Publications by authors named "Patrícia Driusso"

70 Publications

Intravaginal electrical stimulation associated with pelvic floor muscle training for women with stress urinary incontinence: study protocol for a randomized controlled trial with economic evaluation.

Trials 2021 Nov 20;22(1):823. Epub 2021 Nov 20.

Women's Health Research Laboratory, Physical Therapy Post-Graduate Program, Federal University of São Carlos, Rod. Washington Luis, km 235, CEP, São Carlos, SP, 13565-905, Brazil.

Introduction: Pelvic floor muscle training (PFMT) exercises and neuromuscular electrical stimulation (NMES) are described as conservative interventions to prevent or treat female stress urinary incontinence (SUI). However, it has not been described yet the effect of PFMT associated to intravaginal NMES which evaluated the cost-effectiveness and cost-utility of treating.

Aims: To evaluate the effects of intravaginal NMES associated with the PFMT protocol on urinary loss and quality of life in women with SUI and to evaluate the cost-effectiveness and cost-utility and pelvic floor muscle in women with SUI.

Methods: Randomized controlled trial study with economic evaluation. Inclusion criteria are woman (biological), aged ≥ 18 years old and with a report of SUI ≥ once/week. Exclusion criteria are presence of vaginal or urinary infection, virginity, being in the gestational or puerperium period, or neurological disease. Participants will undergo physical therapy assessment and intervention: anamnesis, pelvic floor muscle assessment by vaginal palpation and manometry (Peritron), questionnaires (Short-Form 6 Dimensions-Brazil (SF-6D), King's Health Questionnaire (KHQ) and King´s Health Questionnaire for Scoring Algorithm), health costs, and voiding diary. Participants will be randomly allocated into 3 groups: CG (control group), IG 1 (intervention group 1, PFMT), and IG2 (intervention group 2, PFMT + NMES). The statistical analysis will be performed by intention to treat, and multivariate analysis of mixed effects will be used to compare outcomes. Effect size measurements will be calculated and will be provided by Cohen's d test. A significance level of 5% will be adopted. Additionally, the incremental cost-effectiveness and incremental cost-utility ratios will be used.

Discussion: This protocol can corroborate with the literature in order to identify the effect of techniques, based on the possibility of confirming the hypothesis that the NMES associated with PFMT performed concurrently will be the best treatment option; considering the effectiveness, cost-effectiveness, and cost-utility analysis, it will be used as an option for optimization of the treatment of SUI.

Trial Registration: Brazilian Registry of Clinical Trials (ReBEC) ID: RBR-6gtzg4 . Registered on September 3, 2019.
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http://dx.doi.org/10.1186/s13063-021-05781-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8606065PMC
November 2021

Parasacral versus tibial transcutaneous electrical stimulation to treat urinary urgency in adult women: Randomized controlled clinical trial.

Eur J Obstet Gynecol Reprod Biol 2021 Oct 31;267:167-173. Epub 2021 Oct 31.

Physical Therapy Post-Graduate Program, Universidade Federal de São Carlos (UFSCar), São Carlos, SP, Brazil; Laboratory of Research on Women's Health (LAMU), UFSCar, São Carlos, SP, Brazil. Electronic address:

Introduction: Urinary urgency is a very strong urge to urinate that is difficult to postpone and control. One of the physiotherapeutic resources that can be used in the treatment of urinary urgency is electrical nerve stimulation. The objective of this study is to investigate the effects of parasacral and tibial nerve transcutaneous electrical stimulation in improving urinary urgency in adult women.

Material And Methods: Single-blinded randomized controlled clinical trial.

Participants: Ninety-nine adult women with urgency.

Interventions: Transcutaneous electrostimulation for 12, 20-min sessions, twice a week. The tibial and parasacral groups received a current of F = 10 Hz and 200 μs pulse duration, while the sham group received a current of F = 100 Hz and 100 μs pulse duration, the active electrode placed over the scapula. Primary and secondary outcome measures: The primary outcome measure was urinary urgency, measured by the International Consultation on Incontinence Questionnaire Overactive Bladder (ICIQ-OAB) and Overactive Bladder questionnaire-Validated 8-Question Awareness Tool (OAB-V8). Secondary outcomes were quality of life with the King's Health Questionnaire (KHQ) and voiding habits with the 24-h voiding diary. Assessments occurred pretreatment, after the sixth and 12th post-treatment sessions and at the 30-day follow-up.

Results: Both parasacral and tibial groups in the post-treatment presented fewer episodes of urgency than the sham group. The parasacral group showed better results than the sham group post-treatment for ICIQ-OAB scores, and in KHQ domains Impact of Incontinence and task limitations. Parasacral group participants had OAB-V8 score lower than 8 in the post-treatment and follow-up.

Conclusion: Both tibial and parasacral groups had a positive and similar effect on reducing urinary urgency in adult women. Relative to the quality of life, transcutaneous parasacral electrostimulation was superior to transcutaneous tibial electrostimulation.

Clinical Trial Registration: Brazilian Registry of Clinical Trials (ReBEC), http://ensaiosclinicos.gov.br, protocol RBR-9rf33n.
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http://dx.doi.org/10.1016/j.ejogrb.2021.10.025DOI Listing
October 2021

Mobile health technologies for the monitoring of menstrual cycle: A systematic review of online stores in Brazil.

J Obstet Gynaecol Res 2021 Oct 27. Epub 2021 Oct 27.

Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway.

Aim: To perform a systematic review of available mHealth apps for menstrual cycle monitoring in Brazil.

Methods: A search for menstrual cycle mHealth apps from the Google Play Store and AppStore in Brazil was performed by two independent reviewers on October 2020, and the quality of eligible mHealth apps was assessed using the Mobile App Rating Scale (MARS).

Results: Our review identified 2400 potentially relevant mHealth apps, of which 56 were eligible for inclusion. The majority of the apps offered tools to track menstruation symptoms (63%) and educational content for users (32%). The mean ( ±SD) MARS app quality score for the 28 evaluated apps in Android was 3.5 ± 0.6 on a 0-5 scale. For the 28 evaluated apps in iOS, the mean app quality score was 3.8 ± 0.4. Most of the included apps, for both systems, scored average for credibility, user interface, and engagement.

Conclusion: The majority of available tools in Brazil are of moderate quality and limited functionality for menstrual cycle monitoring. This study highlights the top three mHealth apps available on each online store for individuals seeking menstrual cycle monitoring options.
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http://dx.doi.org/10.1111/jog.15082DOI Listing
October 2021

RE: Wuytack et al. A systematic review of utility-based and disease-specific quality of life measurement instruments for women with urinary incontinence.

Neurourol Urodyn 2021 11 8;40(8):2063-2064. Epub 2021 Sep 8.

Women's Health Research Laboratory (LAMU), Department of Physical Therapy, Federal University of São Carlos, São Carlos, Brazil.

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http://dx.doi.org/10.1002/nau.24789DOI Listing
November 2021

Is there an association of lifestyle habits, anxiety, and depression between incontinent and continent women during COVID-19 pandemic?

Women Health 2021 09 25;61(8):783-790. Epub 2021 Aug 25.

Women's Health Research, Laboratory, Physical Therapy Department, Universidade Federal de São Carlos, São Carlos, Brazil.

Urinary incontinence (UI) is directly correlated with the risk of death and negatively affects the quality of life of women. During the COVID-19 pandemic, women had to adapt their lifestyles to get accustomed to the restrictive measures. The present study aimed to investigate the association between lifestyle habits, anxiety, and depression symptoms during the COVID-19 pandemic between incontinent and continent women. Seventy-seven Brazilian participants aged >18 years were assessed through semi-structured telephonic interviews from July to August 2020. The interview included a questionnaire to investigate lifestyle habit changes and two questions from the King's Health Questionnaire (KHQ) to identify the presence of UI and the Hospital Anxiety and Depression Scale (HADS). Women were allocated into two groups according to their answers to the KHQ: incontinent and continent. The chi-square test was applied, the significance level was set at 5%. Significant differences were found between groups regarding the habit to study and the time spent talking to relatives/friends ( < .05). Neither anxiety nor depression symptoms showed a significant association between the groups. It seems that women with UI changed specific lifestyle habits during the COVID-19 pandemic compared to continent women, while anxiety and depression symptoms did not differ between the groups.
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http://dx.doi.org/10.1080/03630242.2021.1970081DOI Listing
September 2021

Is there agreement between the preference of examiner and women for unidigital and bidigital vaginal palpation? A qualitative study.

Int Urogynecol J 2021 Jul 30. Epub 2021 Jul 30.

Women's Health Research Laboratory, Physical Therapy Department, Federal University of São Carlos, Rodovia Washington Luís, km 235, Monjolinho, São Carlos, SP, 13565-905, Brazil.

Introduction And Hypothesis: The International Continence Society recommends vaginal palpation as a method for assessing pelvic floor muscle (PFM) function. Our aim was to analyze the agreement between preferences of examiner and participants according to unidigital and bidigital vaginal palpation during PFM assessment. The second aim was to investigate qualitatively women's perception of vaginal palpation.

Methods: Maximal voluntary contractions (MVCs) were requested during both types of vaginal palpation and were classified by the Modified Oxford Scale (MOS). Examiner and participants answered if they had preferences regarding vaginal palpation. Women answered qualitatively what they felt during the assessment. Cohen's linear kappa (κ) evaluated the agreement after allocation of the women with a weaker and stronger MVC and qualitative analysis was performed by transcription considering age range (18-35; 36-59; ≥60 years).

Results: Agreement was almost zero for women with weaker and stronger MVC at unidigital (κ = 0.06 and κ = -0.12) and bidigital vaginal palpation (κ = 0.008 and κ = 0.005). Participants associated bidigital palpation with more perception and an easier way of contracting the PFMs. Women between 36 and 59 years associated unidigital palpation with a harder but comfortable way of contracting the PFMs. Subjects aged ≥60 years associated bidigital palpation with an uncomfortable, harder way of contracting PFM, with less space into the vagina.

Conclusions: Agreement between preferences was almost zero neither between women with a weaker and stronger PFM contraction, nor between the types of vaginal palpation. Bidigital palpation increased women's perception, made the contraction easier, and was associated with less space in the vaginal canal and less comfort.
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http://dx.doi.org/10.1007/s00192-021-04935-3DOI Listing
July 2021

Obesity and pelvic floor muscle function in young nulligravid: a cross-sectional study.

Obes Res Clin Pract 2021 Jul-Aug;15(4):409-411. Epub 2021 Jun 11.

Women's Health Research Laboratory (LAMU), Physical Therapy Department, Federal University of São Carlos (UFSCar), São Carlos, SP, Brazil. Electronic address:

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http://dx.doi.org/10.1016/j.orcp.2021.06.002DOI Listing
September 2021

Transcutaneous electrical nerve stimulation for women with primary dysmenorrhea: Study protocol for a randomized controlled clinical trial with economic evaluation.

PLoS One 2021 20;16(5):e0250111. Epub 2021 May 20.

Women's Health Research Laboratory (LAMU), Physical Therapy Department, Universidade Federal de São Carlos, São Carlos, SP, Brazil.

Primary dysmenorrhea (PD) is a common gynecological disorder characterized by cramping pain in the lower abdomen during menstruation, in the absence of identifiable pathology. While Transcutaneous Electrical Nerve Stimulation (TENS) is used to promote PD pain relief, there is still a need to understand the parameters and cost-effectiveness of this intervention. As such, this study aims to disclose a study that will evaluate the effectiveness and cost-effectiveness of TENS on pain intensity in women with PD. This is a protocol for an assessor-blinded randomized controlled trial that includes 174 women with PD, >18 years old, with menstrual pain greater than or equal to four points in the Numerical Rating Scale. Participants will be randomized into three groups (active TENS, placebo TENS, and educational booklet). Participants allocated to the active TENS group will receive electrical stimulation (F = 100 Hz, pulse duration = 200 μs, for 30 min). In contrast, the placebo TENS group will receive placebo stimulation (same parameters, but for only 30 s, and then the current will be ramped off over a 15-s time frame) for three consecutive months during menstruation. Participants allocated to the educational booklet group will receive instructions about health promotion and education actions related to PD. A blinded assessor will evaluate the pain intensity (Numerical Rating Scale), presenteeism (Stanford Presenteeism Scale), Health-Related Quality of Life (Short-Form 6 dimensions and SF-36), and health costs of menstrual pain. This is the first study to propose a health economic evaluation while assessing the benefits of using TENS to treat PD symptoms. It is hypothesized that active TENS will be more effective than placebo TENS or the educational booklet in improving clinical outcomes in the short-, medium- and long-term. The study will also provide information about the cost-effectiveness of TENS, which can be used by policy makers to improve PD care in public and private health systems.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0250111PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8136645PMC
October 2021

Visuo-postural dependency index (VPDI) in human postural control.

BMC Sports Sci Med Rehabil 2021 Jan 26;13(1). Epub 2021 Jan 26.

Laboratory for Advances in Rehabilitation Sciences, Department of Physical Therapy, Western Michigan University, 1903 W Michigan Av., Office # 3454, Kalamazoo, MI, 49008-5383, USA.

Background: Computerized stabilometry has been utilized to investigate the effect of vision on the neuromechanisms of human postural control. However, this approach lacks operational methods to quantify visual dependency during upright stance. This study had three goals: (1) To introduce the concept of visuo-postural dependency indices (VPDI) representing balance sway characteristics in multiple analytical domains (spatial, temporal, frequency, and structural), (2) To investigate the age and gender effects on VPDIs, and (3) To investigate the degree of relationships between VPDI and both subjective visual vertical and horizontal perception (SVV and SVH, respectively).

Methods: 102 participants (16 to 80 years old) performed bipedal stances on a force platform with eyes open and closed. Response variables included the VPDIs computed for each postural index. In addition, 29 participants also performed SVV and SVH assessments.

Results: Fifteen VPDIs showed to be robust indicators of visual input modulation, and the variation across their magnitudes of modulation revealed a non-homogeneous response to changes in visual stimuli. Gender and age were not found to be a significant factor to VPDI modulation.

Conclusions: VPDIs revealed to be potential measures capable to quantitatively assess visuo-postural dependency and aid the assessment of fall risks and balance impairments.
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http://dx.doi.org/10.1186/s13102-021-00235-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7836177PMC
January 2021

Mobile health technologies for the management of urinary incontinence: A systematic review of online stores in Brazil.

Braz J Phys Ther 2021 Jul-Aug;25(4):387-395. Epub 2021 Jan 13.

Physical Therapy Department, Universidade Federal de São Carlos, São Carlos, Brazil. Electronic address:

Background: Urinary incontinence (UI) is a serious condition for which often times insufficient non-surgical treatment options are provided or sought. Mobile health (mHealth) applications (apps) offer potential to assist with the self-management of UI.

Objective: To perform a systematic review of available mHealth apps for UI in Brazil.

Methods: A search for UI mHealth apps from the Google Play Store and AppStore in Brazil was performed by two independent reviewers on June 4 2020, and the quality of eligible mHealth apps was assessed using the Mobile App Rating Scale (MARS).

Results: Of the 1111 mHealth apps found, 12 were eligible for inclusion. Four offered exclusively exercise programs, six offered exercise and educational content, and two offered tools to track patient-reported symptoms. The included apps scored poorly on the MARS quality scale, with a mean ± standard deviation score of 2.7 ± 0.6 on a 0-5 scale. Most apps scored poorly based on credibility, user interface and experience, and engagement.

Conclusion: Although there is growing interest in the development of mHealth technologies to support patients with UI, currently available tools in Brazil are of poor quality and limited functionality. Effective collaboration between industry and research is needed to develop new user-centered mHealth apps that can empower patients with UI.
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http://dx.doi.org/10.1016/j.bjpt.2021.01.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8353310PMC
October 2021

Reliability of the PERFECT scheme assessed by unidigital and bidigital vaginal palpation.

Int Urogynecol J 2021 Jan 8. Epub 2021 Jan 8.

Physical Therapy Department, Women's Health Research Laboratory, Rodovia Washington Luís, km 235, Monjolinho, São Carlos, SP, 13565-905, Brazil.

Introduction And Hypothesis: The aim of the present study was to evaluate the inter- and intra-rater reliability of the PERFECT scheme assessed by uni- and bidigital vaginal palpation in young nulligravid women.

Methods: Forty healthy women [median age 22 (19-34) years] were evaluated by unidigital vaginal palpation by both Examiners A and C, while the other 40 participants [median age 23.5 (19-35) years] were assessed by Examiners B and C by bidigital vaginal palpation. Inter- and intra-rater reliability of all items of the PERFECT scheme were evaluated: P = power (Modified Oxford Scale); E = endurance; R = repetitions; F = fast contractions. Cohen's linear weighted kappa (κw) was used to assess the reliability of the power, while the intraclass correlation coefficient (ICC) was applied for the other items. A priori sample size calculation found that 40 participants would be adequate.

Results: Inter-rater reliability of unidigital palpation was considered fair for power (κw = 0.34) and poor for other items (ICC < 0.50); bidigital inter-rater reliability was considered moderate (power: κw = 0.57; endurance: ICC = 0.53; fast contractions: ICC = 0.65, respectively) and low (repetitions: ICC = 0.27). Intra-rater reliability was substantial for power (κw = 0.73 and 0.62), moderate for fast contractions (ICC = 0.63 and 0.51) and poor for repetitions (ICC < 0.50), respectively, for uni- and bidigital palpation. Endurance showed poor (ICC < 0.50) and moderate (ICC = 0.61) reliability for uni- and bidigital palpation.

Conclusions: The PERFECT scheme carried out by bidigital vaginal palpation presents higher reliability when two examiners carry out the physical examination. When one examiner is responsible for PFM assessment, both types of palpation are recommended for evaluation of power and fast contraction; endurance should be evaluated using bidigital palpation. Examiners should be careful during the assessment of repetition of sustained contractions because inter- and intra-reliabilities for both types of palpation were classified as poor.
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http://dx.doi.org/10.1007/s00192-020-04629-2DOI Listing
January 2021

Diastasis recti abdominis and pelvic floor dysfunction in peri- and postmenopausal women: a cross-sectional study.

Physiother Theory Pract 2020 Dec 7:1-7. Epub 2020 Dec 7.

Pró Reitoria de Pós Graduação e Pesquisa (PRPGP), Centro Universitário Sagrado Coração - UNISAGRADO, Bauru, São Paulo, Brazil.

: Diastasis recti abdominis (DRA) and pelvic floor dysfunction (PFD) occurs commonly with aging; however, little is known about what leads to these changes.: We aimed to investigate and compare the presence or absence of DRA and PFD in peri- and postmenopausal women.: This cross-sectional study involved 150 participants who answered questions on their sociodemographic and clinical profiles related to urinary and fecal incontinence and pelvic organ prolapse. Diastasis recti abdominis was diagnosed with a digital caliper.: Supra-umbilical diastasis occurred in 37.3% of cases, and 78.6% of participants with DRA had PFD. No significant differences existed between participants with and without DRA in terms of background and clinical variables. However, participants with DRA were 2.6 times more likely to have PFD than participants without DRA. Furthermore, the presence of DRA was significantly shown to be a risk factor for PFD on binary logistic regression analyses ( = .01, OR = 3.2).: This cross-sectional study suggests that DRA is a predictive factor of PFD in women aged over 50 years.
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http://dx.doi.org/10.1080/09593985.2020.1849476DOI Listing
December 2020

Inter- and intrarater reliability of unidigital and bidigital vaginal palpation to evaluation of maximal voluntary contraction of pelvic floor muscles considering risk factors and dysfunctions.

Neurourol Urodyn 2021 01 5;40(1):348-357. Epub 2020 Nov 5.

Department of Physical Therapy, Women's Health Research Laboratory, São Carlos, São Paulo, Brazil.

Aims: To evaluate inter- and intrarater reliability of unidigital and bidigital vaginal palpation of pelvic floor muscle (PFM) maximal voluntary contraction (MVC) according to PFM risk factors and dysfunctions.

Methods: A total of 187 women were recruited and evaluated by two examiners. Both performed the evaluation of MVC with unidigital and bidigital palpation, graded by Modified Oxford Scale. After 7-10 days, one examiner repeated the assessment. To analyze reliability by Cohen's linear Kappa (κw), participants were allocated into different groups according to: body mass index (BMI), menopause, parity, type of delivery and PFM dysfunctions, as pelvic organ prolapse (POP), constipation, urgency, urgency urinary incontinence, pelvic pain, and stress urinary incontinence.

Results: Inter-rater reliability of unidigital palpation was considered fair (κw = 0.21-0.40) to moderate (κw = 0.41-0.60) according to BMI, postmenopausal status, parity, type of delivery, and PFM dysfunctions. Inter-rater reliability of bidigital palpation varied from none (κw = 0.00-0.20) to moderate for all risk factors and PFM dysfunctions. Intra-rater reliability of unidigital palpation was considered fair only for women with POP (κw = 0.37) and moderate to substantial (κw = 0.61-0.80) to all other variables. Intra-rater reliability of bidigital palpation ranged from moderate to almost perfect (κw = 0.81-1.00).

Conclusions: When performing vaginal palpation, physiotherapists must consider the way that is performing the evaluation, as some PFM risk factors and dysfunctions could influence the inter- and intrarater reliability of unidigital and bidigital palpation.
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http://dx.doi.org/10.1002/nau.24566DOI Listing
January 2021

Responsiveness of Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Floor Impact Questionnaire (PFIQ-7) after pelvic floor muscle training in women with stress and mixed urinary incontinence.

Eur J Obstet Gynecol Reprod Biol 2020 Dec 22;255:129-133. Epub 2020 Oct 22.

Physical Therapy Post-Graduate Program, Federal University of São Carlos (UFSCar), SP, Brazil. Electronic address:

Objective: To evaluate the responsiveness of Brazilian-Portuguese version of Pelvic Floor Distress Inventory-20 (PFDI-20) and Pelvic Floor Impact Questionnaire-7 (PFIQ-7) after pelvic floor muscle training (PFMT) in women with stress urinary incontinence (SUI) and mixed urinary incontinence (MUI).

Study Design: This is an observational study with 72 women (51.8 ± 11.9SD years) with SUI (n = 33) and MUI (n = 39). Participants answered PFDI-20 and PFIQ-7 before and after PFMT, which consisted of a 12 weeks protocol supervised by a physiotherapist once a week with 30 min of a duration. Wilcoxon test, effect size (ES) and standardized response mean (SRM) were performed on baseline and after three months.

Results: We found a significant reduction in PFDI-20 and PFIQ-7 after PFMT (p < 0.001), except for Pelvic Organ Prolapses Distress Inventory (POPDI-16), Colorectal-Anal Impact Questionnaire (CRAIQ-7) and Pelvic Organ Prolapse Impact Questionnaire (POPIQ-7). The responsiveness of both questionnaires was considered moderate for PFDI-20 (ES = 0.49; SEM = 0.61; p < 0.0001) and PFIQ-7 (ES = 0.51; SEM = 0.52; p < 0.0001).

Conclusions: PFDI-20 and PFIQ-7 Brazilian Portuguese version presented moderate responsiveness in women with SUI and MUI who performed a PFMT.
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http://dx.doi.org/10.1016/j.ejogrb.2020.10.039DOI Listing
December 2020

Cross-cultural adaptation to Brazilian Portuguese and assessment of the measurement properties of the Questionnaire for Urinary Incontinence Diagnosis (QUID).

Eur J Obstet Gynecol Reprod Biol 2020 Dec 17;255:111-117. Epub 2020 Oct 17.

Women's Health Research Laboratory, Physical Therapy Department, Universidade Federal de São Carlos, Brazil. Electronic address:

Objective: This study aimed to adapt the Questionnaire for Urinary Incontinence Diagnosis (QUID) into Brazilian Portuguese (QUID-Br) and evaluate its measurement properties, given as reliability, validity, and responsiveness in women with urinary incontinence.

Study Design: It was a methodological study which enrolled 168 women (mean age = 55.1, standard deviation = 17.9 years old). Translation and cross-cultural adaptation were done and subsequently analysis of the measurement properties of QUID-Br were tested: structural validity (by exploratory and confirmatory factory analysis) internal consistency (Cronbach's α) construct validity (Pearson Correlation), and test-retest reliability (Intraclass Correlation Coefficient).

Results: The QUID-Br two-factor was confirmed showing two domains with three items each: stress urinary incontinence (SUI) and urge urinary incontinence (UUI). Furthermore, QUID-Br showed acceptable internal consistency for both scales (Cronbach's α > 0.70), reliability [intraclass correlation coefficient (ICC = 0.85 for SUI and 0.87 for UUI)] with 95 % confidence interval (CI) and construct validity - with all the hypothesis raised a priori being confirmed.

Conclusions: The results of the present investigation showed that the QUID-Br is a valid, reliable, and consistent instrument to be administered to Brazilian women and its use is recommended in clinical practice and research.
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http://dx.doi.org/10.1016/j.ejogrb.2020.10.005DOI Listing
December 2020

A guide to physiotherapy in urogynecology for patient care during the COVID-19 pandemic.

Int Urogynecol J 2021 01 28;32(1):203-210. Epub 2020 Sep 28.

Physiotherapy in Women's Health Research Laboratory, Department of Physiotherapy, Communication Sciences & Disorders and Occupational Therapy, University of São Paulo (USP), São Paulo, SP, Brazil.

Introduction And Aim: Physiotherapy in urogynecology faces challenges to safely continuing its work, considering the adoption of social distancing measures during the COVID-19 pandemic. Some guidelines have already been published for urogynecology; however, no specific documents have been produced on physiotherapy in urogynecology. This article aimed to offer guidance regarding physiotherapy in urogynecology during the COVID-19 pandemic.

Methods: A group of experts in physiotherapy in women's health performed a literature search in the Pubmed, PEDro, Web of Science and Embase databases and proposed a clinical guideline for physiotherapy management of urogynecological disorders during the COVID-19 pandemic. This document was reviewed by other physiotherapists and a multidisciplinary panel, which analyzed the suggested topics and reached consensus. The recommendations were grouped according to their similarities and allocated into categories.

Results: Four categories of recommendations (ethics and regulation issues, assessment of pelvic floor muscle function and dysfunction, health education and return to in-person care) were proposed. Telephysiotherapy and situations that need in-person care were also discussed. Regionalization is another topic that was considered.

Conclusion: This study provides some guidance for continuity of the physiotherapist's work in urogynecology during the COVID-19 pandemic, considering the World Health Organization recommendations and the epidemiological public health situation of each region. Telephysiotherapy can also be used to provide continuity of the care in this area during the COVID-19 pandemic, opening new perspectives for physiotherapy in urogynecology.
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http://dx.doi.org/10.1007/s00192-020-04542-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7521075PMC
January 2021

The effect of parity on the function of pelvic floor musculature in the long term: cross-sectional study.

Obstet Gynecol Sci 2020 Sep 11;63(5):577-585. Epub 2020 Sep 11.

Department of Physical Therapy, Federal University of São Carlos, São Paulo, Brazil.

Objective: Parity is associated with an increased risk of pelvic floor muscle dysfunction. The aim of this study was to evaluate the long-term effects of parity on this musculature.

Methods: This cross-sectional study was completed at the Department of Physical Therapy, Federal University of São Carlos, Brazil. In total, 143 women participated in the study and were classified into three groups according to parity: nulliparae, primiparae, and secundiparae women. All parous participants had last given birth between 1 and 6 years prior. Pelvic floor muscle function was assessed through unidigital vaginal palpation using the PERFECT scheme, with the contraction grade classified according to the Modified Oxford Scale and through manometry.

Results: There was no difference in scores on the Modified Oxford Scale (the means and standard deviations were 2.5±0.8 in nulliparae women, 2.3±0.9 in primiparae women, and 2.2±0.9 in secundiparae women; P=0.482) and manometry findings (the means and standard deviations were 42.3±22.7 in nulliparae women, 35.0±21.8 in primiparae women, and 33.2±20.0 in secundiparae women; P=0.144) among the assessed groups.

Conclusion: Parity had no effect, regardless of mode of birth, on the function of pelvic floor muscles and the presence of urinary symptoms, such as long-term urinary incontinence after birth.
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http://dx.doi.org/10.5468/ogs.19236DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7494773PMC
September 2020

Pelvic floor dysfunction distress is correlated with quality of life, but not with muscle function.

Arch Gynecol Obstet 2021 01 11;303(1):143-149. Epub 2020 Sep 11.

Physical Therapy Department, Faculty of Medicine, Federal University of Ceará (UFC), Major Weyne Street, 1440 - Rodolfo Teófilo, Fortaleza, Ceará, 60430-450, Brazil.

Objective: To analyze the relationship between the symptoms of pelvic floor dysfunction (PFD) and quality of life (QoL), as well as the function of the pelvic floor muscle (PFM) in women with urinary incontinence (UI).

Methods: A cross-sectional study conducted in two centers in Brazil (Northeast and Southeast regions) with women with stress urinary incontinence (SUI) and mixed urinary incontinence (MUI). Data on pelvic floor symptoms, discomfort and impact on QoL were collected using the Pelvic Floor Distress Inventory-short form (PFDI-SF-20) and the Pelvic Floor Impact Questionnaire (PFIQ-7) instruments. PFM function was assessed by palpation (PERFECT scale) and manometry. Pearson's correlation test, analysis of variance (ANOVA) and the Student's t test were used to discriminate the differences, adopting a significance level of 5%.

Results: A total of 72 women participated in the study (mean age 51.7 ± 11.9 years). The presence and discomfort of pelvic floor symptoms (PFDI-SF-20) were correlated with QoL (PFIQ-7) (r = 0.52, p < 0.001). Deficits in PFM function (power and pressure) were observed, however, there was no correlation between these with the presence and discomfort of the pelvic floor symptoms (PFDI-SF-20).

Conclusion: Greater discomfort due to PFD symptoms were correlated with a worse QoL. However, the relationship between symptoms and PFM function was not significant. These results reinforce the need to assess the aspects of activity and participation which compose functionality and QoL, and not only the PFM functions in women with UI.
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http://dx.doi.org/10.1007/s00404-020-05770-5DOI Listing
January 2021

Cross-cultural adaptation and psychometric evaluation of the Brazilian Portuguese version of the childbirth experience questionnaire.

BMC Pregnancy Childbirth 2020 Aug 20;20(1):477. Epub 2020 Aug 20.

Department of Physical Therapy, Women's Health Research Laboratory, Federal University of São Carlos (UFSCar), São Carlos, Brazil.

Background: The Childbirth Experience Questionnaire (CEQ) is a tool designed to assess women's perceptions about labor and delivery. The aim of this study was to perform the cross-cultural adaptation and validation of the Brazilian Portuguese version of the CEQ (CEQ-Br).

Methods: The original version of the CEQ was translated into Portuguese, analyzed by a committee of experts, back translated, and finally submitted to pilot-test. Two applications of the CEQ-Br were performed along with the quality of life questionnaire Medical Outcomes Study 36 - Item Short-Form Health Survey (SF-36). The SPSS software was used for statistical analysis, the intraclass correlation coefficient was used to investigate test-retest reliability, the internal consistency was investigated with the Cronbach's Alpha, and the construct validity was investigated via the Spearman correlation test. The level of significance was set at 5%.

Results: The study included 308 women with a mean age of 31.1 ± 8.7 years. The internal consistency results for the total CEQ-Br score was considered adequate (0.89), the test-retest showed a substantial result with an ICC of 0.90, and the construct validity was analyzed via the Spearman correlation between all SF-36 dimensions and the total CEQ-B score, the analyses were considered adequate.

Conclusions: The results presented in this CEQ-Br validation study showed that the instrument was reliable in measuring the established psychometric properties and was considered valid. Therefore, the CEQ-Br can be applied to the Brazilian population.
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http://dx.doi.org/10.1186/s12884-020-03163-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7441667PMC
August 2020

Is pelvic floor muscle training able to alter the response of cardiovascular autonomic modulation and provide a possible cardiovascular benefit to pregnant women?

Neurourol Urodyn 2020 11 12;39(8):2272-2283. Epub 2020 Aug 12.

Women's Health Research Laboratory, Physical Therapy Department, Rodovia Washington Luís, km 235, Monjolinho, São Carlos, São Paulo, Brazil.

Aims: To evaluate the acute and chronic effect of an exercise protocol of pelvic floor muscles (PFMs) contraction on the heart period (HP) and systolic arterial pressure (SAP) variabilities and baroreflex sensitivity (BRS) at rest in pregnant women; and to evaluate if this progressive exercise protocol was well-tolerated by the pregnant women studied.

Methods: We evaluated 48 women at 18 weeks of pregnancy by vaginal palpation, vaginal manometry, and cardiopulmonary exercise test. They were divided in control (CG; 31.75 ± 3.91 years) and training groups (TG; 30.71 ± 3.94 years). At 19 and 36 weeks of pregnancy, electrocardiogram and noninvasive peripheral SAP data were collected at rest before and after 10 PFM contractions. TG performed PFMT from the 20th to the 36th week. HP and SAP variabilities were analyzed by spectral and symbolic analysis. The baroreflex was evaluated by cross-spectral analysis between the HP and SAP series.

Results: The groups did not differ in relation to VO , HP and SAP variabilities, and BRS at the beginning of the protocol. TG increased the endurance of the PFM after training. PFM contraction did not change the HP and SAP variabilities, and BRS at the 18th week. After the training, the TG presented lower SAP mean, lower BF of SAP variability, and higher BRS than CG.

Conclusions: Acute PFM contractions did not alter HP and SAP variabilities and BRS, but PFMT resulted in a lower SAP mean and higher BRS in trained pregnant when compared to the untrained.
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http://dx.doi.org/10.1002/nau.24481DOI Listing
November 2020

Multidisciplinary approach between physicians and physiotherapists in urogynecology: how can we make it stronger?

Int Urogynecol J 2020 11 17;31(11):2187-2188. Epub 2020 Jul 17.

Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Rua Alexander Fleming 101, Cidade Universitária, Campinas, SP, 13083-881, Brazil.

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http://dx.doi.org/10.1007/s00192-020-04417-yDOI Listing
November 2020

Intra- and inter-rater reliability of urethral mobility measurement by ultrasound in women: a cross-section study.

Int Urogynecol J 2021 Jan 22;32(1):119-125. Epub 2020 Jun 22.

Women's Health Research Laboratory, Physical Therapy Department, Federal University of São Carlos (UFSCar), Rodovia Washington Luís, km 235, Monjolinho, São Carlos, SP, 13565-905, Brazil.

Introduction And Hypothesis: To verify the intra- and inter-rater reliability of urethral mobility measurement evaluated by ultrasound (US).

Methods: This is a reliability study realized according to Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) recommendations. Twenty-one nulliparous women (25.5 ± 3.3 SD years) were volunteers. Two examiners (E1 and E2) performed the measurement of urethral mobility at rest and Valsalva on the same day. Three measurements were recorded for each moment and the mean of them were used for analysis. To perform the analysis, bladder mobility was calculated using the following equation: [Formula: see text], where "x" is the vertical distance, "y" is the horizontal distance from the dorsocaudal margin of the pubic symphysis, "V" is the Valsalva maneuver, and "R" means rest. The intraclass correlation coefficient (ICC) was calculated considering: ICC ≥ 0.75, excellent; 0.40 ≤ ICC <0.75, satisfactory; ICC < 0.40, poor, with a significance level of 5% and 95% confidence interval.

Results: The intra-rater reliabilities of E1 and E2 were considered excellent between the two evaluations, with ICC 0.98 (p < 0.0001) for the E1 and 0.84 (p < 0.0001) for E2. The inter-rater reliability was considered excellent (ICC = 0.83).

Conclusions: Both intra- and inter-rater reliabilities of urethral mobility measurement were considered to have excellent agreement.
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http://dx.doi.org/10.1007/s00192-020-04381-7DOI Listing
January 2021

Cardiovascular responses to pelvic floor muscle contraction in healthy women: Prospective study.

Eur J Obstet Gynecol Reprod Biol 2020 Sep 9;252:36-42. Epub 2020 Jun 9.

Women's Health Research Laboratory, Physical Therapy Department, Federal University of São Carlos, São Carlos, São Paulo State, Brazil. Electronic address:

Objective: Analyze the acute heart rate and blood pressure responses to two protocols of pelvic floor muscles contractions in premenopausal and postmenopausal women.

Methods: Fifty-four women without pelvic floor muscles disorders were eligible and allocated into two groups: premenopausal and postmenopausal. The groups underwent two protocols and the pelvic floor muscle endurance, heart rate, and blood pressure values were monitored. Both protocols included 10 pelvic floor muscles contractions; one series contained contractions lasting 5 s with 5 s of rest between each contraction and the other series contained contractions lasting 10 s with 10 s of rest.

Results: In both groups, there was a significant increase in the heart rate during pelvic floor muscles contractions (premenopausal: 71.0 ± 7.3 and 80.3 ± 7.7; postmenopausal: 65.4 ± 6.6 and 73.6 ± 6.6, at rest and contractions peak, respectively) and in systolic blood pressure immediately after the contractions. The observed values during exercise returned to basal values seconds after the contractions. A positive correlation between heart rate and vaginal squeeze pressure (r = 0.45, p = 0.0007 and r = 0.48, p = 0.0003, 5- and 10-s series, respectively) was observed.

Conclusion: The proposed protocol of isometric pelvic floor muscles contractions caused an increase in heart rate and blood pressure within the normal range and might not represent a cardiovascular risk for healthy postmenopausal women without urinary incontinence and without cardiovascular dysfunctions.
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http://dx.doi.org/10.1016/j.ejogrb.2020.05.050DOI Listing
September 2020

Effects of individual pelvic floor muscle training vs individual training progressing to group training vs group training alone in women with stress urinary incontinence: A randomized clinical trial.

Neurourol Urodyn 2020 06 30;39(5):1447-1455. Epub 2020 Apr 30.

Physical Therapy Department, Federal University of São Carlos (UFSCar), São Carlos, São Paulo, Brazil.

Aims: To assess the effects of individual pelvic floor muscle (PFM) training vs individual training (IT) progressing to group training (GT) vs group-only training in women with stress urinary incontinence (SUI).

Methods: Randomized controlled and pragmatic clinical trials with 90 women with SUI. Participants were randomly allocated to one of three groups: IT, GT, or four individual sessions progressing to group training (IPGT). The intervention included 12 sessions, once a week, with direct supervision by a physical therapist.

Primary Outcome: severity according to the King's Health Questionnaire.

Secondary Outcomes: PFM function by palpation and manometer, bladder and exercise diaries, PFM training adherence, and self-efficacy. Reassessments were conducted at the end of the intervention, 3 and 6 months after the intervention. Intra- and intergroup analysis for all outcomes was performed using a multivariate analysis of variance. In the mixed-effects model used, the evaluation groups and times and their interactions were considered. A significance level of 5% was adopted.

Results: After the intervention, the severity measure improved in all three groups (P < .001), without difference between them (P = .56). The benefits of the intervention were maintained 3 and 6 months after the end of the supervised training (P < .001). The IPGT group had a significant improvement in PFM function when compared to the other groups posttreatment (P < .001).

Conclusion: PFM training improved the severity of urinary incontinence in all groups after 12 sessions of training supervised by a physical therapist. IT progressing to GT improved the function of upper PFM when compared to the other groups.
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http://dx.doi.org/10.1002/nau.24370DOI Listing
June 2020

Reliability of different electromyographic normalization methods for pelvic floor muscles assessment.

Neurourol Urodyn 2020 04 2;39(4):1145-1151. Epub 2020 Mar 2.

Physical Therapy Department, Universidade Federal de São Carlos, São Carlos, São Paulo, Brazil.

Aims: To evaluate the reliability of different methods to normalize pelvic floor muscles (PFM) electromyography (EMG).

Methods: Thirty nulliparous women (23.9 ± 3.2 years), free from PFM dysfunction, completed two test sessions 7 days apart. For EMG normalization, signals were acquired during four different tasks using a vaginal probe in situ: PFM maximal voluntary contraction (MVC) and three daily activities with increased intra-abdominal pressure (coughing, Valsalva maneuver, and abdominal contraction). The intraclass correlation coefficients (ICC), standard error of measurement (SEM), relative standard error of measurement (%SEM), and minimal detectable change (MDC) were calculated for each variable.

Results: ICC values for test-retest reliability of normalization methods ranged from 0.61 to 0.95. The highest values were obtained for mean root mean square (RMS) of the abdominal contraction and peak RMS of PFM-MVC. Normalization using RMS of PFM-MVC showed the lowest values of SEM and MDC.

Conclusions: The normalization of EMG data is considered a fundamental part of EMG investigations. These findings suggest that the normalization of PFM-EMG by either peak RMS of PFM-MVC or mean and peak RMS of abdominal contraction has excellent reliability and it can be applied in studies involving the evaluation of young women.
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http://dx.doi.org/10.1002/nau.24332DOI Listing
April 2020

Are there differences in short-term pelvic floor muscle function after cesarean section or vaginal delivery in primiparous women? A systematic review with meta-analysis.

Int Urogynecol J 2020 08 15;31(8):1497-1506. Epub 2020 Feb 15.

Physical Therapy Post-Graduate Program, Federal University of São Carlos (UFSCar), Rodovia Washington Luis, km 235, São Paulo, CEP 13565-905, Brazil.

Introduction And Hypothesis: The literature presents controversial results regarding the role of delivery mode in pelvic floor muscle (PFM) function after birth. Some studies showed a greater impairment of PFM function after vaginal delivery compared with cesarean section, while others have not identified a significant difference between these two modes of delivery. This study aimed to investigate whether there was a difference in short-term PFM function after childbirth in primiparous women who underwent cesarean section compared with those who underwent vaginal delivery.

Methods: Up to December 2018, the PubMed-MEDLINE, CINAHL, Embase, Bireme, Scopus, Web of Science, and Science Direct databases were searched. Two independent reviewers performed the selection process based on titles, abstracts, and full-text reading. Observational studies comparing PFM function after cesarean section versus vaginal delivery in primiparous women were included. PRISMA guidelines and Cochrane recommendations were followed. Methodological quality of the primary studies was assessed through the checklist proposed by the Joanna Briggs Institute for cross-sectional studies. Random effects meta-analysis was performed to synthesize evidence regarding PFM strength in primiparous woman after vaginal delivery compared with cesarean section. The GRADE approach was applied to classify the quality of the evidence.

Results: Eleven studies met the inclusion criteria and were included in this review. A total of 1726 primiparous women were analyzed after childbirth. Five studies were included in the meta-analysis. No difference in PFM strength after childbirth was identified when cesarean section was compared with vaginal delivery [standardized mean difference (SMD): -0.15, 95% confidence interval (CI): -0.85 to 0.56]. Differences in PFM strength were identified when patients who underwent cesarean section were compared with those with an episiotomy or instrumented vaginal delivery (SMD: -12.51, CI 95%: -24.57 to -0.44), favoring the cesarean section group. In both cases, the quality of evidence was classified as very low because of the observational design of the included studies and population heterogeneity.

Conclusion: There was no difference in short-term PFM strength after childbirth between primiparous women who underwent cesarean section or vaginal delivery, as assessed through vaginal manometry. However, we identified reduced PFM strength in women who underwent an episiotomy or instrumented vaginal delivery compared with those who underwent cesarean section. Nevertheless, this conclusion should be cautiously considered as the observational design of the primary studies and possible heterogeneity among the primiparous women included in the studies contributed to reducing the quality of the evidence synthesized. Future primary studies with longitudinal designs and long-term follow-up periods are needed to strengthen the quality of evidence and provide more conclusive evidence to guide clinical practice.
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http://dx.doi.org/10.1007/s00192-020-04231-6DOI Listing
August 2020

Different electrode positioning for transcutaneous electrical nerve stimulation in the treatment of urgency in women: a study protocol for a randomized controlled clinical trial.

Trials 2020 Feb 11;21(1):166. Epub 2020 Feb 11.

Physical Therapy Department, Federal University of Sao Carlos (UFSCar), Rodovia Washington Luis Km 235, São Carlos, São Paulo, CEP 13565-905, Brazil.

Background: Urgency is a complaint of sudden, compelling desire to pass urine, which is difficult to defer, caused by involuntary contraction of the detrusor muscle during the bladder-filling stage. To enable detrusor inhibition, electrotherapy resources such as transcutaneous tibial nerve stimulation (TTNS) and parasacral transcutaneous electrical stimulation (PTES) have been used. The objective this study is to publish the study protocol that aims to investigate whether urgency decreases after treatment with both of the techniques.

Methods: This randomized controlled clinical trial will include 99 women, aged more than 18 years old, with urgency (score ≥ 8 in the Overactive Bladder-Validated 8-Question Awareness Tool [OAB-V8]). Women will be randomly allocated into three groups: TTNS, PTES, and placebo. The following questionnaires will be applied: the Anamnesis Record, the Incontinence Questionnaire Overactive Bladder, the King's Health Questionnaire, the 24-Hour Voiding Diary, and the OAB-V8, at four different time points: at baseline prior to the first session, at the 6th session, the 12th session and at follow-up. The current used for the transcutaneous electrical stimulation will be a symmetrical balanced biphasic pulsed current, for 12 sessions, twice a week, for 20 minutes. Qualitative variables will be displayed as frequency and percentage, quantitative variables as mean and standard deviation. Comparison of urgency severity among groups will be performed with a repeated measures ANOVA, considering the effect of the three groups and the four evaluations, and interactions among them.

Discussion: The present study aims to contribute evidence for a more in-depth discussion on electrode positioning for electrostimulation used in urgency treatment. It should be emphasized that, based on the possibility of confirming the hypothesis that urgency will decrease in a similar way after both treatments (TTNS and PTES), the PTES will be used as an option for positioning the electrodes alternatively to the tibial nerve region in special populations, such as amputees or people with severe lower limb sensory impairment.

Trial Registration: Brazilian Registry of Clinical Trials (ReBEC) ID: RBR-9rf33n, date of registration: 17 May 2018.
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http://dx.doi.org/10.1186/s13063-020-4096-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7014940PMC
February 2020

"Comparative intra- and inter-rater reliability of maximal voluntary contraction with unidigital and bidigital vaginal palpation and construct validity with Peritron manometer".

Neurourol Urodyn 2020 02 24;39(2):721-731. Epub 2019 Dec 24.

Women's Health Research Laboratory, Physical Therapy Department, Federal University of São Carlos, São Carlos, São Paulo, Brazil.

Aims: Evaluate the intra- and inter-rater reliability of maximal voluntary contraction (MVC) of pelvic floor muscle (PFM) assessment by unidigital and bidigital vaginal palpation. As a secondary aim, evaluate the construct validity of vaginal palpation and a manometer.

Methods: A total of 120 women were recruited and allocated into three groups according to age (group 1 [G1]: 18-35; G2: 36-59; G3: ≥60 years). Examiner A conducted an interview and examiners B and C performed evaluations of PFM function using both unidigital and bidigital vaginal palpation. Seven to 10 days later, examiner B repeated both types of vaginal palpation and measured the MVC pressure with a Peritron. Reliability was analyzed using Cohen's linear weighted Kappa (κ ). The construct validity was calculated using the Spearman's correlation (r ).

Results: Intra-rater reliability of unidigital and bidigital palpation was κ  = 0.75 and κ  = 0.58 in G1, κ  = 0.59 and κ  = 0.73 in G2, and κ  = 0.79 and κ  = 0.86 in G3, respectively. Inter-rater reliability of unidigital and bidigital palpation was κ  = 0.52 and κ  = 0.48 in G1, κ  = 0.47 and κ  = 0.52 in G2, and κ  = 0.50 and κ  = 0.64 in G3, respectively. Spearman's correlation coefficients were significant at r  = 0.79 and r  = 0.80 for unidigital and bidigital vaginal palpation, respectively.

Conclusions: Unidigital or bidigital vaginal palpation were indicated to evaluate G1 and G2 but bidigital palpation was more reliable in G3 when two examiners performed the evaluation. For the assessment conducted by one examiner, unidigital palpation was more reliable in G1 while bidigital palpation was more reliable in G2 and G3. Both unidigital and bidigital palpation have high measures of validity.
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http://dx.doi.org/10.1002/nau.24263DOI Listing
February 2020
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