In the third and final installment of this three part series: Caring for the complex patient, we will review the patient’s presentation and discuss the outcomes following treatment and how documentation using bestPT supported the treatment.
The patient was a 34 year old female referred to physical therapy (PT) by her obstetrician-gynecologist (OB-GYN) for evaluation of pelvic organ prolapse (POP). The patient presented to physical therapy para 2 grava 2 (P2G2) indicating 2 pregnancies and 2 live births. On the day of evaluation she was 5.5 weeks post vaginal birth after cesarean (VBAC) of her second child. Her primary concern was a feeling of heaviness and a sense that her organs were falling out, especially during standing and lifting tasks. Her physician had not yet performed a complete six week post-delivery examination, though this appointment was scheduled for three days after physical therapy evaluation.
The patient reported neither pain nor unintentional loss of urine (incontinence), though she felt weak throughout the abdominals and pelvic floor. Pertinent past medical history consisted of cesarean section 11/19/12 (almost two years prior to PT evaluation date) with subsequent hematoma at the surgical site which resolved with use of an abdominal binder. She is otherwise a very healthy woman with no comorbidities. The patient lived at home with her husband and two children, works as a physician assistant specializing in hospital based gastroenterology which requires prolonged standing during procedures and patient rounds. She is an avid runner and aerobics instructor. Her primary goal was to be able to safely lift each of her children without the sense of heaviness in the pelvis. Secondary goals were to return to running and teaching aerobics classes which are her primary sources of recreation and stress reduction.
Physical therapy examination revealed abdominal strength to be 3+/5 on the Kendall scale. The Pelvic Floor Impact Questionaire (PFIQ-7) was utilized as standardized outcome tool. This patient received a score total of 0 on the bladder and rectum subsets, and a score of 19 on the pelvis subset for a total score of 19 on the scale. Internal examination and musculoskeletal physical therapy differential diagnosis included pelvic floor dysfunction resulting in prolapse, and increased abdominal pressure due to visceral adhesions from previous c-section.
Treatment technique can be reviewed in the previous post, Caring for the Complex Patient Part II: Treatment Techniques. The patient received manual therapy to the pfannensteil incision including scar mobilization, myofascial release to the abdominal muscles, psoas, hip girdle, and pelvic musculature. She received a progressive pelvic floor muscle and abdominal strengthening program for in clinic and at home. She was progressed from supine position to finally a dynamic co-ordinated exercise program to prepare her for more strenuous activities of daily living and running. Additionally, she received a post-partum educational packet from the APTA and she was educated in safe lifting mechanics for the back and pelvis, as well as self scar tissue management.
The patient attended six physical therapy visits. According to the American Physical Therapy Associations’s “Guide to Physical Therapy”, a clinician can expect a treatment duration of anywhere from 6-36 visits. Her initial sensation of falling out in the pelvic floor subsided significantly. She was able to conduct household activities, lift her toddler or infant with minimal symptoms, and gradually returned to running after approximately two and a half months of physical therapy (approximately three and half months post-partum). She was independent in her home exercises and felt prepared to manage her symptoms independently at the end of the sixth visit. Her goals had been met, and she appeared to understand the importance of maintaining her home exercise program.
The Pfannenstiel incision improved in mobility, and scored a 7/10 on the Vancouver Scar Scale, which was down from her initial score of 10/13. Her final PFIQ score was 5, down from 19. Upon discharge, the prolapse was graded as follows: in supine hooklying Grade I anterior wall, Grade II posterior wall, with bearing down Grade II anterior wall, Grade III posterior wall. In standing the anterior wall was graded I and posterior wall II, and with bearing down the anterior wall was graded II, and posterior wall a grade III.
Upon reflection, this patient had great outcomes which can be attributed to the patient’s motivation and overall adherence to her program. All things considered she may have benefited from the use of Electromyograph (EMG) biofeedback for enhanced learning of pelvic floor muscle isolation. While currently no literature demonstrates benefits of biofeedback specifically for pelvic organ prolapse, there is evidence in support use of biofeedback training for under active pelvic floor muscles associated with urinary incontinence. One may extrapolate that biofeedback may be beneficial in the provision of visual and proprioceptive feedback to enhance pelvic floor muscle strengthening. The patient presented with very good control of the pelvic floor muscles to begin with, thus biofeeedback was not deemed emergent.
Furthernmore, the Pelvic Organ Prolapse/ Urinary Incontinence Sexual Function Questionnaire (PSIQ-12), or the Pelvic Organ Prolapse symptom scale (POP-SS) may have been utilized as an outcome measure, though due to her post-natal status it seemed more pressing to determine the nature of disability across all pelvic floor conditions in relation to her activities of daily living.
Vaginal birth after cesarean is a growing trend, though is still quite rare in some regions of the United States. Understanding the complex nature of the interactions between the impaired pelvic floor following vaginal birth coupled with pre-existing scarring and soft tissue adhesions from prior abdominal or gynecological surgery is necessary in order to address a Pelvic Organ Prolapse. In the event that the patient did not progress with reduction of prolapse symptoms, she would have then been referred to a gynecologist for fitting of a pessary. In this case this was not necessary.
Documentation supported the treatment of this patient throughout. Thankfully, bestPT allows for input of unique characteristics of the patient, and documentation for each treatment session was efficient.
-Amanda Olson, DPT