Guidelines for referring patients to Physiotherapy for the treatment of Pelvic Floor Dysfunction

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1 Guidelines for referring patients to Physiotherapy for the treatment of Pelvic Floor Dysfunction N.B. Staff should be discouraged from printing this document. This is to avoid the risk of out of date printed versions of the document. The Intranet should be referred to for the current version of the document.

2 Contents: 1 Executive Summary Target Audience Aims Clinic Locations Referral mechanisms for patients with pelvic floor dysfunctions Treatment Modalities Available Inclusion criteria for referrals Adults Paediatrics Precautions/Contraindications Further Information References Appendix 1 - Key Information To Include For Patient Referral Appendix 2 - Modified Oxford Muscle grading Scale...10 Page 1

3 1 Executive Summary The Physiotherapy service in Aneurin Bevan Health Board has an established team specialising within the treatment of pelvic floor dysfunction in varying localities across Gwent. Evidence shows that incontinence can have a devastating effect on the quality of life of sufferers and is an enormous cost to the nation (Royal College of Physicians 1995). In 2000, the Department of Health published a document Good practice in continence services, which sets out a model of good practice to help providers achieve more responsive, equitable and effective continence services to benefit patients. It advocates integrated services and states that therapies, including specific pelvic floor muscle exercises, biofeedback and electrotherapy, should be available to all patients. Uk Physiotherapy works with individuals to maximise quality of life by restoring, maintaining and improving function and movement and by promoting physical approaches to optimising health, well-being and illness prevention. (CSP 2010) The core skills used by chartered physiotherapists include manual therapy, therapeutic exercise and the application of electro-physical modalities. Fundamental to the physiotherapist s approach, however, is an appreciation of the psychological, cultural and social factors which influence their clients and the patient s own active role in helping themselves maximise independence and function. NICE Guidelines (2006) state that there is evidence that pelvic floor muscle training used during a first pregnancy reduces the likelihood of post-natal urinary incontinence. Physiotherapists utilise their expertise in thorough assessment of core muscle stability as fundamental to the treatment process for this group of patients. 1.1 Target Audience This document has been produced to assist local healthcare professionals in making appropriate referrals to physiotherapists across Aneurin Bevan Health Board, who specialise in the treatment of pelvic floor dysfunction. It will assist the service in meeting the following Standards for Health Services in Wales (2010). Standard 3 - Health Promotion, Protection and Improvement Standard 7 - Safe and Clinically Effective care Standard 18 - Communicating Effectively Page 2

4 2 Aims The document aims to inform referrers about the various physiotherapy services available across the organisation that assess and treat continence problems and pelvic floor dysfunction. Key information has also been included to assist the referral process and ensure it is as streamlined as possible. 3 Clinic Locations Physiotherapy continence clinics are available for adult patients at the following sites and provide treatment for the population catchment areas identified: Royal Gwent Hospital (Newport Borough and Torfaen residents dependent on patient preferences) Nevill Hall Hospital (Monmouthshire, South Powys and Torfaen residents dependent on patient preferences) Caerphilly Miners Hospital (Caerphilly Borough residents) Ysbyty Aneurin Bevan (Blaenau Gwent and Torfaen residents- dependent on user preference) Referrers should send patient referrals to the Physiotherapy Department at each site. Paediatric Patients The service does not provide specific paediatric physiotherapy continence clinics. A specialist paediatric service is provided by the Continence Service. Paediatric physiotherapists are usually involved in assessment and treatment of positioning to assist in promotion of the normal voiding function. Their involvement is usually as part of the multidisciplinary team. Page 3

5 4 Referral mechanisms for patients with pelvic floor dysfunctions Male Specialist referral via Urologist or Urology Nurse Specialist Continence Problems Female Refer to Continence Service prior to referral to Physiotherapy Mild to Moderate Prolapse Refer to Physiotherapy at nearest site to patient s home Pelvic Pain Refer to Physiotherapy at nearest site to patient s home Faecal Incontinence Refer to Continence Service Page 4

6 Referrals can be accepted from Consultants, Continence Advisors and GPs. Referrers should use standard physiotherapy referral forms that are already in place. If these are not available locally, referrers should contact the appropriate department for your locality, as indicated in section 6, to request a copy/supply as appropriate. Physiotherapy departments are able to accept a written letter of referral if key information is included (see Appendix 1). The Service also accepts referrals from midwives and health visitors for postnatal women who meet the criteria of the Pelvic Floor Clinic pathway that is in place across the Organisation. 5 Treatment Modalities Available All of the sites identified are able to offer treatment for urinary incontinence, pelvic organ prolapse and pelvic pain. Patients also presenting with faecal incontinence as a secondary condition can be treated at all sites. The following treatment modalities are available across all identified sites Patient assessment Patient education Supervised exercise programmes Biofeedback techniques Neuro muscular electrical stimulation Manual therapy techniques 6 Inclusion criteria for referrals 6.1 Adults The Service is able to accept referrals for the following clinical conditions Urinary stress incontinence Urinary urge incontinence Mixed urinary incontinence Urinary and faecal incontinence Mild to moderate prolapse Pelvic pain Page 5

7 Referral to a Physiotherapist as part of the Aneurin Bevan Health Board integrated continence team is particularly indicated for patients that present with An Oxford muscle grading score of the pelvic floor muscle of two or below ( See appendix 2 for Oxford Grading Scale) Women who are pregnant or have delivered within the previous twelve months Referral criteria to the postnatal Pelvic Floor clinic pathway are; Heavy babies > 4.5kgs (10lbs) delivered vaginally 3 rd degree tear 4 th degree tear Pre-existing urinary/anal incontinence Postnatal urinary/anal incontinence 6.2 Paediatrics Objective examination of the pelvic floor is not routinely performed by physiotherapists on children with a continence problem under the age of 18. However it is considered appropriate to undertake objective examination and treat a child under the age of 18 presenting with pelvic floor dysfunction following childbirth, in accordance with the Aneurin Bevan Health Board Consent Policy. Physiotherapists working in the Paediatric Service are able to offer treatment and advice with regard to positioning to facilitate the normal continence mechanism. 6.3 Precautions/Contraindications Prior to making referral we encourage referrers to consider the following precautions / contraindications Known / suspected urinary retention problems It is suggested that a referral to the continence advisor/urologist is more appropriate in the first instance. However once this problem has been managed appropriately, the physiotherapist is able to assess and treat any ongoing urinary incontinence that may co-exist. Page 6

8 6.3.2 Active infection localised to the pelvic/lower abdominal area This must be addressed appropriately before the service is able to commence a treatment programme, as many treatment modalities cannot be implemented if active infection is present. If there is a history of gynaecological disease we encourage referrers to outline appropriate details and medical management as far as possible through the referral process Patients who are awaiting investigation for a potential lower abdominal malignancy or other serious medical condition These investigations should be completed before referring to the physiotherapy service as some treatments may be contraindicated Patients who have undergone treatment for a previous pelvic malignancy / abnormal cervical smear When referring this category of patient for physiotherapy, please state the known current status of the pelvic organs and whether the patient has returned to routine frequency for cervical smear testing. This helps the physiotherapist to determine whether neuro- muscular electrical stimulation can be utilised as part of the treatment plan. 7 Further Information If further guidance is required or referrers would like to discuss individual patient care prior to referral please contact the Physiotherapy Department directly and request to speak with the physiotherapist taking the lead for continence referrals. SITE Telephone No. Caerphilly Miners Hospital Nevill Hall Hospital Royal Gwent Hospital Ysbyty Aneurin Bevan Page 7

9 8 References Laycock J, Standley A, Crothers E, Naylor D, Frank M, Garside S, Kiely E, Knight S, Pearson A. (2001) Clinical Guidelines for the Physiotherapy Management of Females aged with Stress Urinary Incontinence. Chartered Society of Physiotherapy, London Chartered Society of Physiotherapy (2010), Vision for the future of UK Physiotherapy, Chartered Society of Physiotherapy, London. Department of Health (2000). Good Practice in Continence Services. Laycock J, (1994) Clinical evaluation of the pelvic floor. In: Pelvic Floor Reeducation: Principles and Practice. Eds. B Schussler, J Laycock, P Norton, S Stanton. Springler-Verlag, London Nice Guidelines (2006) Urinary Incontinence. The Management of Urinary Incontinence in Women, October Welsh Assembly Government (2010), Doing Well Doing Better : Standards for Health Services in Wales Page 8

10 9 Appendix 1 - Key Information To Include For Patient Referral CORE PATIENT DETAILS Name Address including postcode DOB Tel No. if available GP details including surgery if referral is from Primary care NHS number RELEVANT CLINICAL DETAILS / DIAGNOSIS / SYMPTOMS Should include: Duration of onset How medically managed to date for this condition Details of any ongoing significant investigations Results of any associated tests (urodynamics, urinalysis etc.) PREVIOUS MEDICAL HISTORY Should reference: Systemic disease (cardiac, respiratory, etc.) Gynaecological or urological surgical procedures of relevance Significant disabilities OTHER CONSIDERATIONS Communication difficulties Transport requirements Risk to lone worker Page 9

11 10 Appendix 2 - Modified Oxford Muscle grading Scale (Laycock 1994) 0 - represents a nil response 1 - represents a flicker 2 - represents a weak contraction 3 - represents a moderate contraction, with a degree of lift 4 - represents a good contraction and the patient is able to contract the muscle against some resistance 5 - represents a normal muscle contraction, implying a strong squeeze and lift against resistance Page 10

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