A study to evaluate the effect of manual therapy and exercise on the levator plate in women with pelvic organ prolapse.

Introduction

Pelvic organ prolapse (POP) symptoms, severity and pelvic floor muscle (PFM) strength have been shown to improve significantly with pelvic floor muscle training (PFMT). In this study, a new approach to conservative treatment of POP was investigated by the addition of manual physiotherapy to conventional PFMT.

Aim & Objectives

The aim of this study was to investigate the effect of internal manual therapy and PFMT on the levator plate angle (LPA) in women with stage I or II POP and to investigate the effect of this intervention on stage of POP, POP symptoms and quality of life (QoL). A further objective was to examine inter-tester reliability for MRI measurement in POP.

Methods

A same-subject pre and post test experimental study was undertaken with a sample of 12 subjects with stage I or II POP. MRI measurements as well as POP-Q score, symptom and QoL questionnaires were used as outcome measures before and two weeks after treatment. All subjects received the same intervention including internal manual therapy to the levator plate and muscles and a pelvic floor exercise programme. Pre and post intervention means were analysed using paired t tests for MRI measurements and for POP-Q anterior vaginal wall point, Aa and posterior vaginal wall point, Ap. Wilcoxon signed rank test was used for all other POP-Q measurements. Questionnaire data were analysed using non parametric Wilcoxon signed rank test due to the presence of an outlier. Reliability was calculated using intra-class correlation coefficients (ICC) and Bland and Altman plots were performed.

Results

There was no change in the LPA following the intervention. However, the H line significantly widened by mean 6.98mm (p=0.01). There was a significant improvement in POP-Q stage (p=0.02), with anterior wall point Aa of the POP-Q showing the greatest improvement; becoming higher by 1.75 cm (p=0.00). Point Bp showed a significant change in the opposite direction, demonstrating greater descent on valsalva after treatment by -0.67 cm (p=0.00). The predominant leading edge of prolapse changed from cystocele before treatment to rectocele after treatment. The overall result was an improvement in prolapse stage in a positive direction. The International Consultation Incontinence Questionnaire-Vaginal Symptoms score (ICIQ-VS), ICIQSexual Matters score and QoL score were significantly improved (p=0.01, p=0.02, p=0.00). Inter-rater reliability for LPA measurement was moderate-strong for LPA (ICC 0.80) and for bladder (ICC 0.76). Bland and Altman plots revealed acceptable mean differences for LPA, bladder neck and H line.

Conclusions & Implications

Manual therapy and PFMT intervention did not change the LPA in women with stage I or II POP but significant improvements in POP-Q score, point Aa, ICIQ-VS and QoL were found. These changes are highly clinically significant in the light of the importance of patient's symptoms in clinical evaluation of POP. Inter-rater reliability of MRI measurements was moderate-strong for two of the six measures. Clinical application of these LPA and bladder neck measures cannot be recommended at this time and further psychometric testing is required. The improvement seen in POP-Q, symptoms and QoL in this small group warrants further investigation of this novel intervention in a randomised controlled trial.