Manual Fascial Manipulation in Pregnant Women
Manual Fascial Manipulation in Pregnant Women
Pregnancy and vaginal delivery are considered as the main risk factors for damage to the
 pelvic floor. There are various ways to measure the strength of the pelvic floor and to
 evaluate functional problems. Manual mobilization of the pelvic floor is a well-known
 treatment modality, however, ample knowledge exists on the efficacy of physiotherapy and
 exercise for improvement of pelvic floor function and strength. The aim of this study is to
 analyze the influence of pelvic floor fascial mobilization (PFFM) technique on the function
 and strength of the pelvic floor muscles as well as parameters presumed to be influenced by
 the strength of the pelvic floor in pregnant women.
Pregnancy and vaginal delivery are considered as the main risk factors for damage to the
 pelvic floor at various degrees, starting at mild stress incontinence and up to fool fecal
 incontinence as well as pelvic pains or urination difficulties.

 There are various ways to measure the strength of the pelvic floor and to evaluate functional
 problems. Measured the strength of the pelvic floor muscles by physical examination according
 to Oxford Grading Scale (scale of 0-5) as well as by using Perineometer device, were equally
 efficient and well correlated. Other modalities such as the use of surface electro myography
 (EMG), that presents the level of the muscle electrical activity and expiration volumes and
 the strength of the pelvic floor muscles were also positively correlated to the strength of
 the pelvic floor. Recent studies presented dysfunction of pelvic floor during pregnancy as
 well as in the postpartum period by the use of pelvic floor disability index 20 (PFDI20)
 questionnaire validated in Hebrew.

 Ample knowledge exists on the efficacy of physiotherapy and exercise for improvement of
 pelvic floor function and strength, however, prolonged and continuous exercise is needed to
 achieve good results as well as compliance and perseverance. The long-term effect is
 unwieldly.

 Manual mobilization of the pelvic floor is a well-known treatment modality. However the
 literature regarding the effect of this technique is sparse. A recent series of case reports
 presented immediate and major improvement of pelvic floor dysfunction after manual
 mobilization. The peripartum period is critical for the function of the pelvic floor however
 the yield of manual therapy on function and strength of the pelvic floor was not evaluated in
 pregnant women. We hypothesize that manual therapy can improve the strength and the function
 of the pelvic floor within a short time span and this can be objectively measured by common
 and well used parameters The aim of this study is to analyze the influence of pelvic floor
 fascial mobilization (PFFM) on the function and strength of the pelvic floor muscles as well
 as parameters presumed to be influenced by the strength of the pelvic floor in pregnant women

 Materials and methods

 The study will involve number of phases:

 Phase one: Screening and enrollment of patients Women followed at the high risk pregnancy
 clinic at the Sheba medical center, who carry singleton pregnancy at the ages of 20-45 years
 old and about to have their 2nd to 4th delivery (primiparous and multiparous women) will be
 examined for the following parameters: demographic and medical data, focused interview for
 symptoms of pelvic floor dysfunction including urination and fecal function as well as pelvic
 floor pain, manual assessment according the Oxford grading scale will be performed, and the
 strength of the pelvic floor measured by the use of Perineometer (Peritron 'AV' Combined Anal
 & Vaginal Perineometer NEW MODEL). Other parameters that will be measured include:
 mobilization of the pelvic-femoral joint, Forced expiratory volume 1 (FEV1) (a connection was
 shown between FEV1, intraabdominal pressure and the strength of the pelvic floor, assessment
 of vocal quality ( analyzed by communication clinician, repeat assessment will be performed
 after two weeks and after 4 weeks, estimated assessment time - 20 Min) 80 women are expected
 to be enrolled.

 Phase Two Women who will fulfill one or more of the following parameters will be enrolled to
 the second phase of the study . (n=40)

 1. Oxford grading scale ≤3/5

 2. Pelvic floor strength assessed by perineometer≤ 30 cm/h20

 3. Clinical symptoms of urine, flatus or fecal incontinence

 4. Pelvic floor, hip joint or pelvic joints pain

 Randomization will be performed to one of two groups:

 Group A-Control group (n=20) Group B-Study group (n=20) Guidance towards exercise for
 strengthening of the pelvic floor will be provided for both groups. Study group will be
 treated manually for the pelvic floor in two sessions two weeks apart. The manual
 manipulation of the pelvic floor will involve intra vaginal superficial as well as pelvic
 skin area pressure points. The manipulation will not involve the cervix uterus or rectum.
 Each session will lasts one hour

 Both groups will be assessed by ultrasound for blood flow in the middle cerebral artery,
 umbilical artery and uterine artery as part of the parameters that may show benefit to the
 fetus due to pelvic floor mobilization.

 Reassessment of all the women and repeat treatment for the study group will be performed
 after two and four weeks from the primary assessment.

 The study will be performed at a high risk pregnancy clinic at the Sheba medical center.
 Women will be enrolled voluntarily with no financial benefit.
Inclusion criteria:

 1. Age 20-45 years old

 2. Gestational age 24-30 weeks gestation

 3. Singleton pregnancy

 4. Expected second-4ourth delivery

 Exclusion criteria

 1. First delivery

 2. Gestational age at more than 30 weeks gestation at enrollment

 3. Premature contractions

 4. Cervical insufficiency

 5. Placenta previa

 6. Placenta accrete

 7. Multifetal pregnancy

 8. Maternal chronic illness including connective tissue disease, neurological illness