Tweetable abstract
Vaginal fascial mobilization can improve pelvic floor dysfunction and
cervical length in pregnant women.
Abstract
Objective
Pelvic Floor Fascial Mobilization (PFFM) is an innovative
intervention to improve pelvic
floor dysfunction.
Design
Pregnant women at 24-30 weeks gestation, complaining of pelvic pain, and
or stress urinary incontinence, were prospectively randomized to PFFM
(study group) vs. pelvic floor muscle training (PFMT). Strength and
function of the pelvic floor muscles was compared before and after
interventions.
Setting- Outpatient pregnancy clinic at a tertiary medical center
Sample- 40 women randomly allocated to PFFM or PFMT
Methods
Each patient was treated twice, one week apart and was assessed
immediately before and after each intervention, and one week after the
second treatment.
Main Outcome Measures
PFDI 20 questionnaire , Oxford grading scale, perineometry to measure
pelvic floor symptoms function and strength, transvaginal ultrasound
cervical length
Results
PFFM group Oxford scale improved from 2.65±1.18 to 3.45±1.28 after the
first session (p<0.001) with no difference in the PFMT group
3.40±1.05 vs 3.40±1.05 (p=1). Cervical Length elongated in the PFFM
group after one treatment (39.8±6.5 vs 43.4±10.2 mm, p<0.05,
but not in the PFMT group 40.9±6.7 vs 40.0±8.6 respectively (p=n.s).
Among 26 participants who lasted the entire study – PFMT was associated
with more than 40% improvement in both Oxford as well as PFDI-20 and
Perineometry was improved by 23% (23.13±15.15 vs 28.58±16.07
cmH2O (p<0.05) while no such difference was
found with PFMT; 30.03±12.73 vs 30.25±9.61 cmH2O
respectively (p=n.s).
Conclusions
PFFM may improve pelvic floor function and strength, alleviate symptoms
and elongate the cervix. Further bigger study is needed to better
evaluate this method.
Funding (To include the name of the funding body and the grant
identifier)
No funding was granted for this trial
Key Words : Pelvic floor, Manual Therapy, Pregnancy, Cervical
Length
Introduction
Pregnancy and birth are considered as the main risk factors for damage
to the pelvic floor structure and function. The damage may appear as
stress incontinence, fecal incontinence, pelvic organ prolapses, pelvic
and low back pain or urination and defecation difficulties. Each
pregnancy may intensify the damage and the symptoms become more severe
as gestation advances1-9.
The different modalities of treatment for pelvic floor dysfunction;
includes physiotherapy for Pelvic Floor Muscle Training (PFMT), perineal
massage or manual techniques10.
PFMT have shown promising results with improvement in urinary stress
incontinence (UI), after an intensive intervention program that lasts an
average of 8 to 24 weeks11 12, In a Cochrane database
review of 31 trials, the authors concluded that PFMT could be part of a
first line conservative management program for women with UI. PFMT can
also be used as a preventive mode of treatment during pregnancy with
moderate results. Recently, a Cochrane review of 46 trials, provided
evidence that PFMT in early pregnancy for continent women may prevent
the onset of UI in late pregnancy and postpartum13.
However, prolonged and continuous exercise as well as compliance and
perseverance are needed in order to achieve satisfactory
results14.
Manual technique for the pelvic floor musculature is an optional
treatment modality 15-20, Antenatal digital perineal
massage was shown to reduce the likelihood of perineal trauma (mainly
episiotomies), the reporting of ongoing perineal pain, and is generally
well accepted by women21. Perineal trauma and levator
muscle injury are one of the major causes of pelvic floor dysfunction
after childbirth. However, neither the effectiveness of manual treatment
for pelvic floor dysfunction nor the influence on possible adverse
effects to the pregnancy, such as cervical shortening, preterm birth, or
blood flow to the fetus, was well investigated by randomized controlled
trials. In fact, the influence of manual therapy is unknown, and most of
the literature is dedicated to PFMT, and mainly for postpartum
rehabilitation.
Pelvic Floor Fascial Mobilization (PFFM) is an innovative intra vaginal
and / or intra rectal manual therapy technique developed (by S.N.) to
treat pelvic fascial dysfunction by improving fascial
gliding. Treatment of fascia may
improve muscle function.22 Fascial scar release
techniques by soft tissue mobilization have shown improvements for
treatment of abdominal and pelvic adhesions related
pain.23
This is a pioneer study comparing the influence of PFFM vs. conventional
PFMT on the function and strength of the pelvic floor muscles, in
2nd and 3rd trimester pregnant women
with pelvic floor dysfunction. The primary outcome was the pelvic floor
strength before and after treatment in each group. Secondary outcomes
included: Umbilical Artery (UmbA) blood flow, uterine artery (UA) blood
flow, fetal Middle Cerebral Artery (MCA) flow, and cervical length (CL).
Materials
and Methods
A prospective randomized unblinded controlled trial performed between
January 2018 and July 2019, at an outpatient pregnancy clinic in a
single tertiary medical center. We enrolled primiparous and multiparous
pregnant women at 24-30 weeks gestation, with symptoms related to pelvic
floor dysfunction.
Exclusion criteria included: First delivery, Gestational age
>30 weeks gestation at enrollment, Premature contractions,
Cervical shortening, Placenta previa, Placenta accreta, Multifetal
pregnancy, Maternal connective tissue disease and neurological illness.
Sample size was calculated based on an α-error of 5%, with a power of
80%, based on the assumption that PFFM will improve pelvic floor
strength and function by 30%, compared to control. Randomization was
done with the ”Randomizer.org”24 based on two random
sets of numbers from 1-20. The allocation of each number to study or
control group was in an envelope by the
Research facilitator (I.H.) The patient received the ordinal number for
participation upon signing the informed consent, from the main
researcher (S.N) based on the chronological assignment to the study. The
main researcher was blinded to the association between the chronological
number and the study group allocation prior to the initialization of the
intervention for each patient.
Each patient was treated twice during the study period, one to two weeks
apart and was assessed five times: immediately before and after each
intervention, and one week after the second treatment session.
During the first and fifth assessment women were evaluated for pelvic
floor dysfunction using PFDI-20 questionnaire (pelvic floor disability
index-20) validated in Hebrew. Pelvic muscle strength and function was
assessed 5 times using Oxford Grading Scale, modified by
Laycock25, that includes 6 levels (0-5) and by a
Perineometer device7 (PeritrontmVaginal Perineometer ,Cardio-Design, Australia). Both Oxford scale and
the Perineometer are considered efficient and well correlated with the
use of surface electro myography (SEMG) that present the level of the
muscle electrical activity26-28.
Uterine and fetal blood flow was assessed 5 times as well, before and
after each intervention and one week after the second intervention. All
measurements were performed by the operator who was blinded to study
allocation. Abdominal ultrasound was used to measure: Uterine Artery
(UA) blood flow pulsatility index (PI), umbilical artery (UmbA) blood
flow PI and Middle cerebral artery (MCA) PI, uterine Cervical Length
(CL) was measured by transvaginal ultrasound from the internal to
external cervical os (Voluson P6, General Electric Inc. USA).
Pelvic Floor Facial Mobilization is a manual therapy based upon
the sequences and movement planes of Stecco’s Fascial Manipulation®
technique29-33 relying on similar main principles of
treating fascial densifications along pre-defined routs. According to
Stecco’s method, the body is divided to different segments, each
includes Myofascial units (MFU) that belong to different movement
planes. Embedded in each myofascial unit are centers of perception (CP),
centers of coordination (CC), and centers of fusion (CF). Myofascial
units in the same plane of movement creates a myofascial
sequence.29-33
Centers of Fusion (CF) are the converging points of the vectors for
every two adjacent MFUs and are responsible for coordinating the
movements in intermediate directions between the two planes. CFs are
principally located over the retinacula surrounding the
joints29-31. Since the key fascial areas (CCs) are
different than the areas where pain or symptoms are perceived (CPs),
treatment is applied at a distance, away from the painful area which is
advantageous in management of pain 34 35.
The centers of coordination (CC’s) and centers of fusions (CF’s) in the
pelvic floor region are presented in figure 1, 36