Eficacia de la fisioterapia en mujeres con disfunciones del suelo pélvico

Abstract

The purposes of this Doctoral Thesis were: (I) to evaluate the associations among pelvic floor muscle outcomes measured using different assessment instruments as they are typically used clinically; (II) to analyze the neuromuscular activity of pelvic floor and abdominal muscles during a hypopressive exercise; and (III) to compare three pelvic-perineal physical therapy treatment approaches, based on pelvic floor muscle training vs hypopressive exercises vs a combination of both; besides to explore why women did or did not comply with the home-based exercises. It was designed an intra- and inter-rater reliability study in a first phase, followed by a cross-sectional study to find the reliability and the correlation between digital palpation, vaginal perineometry, vaginal dynamometry and surface electromyography in the assessment of women with pelvic floor dysfunction. One hundred and fifty women with pelvic floor muscle disorders participated on one occasion, and twenty women returned for the same investigations by two different raters on three different days. At each session, pelvic floor muscle strength was assessed using vaginal palpation, vaginal perineometry, and vaginal dynamometry; and pelvic floor muscle activation was assessed using surface electromyography. Lin’s Concordance Correlation Coefficient (CCC), Cohen’s Kappa index (k) and, Bland Altman analyses were used to evaluate the within- and between-session reliability of each measure. Simple linear regression models, considering the coefficient of determination (r2 ) were used to evaluate the relationship between measurements made using the different instruments. Afterwards, a cross-sectional study was developed to know the neuromuscular activity of pelvic floor and abdominal muscles during a supine hypopressive exercise in women who had received an individual treatment based on these exercises for two months. Sixty-six women participated in the study. Pelvic floor muscles, deep abdominal muscles, and rectus abdominis muscles were assessed by surface electromyography during a hypopressive exercise, and during a maximum voluntary contraction of pelvic floor muscles. In order to detect differences in the neuromuscular activation of each muscles between the exercises, the Friedman test and the Wilcoxon Signed Rank Test were used. Last, a mixed method sequential explanatory design study with quantitative priority was performed. Firstly, we noted that both vaginal perineometry and dynamometry seem to be the most reliable tools for the assessment of pelvic floor muscle strength in women with pelvic floor disorders. The different pelvic floor muscles strength measures used clinically are moderately correlated; whereas, pelvic floor muscles activation recorded using surface electromyography should not be interpreted in the context of reporting muscle strength. Second, pelvic floor muscles and deep abdominis muscles are activated through a hypopressive exercise. However, the contraction of pelvic floor muscles seems to be greater when they are voluntarily activated; and deep abdominis muscle contraction is similar in a voluntary pelvic floor muscle contraction and in a hypopressive exercise. Last, individual physical therapy treatment based on pelvic floor muscle direct training, hypopressive exercises or a combination of both, in addition to therapeutic education and the knack maneuver, seem to be effective in symptoms reduction and pelvic floor muscles strength improvement in women with pelvic floor dysfunctions. The therapeutic adherence could be favored with effective physical therapy programs that include home exercises agreed with women and simple movements to introduce in their daily life.