Dr Kay Crotty's Presentation at Women's Health Physio Summit 2015 West Midlands. From early research to wearable technology.

1. Women’s Health PhysiotherapyWomen’s Health Physiotherapy
Summit 2015Summit 2015
Pelvic floor physiotherapy in the 21Pelvic floor physiotherapy in the 21stst
Century: Where have we come fromCentury: Where have we come from
and where are we going to?and where are we going to?
Kay Crotty PhD MCSPKay Crotty PhD MCSP
Consultant Pelvic Floor PhysiotherapistConsultant Pelvic Floor Physiotherapist
www.physiolink.comwww.physiolink.com

2. Evolution of enhancements to practiceEvolution of enhancements to practice
1998
Ultrasound
Imaging
1990’s
Early
imaging
studies
Mid 1990’s
Measurement
Pressure
EMG
1948
Biofeedback
The
Evidence
Base

3. 2-D Dynamic ultrasound imaging:2-D Dynamic ultrasound imaging:
Pre-contraction trainingPre-contraction training
 Observational study (1998)Observational study (1998) nn=27: “The knack” pelvic=27: “The knack” pelvic
floor muscle contraction ahead of and during a deepfloor muscle contraction ahead of and during a deep
cough reduced leakage by 73.3% (cough reduced leakage by 73.3% (pp=0.003)=0.003)
 Observational study (2001):Using The Knack:Observational study (2001):Using The Knack:
bladder neck descent significantly decreased:bladder neck descent significantly decreased:
nn= 11 young continent nullips (4.6mm, p=0.007)= 11 young continent nullips (4.6mm, p=0.007)
11 older parous incontinent (2.7mm11 older parous incontinent (2.7mm pp=0.003)=0.003)
Miller et al (1998) J Am Geriatric Society, 46:870-874
Miller et al (2001) Obstetrics and Gynaecology, 97:255-260

4. 2-D Dynamic ultrasound imaging:2-D Dynamic ultrasound imaging:
Strength TrainingStrength Training
 Prospective Observational Study n=97Prospective Observational Study n=97
 14 weeks of pelvic floor muscle training14 weeks of pelvic floor muscle training

bladder neck position changes:bladder neck position changes:
• valsalva manoeuvre 12.9valsalva manoeuvre 12.9°° ((pp=0.02)=0.02)
• at rest 7.3at rest 7.3°°((pp=0.009)=0.009)
• improved on PFMC 10.4improved on PFMC 10.4°°((pp=0.013)=0.013)
• +ve correlation between improved strength and bladder neck+ve correlation between improved strength and bladder neck
position (n/s)position (n/s)
• Improvement in quantity of urine loss12.2g-5.5g (Improvement in quantity of urine loss12.2g-5.5g (pp=0.001)=0.001)
• No correlation between BNP and improvement in urine lossNo correlation between BNP and improvement in urine loss
Balmforth et al (2004) Neurourology & Urodynamics 23:553-554

5. 3-D Dynamic ultrasound imaging:3-D Dynamic ultrasound imaging:
Strength TrainingStrength Training
 RCT POP grades 1-111RCT POP grades 1-111
 intervention:intervention: nn=59 control:=59 control: nn=50=50
 6 months of intensive PFMT vs Advice6 months of intensive PFMT vs Advice

Morphologic changes:Morphologic changes:
• at rest 4.3mm (at rest 4.3mm (pp=0.001)=0.001)
• Vaginal squeeze pressure increased (Vaginal squeeze pressure increased (pp=0.01)=0.01)
• +ve correlation between increased VSP and BNP+ve correlation between increased VSP and BNP
((pp=0.017)=0.017)
Braekken et al 2010 Obstet Gynecol 115, 317-324

6. MRI:MRI:
Strength TrainingStrength Training
 Observational trial: SUI n=17Observational trial: SUI n=17

12 weekly classes and HEP12 weekly classes and HEP
 Morphologic change:Morphologic change:
• UVJ Height: Rest, MVC, Strain (UVJ Height: Rest, MVC, Strain (pp=0.042)=0.042)
Madill et al 2013 Neurourol and Urodynam 32: 1086-1095

7. 2 and 3-D Dynamic ultrasound2 and 3-D Dynamic ultrasound
Strength trainingStrength training
 RCT SUI: interventionRCT SUI: intervention nn=15 control:=15 control: nn=17=17
 12 weeks of intensive PFMT versus nil12 weeks of intensive PFMT versus nil

Morphologic changes:Morphologic changes:
• Improvement in BNP on cough (Improvement in BNP on cough (pp=0.0005)=0.0005)
• No change in BNP at rest (No change in BNP at rest (pp=not presented)=not presented)
• Increase in sphincter cross sectional areaIncrease in sphincter cross sectional area
((pp=0.004)=0.004)
McClean et al 2013 Neurourol & Urodynam 32:1096-1102

8. Failure to show changeFailure to show change
Meyer et al 2001Meyer et al 2001 Observational studyObservational study nn=107 Investigated usefulness of=107 Investigated usefulness of
post natal PFME. Baseline US pre delivery. Start of intervention 9 weekspost natal PFME. Baseline US pre delivery. Start of intervention 9 weeks
post delivery. Outcome US following 6 weeks of interventionpost delivery. Outcome US following 6 weeks of intervention
Reilly et al 2002Reilly et al 2002 RCTRCT nn= 120/110 Investigated usefulness of pre natal= 120/110 Investigated usefulness of pre natal
PFME. US at 20 weeks gestation and 3 months PP. Confounding variables:PFME. US at 20 weeks gestation and 3 months PP. Confounding variables:
vaginal delivery mid study, no collection of data immediately post partum, novaginal delivery mid study, no collection of data immediately post partum, no
advice/supervision post deliveryadvice/supervision post delivery
Hung et al 2011Hung et al 2011 Observational studyObservational study nn=23(effect size based on studies of=23(effect size based on studies of
vaginal squeeze pressure) ?ethical approval, physiotherapy contactvaginal squeeze pressure) ?ethical approval, physiotherapy contact
optional, exercise diary optional, ? blinding of readers….optional, exercise diary optional, ? blinding of readers….
Hung et al (2011) Phys Ther 91, 1030-1038
Reilly et al (2002) BJOG 109, 67-76
Meyer et al (2001)Obstet Gynecol 92. 613-618

9. Kay CrottyKay Crotty 1,2, 31,2, 3
,Clive I Bartram,Clive I Bartram 11
, Joan Pitkin, Joan Pitkin 22
, Mindy C Cairns, Mindy C Cairns 33
,,
Paul C TaylorPaul C Taylor33
, Grace Dorey, Grace Dorey 44
, Dave Chatoor, Dave Chatoor11
11
St Mark’s Hospital Harrow UK;St Mark’s Hospital Harrow UK; 22
Northwick Park Hospital Harrow UK;Northwick Park Hospital Harrow UK;
33
University of Hertfordshire, Hatfield UK;University of Hertfordshire, Hatfield UK; 44
University of West of England Bristol UKUniversity of West of England Bristol UK
An investigation of optimal instruction
for pelvic floor muscle contraction
using ultrasound imaging

10. HypothesisHypothesis
‘‘Posterior or combined cue isPosterior or combined cue is
more influential in optimisingmore influential in optimising
position of urethrovesicalposition of urethrovesical
structures during a pelvic floorstructures during a pelvic floor
muscle contraction following amuscle contraction following a
brief period of practice, than anbrief period of practice, than an
anterior cue’anterior cue’

11. InstructionsInstructions
 Squeeze and lift from theSqueeze and lift from the
• front as if stopping the flow of urine (FL)front as if stopping the flow of urine (FL)
• back as if stopping the escape of wind (BL)back as if stopping the escape of wind (BL)
• front and back together (Combined)front and back together (Combined)
Crotty K 2013 http://hdl.handle.net/2299/15431

12. Recruitment ♀
nulliparous pre menopausal n=32/17
parous incontinent post menopausal n=30/21
Perineal 2-D US
Teaching of PFMC using three instructions
Home exercise programme with diary
Inability to contract/exclusion:12.5%;23%
EMG
Home Exercise Programme with diary
Inability to select/exclusion:13%;8%
Perineal 2-D US Data collection
Three images collected for each instruction x2

13. Anterior InstructionAnterior Instruction

14. Posterior InstructionPosterior Instruction

15. Combined InstructionCombined Instruction

16. Reliability: reading ultrasoundReliability: reading ultrasound
imagesimages
 Intra- rater reliabilityIntra- rater reliability

ICC: 0.919ICC: 0.919 ExcellentExcellent
 Inter-rater reliabilityInter-rater reliability

ICC: 0.820ICC: 0.820 ExcellentExcellent

17. Repeatability of selective PFMC:Repeatability of selective PFMC:
angle of urethral inclinationangle of urethral inclination
 Continent cohortContinent cohort
ICC: 0.876 ExcellentICC: 0.876 Excellent
 Incontinent CohortIncontinent Cohort
 ICC: 0.954 ExcellentICC: 0.954 Excellent

18. ResultsResults
ANOVA (P>0.05) with Bonferroni post-hoc
Comparison Mean
difference
(degrees)
95% Confidence
Interval
p value
Continent n=17
Anterior-Posterior 4.240 1.213 7.267 0.003
Anterior−combined 3.756 0.729 6.783 0.009
Posterior−combined −0.484 −3.511 2.543 1.000
Incontinent n=21
Anterior−Posterior 3.7003 1.6394 5.76611 .000
Anterior−combined 5.0895 3.0287 7.1503 .000
Posterior−combined 1.389 -0.672 3.450 0.957

19. Limitations of the studyLimitations of the study
 Sample sizeSample size

Small numbersSmall numbers
 Methodological issuesMethodological issues

Surface EMGSurface EMG
 GeneralisabilityGeneralisability

Exclusion of subjects who could apparently not distinguishExclusion of subjects who could apparently not distinguish
between instructionbetween instruction

20. Extrapolation of resultsExtrapolation of results
Three-dimensional model of levator ani subdivisionsThree-dimensional model of levator ani subdivisions
including the pubic bone and pelvic visceraincluding the pubic bone and pelvic viscera

 Left image : Inferior, left 3-quarter view. The pubovaginal, puboperineal and puboanal musclesLeft image : Inferior, left 3-quarter view. The pubovaginal, puboperineal and puboanal muscles
are all combined into a single structure, the pubovisceral muscleare all combined into a single structure, the pubovisceral muscle
 Right image: The same model without the pubic bone. PB=pubic bone; V=vagina; U=uterus;Right image: The same model without the pubic bone. PB=pubic bone; V=vagina; U=uterus;
Ur=urethra; B=bladder; IC=iliococcygeus muscle; PR=puborectal muscle; PVi=pubovisceralUr=urethra; B=bladder; IC=iliococcygeus muscle; PR=puborectal muscle; PVi=pubovisceral
muscle; EAS=external anal sphincter. ©DeLancey 2006 In: Margulies et al (2006)muscle; EAS=external anal sphincter. ©DeLancey 2006 In: Margulies et al (2006) Am J ObstetAm J Obstet
Gynecol 107 (5) 1064-1069Gynecol 107 (5) 1064-1069 Reproduced with kind permission of DeLancey JOLReproduced with kind permission of DeLancey JOL

21. c
1.Integral Sphincters
seal urethra and anus
2. Levator Ani narrow
urogenital hiatus and
assist in closure
Vag
Ur
The Levator Ani
Pubovisceral
Pubovaginalis
puboperineus
puboanalis
Puborectalis
(Iliococcygeus)
Closure MechanismsClosure Mechanisms
anus
ps

22. Physiological Phenomena of PRMPhysiological Phenomena of PRM
 Vaginal pressureVaginal pressure
 High pressure zone found in mid vagina using high definition manometryHigh pressure zone found in mid vagina using high definition manometry
that anatomically can only be explained by PRM acting in a PA directionthat anatomically can only be explained by PRM acting in a PA direction
(Raizada et al 2010)(Raizada et al 2010)
 Nerve blockade of PRM significantly reduced vaginal pressureNerve blockade of PRM significantly reduced vaginal pressure (Guaderrama et(Guaderrama et
al 2005)al 2005)
 Length on shorteningLength on shortening
 PRM from 74.8mm to 63.5mm (14%)PRM from 74.8mm to 63.5mm (14%)
 PVM from 92.4mm to 89.4mm (3%)PVM from 92.4mm to 89.4mm (3%)
 (Li and Guo 2007)(Li and Guo 2007)
Raizada et al (2010) Am J Obstet Gynecol 172;e1-e8
Guaderrama et al (2005) Obstet Gynecol 106; 774-781
Li and Gup (2007) Dis Colon Rectum 50; 1831-1839

23.  Improved adherence to home exercise programmesImproved adherence to home exercise programmes
 Reach more patientsReach more patients
 Easy to use pelvic floor devicesEasy to use pelvic floor devices
 Reliable measurement for outcomeReliable measurement for outcome
purposespurposes
 Dynamic measurement to check theDynamic measurement to check the
stability of the PF during functional activitystability of the PF during functional activity

24. Improved adherence to HEPImproved adherence to HEP

25. Online consultationsOnline consultations
Guardian Professional:Guardian Professional: ‘Many in‘Many in
the NHS remain sceptical,the NHS remain sceptical,
but online consultations couldbut online consultations could
reducereduce
the need for face-to-facethe need for face-to-face
appointments with GPs by 40%’appointments with GPs by 40%’

26. Online ConsultationsOnline Consultations
 Babylonhealth.com £4.99 per monthBabylonhealth.com £4.99 per month
Repeat Prescriptions; Chest or Upper Respiratory Infection; UrinaryRepeat Prescriptions; Chest or Upper Respiratory Infection; Urinary
Tract Infection; Fungal infections; Allergies; Sports Injuries; TravelTract Infection; Fungal infections; Allergies; Sports Injuries; Travel
Medicine; Nausea; Digestive Disorders; Heartburn; Dry Skin – Eczema;Medicine; Nausea; Digestive Disorders; Heartburn; Dry Skin – Eczema;
Back Pain; Depression; Colds and Flu; Diabetes; Thyroid DisordersBack Pain; Depression; Colds and Flu; Diabetes; Thyroid Disorders

27. Online consultationsOnline consultations
‘‘
 Cupris Health:Cupris Health: turns smartphones intoturns smartphones into
medical devices using patent-pendingmedical devices using patent-pending
clip-on attachments (otoscope andclip-on attachments (otoscope and
opthalmoscope)opthalmoscope)

28. TeddiTeddi
BabyWatch:BabyWatch:Features videoFeatures video
sound pattern (or cry)sound pattern (or cry)
analysis, tracking of motoranalysis, tracking of motor
skill development, vitals:skill development, vitals:
temperature, heart rate, andtemperature, heart rate, and
SATSSATS

29. StressfreewomanStressfreewoman

30. Easy to use devicesEasy to use devices
 Pelviva: PelponPelviva: Pelpon
 Neurourol and urodynamics 2013 Jun volNeurourol and urodynamics 2013 Jun vol
32 issue 5 460-632 issue 5 460-6

31. Reliable outcome measurementReliable outcome measurement
tools?tools?
 Dumoulin et al 2003Dumoulin et al 2003
Neurourology and Urodynamics 2003 22(7):648-653Neurourology and Urodynamics 2003 22(7):648-653

32. Wikipedia 2015Wikipedia 2015
 “…“…wearable technology shares the vision of interweavingwearable technology shares the vision of interweaving
technology into the everyday life, of making technology pervasivetechnology into the everyday life, of making technology pervasive
and interaction friction less”and interaction friction less”
 Activity trackers monitor and record fitness activity they haveActivity trackers monitor and record fitness activity they have
accelerometers and altimeters to look at steps, mileage, flightsaccelerometers and altimeters to look at steps, mileage, flights
climbed and measure sleep qualityclimbed and measure sleep quality

33. Advanced technology for PFMAdvanced technology for PFM
fitnessfitness
 Devices that offer:Devices that offer:
 Ease of use through wireless technologyEase of use through wireless technology
 AccelerometersAccelerometers
 Reliable baseline and outcomeReliable baseline and outcome
measurementmeasurement
 Intelligent progression of exercisesIntelligent progression of exercises
 Less boring, fun elementsLess boring, fun elements

34. KGoalKGoal
www.minnalife.com/products/kgoalwww.minnalife.com/products/kgoal

35. SkeaSkea
www.youtube.com/watch?v=8YyU10SRabgwww.youtube.com/watch?v=8YyU10SRabg

36. PericoachPericoach
www.pericoach.comwww.pericoach.com

37. LoopLoop
www.indiegogo.comwww.indiegogo.com

38. ElvieElvie
www.elvie.comwww.elvie.com

39. Data Collection:Data Collection:
 10 sets of data per second:10 sets of data per second:
 Force at multiple levelsForce at multiple levels
 Symmetry of forceSymmetry of force
 Direction of movement bilaterally andDirection of movement bilaterally and
unilaterallyunilaterally
 Angle changeAngle change
 Speed of contractionSpeed of contraction

40. ResearchResearch
 To dateTo date
consumer user testing: reliability and validityconsumer user testing: reliability and validity
 20162016
research for medical write up: Linda McClean Universityresearch for medical write up: Linda McClean University
of Ottowa: reliability, validityof Ottowa: reliability, validity
 Going forwardGoing forward
clinical research:clinical research:
RCT’sRCT’s
Studies of symmetry, speed, co ordination,Studies of symmetry, speed, co ordination,
compartments etccompartments etc

41. SummarySummary
 Feedback/Biofeedback remains one of the centralFeedback/Biofeedback remains one of the central
tenets in PFMTtenets in PFMT
 Ultrasound is the latest innovation that we have inUltrasound is the latest innovation that we have in
clinical practice for feedback and is very useful butclinical practice for feedback and is very useful but
relatively inaccessiblerelatively inaccessible
 Outcome measurement tools currently available areOutcome measurement tools currently available are
advised to be used with cautionadvised to be used with caution
 New era approaching for PFM exercise trackers thatNew era approaching for PFM exercise trackers that
are anticipated to offer greater reliability forare anticipated to offer greater reliability for
measurement as well as providing biofeedback.measurement as well as providing biofeedback.