BOOK
Evidence-Based Physical Therapy for the Pelvic Floor - E-Book
Kari Bo | Bary Berghmans | Siv Morkved | Marijke Van Kampen
(2014)
Additional Information
Book Details
Abstract
Bridging the gap between evidence-based research and clinical practice, Physical Therapy for the Pelvic Floor has become an invaluable resource to practitioners treating patients with disorders of the pelvic floor. The second edition is now presented in a full colour, hardback format, encompassing the wealth of new research in this area which has emerged in recent years.
Kari Bø and her team focus on the evidence, from basic studies (theories or rationales for treatment) and RCTs (appraisal of effectiveness) to the implications of these for clinical practice, while also covering pelvic floor dysfunction in specific groups, including men, children, elite athletes, the elderly, pregnant women and those with neurological diseases. Crucially, recommendations on how to start, continue and progress treatment are also given with detailed treatment strategies around pelvic floor muscle training, biofeedback and electrical stimulation.
- aligns scientific research with clinical practice
- detailed treatment strategies
- innovative practice guidelines supported by a sound evidence base
- colour illustrations of pelvic floor anatomy and related neuroanatomy/ neurophysiology
- MRIs and ultrasounds showing normal and dysfunctional pelvic floor
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front Cover | Cover | ||
| Evidence-based Physical Therapy for the Pelvic Floor: Bridging science and clinical practice | iii | ||
| Copyright | iv | ||
| Contents | v | ||
| Contributors | vii | ||
| Foreword | ix | ||
| Foreword | x | ||
| Foreword | xi | ||
| Preface | xiii | ||
| Chapter 1: Overview of physical therapy for pelvic floor dysfunction | 1 | ||
| PELVIC FLOOR DYSFUNCTION | 1 | ||
| PHYSICAL THERAPY FOR THE PELVIC FLOOR | 2 | ||
| The nature of physical therapy | 2 | ||
| Assessment | 4 | ||
| Diagnosis | 4 | ||
| Planning | 4 | ||
| Intervention | 5 | ||
| Evaluation | 5 | ||
| Linking research and practice | 6 | ||
| ROLE OF THE PHYSICAL THERAPIST IN PELVIC FLOOR DYSFUNCTION | 7 | ||
| REFERENCES | 7 | ||
| Chapter 2: Critical appraisal of randomized trials and systematic reviews of the effects of physical therapy intervention ... | 9 | ||
| RANDOMIZED TRIALS AND SYSTEMATIC REVIEWS | 9 | ||
| Randomized trials | 9 | ||
| Systematic reviews | 10 | ||
| What can’t randomized trials and systematic reviews tell us? | 10 | ||
| How can the evidence be located, and how much evidence is there? | 11 | ||
| Dimensions of quality of randomized trials and systematic reviews | 11 | ||
| SEPARATING THE WHEAT FROM THE CHAFF: DETECTING BIAS IN TRIALS AND REVIEWS | 11 | ||
| Detecting bias in randomized trials | 11 | ||
| Random allocation | 11 | ||
| Blinding | 12 | ||
| Follow-up | 13 | ||
| Detecting bias in systematic reviews | 13 | ||
| The search strategy | 13 | ||
| Assessment of trial quality | 14 | ||
| ASSESSING RELEVANCE OF TRIALS AND SYSTEMATIC REVIEWS | 14 | ||
| Quality of intervention | 15 | ||
| Patients | 15 | ||
| Outcomes | 15 | ||
| USING ESTIMATES OF EFFECTS OF INTERVENTION TO MAKE DECISIONS ABOUT INTERVENTION | 15 | ||
| Obtaining estimates of the effects of intervention from randomized trials and systematic reviews | 16 | ||
| Using estimates of the effects of intervention | 16 | ||
| REFERENCES | 16 | ||
| Chapter 3: Functional anatomy of the female pelvic floor | 19 | ||
| INTRODUCTION | 19 | ||
| HOW IS URINARY CONTINENCE MAINTAINED? | 20 | ||
| THE URINARY SPHINCTERIC CLOSURE SYSTEM | 20 | ||
| CLINICAL CORRELATES OF URETHRAL ANATOMY AND EFFECTS OF AGING | 22 | ||
| URETHRAL (AND ANTERIOR VAGINAL WALL) SUPPORT SYSTEM | 24 | ||
| Levator ani muscles | 24 | ||
| Interactions between the pelvic floor muscles and the endopelvic fasciae | 25 | ||
| PELVIC FLOOR FUNCTION RELEVANT TO STRESS URINARY INCONTINENCE | 26 | ||
| URETHROVESICAL PRESSURE DYNAMICS | 28 | ||
| CLINICAL IMPLICATIONS OF LEVATOR FUNCTIONAL ANATOMY | 28 | ||
| ANATOMY OF THE POSTERIOR VAGINAL WALL SUPPORT AS IT APPLIES TO RECTOCELE | 28 | ||
| REFERENCES | 32 | ||
| ACKNOWLEDGEMENT | 34 | ||
| Chapter 4: Neuroanatomy and neurophysiology of pelvic floor muscles | 35 | ||
| INTRODUCTION | 35 | ||
| INNERVATION OF PELVIC FLOOR MUSCLES | 35 | ||
| Somatic motor pathways | 35 | ||
| Afferent pathways | 36 | ||
| NEURAL CONTROL OF SACRAL FUNCTIONS | 37 | ||
| Neural control of continence | 37 | ||
| Neural control of micturition | 37 | ||
| Neural control of anorectal function | 37 | ||
| Neural control of the sexual response | 38 | ||
| NEUROPHYSIOLOGY OF PELVIC FLOOR MUSCLES | 38 | ||
| Tonic and phasic pelvic floor muscle activity | 38 | ||
| Reflex activity of pelvic floor muscles | 39 | ||
| AWARENESS OF MUSCLE | 40 | ||
| Voluntary activity of pelvic floor muscles | 40 | ||
| NEUROMUSCULAR INJURY TO THE PELVIC FLOOR DUE TO VAGINAL DELIVERY | 41 | ||
| CONCLUSION | 41 | ||
| REFERENCES | 41 | ||
| Chapter 5: Measurement of pelvic floor muscle function and strength, and pelvic organ prolapse | 43 | ||
| 5.1. Introduction | 44 | ||
| CLASSIFICATION AND DEFINITIONS | 44 | ||
| REFERENCES | 46 | ||
| 5.2. Visual observation and palpation | 47 | ||
| VISUAL OBSERVATION | 47 | ||
| Responsiveness | 47 | ||
| Intra- and inter-rater reliability | 47 | ||
| Validity | 47 | ||
| Sensitivity and specificity | 47 | ||
| Conclusion | 48 | ||
| CLINICAL RECOMMENDATIONS | 48 | ||
| PFM assessment using observation | 48 | ||
| VAGINAL PALPATION | 48 | ||
| Validity | 50 | ||
| Lying, sitting or standing? | 50 | ||
| One or two fingers? | 50 | ||
| Sensitivity and specificity | 51 | ||
| Conclusion | 51 | ||
| CLINICAL RECOMMENDATIONS | 51 | ||
| Palpation procedure | 51 | ||
| REFERENCES | 52 | ||
| 5.3. Electromyography | 53 | ||
| INTRODUCTION | 53 | ||
| MUSCLE FIBRE, MOTOR UNIT, MUSCLE | 53 | ||
| KINESIOLOGICAL EMG | 54 | ||
| EMG METHODS TO DIFFERENTIATE NORMAL FROM PATHOLOGICAL MUSCLE | 54 | ||
| Concentric needle EMG | 54 | ||
| CN EMG findings due to denervation and reinnervation | 57 | ||
| Single fibre electromyography | 57 | ||
| USEFULNESS OF EMG IN CLINICAL PRACTICE AND RESEARCH | 57 | ||
| Validity of the EMG signal | 58 | ||
| Responsiveness | 58 | ||
| Reliability | 58 | ||
| USE OF KINESIOLOGICAL EMG AND CN EMG IN PARTICULAR PATIENT GROUPS | 58 | ||
| CLINICAL RECOMMENDATIONS | 59 | ||
| REFERENCES | 60 | ||
| 5.4. Vaginal squeeze pressure measurement | 61 | ||
| RESPONSIVENESS | 61 | ||
| INTRA- AND INTER-TESTER RELIABILITY | 62 | ||
| VALIDITY | 62 | ||
| PLACEMENT OF THE DEVICE | 62 | ||
| SIZE AND SHAPES OF THE DEVICE | 62 | ||
| INFLUENCE FROM INCREASED ABDOMINAL PRESSURE | 63 | ||
| SENSITIVITY AND SPECIFICITY | 63 | ||
| CONCLUSION | 63 | ||
| CLINICAL RECOMMENDATIONS | 64 | ||
| REFERENCES | 65 | ||
| 5.5. Pelvic floor dynamometry | 66 | ||
| INTRODUCTION | 66 | ||
| IN VITRO CALIBRATION STUDIES | 68 | ||
| TEST–RETEST RELIABILITY STUDIES | 68 | ||
| ACCEPTANCE | 72 | ||
| VALIDITY STUDIES | 72 | ||
| Validity criterion | 72 | ||
| Convergent validity | 72 | ||
| Known Groups Method | 73 | ||
| PFM functional differences between continent and incontinent women | 73 | ||
| PFM functional differences between women with and without provoked vestibulodynia | 74 | ||
| PFM functional differences between women with and without pelvic organ prolapse | 74 | ||
| PFM dynamometry in pelvic floor rehabilitation | 74 | ||
| CONCLUSION | 75 | ||
| CLINICAL RECOMMENDATIONS (based on the Montreal dynamometer) | 75 | ||
| REFERENCES | 76 | ||
| 5.6. Urethral pressure measurements | 77 | ||
| DEFINITIONS | 77 | ||
| METHODS OF MEASURING URETHRAL PRESSURE PROFILOMETRY | 78 | ||
| Fluid perfusion technique | 78 | ||
| Catheter size | 78 | ||
| Catheter eyeholes | 78 | ||
| Perfusion rate | 78 | ||
| Catheter withdrawal speed | 78 | ||
| Response time | 78 | ||
| Microtip/fibreoptic catheters | 78 | ||
| Balloon catheters | 78 | ||
| FACTORS AFFECTING MAXIMUM URETHRAL CLOSURE PRESSURES | 79 | ||
| Bladder volume | 79 | ||
| Patient position | 79 | ||
| Pelvic floor activity | 79 | ||
| STANDARDIZATION OF URETHRAL PRESSURE MEASUREMENTS | 79 | ||
| NORMAL URETHRAL PRESSURE PROFILES | 80 | ||
| Urethral pressure profile shape | 80 | ||
| Men | 80 | ||
| Women | 80 | ||
| Urethral pressure profile and incontinence surgery | 80 | ||
| RESTING URETHRAL PRESSURE PROFILES | 82 | ||
| Responsiveness | 82 | ||
| Reliability | 82 | ||
| Validity | 82 | ||
| Sensitivity and specificity | 82 | ||
| STRESS URETHRAL PRESSURE PROFILES | 82 | ||
| URETHRAL REFLECTOMETRY | 82 | ||
| CONCLUSION | 82 | ||
| CLINICAL RECOMMENDATIONS | 82 | ||
| REFERENCES | 83 | ||
| 5.7. Ultrasound in the assessment of PFM and pelvic organ descent | 84 | ||
| INTRODUCTION | 84 | ||
| TECHNIQUE | 84 | ||
| BLADDER NECK POSITION AND MOBILITY | 85 | ||
| LEVATOR ACTIVITY | 86 | ||
| PROLAPSE QUANTIFICATION | 86 | ||
| 3D/4D PELVIC FLOOR IMAGING | 87 | ||
| 3D imaging | 87 | ||
| 4D imaging | 88 | ||
| CLINICAL RESEARCH USING 3D/4D PELVIC FLOOR ULTRASOUND | 88 | ||
| OUTLOOK | 92 | ||
| CONCLUSIONS | 93 | ||
| CLINICAL RECOMMENDATIONS | 94 | ||
| Equipment | 94 | ||
| Examination | 94 | ||
| Documentation for assessment of PFMC | 94 | ||
| REFERENCES | 94 | ||
| 5.8. MRI of intact and injured female pelvic floor muscles | 97 | ||
| INTRODUCTION | 97 | ||
| MRI ANATOMY OF THE NORMAL LEVATOR ANI MUSCLE STRUCTURE | 97 | ||
| MRI APPEARANCE OF THE LEVATOR ANI MUSCLES | 99 | ||
| BIRTH IS A MAJOR EVENT CAUSING PELVIC FLOOR DYSFUNCTION | 99 | ||
| Recovery after vaginal birth | 99 | ||
| Injury from vaginal birth | 99 | ||
| What are the mechanisms of levator injury? | 101 | ||
| WHAT ARE THE CLINICAL IMPLICATIONS OF LEVATOR ANI MUSCLE INJURY? | 107 | ||
| ISSUES IN REHABILITATION | 108 | ||
| REFERENCES | 108 | ||
| ACKNOWLEDGEMENT | 109 | ||
| Chapter 6: Pelvic floor and exercise science | 111 | ||
| 6.1. Motor learning | 111 | ||
| ABILITY TO CONTRACT THE PELVIC FLOOR MUSCLES | 111 | ||
| PRACTICAL TEACHING OF CORRECT PFM CONTRACTION | 112 | ||
| Teaching tools | 113 | ||
| REFERENCES | 116 | ||
| 6.2. Strength training | 117 | ||
| INTRODUCTION TO THE CONCEPT OF STRENGTH TRAINING FOR PELVIC FLOOR MUSCLES | 117 | ||
| TERMINOLOGY AND DEFINITIONS | 120 | ||
| Muscle strength | 120 | ||
| Maximum voluntary contraction | 120 | ||
| Local muscle endurance | 120 | ||
| Muscle power | 120 | ||
| DETERMINANTS OF MUSCLE STRENGTH | 121 | ||
| Neural adaptations | 121 | ||
| Hypertrophy | 122 | ||
| DOSE–RESPONSE ISSUES | 123 | ||
| Mode of exercise | 123 | ||
| Frequency | 123 | ||
| Intensity | 123 | ||
| Duration | 124 | ||
| HOW TO INCREASE MUSCLE STRENGTH AND UNDERLYING COMPONENTS | 124 | ||
| Specificity | 124 | ||
| Overload | 125 | ||
| Progression | 126 | ||
| Maintenance | 127 | ||
| RECOMMENDATION FOR EFFECTIVE TRAINING DOSAGE FOR PELVIC FLOOR MUSCLE TRAINING | 128 | ||
| CLINICAL RECOMMENDATIONS | 128 | ||
| REFERENCES | 129 | ||
| Chapter 7: Female pelvic floor dysfunctions and evidence-based physical therapy | 131 | ||
| 7.1. Female stress urinary incontinence | 132 | ||
| Prevalence, causes and pathophysiology | 132 | ||
| PREVALENCE OF SUI | 133 | ||
| CAUSES AND PATHOPHYSIOLOGY OF SUI | 133 | ||
| General and specific causes | 133 | ||
| Bladder neck and urethral hypermobility | 134 | ||
| Intrinsic sphincter deficiency | 134 | ||
| Mixed urinary incontinence | 135 | ||
| CONCLUSION | 135 | ||
| REFERENCES | 135 | ||
| Lifestyle interventions | 136 | ||
| Modifiable factors associated with urinary incontinence | 136 | ||
| EVIDENCE TO SUPPORT THE IMPACT OF LIFESTYLE CHANGES ON SYMPTOMS OF PELVIC FLOOR DYSFUNCTION | 137 | ||
| Levels of evidence | 137 | ||
| Rating of randomized controlled trials | 141 | ||
| Grades of recommendation | 141 | ||
| Obesity | 141 | ||
| Risk-based rationale for including obesity within the review | 141 | ||
| ICI summary and recommendation | 142 | ||
| Supporting evidence: obesity reduction as a management strategy | 142 | ||
| Physical activity | 143 | ||
| Risk-based rationale for including physical activity within the review | 143 | ||
| ICI summary and recommendation | 143 | ||
| Supporting evidence: changes to physical activity as a management strategy | 143 | ||
| Smoking | 143 | ||
| Risk-based rationale for including smoking cessation within the review | 143 | ||
| Chapter 8. Male pelvic floor dysfunctions and evidence-based physical therapy | 271 | ||
| 8.1. Urinary incontinence and other lower urinary tract symptoms | 271 | ||
| INTRODUCTION | 271 | ||
| Incidence and pathophysiology | 272 | ||
| Postprostatectomy incontinence | 272 | ||
| EVIDENCE FOR EFFECT OF PFMT IN PREVENTION AND TREATMENT OF URINARY INCONTINENCE | 273 | ||
| Research methods | 275 | ||
| Results | 275 | ||
| PFMT is better than no treatment or placebo (7 trials) | 275 | ||
| Preoperative and postoperative PFMT is better than only postoperative PFMT (6 trials) | 287 | ||
| Preoperative PFMT and biofeedback is better than only preoperative information about PFMT (1 trial) | 287 | ||
| Postoperative PFMT is better than only information about PFMT before and after surgery (11 trials) | 288 | ||
| Adding biofeedback to PFMT is better than PFMT alone or information alone (4 trials) | 288 | ||
| Adding rectal stimulation to PFMT is better than PFMT alone or information alone (5 trials) | 288 | ||
| PFMT with adherence strategies give better continence results (1 trial) | 288 | ||
| Adding biofeedback and electrostimulation to PFMT gives better results than PFM exercises alone (1 trial) | 288 | ||
| Adding general exercises to PFMT for incontinence after surgery is better than PFMT alone (1 trial) | 288 | ||
| Guided PFMT for incontinence an average of 18 months after surgery is better than PFMT alone (1 trial) | 288 | ||
| Adverse effects | 288 | ||
| Health economics | 288 | ||
| Discussion | 289 | ||
| SUMMARY AND CLINICAL RECOMMENDATIONS | 289 | ||
| Terminal and post-void dribble | 289 | ||
| EVIDENCE FOR EFFECT OF PFMT FOR TREATMENT OF POST-MICTURITION DRIBBLE | 290 | ||
| SUMMARY AND CLINICAL RECOMMENDATIONS | 290 | ||
| CONCLUSION | 290 | ||
| REFERENCES | 293 | ||
| 8.2. Male sexual dysfunction | 296 | ||
| CLASSIFICATION, PREVALENCE AND PATHOPHYSIOLOGY OF MALE SEXUAL DYSFUNCTION AND ROLE OF THE PFM | 296 | ||
| Low libido | 296 | ||
| Chapter 9: Evidence-based physical therapy for pelvic floor dysfunctions affecting both women and men | 311 | ||
| 9.1. Anal incontinence | 311 | ||
| Epidemiology, anatomy and pathophysiology, and risk factors | 311 | ||
| INTRODUCTION | 311 | ||
| EPIDEMIOLOGY | 312 | ||
| ANATOMY AND PATHOPHYSIOLOGY | 312 | ||
| AETIOLOGY AND RISK FACTORS | 313 | ||
| Obstetric trauma | 313 | ||
| Other aetiological factors | 314 | ||
| REFERENCES | 314 | ||
| Assessment of the nature and severity of AI | 315 | ||
| DIAGNOSTIC ASSESSMENT | 316 | ||
| History taking | 316 | ||
| Physical examination | 316 | ||
| ADDITIONAL DIAGNOSTIC TESTS | 317 | ||
| Additional tests performed by either the physician or the pelvic physical therapist | 317 | ||
| Defecation diary | 317 | ||
| Wexner and Vaizey scores | 317 | ||
| Quality of life evaluation | 318 | ||
| Global Perceived Effect | 318 | ||
| Biofeedback | 318 | ||
| EMG/pressure | 318 | ||
| Rectal balloon | 318 | ||
| Additional tests performed by the physician | 318 | ||
| REFERENCES | 318 | ||
| Conservative interventions for treatment of AI | 319 | ||
| LIFESTYLE INTERVENTION | 320 | ||
| Information and education | 320 | ||
| Weight loss | 320 | ||
| Smoking | 321 | ||
| EVIDENCE FOR EFFECTIVENESS OF PATIENT EDUCATION | 321 | ||
| PELVIC PHYSICAL THERAPY | 321 | ||
| Pelvic floor muscle and sphincter training | 321 | ||
| Biofeedback and rectal balloon training | 322 | ||
| Electrical stimulation | 322 | ||
| EVIDENCE FOR EFFECTIVENESS OF PELVIC PHYSICAL THERAPY | 323 | ||
| Literature search strategy | 323 | ||
| Methodological quality | 328 | ||
| Pelvic floor muscle training | 328 | ||
| Biofeedback | 328 | ||
| Electrical stimulation | 330 | ||
| PREDICTIVE FACTORS FOR SUCCESS OF PELVIC PHYSICAL THERAPY | 331 | ||
| REFERENCES | 331 | ||
| 9.2. Pelvic floor pain and the overactive pelvic floor | 333 | ||
| INTRODUCTION, EPIDEMIOLOGY, AND PATHOPHYSIOLOGY/AETIOLOGY | 333 | ||
| Pelvic floor pain | 335 | ||
| Muscle pain | 336 | ||
| Pelvic floor muscle tension | 336 | ||
| Relationship between pain and tension | 337 | ||
| Diagnostic terminology | 337 | ||
| Summary | 337 | ||
| ASSESSMENT | 338 | ||
| Confirmation of primary pain generator | 338 | ||
| Subjective assessment: symptoms | 338 | ||
| Pain history | 338 | ||
| Pain rating scales | 338 | ||
| Pain mapping | 338 | ||
| Pain questionnaires | 339 | ||
| Objective assessment: signs | 339 | ||
| Examination | 339 | ||
| Further evaluation/investigations | 340 | ||
| Pressure-pain thresholds | 340 | ||
| Pelvic floor muscle tension | 342 | ||
| Examination beyond the pelvic floor muscles | 342 | ||
| Summary of assessment findings | 342 | ||
| OUTCOME MEASURES | 343 | ||
| Summary | 343 | ||
| TREATMENT | 343 | ||
| CONCLUSION | 350 | ||
| REFERENCES | 350 | ||
| Chapter 10: Evidence for pelvic floor physical therapy in children | 355 | ||
| CLASSIFICATION: URINARY INCONTINENCE DURING THE DAY | 355 | ||
| VOIDING DYSFUNCTION | 356 | ||
| PHYSICAL THERAPY INTERVENTION FOR CHILDREN WITH URINARY INCONTINENCE OR DYSFUNCTIONAL VOIDING | 356 | ||
| NOCTURNAL ENURESIS | 357 | ||
| PHYSICAL THERAPY INTERVENTION FOR CHILDREN WITH NOCTURNAL ENURESIS | 360 | ||
| UNDERLYING PATHOPHYSIOLOGY OF BOWEL DYSFUNCTION | 361 | ||
| PHYSICAL THERAPY INTERVENTION FOR FUNCTIONAL CONSTIPATION | 362 | ||
| REFERENCES | 365 | ||
| Chapter 11: Pelvic floor physical therapy in the elderly: where’s the evidence? | 369 | ||
| INTRODUCTION | 369 | ||
| PREVALENCE | 369 | ||
| Classification of incontinence | 370 | ||
| Who are the elderly and ‘frail’ elderly? | 370 | ||
| Prevalence of incontinence in the elderly | 371 | ||
| AETIOLOGY AND PATHOPHYSIOLOGY | 371 | ||
| Central neurological factors affecting control of continence | 372 | ||
| Non-neurological disease | 372 | ||
| Ageing urinary tract | 372 | ||
| Other aetiologies | 373 | ||
| Factors in females | 374 | ||
| Factors in males | 374 | ||
| Faecal incontinence and constipation | 374 | ||
| EVIDENCE FOR EFFECT OF PFMT IN PREVENTION OF UI IN OLDER PERSONS | 374 | ||
| Primary prevention | 376 | ||
| Secondary prevention | 376 | ||
| Tertiary prevention | 377 | ||
| EVIDENCE FOR EFFECT OF PFMT IN OLDER PERSONS | 377 | ||
| Specific treatments | 378 | ||
| Functional activity training | 378 | ||
| PFMT alone or within a ‘package’ of treatment | 378 | ||
| Bladder training and behavioural techniques | 379 | ||
| CLINICAL RECOMMENDATIONS | 380 | ||
| Physical therapy assessment | 380 | ||
| Physical therapy treatment/management | 380 | ||
| REFERENCES | 381 | ||
| Chapter 12: Evidence for pelvic floor physical therapy for neurological diseases | 387 | ||
| INTRODUCTION | 387 | ||
| STROKE | 387 | ||
| Definition | 387 | ||
| Incidence and prevalence | 387 | ||
| Urologic and bowel symptoms and urodynamic investigation | 387 | ||
| Pathophysiology | 388 | ||
| Treatment: evidence for effect (prevention and treatment) | 388 | ||
| Conclusions and clinical recommendations | 393 | ||
| MULTIPLE SCLEROSIS (MS) | 393 | ||
| Definition | 393 | ||
| Incidence and prevalence | 393 | ||
| Urologic and bowel symptoms | 393 | ||
| Pathophysiology | 393 | ||
| Treatment: evidence for effect (prevention and treatment) | 393 | ||
| Evidence-based medicine on MS and pelvic floor physical therapy | 393 | ||
| Clinical recommendations | 394 | ||
| CONCLUSION | 394 | ||
| REFERENCES | 394 | ||
| Chapter 13: Pelvic floor dysfunction, prevention and treatment in elite athletes | 397 | ||
| INTRODUCTION | 397 | ||
| METHODS | 398 | ||
| PREVALENCE OF UI AND PARTICIPATION IN SPORT AND FITNESS ACTIVITIES | 398 | ||
| Prevalence of UI in female elite athletes | 398 | ||
| PELVIC FLOOR AND STRENUOUS PHYSICAL ACTIVITY | 400 | ||
| Hypothesis one: female athletes have strong PFM | 400 | ||
| Hypothesis two: female athletes may overload, stretch and weaken the pelvic floor | 401 | ||
| PREVENTION | 402 | ||
| Preventive devices | 402 | ||
| TREATMENT OF SUI IN ELITE ATHLETES | 402 | ||
| Surgery | 403 | ||
| Bladder training | 403 | ||
| Oestrogen | 403 | ||
| PFMT | 403 | ||
| CONCLUSION | 404 | ||
| CLINICAL RECOMMENDATIONS | 404 | ||
| REFERENCES | 405 | ||
| Chapter 14: The development of clinical practice guidelines | 409 | ||
| INTRODUCTION | 409 | ||
| GUIDING PRINCIPLES IN THE DEVELOPMENT OF CPGs | 410 | ||
| THE DEVELOPMENT PROCESS OF CPGs | 412 | ||
| Phases in development of CPGs | 413 | ||
| Method of development of CPGs | 413 | ||
| 1. The preparatory phase | 413 | ||
| 2. The design phase | 413 | ||
| 3. The implementation phase | 415 | ||
| 4. The evaluation and updating phase | 415 | ||
| DISCUSSION | 415 | ||
| Changing practice | 415 | ||
| FUTURE | 416 | ||
| REFERENCES | 416 | ||
| Index | 419 |