Factors Associated With Nonadherence to Pelvic Floor Physical Therapy Referral for the Treatment of Pelvic Pain in Women.

Abstract

Patients with pelvic pain due to pelvic floor myofascial pain syndrome are often referred for pelvic floor physical therapy, the primary treatment option. However, many patients do not adhere to the treatment. The purpose of this study was to examine the adherence rate and outcomes of patients referred for physical therapy for pelvic floor myofascial pain syndrome and identify risk factors associated with nonadherence. This was a retrospective cohort study. ICD-9 codes were used to identify a cohort of patients with pelvic floor myofascial pain syndrome during a 2-year time period within a single provider's clinical practice. Medical records were abstracted to obtain information on referral to physical therapy, associated comorbidities and demographics, and clinical outcomes. "Primary outcomes" was defined as attendance of at least 1 visit. Secondary outcomes included attendance of at least 6 physical therapist visits and overall improvement in pain. Statistical analysis was performed using chi-square, Fisher exact, and independent t tests. Nonparametric comparisons were performed using Wilcoxon signed rank test. Multivariate analysis was completed to adjust for confounders. Of the 205 patients, 140 (68%) attended at least 1 session with physical therapy. At least 6 visits were attended by 68 (33%) patients. Factors associated with poor adherence included parity and a preexisting psychiatric diagnosis. The odds of attending at least 1 visit were 0.75 (95% confidence interval=0.62-0.90) and 0.44 (95% confidence interval=0.21-0.90), respectively. Patients who attended ≥ 6 visits were more likely to have private insurance (78%) and travel shorter distances to a therapist (mean=16 miles vs 22). Patients with an improvement in pain (compared with those who were unchanged) attended an average of 3 extra physical therapist visits (mean=6.9 vs 3.1). Limitations include reliance on medical records for data integrity; a patient population derived from a single clinic, reducing the generalizability of the results; the age of the data (2010-2012); and the likely interrelatedness of many of the variables. It is possible that maternal parity and psychiatric diagnoses are partial surrogates for social, logistic, or economic constraints and patient confidence. Initial adherence to pelvic floor physical therapy was less likely for multiparous women and women with a history of psychiatric diagnosis. Persistent adherence was more likely with private insurance or if the physical therapist location was closer. Pain improvement correlated with increased number of physical therapist sessions.