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Physical Therapy After OASIs

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Pelvic Floor, Perineal, and Anal Sphincter Trauma During Childbirth

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Abstract

Obstetric anal sphincter injuries (OASIS) increase the risk of anal incontinence (AI), thus potentially affecting a woman’s quality of life. Recent systematic reviews show limited effects of pelvic floor muscle training (PFMT) in treating postpartum AI. However, few studies are actually designed to detect changes in AI. Similarly, quantitative assessment of pelvic floor muscle function and activity tend to be lacking in previous studies, and many interventions include only verbal instruction of PFMT. There is little or no focus on dose-responses and progression in the PFMT protocols. However, studies of postpartum women that identify AI as the main outcome measure and focus on the principles of strength training show promising clinical results: reduced AI symptoms and improved pelvic floor muscle strength are reported. Not surprisingly, women with reduced function or large defects of the pelvic floor muscles and anal sphincter complex have worse outcomes than women with no or minimal defects and confirmed ability to contract their pelvic floor muscles. Furthermore, AI involves a complex interplay of muscular function, stool consistency and bowel function, and women with co-existing symptoms such as constipation, soiling or bowel evacuation problems may improve their symptoms and quality of life if treated using a combination of treatment modalities such as PFMT, laxatives and bulking agents.

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Author information

Authors and Affiliations

  1. Department of Health, Welfare and Organisation, Oestfold University College, Fredrikstad, Norway

    Hege Hoelmo Johannessen

  2. Department of Physical Medicine and Rehabilitation, Oestfold Hospital Trust, Sarpsborg, Norway

    Hege Hoelmo Johannessen

  3. Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway

    Siv Mørkved

  4. Central Norway Health Authority, Stjoerdal, Norway

    Siv Mørkved

Authors
  1. Hege Hoelmo Johannessen
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  2. Siv Mørkved
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Corresponding author

Correspondence to Hege Hoelmo Johannessen .

Editor information

Editors and Affiliations

  1. Croydon University Hospital, London, UK

    Abdul H. Sultan

  2. Croydon University Hospital, London, UK

    Ranee Thakar

  3. Obstetrics and Gynecology; Section of Urogynecology and Reconstructive Pelvic Surgery, University of Chicago, Chicago, IL, USA

    Christina Lewicky-Gaupp

Appendix: MCQ

Appendix: MCQ

Mark each item TRUE or FALSE

18.1.1 Questions

  1. 1.

    In order to optimise tissue repair, what is the current acronym that physical therapy protocols should follow in the acute, subacute and late postpartum recovery after OASI?

    1. (A)

      RICE; Rest, Ice, Compression, Elevation

    2. (B)

      PRICE; Protection, Rest, Ice, Compression, Elevation

    3. (C)

      POLICE; Protection, Optimal Loading, Ice, Compression, Elevation

    4. (D)

      PEaCE & LOVE; Protection, Elevation, (avoid anti-inflammatory drugs), Compression, Education & Load, Optimism, Vascularisation, Exercise

  2. 2.

    In the acute phase, 0–3 weeks following OASI, how should physical therapists advise women on pain management?

    1. (A)

      Encourage use of NSAID rectal suppositories, regular resting periods in comfortable and supported horizontal or side-lying positions, instruct gentle and pain-free activation of the pelvic floor muscles and ensure adequate relaxation between contractions

    2. (B)

      Encourage women to take brisk walks in fresh air and heavy lifting

    3. (C)

      Encourage 3 × 10 maximal pelvic floor contractions daily

    4. (D)

      Educate women on the benefits of endurance training

  3. 3.

    Few studies have explored the effect of physical therapy and pelvic floor muscle training after OASI, however, recent systematic reviews suggest which of the following:

    1. (A)

      Symptoms of pelvic floor disorders will get better as women grow older, apply watchful waiting

    2. (B)

      All women are at risk of postpartum pelvic floor disorders and should be referred for weekly physical therapy the first year after delivery

    3. (C)

      Targeted intervention including pelvic floor muscle training may be effective among women who have sustained an OASI or experience postpartum pelvic floor disorders

    4. (D)

      Encouragement of low-fibre diets, fluid restriction and monthly pelvic floor muscle training

  4. 4.

    In the subacute postpartum recovery phase 3–12 weeks postpartum, what are the appropriate recommendations for physical therapists to give (select all that apply)?

    1. (A)

      Encourage the patient to do correct, gentle to submaximal contractions of the pelvic floor muscles when pain-free

    2. (B)

      Initiate a daily PFMT programme of 3 × 10 contractions as able

    3. (C)

      Apply watchful waiting

    4. (D)

      Avoid physical activity in general

  5. 5.

    In the late postpartum recovery phase 3–12 months postpartum, what are the appropriate recommendations for physical therapists to give (select all that apply)?

    1. (A)

      Avoid all activities that increase the intra-abdominal pressure

    2. (B)

      nitiate a daily pelvic floor muscle training programme of 3 × 10 contractions

    3. (C)

      Progress pelvic floor muscle training by increasing the holding time, adding quick contractions, and or change starting positions

    4. (D)

      Use the “Knack” prior to activities such as sneezing, coughing and lifting

18.1.2 Answers

  1. 1.

    In order to optimise tissue repair, what is the current acronym that physical therapy protocols should follow in the acute, subacute and late postpartum recovery after OASI?

    1. (A)

      FALSE

    2. (B)

      FALSE

    3. (C)

      FALSE

    4. (D)

      TRUE

  2. 2.

    In the acute phase, 0–3 weeks following OASI, how should physical therapists advise women on pain management?

    1. (A)

      TRUE

    2. (B)

      FALSE

    3. (C)

      FALSE

    4. (D)

      FALSE

  3. 3.

    Few studies have explored the effect of physical therapy and pelvic floor muscle training after OASI, however, recent systematic reviews suggest which of the following:

    1. (A)

      FALSE

    2. (B)

      FALSE

    3. (C)

      TRUE

    4. (D)

      FALSE

  4. 4.

    In the subacute postpartum recovery phase 3–12 weeks postpartum, what are the appropriate recommendations for physical therapists to give (select all that apply)?

    1. (A)

      TRUE

    2. (B)

      TRUE

    3. (C)

      FALSE

    4. (D)

      FALSE

  5. 5.

    In the late postpartum recovery phase 3–12 months postpartum, what are the appropriate recommendations for physical therapists to give (select all that apply)?

    1. (A)

      FALSE

    2. (B)

      TRUE

    3. (C)

      TRUE

    4. (D)

      TRUE

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Johannessen, H.H., Mørkved, S. (2024). Physical Therapy After OASIs. In: Sultan, A.H., Thakar, R., Lewicky-Gaupp, C. (eds) Pelvic Floor, Perineal, and Anal Sphincter Trauma During Childbirth. Springer, Cham. https://doi.org/10.1007/978-3-031-43095-4_18

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