitment, retention and appropriateness of outcome measures for a definitive trial was gathered, and data enabled us to undertake an SS calculation. When compared with the control group (n=29), benefits to the intervention group (n=28) were observed in terms of fewer prolapse symptoms at 12 months [mean difference 3.94; 95 % confidence interval (CI) 1.35-6.75; t=3.24, p=0.006]; however, these results must be viewed with caution due to possible selection bias. Conclusion With modifications to design identified in this pilot study, a multicentre RCT is feasible.
Acta Obstetricia et Gynecologica Scandinavica, 2005
The objective of this survey was to obtain information about current physiotherapy practice for p... more The objective of this survey was to obtain information about current physiotherapy practice for patients undergoing pelvic surgery. The aims were to evaluate whether differences exist in service provision between women's health physiotherapists (WHPTs) and hospital physiotherapists (HPTs) and in the guidelines used by physiotherapists to direct their service delivery. METHODS. A questionnaire was posted to the members of the Victorian Continence and Women's Health Physiotherapy Group (n = 130) and physiotherapists working in metropolitan and rural hospitals (n = 90). The questionnaire comprised questions relating to the aspects of treatment, including how referrals are made, funding, interventions provided and how they are delivered, and use of outcome measures. Data were summarized using descriptive statistics and Chi-square analysis of differences between WHPTs and HPTs. The response rate was 75.9%. In 67% of cases, service delivery was initiated by surgeon request, and most commonly for gynecologic patients (85%). Individual consultations were used on 96% of occasions and 8% were group sessions. Content of physiotherapy treatment for in-patients varied, with WHPTs significantly more likely to prescribe pelvic floor muscle exercises (P = 0.003), bowel advice (P = 0.001), avoidance of risk activities (P = 0.002), and awareness of postoperative symptoms (P = 0.001). Conversely, HPTs were significantly more likely to perform respiratory checks (P = 0.002) and mobilization (P = 0.001). Eighty-seven percent of respondents regarded their service as suboptimal, citing the need for evidence to support the content and best timing of intervention. Differences exist in physiotherapy treatment for pelvic surgery patients. Further research is required to establish whether, and which, elements of physiotherapy intervention are effective.
Aims: This paper, the first of four emanating from the International Continence Society's 2011 St... more Aims: This paper, the first of four emanating from the International Continence Society's 2011 State-of-the-Science Seminar on pelvic-floor-muscle training (PFMT) adherence, aimed to summarize the literature on theoretical models to promote PFMT adherence, as identified in the research, or suggested by the seminar's expert panel, and recommends future directions for clinical practice and research. Methods: Existing literature on theories of health behavior were identified through a conventional subject search of electronic databases, reference-list checking, and input from the expert panel. A core eligibility criterion was that the study included a theoretical model to underpin adherence strategies used in an intervention to promote PFM training/exercise. Results: A brief critique of 12 theoretical models/theories is provided and, were appropriate, their use in PFMT adherence strategies identified or examples of possible uses in future studies outlined. Conclusion: A better theoretical-based understanding of interventions to promote PFMT adherence through changes in health behaviors is required. The results of this scoping review and expert opinions identified several promising models. Future research should explicitly map the theories behind interventions that are thought to improve adherence in various populations (e.g., perinatal women to prevent or lessen urinary incontinence). In addition, identified behavioral theories applied to PFMT require a process whereby their impact can be evaluated. Neurourol. Urodynam.
Aims: This review aims to locate and summarize the findings of qualitative studies exploring the ... more Aims: This review aims to locate and summarize the findings of qualitative studies exploring the experience of and adherence to pelvic floor muscle training (PFMT) to recommend future directions for practice and research. Methods: Primary qualitative studies were identified through a conventional subject search of electronic databases, reference-list checking, and expert contact. A core eligibility criterion was the inclusion of verbatim quotes from participants about PFMT experiences. Details of study aims, methods, and participants were extracted and tabulated. Data were inductively grouped into categories describing "modifiers" of adherence (verified by a second author) and systematically displayed with supporting illustrative quotes. Results: Thirteen studies (14 study reports) were included; eight recruited only or predominantly women with urinary incontinence, three recruited postnatal women, and two included women with pelvic organ prolapse. The quality of methodological reporting varied. Six "modifiers" of adherence were described: knowledge; physical skill; feelings about PFMT; cognitive analysis, planning, and attention; prioritization; and service provision. Conclusions: Individuals' experience substantial difficulties with capability (particularly knowledge and skills), motivation (especially associated with the considerable cognitive demands of PFMT), and opportunity (as external factors generate competing priorities) when adopting and maintaining a PFMT program. Expert consensus was that judicious selection and deliberate application of appropriate behavior change strategies directed to the "modifiers" of adherence identified in the review may improve PFMT outcomes. Future research is needed to explore whether the review findings are congruent with the PFMT experiences of antenatal women, men, and adults with fecal incontinence. Neurourol. Urodynam.
Aims: This paper on pelvic-floor-muscle training (PFMT) adherence, the second of four from the In... more Aims: This paper on pelvic-floor-muscle training (PFMT) adherence, the second of four from the International Continence Society's 2011 State-of-the-Science Conference, aims to (1) identify and collate current adherence outcome measures, (2) report the determinants of adherence, (3) report on PFMT adherence strategies, and (4) make actionable clinical and research recommendations. Method: Data were amassed from a literature review and an expert panel (2011 conference), following consensus statement methodology. Experts in pelvic floor dysfunction collated and synthesized the evidence and expert opinions on PFMT adherence for urinary incontinence (UI) and lower bowel dysfunction in men and women and pelvic organ prolapse in women. Results: The literature was scarce for most of the studied populations except for limited research on women with UI. Outcome measures: Exercise diaries were the most widely-used adherence outcome measure, PFMT adherence was inconsistently monitored and inadequately reported. Determinants: Research, mostly secondary analyses of RCTs, suggested that intention to adhere, self-efficacy expectations, attitudes towards the exercises, perceived benefits and a high social pressure to engage in PFMT impacted adherence. Strategies: Few trials studied and compared adherence strategies. A structured PFMT programme, an enthusiastic physiotherapist, audio prompts, use of established theories of behavior change, and user-consultations seem to increase adherence. Conclusion: The literature on adherence outcome measures, determinants and strategies remains scarce for the studied populations with PFM dysfunction, except in women with UI. Although some current adherence findings can be applied to clinical practice, more effective and standardized research is urgently needed across all the sub-populations. Neurourol. Urodynam. # 2015 Wiley Periodicals, Inc.
Aims: There is scant information on pelvic floor muscle training (PFMT) adherence barriers and fa... more Aims: There is scant information on pelvic floor muscle training (PFMT) adherence barriers and facilitators. A web-based survey was conducted (1) to investigate whether responses from health professionals and the public broadly reflected findings in the literature, (2) if responses differed between the two groups, and (3) to identify new research directions. Methods: Health professional and public surveys were posted on the ICS website. PFMT adherence barriers and facilitators were divided into four categories: physical/condition, patient, therapy, and social-economic. Responses were analyzed using descriptive statistics from quantitative data and thematic data analysis for qualitative data. Results: Five hundred and fifteen health professionals and 51 public respondents participated. Both cohorts felt ''patient-related factors'' constituted the most important adherence barrier, but differed in their rankings of short-and long-term barriers. Health professionals rated ''patient-related'' and the public ''therapy-related'' factors as the most important adherence facilitator. Both ranked ''perception of PFMT benefit'' as the most important long-term facilitator. Contrary to published findings, symptom severity was not ranked highly. Neither cohort felt the barriers nor facilitators differed according to PFM condition (urinary/faecal incontinence, pelvic organ prolapse, pelvic pain); however, a large number of health professionals felt differences existed across age, gender, and ethnicity. Half of respondents in both cohorts felt research barriers and facilitators differed from those in clinical practice. Conclusions: An emphasis on ''patient-related'' factors, ahead of ''condition-specific'' and ''therapy-related,'' affecting PFMT adherence barriers was evident. Health professionals need to be aware of the importance of long-term patient perception of PFMT benefits and consider enabling strategies. Neurourol. Urodynam.
Aims: To summarize the findings and ''expert-panel'' consensus of the State-of-the-Science Semina... more Aims: To summarize the findings and ''expert-panel'' consensus of the State-of-the-Science Seminar on pelvic floor muscle training (PFMT) adherence held prior to the 41st International Continence Society scientific meeting, Glasgow, 2011. Methods: Summaries of research and theory about PFMT adherence (based on a comprehensive literature search) were presented by subject experts at the 2011 Seminar to generate discussion and guidance for clinical practice and future research. Supplemental research, post-seminar, resulted in, three review papers summarizing: (1) relevant behavioral theories, (2) adherence measurement, determinants and effectiveness of PFMT adherence interventions, and (3) patients' PFMT experiences. A fourth, reported findings from an online survey of health professionals and the public. Results: Few high-quality studies were found. Paper I summarizes 12 behavioral frameworks relevant to theoretical development of PFMT adherence interventions and strategies. Findings in Paper II suggest both PFMT self-efficacy and intention-to-adhere predict PFMT adherence. Paper III identified six potential adherence modifiers worthy of further investigation. Paper IV found patient-related factors were the biggest adherence barrier to PFMT adherence. Conclusion: Given the lack of high-quality studies, the conclusions were informed by expert opinion. Adherence is central to short-and longer-term PFMT effect. More attention and explicit reporting is needed regarding: (1) applying health behavior theory in PFMT program planning; (2) identifying adherence determinants; (3) developing and implementing interventions targeting known adherence determinants; (4) using patient-centred approaches to evaluating adherence barriers and facilitators; (5) measuring adherence, including refining and testing instruments; and (6) testing the association between adherence and PFMT outcome. Neurourol. Urodynam.
Peer physical examination (PPE) is a method of teaching and learning clinical skills in which stu... more Peer physical examination (PPE) is a method of teaching and learning clinical skills in which students use fellow students as surrogate patients or models. PPE is recognised as useful as an experiential learning method to increase skill development for physiotherapy clinical practice. However students may feel pressured to participate despite discomfort and embarrassment when practising physical examination and treatment skills with their peers. Obtaining students' informed consent to participate in PPE is an important process to address these disadvantages of PPE. This paper proposes a three stage process for obtaining informed consent from postgraduate physiotherapy students learning pelvic floor examination and treatment skills. The process is designed to encourage educators to articulate the ethical issues that are relevant in this area of teaching; to provide information to students to enable them to understand what is involved and to choose to participate, and to offer alternatives to participation through a formalised process of informed consent. These steps mirror students' future obligations and actions when communicating with their patients.
Aims: Pelvic floor muscle training (PFMT) has Level A evidence to treat female urinary incontinen... more Aims: Pelvic floor muscle training (PFMT) has Level A evidence to treat female urinary incontinence (UI). Recently, indirect training of the pelvic floor muscles (PFM) via the transversus abdominis muscle (TrA) has been suggested as a new method to treat UI. The aim of this article is to discuss whether there is evidence for a synergistic co-contraction between TrA and PFM in women with UI, whether TrA contraction is as effective, or more effective than PFMT in treating UI and whether there is evidence to recommend TrA training as an intervention strategy. Methods: A computerized search on PubMed, and hand searching in proceedings from the meetings of the World Confederation of Physical Therapy (1993)(1994)(1995)(1996)(1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007), International Continence Society and International Urogynecology Association (1990Association ( -2007 were performed. Results: While a co-contraction of the TrA normally occurs with PFM contraction, there is evidence that a co-contraction of the PFM with TrA contraction can be lost or altered in women with UI. No randomized controlled trials (RCTs) were found comparing TrA training with untreated controls or sham. Two RCTs have shown no additional effect of adding TrA training to PFMT in the treatment of UI. Conclusions: To date there is insufficient evidence for the use of TrA training instead of or in addition to PFMT for women with UI.
Aims: The aims of this study were to determine the intra-therapist reliability for digital muscle... more Aims: The aims of this study were to determine the intra-therapist reliability for digital muscle testing and vaginal manometry on maximum voluntary contraction strength and endurance. In addition, we assessed how reliability varied with di¡erent tools and di¡erent testing positions. Methods: Subjects included 20 female physiotherapists. The modi¢ed Oxford scale was used for the digital muscle testing, and the Peritron TM perineometer was used for the vaginal resting pressure and vaginal squeeze pressure assessments. Strength and endurance testing were performed. The highest of the maximum voluntary contraction scores was used in strength analysis, and a fatigue index value was calculated from the endurance repetitions. Bent-knee lying, supine, sitting, and standing positions were used. The time interval for between-session reliability was 2^6 weeks. Results: Kappa values for the between-session reliability of digital muscle testing were 0.69, 0.69, 0.86, and 0.79 for the four test positions, respectively. Intra-class correlation coe⁄cient (ICC) values for squeeze pressure readings for the four positions were 0.95, 0.91, 0.96, and 0.92 for maximum voluntary contraction, and 0.05, 0.42, 0.13, and 0.35 for endurance testing. ICC values for resting pressure were 0.74, 0.77, 0.47, and 0.29. Conclusions: Reliability of digital muscle testing was very good in sitting and good in the other three positions. vaginal resting pressure demonstrated very good reliability in all four positions for maximum voluntary contraction, but was unreliable for endurance testing. Vaginal resting pressure was not reliable in upright positions. Both measurement tools are reliable in certain positions, with manometry demonstrating higher reliability coe⁄cients.
Introduction: This assessor-blinded randomized controlled trial investigated the effect of a pre-... more Introduction: This assessor-blinded randomized controlled trial investigated the effect of a pre-and post-operative physiotherapy-supervised pelvic floor muscle (PFM) training program in women undergoing surgery for prolapse or hysterectomy. Methods: Participants were assessed pre-operatively, and at 3, 6, and 12 months post-operatively by a blinded physiotherapy assessor. Following randomization, participants were allocated to a control group (CG) which included ''usual care'' (as provided by the surgeon and the hospital staff), or a treatment group (TG) which included one pre-operative and seven post-operative treatment sessions over 12 months. Primary outcomes were bladder and prolapse symptoms, measured by the Urogenital Distress Inventory (UDI) and the Incontinence Impact Questionnaire (IIQ). Results: Fifty-one participants were randomized. The 12-month post-operative findings showed there was no difference in the prevalence of the primary outcomes (ORs 1.2, 1.3). There were no significant differences between groups on the change scores of the UDI mean: 44.1 [5.1]; 54.0 [5.4], P ¼ 0.20) nor the IIQ (median: 0.0 [9,14]; 10.0 [5,19], P ¼ 0.09). The repeated measures analyses also demonstrated no significant changes. Conclusion: The program tested did not improve bladder or prolapse symptoms in this trial. Reasons may include the effectiveness of surgery alone, wide variance in data, small sample size, insufficient training by the TG, and PFM training by the usual care group. Neurourol. Urodynam. 29:719-725,
Background Pelvic organ prolapse is common and is strongly associated with childbirth and increas... more Background Pelvic organ prolapse is common and is strongly associated with childbirth and increasing age. Women with prolapse are often advised to do pelvic fl oor muscle exercises, but evidence supporting the benefi ts of such exercises is scarce. We aimed to establish the eff ectiveness of one-to-one individualised pelvic fl oor muscle training for reducing prolapse symptoms.
The aims of this study were to analyse the effect of different body positions on pelvic floor mus... more The aims of this study were to analyse the effect of different body positions on pelvic floor muscle (PFM) assessment using digital muscle testing, manometry and transabdominal ultrasound. In addition, subject acceptance of each testing position was recorded. Subjects were 20 women's health physiotherapists. The testing protocol included the best of three maximum voluntary contractions tested in each of four positions (crook lying, supine, sitting and standing). Significant differences in muscle strength and subject acceptance between positions were found with each tool, most often between lying and upright positions. Digital muscle testing and vaginal squeeze-pressure scores were highest in the lying position, and vaginal resting pressure and transabdominal ultrasound scores were highest in the standing position. Subjects preferred the lying positions for internal examinations. The clinical significance of these differences and the reasons for these variations require further investigation.
Introduction and hypothesis There is evidence that in nonsurgical populations, pelvic floor muscl... more Introduction and hypothesis There is evidence that in nonsurgical populations, pelvic floor muscle training (PFMT) and lifestyle advice improves symptoms and stage of pelvic organ prolapse (POP). Some women, however, require surgery, after which de novo symptoms can develop or additional surgery is required due to recurrence. Robust evidence is required as to the benefit of perioperative PFMT in the postsurgery reduction of symptoms and POP recurrence. The aim of this study was to assess the feasibility of and collect pilot data to inform sample size (SS) calculation for a multicentre randomised controlled trial (RCT) of perioperative PFMT following surgical intervention for POP. Methods Fifty-seven participants were recruited and randomised to a treatment group (one pre and six postoperative PFMT sessions) or a control group (usual care). The primary outcome measure was the Pelvic Organ Prolapse Symptom Score (POP-SS) at 12 months; secondary outcome measures included measurement of prolapse, the pelvic floor and questionnaires relating to urinary and bowel incontinence. All outcomes were measured at 0, 6 and 12 months. Results Information on recruitment, retention and appropriateness of outcome measures for a definitive trial was gathered, and data enabled us to undertake an SS calculation. When compared with the control group (n=29), benefits to the intervention group (n=28) were observed in terms of fewer prolapse symptoms at 12 months [mean difference 3.94; 95 % confidence interval (CI) 1.35-6.75; t=3.24, p=0.006]; however, these results must be viewed with caution due to possible selection bias. Conclusion With modifications to design identified in this pilot study, a multicentre RCT is feasible.
Acta Obstetricia et Gynecologica Scandinavica, 2005
The objective of this survey was to obtain information about current physiotherapy practice for p... more The objective of this survey was to obtain information about current physiotherapy practice for patients undergoing pelvic surgery. The aims were to evaluate whether differences exist in service provision between women's health physiotherapists (WHPTs) and hospital physiotherapists (HPTs) and in the guidelines used by physiotherapists to direct their service delivery. METHODS. A questionnaire was posted to the members of the Victorian Continence and Women's Health Physiotherapy Group (n = 130) and physiotherapists working in metropolitan and rural hospitals (n = 90). The questionnaire comprised questions relating to the aspects of treatment, including how referrals are made, funding, interventions provided and how they are delivered, and use of outcome measures. Data were summarized using descriptive statistics and Chi-square analysis of differences between WHPTs and HPTs. The response rate was 75.9%. In 67% of cases, service delivery was initiated by surgeon request, and most commonly for gynecologic patients (85%). Individual consultations were used on 96% of occasions and 8% were group sessions. Content of physiotherapy treatment for in-patients varied, with WHPTs significantly more likely to prescribe pelvic floor muscle exercises (P = 0.003), bowel advice (P = 0.001), avoidance of risk activities (P = 0.002), and awareness of postoperative symptoms (P = 0.001). Conversely, HPTs were significantly more likely to perform respiratory checks (P = 0.002) and mobilization (P = 0.001). Eighty-seven percent of respondents regarded their service as suboptimal, citing the need for evidence to support the content and best timing of intervention. Differences exist in physiotherapy treatment for pelvic surgery patients. Further research is required to establish whether, and which, elements of physiotherapy intervention are effective.
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Papers by Helena Frawley