Evidence-Based: Physical Therapy Pelvic Floor

OVERVIEW

The framework is based on the approach to
disorders of the pelvic floor in women described by
Wall & DeLancey (1991). Wall & DeLancey (1991) stated
that ‘pelvic floor dysfunction, particularly as manifested
by genital prolapse and urinary or fecal incontinence,
remains one of the largest unaddressed issues in
women’s health care today’. In their opinion
lack of success in treating patients with pelvic floor dysfunction
is due to a professional ‘compartmentalization’
of the pelvic floor.

Each of the three outlets in the pelvis has had its own
doctor and medical specialty, with the urethra and
bladder belonging to the urologist, the vagina and
female genital organs belonging to the gynaecologist,
and the colon and rectum belonging to the gastroenterologist
and the colorectal surgeon.

Wall & DeLancey (1991) argue that instead of concentrating
on the three ‘holes’ in the pelvis, one should
look at the ‘whole pelvis’ with the pelvic floor muscles
(PFM), ligaments and fasciae as the common supportive
system for all the pelvic viscera.

The interaction between the PFM and the supportive
ligaments was later elaborated by DeLancey (1993) and
Norton (1993) as the ‘boat in dry dock theory’. The ship
is analogous to the pelvic organs, the ropes to the ligaments
and fasciae and the water to the supportive layer
of the PFM.

DeLancey (1993) argues that as long as the PFM or
levator ani muscles function normally, the pelvic floor
is supportive and the ligaments and fascia are under
normal tension.

When the PFM relax or are damaged, the pelvic
organs must be held in place by the ligaments and
fasciae alone. If the PFM cannot actively support the
organs, over time the connective tissue will become
stretched and damaged.

Bump & Norton (1998) also used this theoretical
framework in their overview on the epidemiology and
natural history of pelvic floor dysfunction. They suggested
that pelvic floor dysfunction may lead to the following
conditions:

• urinary incontinence (stress, urge and mixed
incontinence);
• fecal incontinence;
• pelvic organ prolapse;
• sensory and emptying abnormalities of the lower
urinary tract;
• defecatory dysfunction;
• sexual dysfunction;
• chronic pain syndromes.
Bump & Norton (1998) also described three stages in
the development of pelvic floor dysfunction:
1. a perfect pelvic floor that is anatomically, neurologically,
and functionally normal;
2. a less than perfect, but well-compensated pelvic
floor in an asymptomatic patient;
3. a functionally decompensated pelvic floor in the
patient with end-stage disease with urinary incontinence,
anal incontinence, or pelvic organ prolapse.
A model describing etiological factors possibly
leading to or causing pelvic floor dysfunction in women
has been developed, classifying the factors into:
• predisposing factors (e.g. gender, genetic, neurological,
anatomical, collagen, muscular, cultural and
environmental);
• inciting factors (e.g. childbirth, nerve damage, muscle
damage, radiation, tissue disruption, radical
surgery);
• promoting factors (e.g. constipation, occupation,
recreation, obesity, surgery, lung disease, smoking,
menstrual cycle, infection, medication, menopause);
• decompensating factors (e.g. ageing, dementia, debility,
disease, environment, medications).

Wall & DeLancey (1991) argued that progress in
the treatment of pelvic floor dysfunction in women
would occur more rapidly if a unified, cross disciplinary
approach to disorders of the pelvic support was
developed.
Wall & DeLancey (1991) mentioned only the different
medical professions as part of a multidisciplinary team.
In this book we will argue that physical therapists (PTs),
having assessment and treatment of the musculoskeletal
system in general as their specialty, should be core
professionals in a multidisciplinary approach to pelvic
floor dysfunction.

PHYSICAL THERAPY FOR THE PELVIC FLOOR
The nature of physical therapy

In May 1999, at the 14th General Meeting of The World
Confederation for Physical Therapy (WCPT), a position
statement describing the nature and process of physical
therapy/physical therapy was approved by all member
nations (1999). This description will be used as a foundation
and framework to give an overview of physical
therapy/physical therapy in the area of pelvic floor dysfunction.
The term ‘physical therapy’ will be used
throughout this book, in accordance with the guidelines
of the WCPT Europe.

According to the WCPT, physical therapy is ‘providing
services to people and populations to develop,
maintain and restore maximum movements and functional
ability throughout the lifespan’.

The main area of practice for PT is musculo skeletal
pain and dysfunction. However, many PTs also specialize
in other areas such as the cardiorespiratory fi eld,
neurology, and coronary disease. In all areas PTs
aim to improve functional capacity and improve the
patients’ ability to maintain or increase physical activity
level.

The PFM are not responsible for gross motor movements
alone, but work in synergy with other trunk
muscles. Therefore, pelvic fl oor dysfunction may lead to
symptoms during movement and perceived restriction
in the ability to stay physically active (Bø et al 1989,
Nygaard et al 1990). Several studies have shown that,
for example, urinary incontinence may lead to a change
in movement patterns during physical activities (Bø
et al 1989, Nygaard et al 1990), withdrawal from regular
fi tness activities and bother when being active (Brown
& Miller 2001, Nygaard et al 1990).

Lifelong participation in regular moderate physical
activity is important in the prevention of several diseases,
and is an independent factor in the prevention of
osteoporosis, obesity, diabetes mellitus, high blood
pressure, coronary heart disease, breast and colon
cancer, depression and anxiety (Bouchard et al 1993).
In addition, limitations in the ability to move or
conduct activities of daily living either due to age or
injuries may also lead to other problems, such as secondary
incontinence.

Physical therapy for pelvic floor dysfunction may
therefore also include physical activities for increasing
general function and fitness level.
‘Physical therapy includes the provision of services in
circumstances where movement and function are
threatened by the process of aging or that of injury or
disease’


Hippocrates (5th–4th centuries bc) claimed that ‘all
parts of the body which have a function, if used in
moderation and exercised in labors in which each is
accustomed, become thereby healthy, well-developed
and age more slowly, but if unused and left idle they
become liable to disease, defective in growth, and age
quickly’.

The PFM are subject to continuous strain throughout
the lifespan. In particular, the pelvic fl oor of women is
subject to tremendous strain during pregnancy and
childbirth (Mørkved 2003). In addition, hormonal
changes may infl uence the pelvic fl oor and pelvic organs
and a decline in muscle strength may occur due to
aging. Hence, the PFM may need regular training to stay
healthy throughout life.

‘Physical therapy is concerned with identifying and
maximizing movement potential, within the spheres of
health promotion, prevention, treatment, and
rehabilitation’


Physical therapists may promote PFM training
(PFMT) by writing about the issue in newspapers and
women’s magazines, informing all their regular patients
about PFMT, including PFMT in regular exercise classes
and in particular in antenatal and postnatal training, as
well as before and after pelvic surgery in men and
women. Physical therapists who treat pelvic floor dysfunction
should be fully trained in this specialty or
should refer to colleagues who have the thorough
knowledge to treat patients according to the principles
of evidence based physical therapy.
‘Physical therapy is an essential part of the health services
delivery system’

‘PTs practice independently of other health care providers
and also within interdisciplinary rehabilitation/
habilitation programs for the restoration of optimal
function and quality of life in individuals with loss and
disorders of movement’

In most countries physical therapy work is by referral
from medical practitioners. However, during recent
decades this has changed in some countries such as
Australia and New Zealand. In 2006 Dutch PTs have
also become primary contact practitioners. Both systems
require good collaboration between the medical and
physical therapy professions.

The referral system implies that the medical practitioner
is aware of what the PT can offer, and also has
PTs available to send referrals to. One of the weaknesses
of this system is that medical practitioners who are not
motivated or who have insuffi cient knowledge about
the evidence for different physical therapy interventions
will not send suitable patients to physical therapy. The
patients will more likely be offered traditional medical
treatment options such as medication or surgery. These
treatments may have adverse effects and are more
expensive than exercise therapy (Black & Downs 1996,
Smith et al 2002). In addition, the referral system is
expensive because it involves an extra consultation.
The argument against PTs as primary contact practitioners
has been that PTs do not have enough education
to make differential diagnoses, and may therefore not
detect more serious diseases such as cancer or neurological
disease underlying the symptoms.

We believe that prevention
and treatment of pelvic floor dysfunction needs
a multidisciplinary approach and would encourage collaboration
between physicians and PTs at all levels of
assessment and treatment.

‘Physical therapy involves “. . . using knowledge and
skills unique to physical therapists and, is the service
ONLY (author’s emphasis) provided by, or under the
direction and supervision of a physical therapist” ’


The educational standard of PTs differs between
countries throughout the world. In the US, physical
therapy is at master’s degree level (although this is based
on an undergraduate degree other than physical therapy),
whereas in most countries in Europe, Asia, Africa, it is a
3-year bachelor degree and in Australia and New
Zealand it is a 4-year bachelor degree with the possibility
to continue with a master’s degree and PhD.
Physical therapy schools are within the university in
many countries, but in other countries physical therapy
is taught in polytechnic schools or colleges below
university level.

There can be different educational requirements
for entry into undergraduate programmes within one
country and from country to country. In most countries,
however, physical therapy is a professional education
and the entry level for physical therapy undergraduate
studies is very high, in some countries being at the same
level as medicine. In the area of pelvic fl oor dysfunction,
several PTs are professors and many PTs throughout
the world have master’s and PhDs.
The emphasis on pelvic fl oor dysfunction in undergraduate
physical therapy curricula varies between
countries at both undergraduate and postgraduate
physical therapy level. The broad knowledge of anatomy
and physiology, medical science, clinical assessment
and treatment modalities learnt by all PTs can be applied
to the pelvic fl oor. Several countries also have postgraduate
education programmes for PTs specializing
either in women’s health or pelvic or pelvic fl oor physical
therapy with education level and content varying
between countries.
‘The physical therapy process includes assessment,
diagnosis, planning, intervention, and evaluation’

Assessment
‘Assessment includes both the examination of individuals
or groups with actual or potential impairments,
functional limitations, disabilities, or other conditions
of health by history taking, screening and the use of
specific tests and measures, and evaluation of the
results of examination through analysis and synthesis
within a process of clinical reasoning’

In patients with pelvic floor dysfunction, after thorough
history taking, the PT will assess the function of
the pelvic floor by visual observation, vaginal palpation
and/or measurement of muscle activity (measurement
of vaginal or urethral squeeze pressure, electromyography
[EMG], ultrasound) (Bø & Sherburn 2005).

Diagnosis
‘In carrying out the diagnostic process, physical therapists
may need to obtain additional information from
other professionals’

Most PTs in private practice obtain referrals of patients
from general practitioners. These medical practitioners
themselves seldom have access to urodynamics, EMG,
magnetic resonance imaging (MRI) or ultrasound.

the only information that should lead to a drastic change
of clinical practice are results (positive or negative) from
RCTs.

When undertaking research and deciding on a PT
intervention, the PT must be aware that the ‘quality of
the intervention’, particularly the intensity of the physical
therapy intervention, will affect the outcome. Ineffective
(low dose) or even harmful treatments can be in
a RCT that has high-quality methodology. These research
challenges are the same when conducting RCTs
that include both surgery and PFMT, and the methodological
quality of studies of both surgery and PFMT
has been variable (Hay-Smith et al 2001, Smith et al
2002).
When participating in research led by other professionals
it is important that the physical therapy intervention
meets quality standards. No drug company
would dream of conducting a study with a non-optimal
dosage of the drug. In published RCTs, there are several
PFMT programmes with low dosage showing little or
no effect (Hay-Smith et al 2001).

Evaluation
‘Evaluation necessitates re-examination for the purpose
of evaluating outcomes’

Using the same outcome measures before and after
treatment is mandatory for the purpose of evaluating
outcomes in clinical practice.
In treating symptoms of pelvic floor dysfunction the
PT uses different forms of PFMT (independent variable
in experimental research) to change the condition
(named dependent variable in experimental research
e.g. stage of pelvic organ prolapse, pelvic pain or
SUI).

It is mandatory that PTs use the concept of the International
Classification of Impairment, Disability and
Handicap (ICIDH) (1997), later changed to International
Classification of Function (ICF) (2002) to evaluate efficacy
of the intervention. The ICF is a World Health
Organization (WHO)-approved system designed to
classify health and health related states. According to
this system (see Ch. 5.1) different health components are
related to specific diseases and conditions:

• body functions: physiological and psychological
functions of body systems (e.g. delayed motor latency
of the nerves to the PFM);
• body structures: anatomical parts (e.g. rupture or
atrophy of the PFM);
• impairments: problems in body function or structure
such as signifi cant deviation or loss (e.g. weak or
non-coordinated PFM);
• activity: execution of a task or action by an individual
(e.g. to stay continent during increase in abdominal
pressure);
• participation: involvement in a life situation (being
able to participate in social situations such as playing
tennis or aerobic dancing without fear or embarrassment
of leaking);
• environment (e.g. easy access to the bathroom).
Physical therapy aims to improve factors involving
all these components. Therefore we need to select
different outcome measures for different components.
For example, PFMT may improve timing of the cocontraction
during cough (ICF: body functions; neurophysiology).
This may be measured by wire or needle
EMG.

One of the aims for PFMT in treating pelvic organ
prolapse (POP) is to alter the length/stiffness of the
PFM so they sit at a higher anatomical location inside
the pelvis (ICF: body structure, anatomy). This may be
measured using MRI or ultrasound.
Impairment of the PFM can result from inability
to produce optimal strength (force). Muscle strength
can be measured by manometers or dynamometers
during attempts of maximal contraction.
Ambulatory urodynamics of urethral pressure during
physical activities may be developed as a future measure
of automatic co-contraction during activity.
Urinary leakage could be classifi ed as disability in
the ICIDH and as activity in the new ICF system. The
actual leakage can be measured by number of leakage
episodes (self report) or pad tests.
Physical therapy also aims at, for example, reducing
urinary leakage to a point where this is no longer
restricting the patient from participation in social activities
(ICF: participation). This can be measured by quality
of life questionnaires. PTs can also work politically to
improve the environment such as advocating for easy
access to toilets in public buildings.
Ideally, PTs should assess the effect of the physical
therapy intervention in all these components using
outcome measures with high responsiveness (measurement
tools that can detect small differences), reliability
(intra- and inter-tester reproducibility), and validity (to
what degree the measurement tool measures what it is
meant to measure).
PTs should ‘use terminology that is widely understood
and adequately defined’ and ‘recognize internationally
accepted models and definitions’

In the area of pelvic floor dysfunction we are fortunate
to have international committees working on
standardization and terminology. The International
Continence Society (ICS) constantly revises its standardization
of terminology (Abrams et al 2002), and the
Clinical Assessment Group within the same society
has also delivered a standardization document

Physical therapists must refer to definitions and terminology
from the WHO, the WCPT and for definitions
and standards developed in exercise science and motor
learning and control to be able to communicate effectively
with other professions.
Linking research and practice
‘Emphasise the need for practice to be evidence based
whenever possible’ and ‘appreciate the interdependence
of practice, research and education within
the profession’

Sackett et al (2000) has defined evidence-based medicine
as ‘the conscientious, explicit and judicious use of
current best evidence in making decisions about care of
individual patients’. Neither the best available external
clinical evidence (RCTs) nor clinical expertise alone is
good enough for decision making in clinical practice.
Without clinical experience, ‘evidence’ can ignore the
individual’s needs and circumstances, and without
evidence, ‘experience’ can become old fashioned/out
of date.

Evidence-based (PT) practice has a theoretical body
of knowledge, uses the best available scientific evidence
in clinical decision making and uses standardized
outcome measures to evaluate the care provided

Herbert et al (2005) have stated that research conducted
as part of routine clinical practice can be prone
to bias because there is often a lack of comparison of
outcomes with outcomes of randomized controls. In
such studies it may be difficult to distinguish between
effects of intervention and natural recovery or statistical
regression. In addition, self-reported outcomes may be
biased because patients may feel obliged to the therapist.
There may be no record or follow-up of dropouts,
outcome measures may be distorted by assessors’
expectations of intervention, adherence to the training
protocol is seldom reported and long-term results
are often not available. The best evidence of effects of
intervention comes from randomized trials with adequate
follow-up and blinding of assessors and, where
possible, blinding of patients too.
Our understanding of the mechanisms of therapies
is often incomplete, and it is unknown whether the
effects of some PT interventions are large enough to be
worthwhile (effect size).
Only high-quality clinical research (RCTs) potentially
provides unbiased estimates of the effect size (Herbert
2000a, b). This provides several challenges in clinical
practice.
To increase their level of knowledge in clinical practice
PTs need to:
• stay updated in pathophysiology;
• use interventions for which we have evidence-based
knowledge of dose–response issues;
• if possible: use interventions/protocols based on
results/protocols from high quality RCTS with positive
results (clinically relevant effect-size);
• use pre- and post-treatment tests that are responsive,
reliable, and valid;
• measure adherence and adverse effects!
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