Stretching and Splinting Interventions for Poststroke Spasticity, Hand Function, and Functional Tasks: A Systematic Review.

IMPORTANCE: Spasticity is one of the most common and disabling motor impairments after stroke. OBJECTIVE: To examine the evidence for the effectiveness of stretching interventions, including splinting, on reducing upper extremity spasticity, increasing hand function, and improving functional tasks for adults with poststroke spasticity. DATA SOURCES: Databases searched were MEDLINE, CINAHL, OTseeker, AgeLine, and the Cochrane Library; results were limited to studies published from 2004 to January 2017. STUDY SELECTION AND DATA COLLECTION: Following PRISMA guidelines, we included articles describing Level I-III studies with participants who were adults with upper extremity spasticity and received a stretching intervention. FINDINGS: Eleven articles describing 6 Level I and 5 Level III studies met inclusion criteria. CONCLUSION AND RELEVANCE: For reducing upper extremity spasticity, low strength of evidence was found to support the use of static splinting, strong strength of evidence was found for the use of stretching devices, and low strength of evidence was found to support the use of dynamic splinting; no evidence was found for manual stretching to address spasticity. For increasing hand function, moderate strength of evidence was found to support the use of static splinting, dynamic splinting, and manual stretching, and low strength of evidence was found for the use of stretching devices. For improving functional tasks, moderate strength of evidence was found to support the use of static splinting, dynamic splinting, and manual stretching, and low strength of evidence was found for the use of stretching devices. WHAT THIS ARTICLE ADDS: This updated synthesis summarizes the current literature regarding the effectiveness of stretching interventions to improve poststroke spasticity, hand function, and functional tasks.

Prevalence and risk factors of fecal incontinence in women undergoing stress incontinence surgery.

OBJECTIVE: The objective of the study was to determine the prevalence and identify potential risk factors for monthly fecal incontinence (FI) in women presenting for stress urinary incontinence (UI) surgery. STUDY DESIGN: From 655 women enrolled in the Stress Incontinence Surgical Treatment Efficacy Trial, baseline data were analyzed. FI was defined as occurring at least monthly. Independent variables included sociodemographics, health status and history, physical examination, and validated UI questionnaires. Multivariable logistic regression models compared women with FI with women with only UI. RESULTS: Prevalence of monthly FI was 16%, 10% for liquid stool, and 6% for solid stool. In multivariable analysis, increased risk of FI was associated (odds ratio, 95% confidence interval) with decreased anal sphincter contraction (4.5, 2.0 to 10.4), perimenopausal status (2.4, 1.1 to 5.0), prior incontinence surgery/treatment (1.8, 1.1 to 2.9), and increased UI bother (1.1, 1.1 to 1.2). CONCLUSION: Women enrolled in a stress UI surgical trial have high rates of monthly FI and further evaluation of FI symptoms may be warranted.

Clinical and demographic factors associated with valsalva leak point pressure among women undergoing burch bladder neck suspension or autologous rectus fascial sling procedures.

AIMS: Many parameters have been utilized to try to estimate severity of stress urinary incontinence (SUI). Valsalva leak point pressure (VLPP) measurements, have been proposed as a reliable means of gauging the severity of SUI during urodynamic studies (UDS). Certain, non-invasive, measures of incontinence severity have been proposed, but the correlation of these measures with VLPP is not known. In addition, the correlation of other important UDS measures and VLPP has not been evaluated. In this study we sought to define the relationship between demographic characteristics, physical exam findings, and non-sphincteric UDS measures with VLPP in a large multicenter randomized surgical trial comparing Burch urethropexy and fascial sling for the treatment of SUI. MATERIALS AND METHODS: Pre-surgical, standardized urodynamic measures were obtained in all participants in the Stress Incontinence Treatment Efficacy Trial (SISTEr) trial. All UDS were assessed for quality assurance and protocol compliance. VLPP was assessed using a <8 Fr water transducer catheter during graded Valsalva maneuvers at 200 ml, and then at 100 ml intervals and bladder capacity if no SUI was noted earlier. Only data from women who had SUI on at least two of three consecutive valsalva maneuvers was utilized for this analysis. Delta VLPP was determined as the average value, and the baseline vesical pressure was subtracted from the absolute vesical pressure to arrive at the reported VLPP value. Independent variables studied to assess their relationship to VLPP value included demographic characteristics (age, number of pregnancies, # vaginal deliveries, hormone usage, previous hysterectomy, previous SUI surgery), physical exam parameters [body mass index--BMI, Pelvic Organ Prolapse-Quantified POPQ stage, POPQ Aa measurement, Q-tip angle (rest) and Q-tip angle (strain), and change in angle], and other urodynamic parameters (volume of first leakage, volume at first sensation, presence of detrusor overactivity, maximum cystometric capacity--MCC, maximum flow rate--Q(max), and detrusor pressure at maximum flow rate--pdet.Q(max)). RESULTS: Among the 655 women randomized, 424 were found to have evaluable VLPPs. Thirty-four had stage 3 or 4 prolapse and were excluded from the VLPP analysis. The remaining 390 women had a mean VLPP of 81.1 cm H(2)O. On bivariate analysis, there were significant positive associations with VLPP and BMI (P = 0.026), Q-tip straining angle (P = 0.0002) change in Q-tip angle (P = 0.0046), MCC (P < 0.0001) and pdet.Q(max) (P = 0.0003). Age was negatively associated with VLPP (P < 0.0001). For categorical values, lower POPQ stage (0/1), post menopausal status, and use of hormones were all associated with lower VLPP values. For example, patients with stage 2 had, on the average, VLPP values that were more than 10 cm H(2)O greater than those with stage 0/1. On multivariate analysis, however, only lower age, greater BMI, greater MCC, greater pdet.Q(max), and lower Q(max) were found to be independent associated with higher delta VLPP. CONCLUSIONS: Advancing age, lower BMI, higher maximum flow rate, and lower voiding pressures are all independently associated with lower VLPP in women undergoing surgery for SUI. Lower voiding pressures and higher flow rates among women with more severe SUI may reflect the chronic loss of urethral resistance associated with SUI. Interestingly, urethral hypermobility as assessed by Q-tip testing angle does not achieve a statistically significant association with VLPP on multivariate testing when controlling for POP-Q stage. Thus, as clinically suspected, the Q-tip test is not predictive of VLPP in women with urethral hypermobility and SUI.

Pelvic organ prolapse in nulliparous women and their parous sisters.

OBJECTIVE: To investigate the role of vaginal delivery and familial factors in the development of pelvic organ prolapse by comparing the prevalence of this condition in nulliparous women and their parous sisters. METHODS: Pairs of nulliparous and parous postmenopausal sisters were recruited for assessment of pelvic organ prolapse. One hundred one sister pairs underwent clinical evaluation. Pelvic organ prolapse was recorded using the Pelvic Organ Prolapse Quantification System. RESULTS: The majority of women had no pelvic organ prolapse. By compartment there was a 74.3% to 91.1% concordance in prolapse stage within sister pairs. In discordant sister pairs, the parous sister was found to have the more advanced prolapse 88% of the time. CONCLUSION: High concordance of pelvic organ prolapse in nulliparous and parous sister pairs suggests a familial predisposition toward developing this condition. However, vaginal delivery does appear to confer a risk for more advanced pelvic organ prolapse. LEVEL OF EVIDENCE: II-2.

Urinary incontinence in nulliparous women and their parous sisters.

OBJECTIVE: To investigate the role of vaginal delivery and familial factors in the development of urinary incontinence by comparing the prevalence of this condition in nulliparous women and their parous sisters. METHODS: A sample of 143 pairs of nulliparous/parous postmenopausal sisters completed a comprehensive questionnaire regarding symptoms of pelvic floor disorders. Of these, 101 pairs underwent clinical evaluation of urinary incontinence and genital prolapse. RESULTS: Among this sample of biological sisters, urinary incontinence was reported by 47.6% of nulliparous women and by 49.7% of parous women (P = .782). We found no difference in the severity or type of urinary incontinence between these 2 groups. There was a high concordance in continence status, however, within biological sisters. CONCLUSION: Vaginal birth does not seem to be associated with urinary incontinence in postmenopausal women. Considering the high concordance in continence status between sister pairs, and considering that the majority of parous women are continent, an underlying familial predisposition toward the development of urinary incontinence may be present.

Bulking agents in the treatment of stress urinary incontinence: history, outcomes, patient populations, and reimbursement profile.

Stress urinary incontinence (SUI) can be defined as involuntary loss of urine during a period of increased abdominal pressure and in the absence of detrusor activity. Bulking agents used in the urethra are one of the newer but established technologies for the treatment of SUI. An understanding of the demographics of SUI will help in the selection of patients for bulking agent therapy. Knowledge of available materials, including their positive and negative aspects, is also required. Autologous fat, silicone beads, collagen, carbon particles, and polytetrafluoroethylene paste have all demonstrated success to some degree, but none have met both criteria for success (remaining efficacious over time and maintaining a low side-effect profile). An implantable solution of ethylene vinyl alcohol suspended in dimethyl sulfoxide, currently in clinical testing and review, shows minimal foreign body reaction and is one option being investigated to address patient needs for improved bulking therapy.