Physiotherapy - Theses
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ItemPelvic floor disorders in exercising women( 2023-09)Physical inactivity is a global societal and economic burden, increasing the risk of chronic disease. Women participate in organised sports at lower rates than men and 86% of Australian women do not meet all components of the National Physical Activity Guidelines. Sport and exercise activities may provoke symptoms of pelvic floor (PF) disorders. Pelvic floor symptoms are highly prevalent in exercising women. One in three women report symptoms of urinary incontinence (UI) across all sports and up to 80% of women engaging in high impact sports or heavy weight-lifting report UI and/or anal incontinence (AI). It is therefore important to understand how PF symptoms limit or stop exercise participation in women. The thesis research aimed to: establish the impact of female PF symptoms (UI, AI and pelvic organ prolapse) on sport and exercise participation; determine current PF symptom screening and management within Australian sport and exercise settings; and explore the preferences, barriers and enablers for future PF symptom screening and management within sport and exercise settings from the perspectives of exercising women and health or exercise professionals. Study One was a systematic review of the impact of PF symptoms on sport and exercise. Whilst UI adversely impacted exercise in one in two women, the evidence certainty was low. Important gaps in the knowledge of other PF symptoms (beyond UI) and the degree and nature of impact of all PF symptoms on participation were established. Study Two, an observational, cross-sectional study of 4,556 Australian women with PF symptoms, examined the research gaps determined by systematic review. One in two women stopped a form of exercise they had previously participated in, secondary to PF symptoms. A secondary data analysis (Study Two, Part B) found that women with more severe UI symptoms (OR=4.77; 95% CI:7.24 to 14.37), and higher bother (UI: OR=10.19; 95% CI:7.24 to 14.37; POP: OR=22.38; 95% CI:13.0 to 36.60; AI: OR=29.66; 95% CI: 7.21 to 122.07) were at greater odds of identifying their PF symptoms as a barrier stopping participation (often or all the time). Study Three, a qualitative descriptive study, interviewed symptomatic women (n=23) about their experience of PF symptoms within sport and exercise settings. Symptoms inhibited their ability to participate in exercise in the manner they wanted. Restrictive and complex coping strategies were used to avoid symptom provocation, which limited their spontaneity and enjoyment of sport and exercise. Study Four, an observational, cross-sectional survey study completed by Australian health and exercise professionals (n=636), found that PF symptom screening was not common practice within Australian sports and exercise settings, especially in at-risk groups such as high-impact athletes. Professionals were willing to engage in future screening and management, but required training, resources and access to referral networks prior to implementation. Study Five, an explanatory-sequential mixed methods design, synthesised quantitative and qualitative data (‘following a thread’) exploring symptomatic women’s experience of PF symptom disclosure and screening within sports and exercise settings. Most women had not told anyone about their symptoms due to embarrassment, limited pelvic health knowledge or not being asked. Women conveyed important preferences for future screening and management of PF symptoms within sports settings, including recommendations for how to start a conversation on pelvic health in an acceptable manner. Additional factors to facilitate disclosure, and make sports and exercise settings safer and more inclusive for symptomatic women were explored. Together, this thesis established that PF symptoms stop women from participating in sports and exercise in their preferred manner, limiting enjoyment and increasing the odds of physical inactivity. Currently, women are not usually provided the opportunity to seek help for their symptoms within sports and exercise settings. However, women and professionals felt that the provision of screening, education and management would be acceptable if appropriate support was provided and sensitively and safely implemented.
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ItemPelvic floor disorders after gynaecological cancer treatment( 2023-05)Gynaecological cancers are the third most common type of cancer in women, accounting for 16% of cancers diagnosed in women worldwide. They include endometrial, cervical, ovarian, vulval, vaginal and fallopian tube cancers. The most common treatments for gynaecological cancer are surgery, most frequently hysterectomy, radiotherapy and chemotherapy. The sequelae of gynaecological cancer treatments impose a substantial burden on survivors and society. Gynaecological cancer survivors experience high rates of pelvic floor disorders, such as urinary incontinence, faecal incontinence and dyspareunia. However, many gynaecological cancer care pathways do not include screening for pelvic floor disorders, or only include screening and referral for sexual dysfunction, but not other pelvic floor disorders. Pelvic floor muscle training, an evidence-based treatment for urinary incontinence, faecal incontinence and dyspareunia in other populations, is currently not recommended in gynaecological cancer care pathways. More data are needed on the prevalence, history and experience of pelvic floor disorders in gynaecological cancer survivors, and the feasibility and effectiveness of pelvic floor muscle training in this population, before such recommendations can be included in gynaecological cancer care pathways. Therefore, this thesis aimed to investigate the prevalence and natural history of pelvic floor disorders after gynaecological cancer treatment, the experience of gynaecological cancer survivors with pelvic floor disorders and their preferences for treatment, and the feasibility and efficacy of pelvic floor muscle training for treating pelvic floor disorders in gynaecological cancer survivors. Study One documented the prevalence of pelvic floor disorders, including urinary incontinence, after gynaecological cancer surgery and involved the assessment of pelvic floor symptoms, health-related quality-of-life and physical activity before and after hysterectomy with or without radiotherapy or chemotherapy for gynaecological cancer. This study used psychometrically sound patient-reported outcomes completed before or in the first week after surgery, 6-weeks after surgery and 3-months after surgery. The prevalence of urinary incontinence and faecal incontinence were high, and rates of sexual activity were low both before and after surgery. Adjuvant therapy (radiotherapy or chemotherapy) was associated with increased odds of having moderate-to-very severe urinary incontinence. Symptoms of pelvic floor disorders 3-months after hysterectomy were associated with lower health-related quality-of-life, but not lower physical activity levels. These findings suggest that clinicians working with gynaecology-oncology patients undergoing hysterectomy may need to consider screening and offering treatment options for pelvic floor disorders. Study Two, a qualitative study, explored the experiences of gynaecological cancer survivors with pelvic floor disorders, and gynaecology-oncology clinicians. This included their attitudes to screening and management of pelvic floor disorders, and their perceptions of barriers and enablers to treatment for pelvic floor disorders after gynaecological cancer treatment. Differences between what participants had experienced and what they felt should happen highlighted a perceived need to improve the screening and management for pelvic floor disorders. Barriers to screening, disclosure and management of pelvic floor disorders identified by both gynaecological cancer survivors and clinicians included patients feeling unwell, emotional, and overwhelmed with the logistics of oncology appointments. Gynaecological cancer survivors also identified discontinuity of care as a barrier to disclosure of pelvic floor disorders, while clinicians identified time pressure as a barrier to screening for pelvic floor disorders. Enablers to screening, disclosure and management of pelvic floor disorders identified by both by gynaecological cancer survivors and clinicians included the patient-clinician relationship and patient agency. Opportunities for improving management included integrating nursing and pelvic floor physiotherapy with oncology appointments and providing streamlined referral pathways for treatment. Gynaecological cancer survivors and clinicians were supportive of integrated treatment pathways for pelvic floor disorders after gynaecological cancer treatment. Study Three was a systematic review and meta-analysis of conservative pelvic floor muscle therapies for pelvic floor disorders after gynaecological cancer treatment. Five randomised controlled trials and two cohort studies were identified, with moderate-level evidence that pelvic floor muscle training with core exercises (i.e. strengthening deep abdominal pelvic floor muscles, diaphragmatic breathing, and stretching of pelvic girdle muscles) or yoga improves health-related quality-of-life and sexual function, and very low-level evidence that high frequency of vaginal dilator training may reduce vaginal complications after treatment for endometrial and cervical cancer. There were insufficient data for meta-analysis of the effect of conservative pelvic floor therapies on bladder or bowel function. Given the levels of evidence found, a need for further high-quality studies was identified, especially studies investigating conservative pelvic floor muscle therapies for urinary and/or faecal incontinence after gynaecological cancer treatment. Study Four, a cohort clinical trial, investigated the feasibility of recruiting to and delivering a pelvic floor muscle training intervention via telehealth to treat urinary and/or faecal incontinence after gynaecological cancer surgery. Participants underwent a 12-week physiotherapist-supervised telehealth-delivered pelvic floor muscle training program. The intervention involved seven videoconference sessions with real-time feedback using an intra-vaginal biofeedback device, and a daily home pelvic floor muscle training program. Outcomes of high consent rates, participant engagement and retention, and self-reported acceptability and satisfaction support the feasibility and acceptability of telehealth-delivered pelvic floor muscle training to treat urinary and/or faecal incontinence after gynaecological cancer treatment. In conclusion, the findings of this thesis indicate that patients experienced high rates of pelvic floor disorders before and after gynaecological cancer. Gynaecological cancer survivors wanted more information on pelvic floor disorders and gynaecological cancer survivors and clinicians were supportive of integrated treatment pathways for pelvic floor disorders after gynaecological cancer treatment. There is emerging evidence for pelvic floor muscle training to improve health-related quality of life and sexual function for gynaecological cancer survivors. There is insufficient evidence for pelvic floor muscle training to improve urinary and/or faecal incontinence after gynaecological cancer treatment, however pelvic floor muscle training delivered via telehealth may be feasible and acceptable in this setting. The findings of this thesis have already informed the design of a large randomised controlled trial (ANZCTR registration ACTRN12622000580774) to investigate the clinical efficacy of pelvic floor muscle training delivered via telehealth for urinary incontinence after gynaecological cancer treatment. Future research should investigate which subgroups of patients with gynaecological cancer (e.g. type of gynaecological cancer, stage of cancer or treatment type/combinations) are most at risk of experiencing pelvic floor disorders, and which aspects of intervention (e.g. in-person or telehealth, starting before or after cancer treatment, using pelvic floor muscle training alone or multimodal pelvic floor physiotherapy interventions) provide the most feasible and effective treatment for pelvic floor disorders after gynaecological cancer treatment.
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ItemPelvic floor disorders in women with breast cancer( 2022)Problems related to bladder, bowel, sexual and pelvic floor (PF) muscle function are collectively termed PF disorders. Previous literature suggests that women with breast cancer may experience PF disorders at higher rates following cancer treatment than prior to cancer treatment. A causal pathway for this observation has not been clearly established. Pelvic floor muscle training (PFMT), the first-line management for treating PF disorders such as urinary incontinence (UI) and pelvic organ prolapse (POP), currently does not appear in breast cancer clinical care pathways. More data about PF disorders in women with breast cancer are required before PFMT can be included in clinical care pathways. Therefore, the aim of this thesis was to investigate PF disorders in women with breast cancer. While the abrupt precipitation of female sexual dysfunction (FSD) after breast cancer treatments is well documented, much less is known about bladder and bowel symptoms in this population. Study one, a systematic review and meta-analysis, assessed the prevalence and impact of bladder and bowel disorders in women with breast cancer. Results showed that 33% of women with breast cancer reported experiencing bladder disorders and 18% reported bowel disorders. The impact of bladder and bowel disorders in studies that used cancer-specific questionnaires was rated as low. Further studies using validated PF-specific questionnaires are required to assess the prevalence and impact of PF symptoms in this population. To address the research gap identified in the previous study, study two, a cross-sectional study, was conducted to compare the prevalence, distress and impact of PF disorders between women with and without breast cancer. Women in this study with breast cancer had a higher prevalence (although not significant) of UI, and significantly higher distress and impact of UI compared to women without breast cancer. These findings highlight that more studies are needed to understand which subgroups of women with breast cancer (e.g., women who have undergone a specific type of cancer treatment such as chemotherapy) may be most at risk of developing these symptoms. Study three, a secondary analysis of data collected as part of the previous cross-sectional study (study 2), was conducted to determine the prevalence of PF disorders according to breast cancer characteristics such as breast cancer stage and treatment type. Women in this study who underwent chemotherapy experienced the highest rates of UI (79%) and FI (24%) although this association was not statistically significant. The impact of PF disorders also appeared to increase with more time after breast cancer diagnosis. This demonstrates that the screening and treatment of PF disorders may be indicated as women enter the survivorship phase of their cancer recovery. Sexual dysfunction is another symptom that has been reported to have long-term negative impacts in women with breast cancer. Sexual function in women with breast cancer who experience UI has not been investigated. Study four, a matched control study using data collected as part of study two, compared the prevalence and severity of sexual dysfunction in matched women with and without breast cancer who experienced UI. Women who participated in this study with breast cancer and experience of UI reported significantly higher rates and severity of sexual dysfunction than women with UI of the same age, body mass index and parity without breast cancer. This finding adds to the existing body of literature that highlights the burden of FSD in women with breast cancer, and implies that clinicians may wish to consider the impact of UI when addressing FSD in this population. Study five, a cross-sectional study, compared the PF muscle function in women with and without breast cancer. The group of women in this study with breast cancer had reduced PF muscle strength and poorer relaxation ability compared to women without breast cancer. This suggests that PF therapies such as PF muscle training or relaxation techniques may be a therapeutic target to improve PF muscle function in women with breast cancer. Additionally, there is a need to better understand whether women with breast cancer who experience PF disorders are interested in seeking treatment for these symptoms during, or after breast cancer treatment. Study six, a qualitative study, explored the experiences of women with breast cancer who had PF disorders, and their perceived enablers and barriers to the uptake of treatment for PF disorders during their breast cancer recovery. Women in this study were divided as to whether they felt resigned to, or bothered by PF disorders. Their reactions to the experiences of PF disorders acted as a barrier or enabler to accessing treatment for PF disorders. For those who are interested in treatment for their symptoms, further research is required to investigate whether PF muscle therapies are a feasible treatment option for women with breast cancer. No trials to date have tested the feasibility of implementing a PFMT program in women with breast cancer. Study seven, a pilot clinical trial, assessed the feasibility of recruiting into a PFMT delivered via telehealth to treat UI in women with breast cancer. Women underwent a 12-week individualised PFMT program using a home-based intra-vaginal pressure biofeedback device (femfit). The consent rate was 100%. A significant decline in the prevalence, frequency and severity of UI was observed in this feasibility study following treatment. Pelvic floor muscle strength increased significantly from pre- to post-intervention, a mean difference of 4.8 mmHg (95%CI 3.9, 5.5). This indicated that PFMT delivered via telehealth may potentially be beneficial in treating UI, particularly stress UI in women with breast cancer. In conclusion, the findings of this thesis highlight that women with breast cancer may experience PF disorders, particularly UI, at a higher magnitude than women without breast cancer. Women with breast cancer who are bothered by their PF symptoms are interested in receiving information and treatment for PF disorders. This indicates that there may be a role of PF physiotherapy in addressing PF disorders in this population. While further research is required, these findings present an opportunity to place PF physiotherapy in breast cancer care pathways to ultimately improve the quality of life in women with breast cancer.