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Consideration of pelvic floor myofascial release for overactive bladder
Journal Pre-proof CONSIDERATION OF PELVIC FLOOR MYOFASCIAL RELEASE FOR OVERACTIVE BLADDER Birte J. Wolff, Cara J. Joyce, Lindsey A. McAlarnen, Cynthia A. Brincat, Elizabeth R. Mueller, Colleen M. Fitzgerald PII:
S1360-8592(19)30394-8
DOI:
https://doi.org/10.1016/j.jbmt.2019.10.018
Reference:
YJBMT 1902
To appear in:
Journal of Bodywork & Movement Therapies
Received Date: 1 February 2019 Revised Date:
24 May 2019
Accepted Date: 30 October 2019
Please cite this article as: Wolff, B.J., Joyce, C.J., McAlarnen, L.A., Brincat, C.A., Mueller, E.R., Fitzgerald, C.M., CONSIDERATION OF PELVIC FLOOR MYOFASCIAL RELEASE FOR OVERACTIVE BLADDER, Journal of Bodywork & Movement Therapies, https://doi.org/10.1016/j.jbmt.2019.10.018. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Elsevier Ltd. All rights reserved.
CONSIDERATION OF PELVIC FLOOR MYOFASCIAL RELEASE FOR OVERACTIVE BLADDER
Birte J. Wolff, MDa, Cara J. Joyce, PhDb, Lindsey A. McAlarnen, MD MScc, Cynthia A. Brincat, MD PhDa, Elizabeth R. Mueller, MDa, Colleen M. Fitzgerald, MDa a
Department of Obstetrics/Gynecology and Urology, Loyola University Chicago Stritch School of Medicine and Loyola University Medical Center c
Center for Translational Research and Education Loyola University Chicago d
Department of Obstetrics/Gynecology Rush University Medical Center
Corresponding author Birte Johanna Wolff, MD 2160 S First Ave. Maywood IL 60153 Fax: 708 216-2171 Phone: 708-216-2170 [email protected]
Declarations of interest: None This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
ABSTRACT
1 2
Introduction: Physical therapy has been shown to be effective for women with overactive
3
bladder (OAB). We report on our experience with pelvic floor physical therapy (PFPT)
4
with or without myofascial release as treatment for women with symptoms of urinary
5
urgency or urge incontinence.
6
Methods: We performed a retrospective chart review, of patients who presented to our
7
tertiary care Urogynecology practice. These women were evaluated and treated between
8
August 2016 and December 2016. We abstracted for symptoms as per history of present
9
illness and the pelvic floor muscle examination. PFPT progress notes were reviewed to
10
determine whether patients received myofascial release techniques, or if therapy was
11
limited to behavioral interventions and urge suppression techniques. We recorded the
12
number of PFPT sessions attended, and whether the patient reported improvement.
13
Results: 77 patients with symptoms of OAB met inclusion criteria and initiated PFPT.
14
Myofascial tenderness of the pelvic floor muscles was found in 56.5% of patients. PFPT
15
was limited to behavioral and urge suppression in 18 patients, while 59 patients received
16
myofascial release techniques. Improvement was reported by 71.4% (n=55/77) of patients.
17
Improvement increased with number of sessions attended: 1-2: 6% (1/17), 3-5: 94%
18
(16/17), 6-8: 91% (29/32), and >8: 80% (9/11) improved, respectively (p<0.001). Among
19
patients who had myofascial release, 84.7% reported improvement when compared to only
20
27.8% of patients without myofascial release.
21
Conclusions: The data support the inclusion of myofascial release during pelvic floor
22
physical therapy for overactive bladder. At least three sessions of PFPT are necessary for
23
patient reported improvement.
24 25
Word Count: 250
26 27 28 29
Keywords:
30
Overactive bladder, physical therapy, pelvic pain, urinary urgency, myofascial release
31
therapy
32
33
INTRODUCTION
34 35
Overactive bladder (OAB) is a disorder characterized by urinary urgency and frequency
36
with or without urgency urinary incontinence, which affects 11% of the population and
37
diminishes quality of life (Stewart et al 2003). While the pathophysiology of OAB is still
38
not completely understood. One proposed theory includes hyperactivity of the pelvic floor
39
muscles (Kuo et al 2015). The same cause has also been suspected in the pathophysiology
40
of various pelvic pain syndromes such as myofascial trigger points, self-reported chronic
41
pelvic pain or atypical cyclic pain (Schneider 1995,C. M. Fitzgerald et al 2011,Reiter &
42
Gambone 1991).
43 44
Pelvic pain often occurs in complex presentation including symptoms of the lower urinary
45
tract (Kotarinos 2012,Bernstein et al 1992). Studies on animal models of pelvic pain have
46
found that vaginal hyperalgesia reduces the bladder filling volume at which voiding begins
47
(Berkley 2005). Hoffman (2011) provides possible explanations of this overlap in
48
symptoms as viscerosomatic convergence, which is sensory innervation of the muscle that
49
may have neural cross-talk to the viscera via the dorsal horn of the spinal cord (Pezzone et
50
al 2005). Among women with chronic pelvic pain, 89% had physical exam findings of
51
tenderness of the levator ani muscle (Montenegro et al 2010). These findings led to a
52
definition of pelvic floor muscle myofascial pain as: a complex form of neuromuscular
53
dysfunction consisting of motor and sensory abnormalities involving both the peripheral
54
and central nervous systems (Spitznagle & Robinson 2014).
55
56
Physical therapy is an effective treatment of myofascial pain with or without trigger points
57
in other anatomic areas (Giamberardino et al 2011). One theory of pathophysiology of
58
myofascial tenderness and trigger points specifically, is related to chronic muscle overuse
59
(Shah et al. 2015). Shah & Gilliams (2008) found a relatively hypoxic environment inside
60
trigger points, and theorize that a sustained low level of activity may downregulate the
61
perfusion of the muscle, and as a result perpetuate a cycle of ischemic changes and
62
sarcomere contraction. Physical therapist techniques of sustained compression may result
63
in improvement by reducing the sarcomere contracture and reducing the actin and myosin
64
overlap resulting in decreased need for ATP (Shah et al. 2015). Trigger points may be
65
considered "active" if there is spontaneous pain or "latent" if there is only pain on palpation
66
(Lucas et al. 2010). Latent trigger points may convert to active trigger points, but even the
67
latent trigger may already cause changes in muscle activation and an erratic muscle firing
68
pattern, as seen in the shoulder muscle for example (Lucas et al. 2010). There is some
69
convincing evidence that treatment of the pelvic location could be included (M. P.
70
Fitzgerald et al 2013). The original description of massage therapy for pelvic floor
71
dysfunction by Thiele in 1963 was transrectal massage therapy for patients with
72
cyccodynia (THIELE 1963). The utility of vaginal manual therapy was further described
73
by Oyama (Oyama et al 2004). Indeed, newer retrospective data support that view: Among
74
women with myofascial pain syndrome of the pelvic floor muscles, 63% of the patients
75
improved with physical therapy (Bedaiwy et al 2013), and the finding was confirmed in
76
other patient groups (Spitznagle & Robinson 2014).
77
78
With this background, it is common practice in our clinic to prescribe PFPT as first line
79
treatment for patients with OAB, especially when pelvic floor myofascial tenderness to
80
palpation (TTP) is found on physical exam. There are some circumstances where
81
cognitive/behavioral therapy might be more helpful for those without documented pelvic
82
floor myofascial TTP, but data to support such concepts are yet missing (Burgio et al
83
1985,McDowell et al 1992,Burgio et al 1998,Burgio et al 2002). It is also unclear in the
84
literature how many sessions should be prescribed. Hence, the objective of our study was
85
to determine how many and what type of pelvic floor physical therapy (PFPT) sessions are
86
necessary for symptom improvement in women with OAB.
87
88
89
90
MATERIALS AND METHODS
91
After receiving IRB-approval (#LU209380) we used our electronic medical record system
92
to review the charts of new patients who presented to a tertiary urogynecology clinic
93
between August and December 2016 as a representative convenience sample. Per the
94
standard of our medical practice, all patients provided the information used here on a
95
completely voluntary basis and gave verbal consent to all of the physical examinations.
96
Chaperoning is offered to everyone and commonly provided. The inclusion criterion was
97
the presence of symptoms of overactive bladder (OAB) specifically urinary urgency with
98
or without urinary urge incontinence. This was derived from patient complaints of urinary
99
urgency or frequency, or urinary urgency incontinence in history of present illness or from
100
the results of the validated questionnaire PFDI-SF20 (Pelvic Floor Disability Index Short
101
Form 20 (Barber et al 2005)). In this questionnaire specifically questions 15: “Do you
102
usually experience frequent urination?” and question 16: “Do you usually experience urine
103
leakage associated with a feeling of urgency that is a strong sensation of needing to go to
104
the bathroom?” were used to define eligibility. We reviewed both their clinic notes as well
105
as their PFPT progress notes. Patients were excluded from the final analysis if they did not
106
initiate physical therapy. These records were reviewed for patients’ initial therapy date,
107
initial date of improvement, and last day of observation. Demographic information
108
consisting of age, BMI, race, and parity were collected. Comorbidities of depression and
109
fibromyalgia were recorded. Additionally, we noted whether patients were prescribed
110
medication for their OAB symptoms at the same time of starting their physical therapy.
111
The medications recorded were vaginal estrogen, anticholinergics, and mirabegron. Per
112
routine for all new patients, a pelvic organ prolapse examination was performed by the
113
physician, and this was recorded as pelvic organ prolapse stage 0-4.
114
The pelvic floor muscle physical examination and its documentation are standardized and
115
conducted for every new patient in our clinic. For the purpose of this study the presence of
116
pelvic floor myofascial TTP was defined as follows: while pressing digitally on the various
117
pelvic floor areas the patient was asked if any pain was provoked. If she reported “yes” she
118
was asked to place the highest pain provoked during the examination on a numeric scale of
119
1-10. First the physician palpated and pressed using the index finger externally in the
120
region of bulbocavernosus and transverse perineal muscles. Next the physician examined
121
by palpation, pressing transvaginally, using index finger alone or both index and middle
122
finger together. Beginning most distally, the examiner will reach the pubococcygeus,
123
illeococcygeus laterally and then coccygeus posteriorly on both sides of the vaginal walls.
124
To evaluate the obturator internus the patient was asked to press her knee laterally against
125
the examiners other hand, externally rotating her hip while the physician palpated the
126
ipsilateral anterolateral vaginal side wall.
127
While not all therapists had standardized training or procedures in the context of this study,
128
there was still a high level of consistency. All myofascial release techniques performed in
129
the context of the study involved intravaginal manual myofascial therapy by a physical
130
therapist trained in PFPT. With the patient in a supine position and in frog leg position, the
131
soft tissues of the pelvic floor including connective tissue and muscles were palpated by
132
the therapist digitally via the vagina. If either hypertonic muscle bands (tight/stiff pelvic
133
floor muscles) or painful trigger points (specific spot of sudden strong pain, usually
134
~1x1cm), or a combination of both were identified, these areas would be specifically
135
targeted. Two typical methods for these focus areas were: 1) sustained pressure technique
136
and 2) myofascial stretch (Oyama et al 2004). The sustained pressure technique consists of
137
sustained pressure on the area without volitional muscle contraction by the patient; and the
138
pressure threshold is dictated by the patient as the pressure, at which the patient can still
139
tolerate the discomfort well. The myofascial stretch which is geared to achieve lengthening
140
of the muscle by stroking along the fibers, at times referred to as "down training". The total
141
duration of intravaginal massage is less well defined, and based on the personalized
142
treatment approach and on patient tolerance. Typically one session lasts 45 minutes, with
143
10 or more minutes concentrated on myofascial release. Alternatively, patients could have
144
received PFPT without any myofascial release techniques. Instead, during these PFPT
145
sessions, patients were taught behavioral interventions, bladder training including urge
146
suppression techniques and in some cases included pelvic floor muscle strengthening
147
exercise.
148
Descriptive statistics (means +/- standard deviations or medians and interquartile range
149
[25th percentile, 75th percentile] for continuous data, frequencies and percentages for
150
categorical data) were calculated for subjects on demographic and clinical characteristics.
151
The associations between patient demographics and physician prescription of physical
152
therapy, physical therapy attendance, and rate of improvement with therapy with or
153
without myofascial release were assessed via the Cochran-Armitage Trend tests for ordinal
154
variables and chi-square or Fisher’s exact test as appropriate for nominal variables. A
155
logistic regression model was used to estimate the odds ratio and 95% confidence interval
156
for myofascial release associated with improvement. For all analyses, a result was
157
considered statistically significant at the p<0.05 level of significance. Analyses were
158
performed using SAS 9.4 (Cary, NC).
159 160
RESULTS
161 162
193 of 273 patients met at least one of the following inclusion criteria for this study: self-
163
reported symptoms of urinary urgency/frequency or urgency urinary incontinence. The
164
included patients had a mean age of 58.9 years (±16.6 SD), mean BMI 30.3 kg/m2 (±7.5
165
SD), median parity 2 (range 0-10), and physican exam median stage of prolapse 1 (range
166
0-4). A past medical history of depression was found in 31.2% (24/77) of the patients.
167
None of the patients had a history of fibromyalgia. Myofascial tenderness of the pelvic
168
floor muscles (TTP) was elicited by the physician in over half (109, 56.5%) of patients on
169
exam. PFPT was prescribed to 162 women (83.9%), which 77 (47.5%) attended. Among
170
those women who initiated PFPT, 70% (54/77) had pelvic floor myofascial TTP.
171
Myofascial release techniques were applied in 59 patients, of whom 45 (76.3%) had pelvic
172
floor TTP. The remaining 18 patients of whom 9 (50.0%) had pelvic floor TTP, had
173
treatment with a cognitive/behavioral or muscle strengthening focus. There was no specific
174
cut-off for the amount of TTP found on exam that would trigger the physican to prescribe
175
PFPT more often. The subgroup to which PFPT was not prescribed had higher stages of
176
prolapse (40.0% prolapse stage 3-4; p<0.001) and were older (mean age: 68±13 years SD;
177
p=0.003) (Table 1). Among those women who initiated PFPT, 16 patients were also
178
prescribed new medication as concomitant management for OAB (anticholinergic or
179
mirabegron n=8, vaginal estrogen n=8).
180 181
182
Per PFPT progress notes, symptom improvement was reported in 55 of 77 patients (71.4%)
183
who attended PFPT using non-validated measures. All of the women (8/8) who started
184
concomitant an oral anticholinergic or mirabegron noted improvement during the course of
185
physical therapy, however this did not reach statistical significance in this small sample
186
(p=0.096). While there was also a trend toward improvement with concomitant vaginal
187
estrogen, this was also not statistically significant (7 of 8 women reported improvement).
188
Interestingly, rates of improvement were similar for those with presence and absence of
189
pelvic floor myofascial TTP on examination. Of the 54 women with presence of
190
myofascial pain, 37 (68.5%) experienced improvement compared to 18/23 (78.3%) who
191
did not have myofascial pain, however this was not statistically significant. Improvement
192
was not associated with age, concomitant medical therapy for OAB, presence of
193
depression, prolapse stage or specific pelvic floor symptom, but it was dependent on the
194
length of treatment and whether physical therapy sessions included myofascial release
195
(Table 2).
196
197
The frequency of improvement depended on the number of therapeutic sessions attended:
198
1-2 sessions: 6% (1/17), 3-5 sessions: 94% (16/17), 6-8 sessions: 91% (29/32) and >8
199
sessions: 80% (9/11) improved, respectively (p<0.001) (Figure 1).
200
201
84.7% (50/59) of patients who had myofascial release techniques applied reported
202
improvement in their symptoms when compared to only 26.3% (5/18) of patients who had
203
physical therapy without myofascial release (p<0.001, Table 2). The odds of improvement
204
were 14.44 times greater (95% CI: 4.13-50.51) for those with myofascial release
205
performed compared to those without.
206 207
Stratifying by myofascial release, the subgroup analysis demonstrated similar results with
208
respect to association tests of improvement with age, parity, ethnicity, BMI, concomitant
209
medical therapy for OAB, prolapse stage or specific pelvic floor symptom. The stratified
210
analysis also confirmed the relation of length of treatment and improvement; the finding
211
reached statistical significance for both subgroups. However, there was a finding not
212
obvious in the previous analysis: There was a trend for the improvement after myofascial
213
release therapy to be higher among women who did not have pelvic floor myofascial TTP.
214
The trend was of borderline statistical significance (improvement rates 80.0% for those
215
with pelvic floor myofascial TTP versus 100% for those without pelvic floor myofascial
216
TTP, p=0.098). Unfortunately, this was a limit of the data: The sample size was small for
217
those without pelvic floor myofascial TTP.
218 219
DISCUSSION
220 221
Our study indicates that pelvic floor myofascial tenderness is found on physical exam of
222
more than half of the women presenting with complaints of overactive bladder, and that
223
PFPT with myofascial release improved outcomes in patients with OAB. The rate of
224
improvement was dependent on the length of PFPT treatment with more sessions attended
225
leading to higher rates of improvement. In contrast, improvement was independent of age
226
and prolapse stage.
227 228
The odds of improvement in OAB symptoms were 14.44 times greater for those with
229
myofascial release performed as a part of their PFPT compared to those without. While
230
this study did not have standardized formal training for each therapist in the context of this
231
study, all therapists performed intravaginal soft tissue mobilization/myofascial release per
232
common philosophy in our multidisciplinary practice. This finding is congruent with prior
233
studies (Weiss 2001,Pezzone et al 2005,Berry et al 2011,Peters et al 2007,Hanno et al
234
2011). FitzGerald et al. (2012) found that women with interstitial cystitis/painful bladder
235
syndrome had higher rates of improvement with PFPT that included pelvic floor
236
myofascial therapy compared to nonspecific global therapeutic massage. It is unclear if the
237
symptoms of OAB preceeded the muscle pain or vice versa. On the one hand one may
238
postulate that patients with OAB may possibly have increased need for the use of the
239
pelvic floor muscles in attempt to perform urge suppression, which may result in muscle
240
pain. In this case performing myofascial release with downtraining would potentially not
241
affect the OAB symptoms. However, there is most likely a complex viscerosomatic
242
convergence at play. The muscles pain may have a continual efferent output to the dorsal
243
horn which perpetuates the OAB symptoms. Therefore, with proper treatment and
244
dampening of this imput would decrease the OAB through viscerosomatic convergence.
245
On the other hand, patients may have a primary muscle issue with multifactorial causes
246
such as overall abdominal core weakness affecting the pelvic floor muscles and as a result
247
cause the inability to perform urge suppression well resulting in OAB. Indeed the
248
connection between abdominal muscles and the pelvic floor has been described. Travell
249
and Simon described abdominal trigger points which could cause spasm of the detrusor
250
muscles and bladder pain (Travell and Simon 1999). We suspect the inclusion of
251
examination of surrounding muscles such as abdominal core and adductor muscles would
252
be helpful in future studies. While our therapists are trained in techniques adressing
253
adductors and abdominal core, we did not record such techinques and examinations due to
254
lack of consistent standardized examination by the physician.
255 256
Another important finding was that the rate of improvement was dependent on the number
257
of treatments. The more sessions attended, the higher the rates of improvement. The trend
258
was linear for the first three sessions, after which a maximal plateau was reached with the
259
highest levels of improvement were achieved in women who attended 4 sessions or more.
260
It is our experience that women are often discouraged about the long duration of therapy
261
needed when prescribed 12 weekly sessions. It appears intuitively obvious that the
262
treatment will help only when completed. However an alternative explanation for our
263
finding is, that the treatment naturally only works in a subgroup of patients and those in
264
which it did not work discontinued earlier. Addressing this question will require a
265
randomized study with two lengths of treatment. In the absence of such a study our data
266
may be used to encourage patients to stay on at least until the fourth treatment before
267
discontinuing because success comes only then for the majority of patients with OAB.
268 269
Interestingly not all women with symptoms of OAB were prescribed PFPT. Observing the
270
preferences of physicians is another result of this study. Indeed, older women with
271
advanced stage prolapse and who were older were not prescribed PFPT. Women with
272
advanced prolapse may be thought to benefit more from pessary or surgery, while older
273
women may be expected to have trouble attending therapy regularly due to transportation
274
or other social issues, or even medical complexity. The outcome data of this study do not
275
support these treatment choices. We found that improvement by therapy was independent
276
of age and prolapse. In light of our findings, physicians may wish to prescribe PFPT to a
277
broader group of women, even those with prolapse and older women.
278 279
Of the patients who were prescribed PFPT, only a few were prescribed concomitant
280
medication. This may be due to patient preference to try the treatment with the least chance
281
of side effects first. However, the study cannot provide evidence to support this choice. In
282
contrast, patients who started vaginal estrogen did show a higher rate of improvement, but
283
this was not statistically significant. Other possible confounding medication include pain
284
medication, but these were not recorded during this chart review.
285
Limitations:
286
The improvement of symptoms occurred at three times higher rate after PFPT with
287
myofascial release technique than without. This may indicate the effectiveness of the
288
technique. However, the finding cannot be extrapolated to all patients with OAB. To this
289
point, the weakness of a retrospective chart review becomes relevant. We also saw the
290
differences in prescribing pattern. In this retrospective study, most of the women attending
291
PFPT who had pelvic floor myofascial TTP on the physican examination, were given
292
myofascial release therapy, and most of the women having myofascial release therapy had
293
pelvic floor myofascial TTP on the physican examination. There were women who had
294
myofascial release during their therapy sessions although the physician had not detected
295
pelvic floor myofascial TTP. We suspect that since the therapists perform a detailed
296
physical examination of their patients on the day of their initial visit, which may have been
297
somewhat different from the physican examination. This could have been due to
298
interexaminer variability, but also due to potential fluctuations in the patients' pelvic floor
299
muscle examination on daily or weekly basis, as physical therapy would not have been
300
intiated on the same day. However we did not analyze the physical therapists examinations
301
in keeping of an intention to treat analysis. The physical therapists personalize the patients’
302
treatment plans, and will routinely perform myofascial release if a patient is found with
303
myofascial pain, while they would not commonly perform myofascial release techniques if
304
the patient had no pain on examination at their PFPT intake visit. While this analysis is
305
underpowered to answer this question, a future prospective randomized study is indicated
306
to further investigate these relationships among OAB, pelvic floor myofascial TTP,
307
presence of active versus latent trigger points, and PFPT. Until such study is conducted, it
308
remains standing that among women with pelvic floor myofascial TTP, the technique of
309
myofascial release had a high success rate.
310 311
There are other weaknesses of this study as it was a retrospective analysis in a convenience
312
sample of 4 months duration. It may be that the few women who attended therapy (only
313
48% of those prescribed) were especially motivated. This bias may account for the
314
relatively high rate of improvement (71.4%) for patients who attended PFPT. What
315
remains true is that the technique was met with a high improvement rate.
316
The initial physical examinations during this study were performed by a potential total of
317
10 physicians of various levels of training (attending (3), fellow (3), resident (4)). The
318
interexaminer variability is a potential confounding variable however was limited as new
319
patients were most often examined by a Urogynecology fellow who is in the 5th to 7th year
320
of training or the attending physician. In a future study, limiting the number of examiners
321
may improve the data quality further. In the future it would perhaps be even more helpful
322
to eliminate the subjective component in the myofascial exam even further such that it can
323
be quantified. We have made strides in this direction studying a pressure algometer placed
324
on the examiner’s fingers. Other quantification measurements could include measurement
325
of the muscles electrical activity via EMG patch electrodes. To further study the pelvic
326
floor myofascial TTP, these quantification measurements could be taken before and after
327
PFPT.
328
329
A further weakness of the study is that our main outcome measure was not standardized by
330
validated questionnaire. The physical therapy notes, written after each visit, usually
331
consisted of a paragraph of subjective updates about the therapy and will not always assess
332
all the patients’ specific symptoms. However, most of the charts had an obvious date
333
within the therapy where the patient indicated distinct improvement. Few charts showed
334
some improvement at one time, followed by worsening, followed by further improvement.
335
In this case the first date of improvement was recorded. Whether myofascial release is
336
helpful for all women with OAB or has higher rates of improvement in women who have
337
pelvic floor myofascial TTP remains an important topic for future investigation. Follow-up
338
studies should include standardized, validated questionnaires at initial MD exam, initial
339
physical therapy visit, and each follow up visit as well as at discharge. To minimize
340
questionaieres the patient impression of improvement could be considered at each visit
341
alone.
342
CONCLUSION
343 344
Women with OAB have high rates of tenderness when their pelvic floor muscles are
345
examined and high rates of improvement with PFPT, especially when receiving myofascial
346
release techniques. This suggests a muscular component in the etiology of OAB and
347
warrants a future prospective trial comparing the standardized myofascial technique for
348
myofascial release to behavioral therapy using validated outcome measures. Given this
349
data, patients with OAB may be encouraged to attend at least three sessions to experience
350
improvement. Myofascial release technique was related to higher improvement rates, yet
351
this might be related to the selection bias of patients who have this technique prescribed.
352 353 354
Statement of interest:
355
Drs Wolff, Joyce, McAlarnen, Mueller and Fitzgerald are affiliated with Loyola University
356
Medical Center, and Dr Brincat is affiliated with Rush University Medical Center. Both
357
organizations promote the recognition and treatment of individuals with myofascial pain.
358
None of the authors have any relevant conflict of interests for this work.
359 360 361
Clinical Relevance:
362 363
•
364
•
Women with symptoms of overactive bladder should receive an internal pelvic floor muscle examination Consideration of pelvic floor physical therapy for women with OAB is advised
365 366 367
•
368
•
369
Ensure communication with pelvic floor therapist and guidance that internal myofascial release therapy (sometimes called soft tissue manipulation) may be helpful Encourage patients that improvement is often noticed after 3 sessions already
370
REFERENCES
371
372
Barber MD, Walters MD, Bump RC 2005 Short forms of two condition-specific quality-of-life
373
questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7). American Journal of
374
Obstetrics and Gynecology 193: 103-13.
375
Bedaiwy MA, Patterson B, Mahajan S 2013 Prevalence of myofascial chronic pelvic pain and the
376
effectiveness of pelvic floor physical therapy. The Journal of reproductive medicine 58: 504-10.
377
Berkley KJ 2005 A life of pelvic pain. Physiology & Behavior 86: 272-80.
378
Bernstein AM, Philips HC, Linden W, Fenster H 1992 A psychophysiological evaluation of female
379
urethral syndrome: evidence for a muscular abnormality. Journal of Behavioral Medicine 15: 299-
380
312.
381
Berry SH, Elliott MN, Suttorp M, Bogart LM, Stoto MA, Eggers P, Nyberg L, Clemens JQ 2011
382
Prevalence of symptoms of bladder pain syndrome/interstitial cystitis among adult females in the
383
United States. The Journal of urology 186: 540-4.
384
Burgio KL, Goode PS, Locher JL, Umlauf MG, Roth DL, Richter HE, Varner RE, Lloyd LK 2002
385
Behavioral training with and without biofeedback in the treatment of urge incontinence in older
386
women: a randomized controlled trial. Jama 288: 2293-9.
387
Burgio KL, Locher JL, Goode PS, Hardin JM, McDowell BJ, Dombrowski M, Candib D 1998
388
Behavioral vs drug treatment for urge urinary incontinence in older women: a randomized
389
controlled trial. Jama 280: 1995-2000.
390
Burgio KL, Whitehead WE, Engel BT 1985 Urinary incontinence in the elderly. Bladder-sphincter
391
biofeedback and toileting skills training. Annals of Internal Medicine 103: 507-15.
392
Fitzgerald CM, Neville CE, Mallinson T, Badillo SA, Hynes CK, Tu FF 2011 Pelvic floor muscle
393
examination in female chronic pelvic pain. The Journal of reproductive medicine 56: 117-22.
394
Fitzgerald MP, Anderson RU, Potts J, Payne CK, Peters KM, Clemens JQ, Kotarinos R, Fraser L,
395
Cosby A, Fortman C, Neville C, Badillo S, Odabachian L, Sanfield A, O'Dougherty B, Halle-Podell R,
396
Cen L, Chuai S, Landis JR, Mickelberg K, Barrell T, Kusek JW, Nyberg LM, Urological Pelvic Pain
397
Collaborative Research Network 2013 Randomized multicenter feasibility trial of myofascial
398
physical therapy for the treatment of urological chronic pelvic pain syndromes. The Journal of
399
urology 189: S75-85.
400
Giamberardino MA, Affaitati G, Fabrizio A, Costantini R 2011 Myofascial pain syndromes and their
401
evaluation. Best practice & research. Clinical rheumatology 25: 185-98.
402
Hanno PM, Burks DA, Clemens JQ, Dmochowski RR, Erickson D, Fitzgerald MP, Forrest JB, Gordon
403
B, Gray M, Mayer RD, Newman D, Nyberg L,Jr, Payne CK, Wesselmann U, Faraday MM, Interstitial
404
Cystitis Guidelines Panel of the American Urological Association Education and Research, Inc 2011
405
AUA guideline for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. The
406
Journal of urology 185: 2162-70.
407
Hoffman D, 2011 Understanding multisymptom presentations in chronic pelvic pain: The inter-
408
relationships between the viscera and myofascial pelvic floor dysfunction. Current Pain and
409
Headache Reports 15:343-346.
410
Kotarinos R 2012 Myofascial pelvic pain. Current pain and headache reports 16: 433-8.
411
Kuo TL, Ng LG, Chapple CR 2015 Pelvic floor spasm as a cause of voiding dysfunction. Current
412
opinion in urology 25: 311-6.
413
Lucas KR, Rich PA, Polus BI 2010 Muscle activation patterns in the scapular positioning muscles
414
during loaded scapular plane elevation: the effects of Latent Myofascial Trigger Points 25:765-
415
770.
416
McDowell BJ, Burgio KL, Dombrowski M, Locher JL, Rodriguez E 1992 An interdisciplinary
417
approach to the assessment and behavioral treatment of urinary incontinence in geriatric
418
outpatients. Journal of the American Geriatrics Society 40: 370-4.
419
Montenegro ML, Mateus-Vasconcelos EC, Rosa e Silva JC, Nogueira AA, Dos Reis FJ, Poli Neto OB
420
2010 Importance of pelvic muscle tenderness evaluation in women with chronic pelvic pain. Pain
421
medicine (Malden, Mass.) 11: 224-8.
422
Oyama IA, Rejba A, Lukban JC, Fletcher E, Kellogg-Spadt S, Holzberg AS, Whitmore KE 2004
423
Modified Thiele massage as therapeutic intervention for female patients with interstitial cystitis
424
and high-tone pelvic floor dysfunction. Urology 64: 862-5.
425
Peters KM, Carrico DJ, Kalinowski SE, Ibrahim IA, Diokno AC 2007 Prevalence of pelvic floor
426
dysfunction in patients with interstitial cystitis. Urology 70: 16-8.
427
Pezzone MA, Liang R, Fraser MO 2005 A model of neural cross-talk and irritation in the pelvis:
428
implications for the overlap of chronic pelvic pain disorders. Gastroenterology 128: 1953-64.
429
Reiter RC, Gambone JC 1991 Nongynecologic somatic pathology in women with chronic pelvic
430
pain and negative laparoscopy. The Journal of reproductive medicine 36: 253-9.
431
Schneider MJ 1995 Tender points/fibromyalgia vs. trigger points/myofascial pain syndrome: a
432
need for clarity in terminology and differential diagnosis. Journal of manipulative and
433
physiological therapeutics 18: 398-406.
434
Shah JP, Gilliams EA 2008 Uncovering the biochemical milieu of myofascial trigger points using in
435
vivo microdialysis: an application of muscle pain concepts to myofascial pain syndrome. Journal of
436
Bodywork and Movement Therapies 12:371–384.
437
Shah JP, Thaker N, Heimur J, Aredo JV, Sikdar S, Gerber L 2015 Myofascial Trigger Points Then and
438
Now: A Historical and Scientific Perspective. PM&R 7:746–761.
439
Simons DG, Travell JG, Simons LS 1999a Travell and Simons’ myofascial pain and dysfunction: The
440
trigger point manual. 2nd ed. Vol. 1. Williams and Wilkins; Baltimore
441
Simons DG, Travell JG, Simons LS 1999b Travell and Simon’ myofascial pain and dysfunction: The
442
trigger point manual. 2nd ed. Vol. 2. Williams and Wilkins; London
443
444
445
Spitznagle TM, Robinson CM 2014 Myofascial pelvic pain. Obstetrics and gynecology clinics of
446
North America 41: 409-32.
447
Stewart WF, Van Rooyen JB, Cundiff GW, Abrams P, Herzog AR, Corey R, Hunt TL, Wein AJ 2003
448
Prevalence and burden of overactive bladder in the United States. World journal of urology 20:
449
327-36.
450
THIELE GH 1963 Coccygodynia: Cause and Treatment. Diseases of the colon and rectum 6: 422-36.
451
Weiss JM 2001 Pelvic floor myofascial trigger points: manual therapy for interstitial cystitis and
452
the urgency-frequency syndrome. The Journal of urology 166: 2226-31.
453 454
455
TABLES
456
TABLE 1. Patient characteristics by initiation of therapy
457
Initiated
PT only
myofascial
n (%)
PT
PT not
Prescribed recommended
release in
but not
PT
done
59 (30.6)
19 (9.8)
84 (43.5)
31 (16.1)
56.3 (17.1)
64.3 (14.7)
56.6 (16.0)
67.5 (12.8)
Caucasian
31 (52.5)
13 (68.4)
54 (64.3)
25 (80.6)
Black
17 (28.8)
2 (10.5)
13 (15.5)
4 (12.9)
Age, mean in years (SD)
p-value
0.003
Ethnicity, n (%)
0.19 Hispanic
7 (11.9)
4 (21.1)
14 (16.7)
2 (6.5)
4 (6.8)
0 (0.0)
3 (3.6)
0 (0.0)
0
9 (15.3)
1 (5.3)
8 (9.5)
3 (9.7)
1
9 (15.3)
3 (15.8)
23 (27.4)
2 (6.5)
41 (69.5)
15 (78.9)
53 (63.1)
26 (83.9)
41 (71.9)
11 (57.9)
55 (66.3)
11 (36.7)
Other Parity, n (%)
≥2
0.16
Prolapse stage, n (%) 0-1
<0.001 2
13 (22.8)
5 (26.3)
24 (28.9)
7 (23.3)
3-4
3 (5.3)
3 (15.8)
4 (4.8)
12 (40.0)
BMI (kg/m²), mean (SD)
31.3 (8.2)
34.5 (7.3)
30.5 (8.1)
30.3 (6.2)
0.21
Myofascial pain, n (%)
45 (76.3)
9 (47.4)
45 (53.6)
10 (32.3)
<0.001
UUI
42 (71.2)
15 (78.9)
64 (76.2)
15 (48.4)
0.026
Urgency
50 (84.7)
17 (89.5)
71 (84.5)
14 (45.2)
<0.001
Frequency
47 (79.7)
17 (89.5)
74 (88.1)
17 (54.8)
<0.001
6 (10.2)
1 (5.3)
12 (14.3)
0 (0.0)
0.10
10 (16.9)
0 (0.0)
20 (23.8)
3 (9.7)
0.051
Pelvic floor symptoms, n (%)
Dysuria Pelvic pain 458
459
Table 1 legend: Patients demographics, symptoms and exam findings are shown for all
460
patients analyzed. The patients have been placed into one of four subgroups based on their
461
therapy: Patients initiated physical therapy and it included myofascial release techniques
462
applied, Patients initiated physical therapy but did not have myofascial release, Patients
463
who did not attend the prescribed physical therapy and Patients for whom physical therapy
464
was not recommended. The last column indicates whether there was a statistical difference
465
between the groups with respect to each characteristic. PT-physical therapy; BMI- Body
466
mass index; UUI-Urgency urinary incontinence;
467 468
469
TABLE 2. Patient characteristics and therapy outcomes for those who initiated physical
470
therapy n
n (%)
p-value
improved Overall
77
55 (71.4)
< 60
40
28 (70.0)
≥ 60
37
27 (73.0)
43
31 (72.1)
Age
0.77
Ethnicity Caucasian
0.88 Non-Caucasian
34
24 (70.6)
0
10
8 (80.0)
≥1
67
47 (70.1)
52
38 (73.1)
Parity
0.72
Prolapse stage 0-1
0.64 25
17 (68.0)
< 30
37
26 (70.3)
≥ 30
40
29 (72.5)
8
8 (100.0)
≥2 BMI (kg/m²)
0.83
Started anticholinergic/mirabegron
0.096
Started vaginal estrogen
8
7 (87.5)
0.43
54
37 (68.5)
0.39
UUI
56
42 (75.0)
0.26
Urgency
66
46 (69.7)
0.50
Frequency
63
44 (69.8)
0.75
7
4 (57.1)
0.41
10
8 (80.0)
0.72
59
50 (84.7)
Myofascial pain Pelvic floor symptoms
Dysuria Pelvic pain Myofascial release Yes
<0.001 No
18
5 (27.8)
1-2
17
1 (5.9)
3-5
17
16 (94.1)
6-8
32
29 (90.6)
≥9
11
9 (81.8)
Number of sessions
<0.001
471
472
Table 2 legend: This table shows whether patient characteristics were associated with
473
reaching improvement during physical therapy. The first column shows the subgroup
474
definitions. The second column shows how many patients fall in each subgroup. The third
475
column shows the number of patients who improved in that subgroup and which percent of
476
patients improved in each subgroup is shown in brackets. The last column shows the p-
477
values of each univariate analysis via the Cochran-Armitage Trend tests for ordinal
478
variables and chi-square or Fisher’s exact test as appropriate for nominal variables. The
479
data are limited to the patients who initiated therapy (n=77).
480
481
TABLE 3. Patient characteristics and therapy outcomes with and without myofascial
482
release Myofascial Release n
n (%)
No Myofascial Release
p-value
n
improved Overall
n (%)
p-
improved
value
59
50 (84.7)
18
5 (27.8)
< 60
32
27 (84.4)
8
1 (12.5)
≥ 60
27
23 (85.2)
10
4 (40.0)
31
27 (87.1)
12
4 (33.3)
Age
0.99
0.31
Ethnicity Caucasian
0.72 Non-Caucasian
0.61
28
23 (82.1)
6
1 (16.7)
9
8 (88.9)
1
0 (0.0)
50
42 (84.0)
17
5 (29.4)
42
35 (83.3)
10
3 (30.0)
Parity 0
0.99 ≥1
0.99
Prolapse stage 0-1
0.99
0.99
17
15 (88.2)
8
2 (25.0)
< 30
31
24 (77.4)
6
2 (33.3)
≥ 30
28
26 (92.9)
12
3 (25.0)
≥2 BMI (kg/m²)
0.15
0.99
Started
7
7 (100.0)
1
1 (100.0)
0.58
0.28
anticholinergic/mirabegron Started vaginal estrogen
7
6 (85.7)
0.99
1
1 (100.0)
0.28
45
36 (80.0)
0.098
9
1 (11.1)
0.29
UUI
42
38 (90.5)
0.10
14
4 (28.6)
0.99
Urgency
50
41 (82.0)
0.33
16
5 (31.3)
0.99
Frequency
47
39 (83.0)
0.67
16
5 (31.3)
0.99
6
4 (66.7)
0.22
1
0 (0.0)
0.99
10
8 (80.0)
0.64
--
--
--
1-2
5
0 (0.0)
12
1 (8.3)
3-5
14
13 (92.9)
3
3 (100.0)
6-8
30
28 (93.3)
2
1 (50.0)
≥9
10
9 (90.0)
1
0 (0.0)
Myofascial pain Pelvic floor symptoms
Dysuria Pelvic pain Number of sessions
<0.001
0.005
483
Table 3 legend: Patients who initiated physical therapy were stratified based on whether
484
myofascial release techniques were applied or not. The "p-value" corresponds to the
485
within-strata test of association. The data are limited to patients who initiated therapy with
486
or without myofascial release and known improvement status (n=77). PT-physical therapy;
487
BMI- Body mass index; UUI-Urgency urinary incontinence;
488
FIGURES
489
CAPTION TO FIGURE 1:
490
Subgroups of patients who attended one, two, three, or over three sessions were formed,
491
and the % of patients who improved in each group are shown.
492
493
494 495 496
Figure 1: Patient improvement by number of physical therapy sessions attended
S1360-8592(19)30394-8
DOI:
https://doi.org/10.1016/j.jbmt.2019.10.018
Reference:
YJBMT 1902
To appear in:
Journal of Bodywork & Movement Therapies
Received Date: 1 February 2019 Revised Date:
24 May 2019
Accepted Date: 30 October 2019
Please cite this article as: Wolff, B.J., Joyce, C.J., McAlarnen, L.A., Brincat, C.A., Mueller, E.R., Fitzgerald, C.M., CONSIDERATION OF PELVIC FLOOR MYOFASCIAL RELEASE FOR OVERACTIVE BLADDER, Journal of Bodywork & Movement Therapies, https://doi.org/10.1016/j.jbmt.2019.10.018. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Elsevier Ltd. All rights reserved.
CONSIDERATION OF PELVIC FLOOR MYOFASCIAL RELEASE FOR OVERACTIVE BLADDER
Birte J. Wolff, MDa, Cara J. Joyce, PhDb, Lindsey A. McAlarnen, MD MScc, Cynthia A. Brincat, MD PhDa, Elizabeth R. Mueller, MDa, Colleen M. Fitzgerald, MDa a
Department of Obstetrics/Gynecology and Urology, Loyola University Chicago Stritch School of Medicine and Loyola University Medical Center c
Center for Translational Research and Education Loyola University Chicago d
Department of Obstetrics/Gynecology Rush University Medical Center
Corresponding author Birte Johanna Wolff, MD 2160 S First Ave. Maywood IL 60153 Fax: 708 216-2171 Phone: 708-216-2170 [email protected]
Declarations of interest: None This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
ABSTRACT
1 2
Introduction: Physical therapy has been shown to be effective for women with overactive
3
bladder (OAB). We report on our experience with pelvic floor physical therapy (PFPT)
4
with or without myofascial release as treatment for women with symptoms of urinary
5
urgency or urge incontinence.
6
Methods: We performed a retrospective chart review, of patients who presented to our
7
tertiary care Urogynecology practice. These women were evaluated and treated between
8
August 2016 and December 2016. We abstracted for symptoms as per history of present
9
illness and the pelvic floor muscle examination. PFPT progress notes were reviewed to
10
determine whether patients received myofascial release techniques, or if therapy was
11
limited to behavioral interventions and urge suppression techniques. We recorded the
12
number of PFPT sessions attended, and whether the patient reported improvement.
13
Results: 77 patients with symptoms of OAB met inclusion criteria and initiated PFPT.
14
Myofascial tenderness of the pelvic floor muscles was found in 56.5% of patients. PFPT
15
was limited to behavioral and urge suppression in 18 patients, while 59 patients received
16
myofascial release techniques. Improvement was reported by 71.4% (n=55/77) of patients.
17
Improvement increased with number of sessions attended: 1-2: 6% (1/17), 3-5: 94%
18
(16/17), 6-8: 91% (29/32), and >8: 80% (9/11) improved, respectively (p<0.001). Among
19
patients who had myofascial release, 84.7% reported improvement when compared to only
20
27.8% of patients without myofascial release.
21
Conclusions: The data support the inclusion of myofascial release during pelvic floor
22
physical therapy for overactive bladder. At least three sessions of PFPT are necessary for
23
patient reported improvement.
24 25
Word Count: 250
26 27 28 29
Keywords:
30
Overactive bladder, physical therapy, pelvic pain, urinary urgency, myofascial release
31
therapy
32
33
INTRODUCTION
34 35
Overactive bladder (OAB) is a disorder characterized by urinary urgency and frequency
36
with or without urgency urinary incontinence, which affects 11% of the population and
37
diminishes quality of life (Stewart et al 2003). While the pathophysiology of OAB is still
38
not completely understood. One proposed theory includes hyperactivity of the pelvic floor
39
muscles (Kuo et al 2015). The same cause has also been suspected in the pathophysiology
40
of various pelvic pain syndromes such as myofascial trigger points, self-reported chronic
41
pelvic pain or atypical cyclic pain (Schneider 1995,C. M. Fitzgerald et al 2011,Reiter &
42
Gambone 1991).
43 44
Pelvic pain often occurs in complex presentation including symptoms of the lower urinary
45
tract (Kotarinos 2012,Bernstein et al 1992). Studies on animal models of pelvic pain have
46
found that vaginal hyperalgesia reduces the bladder filling volume at which voiding begins
47
(Berkley 2005). Hoffman (2011) provides possible explanations of this overlap in
48
symptoms as viscerosomatic convergence, which is sensory innervation of the muscle that
49
may have neural cross-talk to the viscera via the dorsal horn of the spinal cord (Pezzone et
50
al 2005). Among women with chronic pelvic pain, 89% had physical exam findings of
51
tenderness of the levator ani muscle (Montenegro et al 2010). These findings led to a
52
definition of pelvic floor muscle myofascial pain as: a complex form of neuromuscular
53
dysfunction consisting of motor and sensory abnormalities involving both the peripheral
54
and central nervous systems (Spitznagle & Robinson 2014).
55
56
Physical therapy is an effective treatment of myofascial pain with or without trigger points
57
in other anatomic areas (Giamberardino et al 2011). One theory of pathophysiology of
58
myofascial tenderness and trigger points specifically, is related to chronic muscle overuse
59
(Shah et al. 2015). Shah & Gilliams (2008) found a relatively hypoxic environment inside
60
trigger points, and theorize that a sustained low level of activity may downregulate the
61
perfusion of the muscle, and as a result perpetuate a cycle of ischemic changes and
62
sarcomere contraction. Physical therapist techniques of sustained compression may result
63
in improvement by reducing the sarcomere contracture and reducing the actin and myosin
64
overlap resulting in decreased need for ATP (Shah et al. 2015). Trigger points may be
65
considered "active" if there is spontaneous pain or "latent" if there is only pain on palpation
66
(Lucas et al. 2010). Latent trigger points may convert to active trigger points, but even the
67
latent trigger may already cause changes in muscle activation and an erratic muscle firing
68
pattern, as seen in the shoulder muscle for example (Lucas et al. 2010). There is some
69
convincing evidence that treatment of the pelvic location could be included (M. P.
70
Fitzgerald et al 2013). The original description of massage therapy for pelvic floor
71
dysfunction by Thiele in 1963 was transrectal massage therapy for patients with
72
cyccodynia (THIELE 1963). The utility of vaginal manual therapy was further described
73
by Oyama (Oyama et al 2004). Indeed, newer retrospective data support that view: Among
74
women with myofascial pain syndrome of the pelvic floor muscles, 63% of the patients
75
improved with physical therapy (Bedaiwy et al 2013), and the finding was confirmed in
76
other patient groups (Spitznagle & Robinson 2014).
77
78
With this background, it is common practice in our clinic to prescribe PFPT as first line
79
treatment for patients with OAB, especially when pelvic floor myofascial tenderness to
80
palpation (TTP) is found on physical exam. There are some circumstances where
81
cognitive/behavioral therapy might be more helpful for those without documented pelvic
82
floor myofascial TTP, but data to support such concepts are yet missing (Burgio et al
83
1985,McDowell et al 1992,Burgio et al 1998,Burgio et al 2002). It is also unclear in the
84
literature how many sessions should be prescribed. Hence, the objective of our study was
85
to determine how many and what type of pelvic floor physical therapy (PFPT) sessions are
86
necessary for symptom improvement in women with OAB.
87
88
89
90
MATERIALS AND METHODS
91
After receiving IRB-approval (#LU209380) we used our electronic medical record system
92
to review the charts of new patients who presented to a tertiary urogynecology clinic
93
between August and December 2016 as a representative convenience sample. Per the
94
standard of our medical practice, all patients provided the information used here on a
95
completely voluntary basis and gave verbal consent to all of the physical examinations.
96
Chaperoning is offered to everyone and commonly provided. The inclusion criterion was
97
the presence of symptoms of overactive bladder (OAB) specifically urinary urgency with
98
or without urinary urge incontinence. This was derived from patient complaints of urinary
99
urgency or frequency, or urinary urgency incontinence in history of present illness or from
100
the results of the validated questionnaire PFDI-SF20 (Pelvic Floor Disability Index Short
101
Form 20 (Barber et al 2005)). In this questionnaire specifically questions 15: “Do you
102
usually experience frequent urination?” and question 16: “Do you usually experience urine
103
leakage associated with a feeling of urgency that is a strong sensation of needing to go to
104
the bathroom?” were used to define eligibility. We reviewed both their clinic notes as well
105
as their PFPT progress notes. Patients were excluded from the final analysis if they did not
106
initiate physical therapy. These records were reviewed for patients’ initial therapy date,
107
initial date of improvement, and last day of observation. Demographic information
108
consisting of age, BMI, race, and parity were collected. Comorbidities of depression and
109
fibromyalgia were recorded. Additionally, we noted whether patients were prescribed
110
medication for their OAB symptoms at the same time of starting their physical therapy.
111
The medications recorded were vaginal estrogen, anticholinergics, and mirabegron. Per
112
routine for all new patients, a pelvic organ prolapse examination was performed by the
113
physician, and this was recorded as pelvic organ prolapse stage 0-4.
114
The pelvic floor muscle physical examination and its documentation are standardized and
115
conducted for every new patient in our clinic. For the purpose of this study the presence of
116
pelvic floor myofascial TTP was defined as follows: while pressing digitally on the various
117
pelvic floor areas the patient was asked if any pain was provoked. If she reported “yes” she
118
was asked to place the highest pain provoked during the examination on a numeric scale of
119
1-10. First the physician palpated and pressed using the index finger externally in the
120
region of bulbocavernosus and transverse perineal muscles. Next the physician examined
121
by palpation, pressing transvaginally, using index finger alone or both index and middle
122
finger together. Beginning most distally, the examiner will reach the pubococcygeus,
123
illeococcygeus laterally and then coccygeus posteriorly on both sides of the vaginal walls.
124
To evaluate the obturator internus the patient was asked to press her knee laterally against
125
the examiners other hand, externally rotating her hip while the physician palpated the
126
ipsilateral anterolateral vaginal side wall.
127
While not all therapists had standardized training or procedures in the context of this study,
128
there was still a high level of consistency. All myofascial release techniques performed in
129
the context of the study involved intravaginal manual myofascial therapy by a physical
130
therapist trained in PFPT. With the patient in a supine position and in frog leg position, the
131
soft tissues of the pelvic floor including connective tissue and muscles were palpated by
132
the therapist digitally via the vagina. If either hypertonic muscle bands (tight/stiff pelvic
133
floor muscles) or painful trigger points (specific spot of sudden strong pain, usually
134
~1x1cm), or a combination of both were identified, these areas would be specifically
135
targeted. Two typical methods for these focus areas were: 1) sustained pressure technique
136
and 2) myofascial stretch (Oyama et al 2004). The sustained pressure technique consists of
137
sustained pressure on the area without volitional muscle contraction by the patient; and the
138
pressure threshold is dictated by the patient as the pressure, at which the patient can still
139
tolerate the discomfort well. The myofascial stretch which is geared to achieve lengthening
140
of the muscle by stroking along the fibers, at times referred to as "down training". The total
141
duration of intravaginal massage is less well defined, and based on the personalized
142
treatment approach and on patient tolerance. Typically one session lasts 45 minutes, with
143
10 or more minutes concentrated on myofascial release. Alternatively, patients could have
144
received PFPT without any myofascial release techniques. Instead, during these PFPT
145
sessions, patients were taught behavioral interventions, bladder training including urge
146
suppression techniques and in some cases included pelvic floor muscle strengthening
147
exercise.
148
Descriptive statistics (means +/- standard deviations or medians and interquartile range
149
[25th percentile, 75th percentile] for continuous data, frequencies and percentages for
150
categorical data) were calculated for subjects on demographic and clinical characteristics.
151
The associations between patient demographics and physician prescription of physical
152
therapy, physical therapy attendance, and rate of improvement with therapy with or
153
without myofascial release were assessed via the Cochran-Armitage Trend tests for ordinal
154
variables and chi-square or Fisher’s exact test as appropriate for nominal variables. A
155
logistic regression model was used to estimate the odds ratio and 95% confidence interval
156
for myofascial release associated with improvement. For all analyses, a result was
157
considered statistically significant at the p<0.05 level of significance. Analyses were
158
performed using SAS 9.4 (Cary, NC).
159 160
RESULTS
161 162
193 of 273 patients met at least one of the following inclusion criteria for this study: self-
163
reported symptoms of urinary urgency/frequency or urgency urinary incontinence. The
164
included patients had a mean age of 58.9 years (±16.6 SD), mean BMI 30.3 kg/m2 (±7.5
165
SD), median parity 2 (range 0-10), and physican exam median stage of prolapse 1 (range
166
0-4). A past medical history of depression was found in 31.2% (24/77) of the patients.
167
None of the patients had a history of fibromyalgia. Myofascial tenderness of the pelvic
168
floor muscles (TTP) was elicited by the physician in over half (109, 56.5%) of patients on
169
exam. PFPT was prescribed to 162 women (83.9%), which 77 (47.5%) attended. Among
170
those women who initiated PFPT, 70% (54/77) had pelvic floor myofascial TTP.
171
Myofascial release techniques were applied in 59 patients, of whom 45 (76.3%) had pelvic
172
floor TTP. The remaining 18 patients of whom 9 (50.0%) had pelvic floor TTP, had
173
treatment with a cognitive/behavioral or muscle strengthening focus. There was no specific
174
cut-off for the amount of TTP found on exam that would trigger the physican to prescribe
175
PFPT more often. The subgroup to which PFPT was not prescribed had higher stages of
176
prolapse (40.0% prolapse stage 3-4; p<0.001) and were older (mean age: 68±13 years SD;
177
p=0.003) (Table 1). Among those women who initiated PFPT, 16 patients were also
178
prescribed new medication as concomitant management for OAB (anticholinergic or
179
mirabegron n=8, vaginal estrogen n=8).
180 181
182
Per PFPT progress notes, symptom improvement was reported in 55 of 77 patients (71.4%)
183
who attended PFPT using non-validated measures. All of the women (8/8) who started
184
concomitant an oral anticholinergic or mirabegron noted improvement during the course of
185
physical therapy, however this did not reach statistical significance in this small sample
186
(p=0.096). While there was also a trend toward improvement with concomitant vaginal
187
estrogen, this was also not statistically significant (7 of 8 women reported improvement).
188
Interestingly, rates of improvement were similar for those with presence and absence of
189
pelvic floor myofascial TTP on examination. Of the 54 women with presence of
190
myofascial pain, 37 (68.5%) experienced improvement compared to 18/23 (78.3%) who
191
did not have myofascial pain, however this was not statistically significant. Improvement
192
was not associated with age, concomitant medical therapy for OAB, presence of
193
depression, prolapse stage or specific pelvic floor symptom, but it was dependent on the
194
length of treatment and whether physical therapy sessions included myofascial release
195
(Table 2).
196
197
The frequency of improvement depended on the number of therapeutic sessions attended:
198
1-2 sessions: 6% (1/17), 3-5 sessions: 94% (16/17), 6-8 sessions: 91% (29/32) and >8
199
sessions: 80% (9/11) improved, respectively (p<0.001) (Figure 1).
200
201
84.7% (50/59) of patients who had myofascial release techniques applied reported
202
improvement in their symptoms when compared to only 26.3% (5/18) of patients who had
203
physical therapy without myofascial release (p<0.001, Table 2). The odds of improvement
204
were 14.44 times greater (95% CI: 4.13-50.51) for those with myofascial release
205
performed compared to those without.
206 207
Stratifying by myofascial release, the subgroup analysis demonstrated similar results with
208
respect to association tests of improvement with age, parity, ethnicity, BMI, concomitant
209
medical therapy for OAB, prolapse stage or specific pelvic floor symptom. The stratified
210
analysis also confirmed the relation of length of treatment and improvement; the finding
211
reached statistical significance for both subgroups. However, there was a finding not
212
obvious in the previous analysis: There was a trend for the improvement after myofascial
213
release therapy to be higher among women who did not have pelvic floor myofascial TTP.
214
The trend was of borderline statistical significance (improvement rates 80.0% for those
215
with pelvic floor myofascial TTP versus 100% for those without pelvic floor myofascial
216
TTP, p=0.098). Unfortunately, this was a limit of the data: The sample size was small for
217
those without pelvic floor myofascial TTP.
218 219
DISCUSSION
220 221
Our study indicates that pelvic floor myofascial tenderness is found on physical exam of
222
more than half of the women presenting with complaints of overactive bladder, and that
223
PFPT with myofascial release improved outcomes in patients with OAB. The rate of
224
improvement was dependent on the length of PFPT treatment with more sessions attended
225
leading to higher rates of improvement. In contrast, improvement was independent of age
226
and prolapse stage.
227 228
The odds of improvement in OAB symptoms were 14.44 times greater for those with
229
myofascial release performed as a part of their PFPT compared to those without. While
230
this study did not have standardized formal training for each therapist in the context of this
231
study, all therapists performed intravaginal soft tissue mobilization/myofascial release per
232
common philosophy in our multidisciplinary practice. This finding is congruent with prior
233
studies (Weiss 2001,Pezzone et al 2005,Berry et al 2011,Peters et al 2007,Hanno et al
234
2011). FitzGerald et al. (2012) found that women with interstitial cystitis/painful bladder
235
syndrome had higher rates of improvement with PFPT that included pelvic floor
236
myofascial therapy compared to nonspecific global therapeutic massage. It is unclear if the
237
symptoms of OAB preceeded the muscle pain or vice versa. On the one hand one may
238
postulate that patients with OAB may possibly have increased need for the use of the
239
pelvic floor muscles in attempt to perform urge suppression, which may result in muscle
240
pain. In this case performing myofascial release with downtraining would potentially not
241
affect the OAB symptoms. However, there is most likely a complex viscerosomatic
242
convergence at play. The muscles pain may have a continual efferent output to the dorsal
243
horn which perpetuates the OAB symptoms. Therefore, with proper treatment and
244
dampening of this imput would decrease the OAB through viscerosomatic convergence.
245
On the other hand, patients may have a primary muscle issue with multifactorial causes
246
such as overall abdominal core weakness affecting the pelvic floor muscles and as a result
247
cause the inability to perform urge suppression well resulting in OAB. Indeed the
248
connection between abdominal muscles and the pelvic floor has been described. Travell
249
and Simon described abdominal trigger points which could cause spasm of the detrusor
250
muscles and bladder pain (Travell and Simon 1999). We suspect the inclusion of
251
examination of surrounding muscles such as abdominal core and adductor muscles would
252
be helpful in future studies. While our therapists are trained in techniques adressing
253
adductors and abdominal core, we did not record such techinques and examinations due to
254
lack of consistent standardized examination by the physician.
255 256
Another important finding was that the rate of improvement was dependent on the number
257
of treatments. The more sessions attended, the higher the rates of improvement. The trend
258
was linear for the first three sessions, after which a maximal plateau was reached with the
259
highest levels of improvement were achieved in women who attended 4 sessions or more.
260
It is our experience that women are often discouraged about the long duration of therapy
261
needed when prescribed 12 weekly sessions. It appears intuitively obvious that the
262
treatment will help only when completed. However an alternative explanation for our
263
finding is, that the treatment naturally only works in a subgroup of patients and those in
264
which it did not work discontinued earlier. Addressing this question will require a
265
randomized study with two lengths of treatment. In the absence of such a study our data
266
may be used to encourage patients to stay on at least until the fourth treatment before
267
discontinuing because success comes only then for the majority of patients with OAB.
268 269
Interestingly not all women with symptoms of OAB were prescribed PFPT. Observing the
270
preferences of physicians is another result of this study. Indeed, older women with
271
advanced stage prolapse and who were older were not prescribed PFPT. Women with
272
advanced prolapse may be thought to benefit more from pessary or surgery, while older
273
women may be expected to have trouble attending therapy regularly due to transportation
274
or other social issues, or even medical complexity. The outcome data of this study do not
275
support these treatment choices. We found that improvement by therapy was independent
276
of age and prolapse. In light of our findings, physicians may wish to prescribe PFPT to a
277
broader group of women, even those with prolapse and older women.
278 279
Of the patients who were prescribed PFPT, only a few were prescribed concomitant
280
medication. This may be due to patient preference to try the treatment with the least chance
281
of side effects first. However, the study cannot provide evidence to support this choice. In
282
contrast, patients who started vaginal estrogen did show a higher rate of improvement, but
283
this was not statistically significant. Other possible confounding medication include pain
284
medication, but these were not recorded during this chart review.
285
Limitations:
286
The improvement of symptoms occurred at three times higher rate after PFPT with
287
myofascial release technique than without. This may indicate the effectiveness of the
288
technique. However, the finding cannot be extrapolated to all patients with OAB. To this
289
point, the weakness of a retrospective chart review becomes relevant. We also saw the
290
differences in prescribing pattern. In this retrospective study, most of the women attending
291
PFPT who had pelvic floor myofascial TTP on the physican examination, were given
292
myofascial release therapy, and most of the women having myofascial release therapy had
293
pelvic floor myofascial TTP on the physican examination. There were women who had
294
myofascial release during their therapy sessions although the physician had not detected
295
pelvic floor myofascial TTP. We suspect that since the therapists perform a detailed
296
physical examination of their patients on the day of their initial visit, which may have been
297
somewhat different from the physican examination. This could have been due to
298
interexaminer variability, but also due to potential fluctuations in the patients' pelvic floor
299
muscle examination on daily or weekly basis, as physical therapy would not have been
300
intiated on the same day. However we did not analyze the physical therapists examinations
301
in keeping of an intention to treat analysis. The physical therapists personalize the patients’
302
treatment plans, and will routinely perform myofascial release if a patient is found with
303
myofascial pain, while they would not commonly perform myofascial release techniques if
304
the patient had no pain on examination at their PFPT intake visit. While this analysis is
305
underpowered to answer this question, a future prospective randomized study is indicated
306
to further investigate these relationships among OAB, pelvic floor myofascial TTP,
307
presence of active versus latent trigger points, and PFPT. Until such study is conducted, it
308
remains standing that among women with pelvic floor myofascial TTP, the technique of
309
myofascial release had a high success rate.
310 311
There are other weaknesses of this study as it was a retrospective analysis in a convenience
312
sample of 4 months duration. It may be that the few women who attended therapy (only
313
48% of those prescribed) were especially motivated. This bias may account for the
314
relatively high rate of improvement (71.4%) for patients who attended PFPT. What
315
remains true is that the technique was met with a high improvement rate.
316
The initial physical examinations during this study were performed by a potential total of
317
10 physicians of various levels of training (attending (3), fellow (3), resident (4)). The
318
interexaminer variability is a potential confounding variable however was limited as new
319
patients were most often examined by a Urogynecology fellow who is in the 5th to 7th year
320
of training or the attending physician. In a future study, limiting the number of examiners
321
may improve the data quality further. In the future it would perhaps be even more helpful
322
to eliminate the subjective component in the myofascial exam even further such that it can
323
be quantified. We have made strides in this direction studying a pressure algometer placed
324
on the examiner’s fingers. Other quantification measurements could include measurement
325
of the muscles electrical activity via EMG patch electrodes. To further study the pelvic
326
floor myofascial TTP, these quantification measurements could be taken before and after
327
PFPT.
328
329
A further weakness of the study is that our main outcome measure was not standardized by
330
validated questionnaire. The physical therapy notes, written after each visit, usually
331
consisted of a paragraph of subjective updates about the therapy and will not always assess
332
all the patients’ specific symptoms. However, most of the charts had an obvious date
333
within the therapy where the patient indicated distinct improvement. Few charts showed
334
some improvement at one time, followed by worsening, followed by further improvement.
335
In this case the first date of improvement was recorded. Whether myofascial release is
336
helpful for all women with OAB or has higher rates of improvement in women who have
337
pelvic floor myofascial TTP remains an important topic for future investigation. Follow-up
338
studies should include standardized, validated questionnaires at initial MD exam, initial
339
physical therapy visit, and each follow up visit as well as at discharge. To minimize
340
questionaieres the patient impression of improvement could be considered at each visit
341
alone.
342
CONCLUSION
343 344
Women with OAB have high rates of tenderness when their pelvic floor muscles are
345
examined and high rates of improvement with PFPT, especially when receiving myofascial
346
release techniques. This suggests a muscular component in the etiology of OAB and
347
warrants a future prospective trial comparing the standardized myofascial technique for
348
myofascial release to behavioral therapy using validated outcome measures. Given this
349
data, patients with OAB may be encouraged to attend at least three sessions to experience
350
improvement. Myofascial release technique was related to higher improvement rates, yet
351
this might be related to the selection bias of patients who have this technique prescribed.
352 353 354
Statement of interest:
355
Drs Wolff, Joyce, McAlarnen, Mueller and Fitzgerald are affiliated with Loyola University
356
Medical Center, and Dr Brincat is affiliated with Rush University Medical Center. Both
357
organizations promote the recognition and treatment of individuals with myofascial pain.
358
None of the authors have any relevant conflict of interests for this work.
359 360 361
Clinical Relevance:
362 363
•
364
•
Women with symptoms of overactive bladder should receive an internal pelvic floor muscle examination Consideration of pelvic floor physical therapy for women with OAB is advised
365 366 367
•
368
•
369
Ensure communication with pelvic floor therapist and guidance that internal myofascial release therapy (sometimes called soft tissue manipulation) may be helpful Encourage patients that improvement is often noticed after 3 sessions already
370
REFERENCES
371
372
Barber MD, Walters MD, Bump RC 2005 Short forms of two condition-specific quality-of-life
373
questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7). American Journal of
374
Obstetrics and Gynecology 193: 103-13.
375
Bedaiwy MA, Patterson B, Mahajan S 2013 Prevalence of myofascial chronic pelvic pain and the
376
effectiveness of pelvic floor physical therapy. The Journal of reproductive medicine 58: 504-10.
377
Berkley KJ 2005 A life of pelvic pain. Physiology & Behavior 86: 272-80.
378
Bernstein AM, Philips HC, Linden W, Fenster H 1992 A psychophysiological evaluation of female
379
urethral syndrome: evidence for a muscular abnormality. Journal of Behavioral Medicine 15: 299-
380
312.
381
Berry SH, Elliott MN, Suttorp M, Bogart LM, Stoto MA, Eggers P, Nyberg L, Clemens JQ 2011
382
Prevalence of symptoms of bladder pain syndrome/interstitial cystitis among adult females in the
383
United States. The Journal of urology 186: 540-4.
384
Burgio KL, Goode PS, Locher JL, Umlauf MG, Roth DL, Richter HE, Varner RE, Lloyd LK 2002
385
Behavioral training with and without biofeedback in the treatment of urge incontinence in older
386
women: a randomized controlled trial. Jama 288: 2293-9.
387
Burgio KL, Locher JL, Goode PS, Hardin JM, McDowell BJ, Dombrowski M, Candib D 1998
388
Behavioral vs drug treatment for urge urinary incontinence in older women: a randomized
389
controlled trial. Jama 280: 1995-2000.
390
Burgio KL, Whitehead WE, Engel BT 1985 Urinary incontinence in the elderly. Bladder-sphincter
391
biofeedback and toileting skills training. Annals of Internal Medicine 103: 507-15.
392
Fitzgerald CM, Neville CE, Mallinson T, Badillo SA, Hynes CK, Tu FF 2011 Pelvic floor muscle
393
examination in female chronic pelvic pain. The Journal of reproductive medicine 56: 117-22.
394
Fitzgerald MP, Anderson RU, Potts J, Payne CK, Peters KM, Clemens JQ, Kotarinos R, Fraser L,
395
Cosby A, Fortman C, Neville C, Badillo S, Odabachian L, Sanfield A, O'Dougherty B, Halle-Podell R,
396
Cen L, Chuai S, Landis JR, Mickelberg K, Barrell T, Kusek JW, Nyberg LM, Urological Pelvic Pain
397
Collaborative Research Network 2013 Randomized multicenter feasibility trial of myofascial
398
physical therapy for the treatment of urological chronic pelvic pain syndromes. The Journal of
399
urology 189: S75-85.
400
Giamberardino MA, Affaitati G, Fabrizio A, Costantini R 2011 Myofascial pain syndromes and their
401
evaluation. Best practice & research. Clinical rheumatology 25: 185-98.
402
Hanno PM, Burks DA, Clemens JQ, Dmochowski RR, Erickson D, Fitzgerald MP, Forrest JB, Gordon
403
B, Gray M, Mayer RD, Newman D, Nyberg L,Jr, Payne CK, Wesselmann U, Faraday MM, Interstitial
404
Cystitis Guidelines Panel of the American Urological Association Education and Research, Inc 2011
405
AUA guideline for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. The
406
Journal of urology 185: 2162-70.
407
Hoffman D, 2011 Understanding multisymptom presentations in chronic pelvic pain: The inter-
408
relationships between the viscera and myofascial pelvic floor dysfunction. Current Pain and
409
Headache Reports 15:343-346.
410
Kotarinos R 2012 Myofascial pelvic pain. Current pain and headache reports 16: 433-8.
411
Kuo TL, Ng LG, Chapple CR 2015 Pelvic floor spasm as a cause of voiding dysfunction. Current
412
opinion in urology 25: 311-6.
413
Lucas KR, Rich PA, Polus BI 2010 Muscle activation patterns in the scapular positioning muscles
414
during loaded scapular plane elevation: the effects of Latent Myofascial Trigger Points 25:765-
415
770.
416
McDowell BJ, Burgio KL, Dombrowski M, Locher JL, Rodriguez E 1992 An interdisciplinary
417
approach to the assessment and behavioral treatment of urinary incontinence in geriatric
418
outpatients. Journal of the American Geriatrics Society 40: 370-4.
419
Montenegro ML, Mateus-Vasconcelos EC, Rosa e Silva JC, Nogueira AA, Dos Reis FJ, Poli Neto OB
420
2010 Importance of pelvic muscle tenderness evaluation in women with chronic pelvic pain. Pain
421
medicine (Malden, Mass.) 11: 224-8.
422
Oyama IA, Rejba A, Lukban JC, Fletcher E, Kellogg-Spadt S, Holzberg AS, Whitmore KE 2004
423
Modified Thiele massage as therapeutic intervention for female patients with interstitial cystitis
424
and high-tone pelvic floor dysfunction. Urology 64: 862-5.
425
Peters KM, Carrico DJ, Kalinowski SE, Ibrahim IA, Diokno AC 2007 Prevalence of pelvic floor
426
dysfunction in patients with interstitial cystitis. Urology 70: 16-8.
427
Pezzone MA, Liang R, Fraser MO 2005 A model of neural cross-talk and irritation in the pelvis:
428
implications for the overlap of chronic pelvic pain disorders. Gastroenterology 128: 1953-64.
429
Reiter RC, Gambone JC 1991 Nongynecologic somatic pathology in women with chronic pelvic
430
pain and negative laparoscopy. The Journal of reproductive medicine 36: 253-9.
431
Schneider MJ 1995 Tender points/fibromyalgia vs. trigger points/myofascial pain syndrome: a
432
need for clarity in terminology and differential diagnosis. Journal of manipulative and
433
physiological therapeutics 18: 398-406.
434
Shah JP, Gilliams EA 2008 Uncovering the biochemical milieu of myofascial trigger points using in
435
vivo microdialysis: an application of muscle pain concepts to myofascial pain syndrome. Journal of
436
Bodywork and Movement Therapies 12:371–384.
437
Shah JP, Thaker N, Heimur J, Aredo JV, Sikdar S, Gerber L 2015 Myofascial Trigger Points Then and
438
Now: A Historical and Scientific Perspective. PM&R 7:746–761.
439
Simons DG, Travell JG, Simons LS 1999a Travell and Simons’ myofascial pain and dysfunction: The
440
trigger point manual. 2nd ed. Vol. 1. Williams and Wilkins; Baltimore
441
Simons DG, Travell JG, Simons LS 1999b Travell and Simon’ myofascial pain and dysfunction: The
442
trigger point manual. 2nd ed. Vol. 2. Williams and Wilkins; London
443
444
445
Spitznagle TM, Robinson CM 2014 Myofascial pelvic pain. Obstetrics and gynecology clinics of
446
North America 41: 409-32.
447
Stewart WF, Van Rooyen JB, Cundiff GW, Abrams P, Herzog AR, Corey R, Hunt TL, Wein AJ 2003
448
Prevalence and burden of overactive bladder in the United States. World journal of urology 20:
449
327-36.
450
THIELE GH 1963 Coccygodynia: Cause and Treatment. Diseases of the colon and rectum 6: 422-36.
451
Weiss JM 2001 Pelvic floor myofascial trigger points: manual therapy for interstitial cystitis and
452
the urgency-frequency syndrome. The Journal of urology 166: 2226-31.
453 454
455
TABLES
456
TABLE 1. Patient characteristics by initiation of therapy
457
Initiated
PT only
myofascial
n (%)
PT
PT not
Prescribed recommended
release in
but not
PT
done
59 (30.6)
19 (9.8)
84 (43.5)
31 (16.1)
56.3 (17.1)
64.3 (14.7)
56.6 (16.0)
67.5 (12.8)
Caucasian
31 (52.5)
13 (68.4)
54 (64.3)
25 (80.6)
Black
17 (28.8)
2 (10.5)
13 (15.5)
4 (12.9)
Age, mean in years (SD)
p-value
0.003
Ethnicity, n (%)
0.19 Hispanic
7 (11.9)
4 (21.1)
14 (16.7)
2 (6.5)
4 (6.8)
0 (0.0)
3 (3.6)
0 (0.0)
0
9 (15.3)
1 (5.3)
8 (9.5)
3 (9.7)
1
9 (15.3)
3 (15.8)
23 (27.4)
2 (6.5)
41 (69.5)
15 (78.9)
53 (63.1)
26 (83.9)
41 (71.9)
11 (57.9)
55 (66.3)
11 (36.7)
Other Parity, n (%)
≥2
0.16
Prolapse stage, n (%) 0-1
<0.001 2
13 (22.8)
5 (26.3)
24 (28.9)
7 (23.3)
3-4
3 (5.3)
3 (15.8)
4 (4.8)
12 (40.0)
BMI (kg/m²), mean (SD)
31.3 (8.2)
34.5 (7.3)
30.5 (8.1)
30.3 (6.2)
0.21
Myofascial pain, n (%)
45 (76.3)
9 (47.4)
45 (53.6)
10 (32.3)
<0.001
UUI
42 (71.2)
15 (78.9)
64 (76.2)
15 (48.4)
0.026
Urgency
50 (84.7)
17 (89.5)
71 (84.5)
14 (45.2)
<0.001
Frequency
47 (79.7)
17 (89.5)
74 (88.1)
17 (54.8)
<0.001
6 (10.2)
1 (5.3)
12 (14.3)
0 (0.0)
0.10
10 (16.9)
0 (0.0)
20 (23.8)
3 (9.7)
0.051
Pelvic floor symptoms, n (%)
Dysuria Pelvic pain 458
459
Table 1 legend: Patients demographics, symptoms and exam findings are shown for all
460
patients analyzed. The patients have been placed into one of four subgroups based on their
461
therapy: Patients initiated physical therapy and it included myofascial release techniques
462
applied, Patients initiated physical therapy but did not have myofascial release, Patients
463
who did not attend the prescribed physical therapy and Patients for whom physical therapy
464
was not recommended. The last column indicates whether there was a statistical difference
465
between the groups with respect to each characteristic. PT-physical therapy; BMI- Body
466
mass index; UUI-Urgency urinary incontinence;
467 468
469
TABLE 2. Patient characteristics and therapy outcomes for those who initiated physical
470
therapy n
n (%)
p-value
improved Overall
77
55 (71.4)
< 60
40
28 (70.0)
≥ 60
37
27 (73.0)
43
31 (72.1)
Age
0.77
Ethnicity Caucasian
0.88 Non-Caucasian
34
24 (70.6)
0
10
8 (80.0)
≥1
67
47 (70.1)
52
38 (73.1)
Parity
0.72
Prolapse stage 0-1
0.64 25
17 (68.0)
< 30
37
26 (70.3)
≥ 30
40
29 (72.5)
8
8 (100.0)
≥2 BMI (kg/m²)
0.83
Started anticholinergic/mirabegron
0.096
Started vaginal estrogen
8
7 (87.5)
0.43
54
37 (68.5)
0.39
UUI
56
42 (75.0)
0.26
Urgency
66
46 (69.7)
0.50
Frequency
63
44 (69.8)
0.75
7
4 (57.1)
0.41
10
8 (80.0)
0.72
59
50 (84.7)
Myofascial pain Pelvic floor symptoms
Dysuria Pelvic pain Myofascial release Yes
<0.001 No
18
5 (27.8)
1-2
17
1 (5.9)
3-5
17
16 (94.1)
6-8
32
29 (90.6)
≥9
11
9 (81.8)
Number of sessions
<0.001
471
472
Table 2 legend: This table shows whether patient characteristics were associated with
473
reaching improvement during physical therapy. The first column shows the subgroup
474
definitions. The second column shows how many patients fall in each subgroup. The third
475
column shows the number of patients who improved in that subgroup and which percent of
476
patients improved in each subgroup is shown in brackets. The last column shows the p-
477
values of each univariate analysis via the Cochran-Armitage Trend tests for ordinal
478
variables and chi-square or Fisher’s exact test as appropriate for nominal variables. The
479
data are limited to the patients who initiated therapy (n=77).
480
481
TABLE 3. Patient characteristics and therapy outcomes with and without myofascial
482
release Myofascial Release n
n (%)
No Myofascial Release
p-value
n
improved Overall
n (%)
p-
improved
value
59
50 (84.7)
18
5 (27.8)
< 60
32
27 (84.4)
8
1 (12.5)
≥ 60
27
23 (85.2)
10
4 (40.0)
31
27 (87.1)
12
4 (33.3)
Age
0.99
0.31
Ethnicity Caucasian
0.72 Non-Caucasian
0.61
28
23 (82.1)
6
1 (16.7)
9
8 (88.9)
1
0 (0.0)
50
42 (84.0)
17
5 (29.4)
42
35 (83.3)
10
3 (30.0)
Parity 0
0.99 ≥1
0.99
Prolapse stage 0-1
0.99
0.99
17
15 (88.2)
8
2 (25.0)
< 30
31
24 (77.4)
6
2 (33.3)
≥ 30
28
26 (92.9)
12
3 (25.0)
≥2 BMI (kg/m²)
0.15
0.99
Started
7
7 (100.0)
1
1 (100.0)
0.58
0.28
anticholinergic/mirabegron Started vaginal estrogen
7
6 (85.7)
0.99
1
1 (100.0)
0.28
45
36 (80.0)
0.098
9
1 (11.1)
0.29
UUI
42
38 (90.5)
0.10
14
4 (28.6)
0.99
Urgency
50
41 (82.0)
0.33
16
5 (31.3)
0.99
Frequency
47
39 (83.0)
0.67
16
5 (31.3)
0.99
6
4 (66.7)
0.22
1
0 (0.0)
0.99
10
8 (80.0)
0.64
--
--
--
1-2
5
0 (0.0)
12
1 (8.3)
3-5
14
13 (92.9)
3
3 (100.0)
6-8
30
28 (93.3)
2
1 (50.0)
≥9
10
9 (90.0)
1
0 (0.0)
Myofascial pain Pelvic floor symptoms
Dysuria Pelvic pain Number of sessions
<0.001
0.005
483
Table 3 legend: Patients who initiated physical therapy were stratified based on whether
484
myofascial release techniques were applied or not. The "p-value" corresponds to the
485
within-strata test of association. The data are limited to patients who initiated therapy with
486
or without myofascial release and known improvement status (n=77). PT-physical therapy;
487
BMI- Body mass index; UUI-Urgency urinary incontinence;
488
FIGURES
489
CAPTION TO FIGURE 1:
490
Subgroups of patients who attended one, two, three, or over three sessions were formed,
491
and the % of patients who improved in each group are shown.
492
493
494 495 496
Figure 1: Patient improvement by number of physical therapy sessions attended