Evidence-Based Practice

The physical therapy profession recognizes the use of evidence-based practice (EBP) as central to providing high-quality care and decreasing unwarranted variation in practice. Midwest Physical Therapy Services includes the integration of best available research and clinical expertise to provide the best possible care for our patients. As we review dozens of articles each month, we want to provide our community with some of the findings. Below, you will find summaries of some of the latest research in addition to the reference to obtain the full article if desired. New posts will be added throughout the year. Click on the ‘-‘ in the right corner to minimize a summary.
Pelvic Floor PT Improves Pelvic Pain

Reference: Hilton L, Pelvic Floor PT Improves Pelvic Pain, Voiding Symptoms. http://www.urologytimes.com/modern-medicine-feature-articles/pelvic-floor-pt-improves-pelvic-pain-voiding-symptoms

Patients with long standing pelvic floor issues can eventually lead to pain, bowel and bladder issues, and sexual dysfunction after time. These can be masked with medications, however the issues can only be cured with proper physical therapy to retrain the effected muscles for these functional tasks. Dr. Natalie Gaines, an MD of Beaumont Hospital in Royal Oak, MI conducted a retrospective chart review on 95 women that reported either pain and/or symptoms as mentioned previously. Studies had shown a drastic decline in their pain levels, on their worst days, from an 8 to a 4.8 on the visual analog scale from pre physical therapy to post physical therapy with a focus on pelvic floor dysfunction.

Effectiveness of a Multidimensional Physical Therapy Program on Pain

Reference: Hilton L, Pelvic Floor PT Improves Pelvic Pain, Voiding Symptoms. http://www.urologytimes.com/modern-medicine-feature-articles/pelvic-floor-pt-improves-pelvic-pain-voiding-symptoms

This article examined a multidimensional physical therapy program that included strengthening exercises and massage as major components. It monitored the effects on shoulder pain and pressure hyperalgesia. With breast cancer symptoms, central sensitization is present independently with the breast cancer surgery received along with the prevalence of active muscle trigger points which also increase pressure/pain sensitivity. These changes in the nervous system may enhance the experience of pain for breast cancer survivors. Results of the study concluded that an 8-week multidimensional physical therapy program including strengthening and endurance exercises, relaxation and massage, induced changes in nociceptive processing in breast cancer survivors with a noted reduction in neck, shoulder, and axillary pain, presence of trigger points. It also exhibited a decrease in pressure pain hypersensitivity as compared with usual breast cancer care.

Physiotherapy Management of Axillary Web Syndrome following Breast Cancer Treatment

Reference: Fourie, W.j., and K.a. Robb. “Physiotherapy Management of Axillary Web Syndrome following Breast Cancer Treatment: Discussing the Use of Soft Tissue Techniques.” Physiotherapy 95.4 (2009): 314-20. Web.

Following breast cancer surgery and treatment multiple women develop edema, pain, decreased shoulder mobility, and both sensory and motor dysfunction and axillary webbing. Patient usually present with limited and painful shoulder flexion and abduction. With the help of manual soft tissue techniques the axillary cords will be released therefor increasing range of motion and decreasing the patient’s edema and pain.

A Preliminary Study on Balance Performance and Fall Status in Older Women

Reference: Nelson PR, Irish KR, Cleary KK. A Preliminary Study on Balance Performance and Fall Status in Older Women With Urinary Incontinence. Journal of Womenʼs Health Physical Therapy. 2015;39(3):102-108. doi:10.1097/jwh.0000000000000036.

Urinary incontinence (UI) is often cited as a reason for falls in the older population, but there is limited evidence using typical fall assessments for this. This study used the Tinetti Gait and Balance, Berg Balance Scale and Four Square Step Test to correlate balance scores, number of falls and patients who report UI. Those with UI scored significantly worse on all three tests and reported a higher number of falls than those without UI. This condition causes measurable impacts and distress on patients who have it. Screening for fall risk due to UI in older women is important, and physical therapists are equipped to both improve the impact of UI and also improve functional balance and mobility; making our patients safer in the community and in their homes.

The cancer rehabilitation journey

Reference: Blaney, J, A Lowe-Strong, et al. “The cancer rehabilitation journey: barriers to and facilitators of exercise among patients with cancer-related fatigue.” Physical Therapy. 90.8 (2010): 1135/1147. Print.

Researchers have begun exploring reasons for the decline in physical activity and progression toward sedentary living during, immediately after, and even years after cancer treatment. Cancer Related Fatigue (CRF) has always been expected but exercise has not been integrated as part of cancer care as a solution. Studies show that exercise is the best tool used to manage CRF and counteract the side effects induced by surgery and anti-cancer treatments. Most patients who complained about barriers to exercise also claimed later that an exercise program would have been beneficial. Most participants emphasized that an exercise program should be supervised and administered by a trained healthcare professional. The program should also be tailored specifically to the individual. Physical therapists are ideal and are trained to design and deliver exercise programs to help patients manage their fatigue and thus improve their functional status and quality of life.

A Preliminary Study on Balance Performance and Fall Status in Older Women

Reference: Nelson, Patricia R., Kathryn R. Irish, and Kimberly K. Cleary. “A Preliminary Study on Balance Performance and Fall Status in Older Women With Urinary Incontinence.” Journal of Womenʼs Health Physical Therapy 39.3 (2015): 102-08. Web.

Urinary Incontinence is prevalent in 29% of women older than 65 years old. These women that have been diagnosed with UI also have an increased risk for falls. This is due to when a person is rushing to get to the bathroom or getting up often during the night to urinate. It is also due to patient’s with more particular stress UT, the PF and trunk muscles are activate to maintain the continence and not for their balance control. In this study, women were questioned on specific questionnaires for incontinence and had to perform balance tests, which came to the conclusion that women of 65 years and older and diagnosed with UI have an increased risk for falls.

Effects of Mastectomy on Shoulder and Spinal Kinematics

Reference: Crosbie, Jack, Sharon Kilbreath, Elizabeth Dylke, et al. “Effects of Mastectomy on Shoulder and Spinal Kinematics During Bilateral Upper-Limb Movement.” Physical Therapy. 90.5 (2010): 679-692. Print.

Poor kinematics is just one byproduct of a mastectomy having been performed. While other symptoms such as lymphedema may be unavoidable increased ability of movement and patient’s range of motion is something which Physical Therapists should be able to treat. Treatment of post-surgical effects could increase functionality and quality of life as well as deter some effects which cause pain and aching.

Effect of pelvic floor muscle training compared with watchful waiting

Reference: Wiegersma M, Panman CMCR, Kollen BJ, Berger MY, Leeuwen YL-V, Dekker JH. Effect of pelvic floor muscle training compared with watchful waiting in older women with symptomatic mild pelvic organ prolapse: randomised controlled trial in primary care. Bmj. 2014;349(dec22 1).

This was a randomized controlled trial of women 55 years and older who had symptomatic mild pelvic organ prolapse. Those in the intervention group were given pelvic floor muscle training versus watchful waiting in the control group. 57% of the women in the intervention group found an improvement of overall symptoms. Physical therapy can train women with pelvic organ prolapse to strengthen their pelvic floor, improve their symptoms and therefore improve their overall quality of life.

Shoulder Impairment Before Breast Cancer Surgery

Reference: Flores, Ann Marie, and Kathleen Dwyer. “Shoulder Impairment Before Breast Cancer Surgery.” Journal of Womenʼs Health Physical Therapy 38.3 (2014): 118-24. Print.

There is little information regarding the quality of life of patients with breast cancer (BCA) after they have been diagnosed but before they receive curative treatment, and regarding the quality of life of patients with BCA coming from a minority population. Impaired joint range of motion (ROM), fatigue, pain, and needing to alter activities of daily living are some of the most common findings. While both Caucasian and African American (AA) patients had decreased shoulder AROM following biopsy but prior to surgery, AA were shown to have a greater difference. This finding, in addition to other studies cited by the authors, suggests that rehabilitation including resistance training for BCA survivors can be beneficial for improving strength, cardiac endurance, pain, and fatigue, as well as contribute to successful lymphedema management secondary to cancer treatment.

Managing a Patient's Constipation With Physical Therapy

Reference: Harrington, K., & Haskvitz, E. (2006). Managing a Patient’s Constipation With Physical Therapy. Physical Therapy, 1511-1519.

Patients suffering from constipation have been shown to respond well to physical therapy intervention, decreasing the frequency in use of laxatives and risk of colon cancer. Biofeedback training has seen an 80% improvement in the restoration of normal bowel function when used as a physical therapy intervention for patients with constipation resulting from pelvic-floor or anal sphincter dysfunction. For patients with both slow-transit and normal-transit constipation, physical therapy intervention includes focusing on moderate aerobic exercise which has been found to have an effect on increasing gut transit without affecting defecation frequency, as well as a strength training program of force-generating capacity which has been shown to accelerate whole-bowel transit time. Finally, abdominal massage for 10 – 15 minutes daily has been shown to decrease abdominal spasticity allowing the bowels to spontaneously open.

Effect of Pelvic-Floor Muscle Strengthening on Bladder Neck Mobility

Reference: Hung, H.-C., S.-M. Hsiao, S.-Y. Chih, H.-H. Lin, and J.-Y. Tsauo. “Effect of Pelvic-Floor Muscle Strengthening on Bladder Neck Mobility: A Clinical Trial.” Physical Therapy 91.7 (2011): 1030-038. Print.

A counterbracing technique called “knack” involving contracting the pelvic floor muscle (PFM) right before an increase in intra-abdominal pressure has been shown to significantly reduce urinary leakage after 1 week of training. Pelvic floor muscle (PFM) rehabilitation has also been shown to have the ability to significantly elevate the neck of the bladder at rest and increase bladder neck stiffness during the Valsalva maneuver. The authors of this study found that a 4-month daily PFM strengthening program could improve the ability of the pelvic floor to elevate the neck of the bladder, improve urinary continence, and enhance PFM strength, but not reduce the caudal displacement of the bladder neck during a cough of the Valsalva maneuver.

Characteristics of Patients Seeking Outpatient Rehabilitation for Pelvic-Floor Dysfunction

Reference: Wang, Ying-Chih, Dennis Hart, and Jerome Mioduski. “Characteristics of Patients Seeking Outpatient Rehabilitation for Pelvic-Floor Dysfunction.” Physical Therapy. 92.9 (2012): 1160-1174. Print.

The purposes of this study were to describe the characteristics of individuals with disorders associated with PFD who were seeking outpatient physical therapy. As the patients progressed from initial evaluation to discharge, they completed several self-report surveys specific to PFD. Overall, PFD disorders were more common in female patients than in male patients. It was also found that the majority of the patients were 65 years or older. The most common disorder was urinary disorder, with 67% of patients. It was found that combinations of urinary, bowel, or pelvic-floor pain disorders were not uncommon.

Effect of Pelvic-Floor Muscle Strengthening on Bladder Neck Mobility

Reference: Effect of Pelvic-Floor Muscle Strengthening on Bladder Neck Mobility: A Clinical Trail Hung HC1, Hsiao SM, Chih SY, Lin HH, Tsauo JY.

This study was directed to examine the effect of pelvic floor muscle strengthening on women population with stress or mixed urinary incontinence problems. Tasks were completed over a 4 month trial that included interventions and methods to score the results before and after treatments. Position of the bladder neck during strengthening interventions altered the position to be elevated displaying great improvement. During other stressful simulations such as the Valsalva maneuver, the bladder neck position and mobility showed no change yielding no theoretical results. Studies and results conclude that pelvic floor strengthening may in fact elevate the bladder neck, but lead to no enhancements of the stiffness during any intra- abdominal pressure.