Jan 23, 2018 - best scientifically supported techniques, while journals pub- lish new knowledge every day. Classic articles [4] tend to compile what many ...
International Urogynecology Journal https://doi.org/10.1007/s00192-018-3573-y
REVIEW ARTICLE
Classic papers on pelvic floor physiotherapy: the most frequently cited articles in three decades (1983–2013) Alexandre Fornari 1 & Cristiane Carboni 2 Received: 23 October 2017 / Accepted: 23 January 2018 # The International Urogynecological Association 2018
Abstract Introduction and hypothesis Pelvic floor physiotherapy has been utilized extensively over the past decades for the treatment of pelvic floor dysfunctions. The aim of this study was to identify and characterize the most frequently cited articles on pelvic floor physiotherapy published in the last 30 years. Methods A PubMed search of all articles published between 1983 and 2013 was performed. Articles with more than 100 citations were identified as Bclassic,^ and were further analyzed based on author names, year of publication, journal of publication, subject, study design, country of research, and number of citations. In 2017, a new search for papers on pelvic floor physiotherapy was conducted using the same methods to compare them with the 2013 data. Results Of 1,285 articles published between 1983 and 2013, only 20 articles were cited more than 100 times. Among them, we found 12 randomized clinical trials (RCTs) and only 4 reviews. The most common topics among the classic articles were behavior therapy, pelvic floor muscle training (PFMT), biofeedback-assisted PFMT, and neuromuscular electrical stimulation. In 2017, we found 1,745 papers containing the term Bpelvic floor physiotherapy,^ indicating an increase of around 35% in 4 years. Conclusions Although there is a fast-growing number of publications, we still have few classic papers on pelvic floor physiotherapy, concentrated in a few research centers. However, the large number of RCTs shows that these papers have a high scientific level, confirming that they can be classified as classic papers. Keywords Classic article . Pelvic floor . Physiotherapy
Introduction As knowledge on pelvic floor physiotherapy advances significantly, it is increasingly important to understand the history of this field, particularly the issues and trends that have influenced clinical practice over the past decades [1]. The multidisciplinary approach to pelvic floor dysfunction is the best treatment for this type of disease and is recommended by all of the main international societies [2]. Physical therapists are professionals qualified to treat pelvic floor muscle dysfunctions using conservative management techniques. These include behavior therapy, pelvic floor muscle training (PFMT),
* Alexandre Fornari
1
Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil
2
Inspirar College, Porto Alegre, RS, Brazil
biofeedback-assisted PFMT and neuromuscular electrical stimulation. Research indicates that conservative management is effective in treating conditions associated with pelvic floor dysfunctions [3], but it is important to identify which are the best scientifically supported techniques, while journals publish new knowledge every day. Classic articles [4] tend to compile what many consider to be seminal pieces of work that help us to understand the historical context of a specific field of study, in addition to research traditions and the development of knowledge. Usually, an article that has been cited more than 100 times is considered a Bclassic^ [5]. In other words, in a world where health professionals rely on evidence-based medicine to support their clinical practice, it is important to know the origin of such evidence, which often comes from classic articles. This study was aimed at identifying classic articles on pelvic floor physiotherapy published in indexed journals to gain an insight into the types of publications that have had an impact on clinical practice in the field of urogynecological physiotherapy in the last 30 years.
Int Urogynecol J
Materials and methods We performed a search for classic papers using the database of the US National Library of Medicine and the PubMed search engine [6]. The search term used was Bpelvic floor physiotherapy,^ and the papers retrieved spanned from January 1983 to September 2013. We used the descriptive term Bpelvic floor physiotherapy^ because this was the most precise descriptor in the MeSH database. Citation frequency was determined by accessing the Institute for Scientific Information (ISI) [7] database via the Science Citation Index Expanded (SCI) and the Journal Citation Reports [8]. Papers with more than 100 citations were considered Bclassic^ papers and were included in a table for further analysis. Data collected were number of citations, authors, journal of publication, country of research, main subject, year of publication, and methodological aspects of the paper (study design). In June 2017, we determined the number of papers related to the term Bpelvic floor physiotherapy^ using the same methods to compare them with the 2013 data. The present study does not need IRB approval because study data were obtained from articles freely available on the internet instead of being directly collected from patients or institutions.
Results In September 2013, we retrieved 1,285 articles related to the term Bpelvic floor physiotherapy^, but only 20 of them were considered classics as per the previously specified criteria of having 100 citations. These papers included 12 randomized clinical trials (RCT), 1 experimental study, 1 case–control study, 2 clinical studies that did not meet the criteria for an RCT, and 4 reviews. Subject-wise, the papers were divided into behavior therapy and bladder training (4 papers), neuromuscular electrical stimulation (4 papers), biofeedbackassisted PFMT (4 papers), PFMT (5 papers), and other subjects (3 papers). Nine papers had the participation of one of two authors, Bø and Burgio, from Norway and the USA respectively, representing the two main research groups in this area. All of these papers except one were published in medical journals, as shown in Table 1. When these data were accessed in June 2017, we found 1,745 papers containing the term Bpelvic floor physiotherapy,^ indicating an increase of around 35% in 4 years.
Discussion Between 1983 and 2013, only 20 classic papers on pelvic floor physiotherapy were identified, most of them RCTs. This is a small number when compared with other medical
specialties [29, 30], though it should be noted that pelvic floor physiotherapy is a relatively new subspecialty. Papers in the area are still sparse and recent. On the other hand, the high number of RCTs, widely considered to present the highestquality evidence, suggests good-quality science. The definition of classic articles as papers with more than 100 citations came from Gehanno et al. [5], although it is not a universally accepted concept. For some authors, classic papers start at 400 citations; for others, it means the most cited piece of work in a certain specialty, although they do not take into account the scientific rigor. We considered the threshold of 100 citations to be the most adequate and the least limiting one, as there are currently no papers with more than 400 citations in the pelvic floor physiotherapy field [4]. The increase in the number of publications identified in our study, around 35% over 4 years, reflects the quick advancement of this subspecialty and the ever-growing number of pelvic floor physiotherapists. This is not a new phenomenon. The same was observed in the otolaryngology/head and neck surgery field, which had 80 classic papers in 2001 and an increase of more than 11-fold a decade later [29]. Thus, an increased number of classic articles could be expected in the pelvic floor physiotherapy field within the next few years. Classic papers should carry the most important and relevant information and the strongest evidence on a certain specialty. However, they may not always be cited directly, as authors may reference only the review articles in which the papers are mentioned, undermining the notion of the Bclassic paper^ presented here. This was not the case in our study, as we identified 12 RTCs and only 4 review articles among the selected papers. According to the study by Thomas et al. on classic papers [30], two limiting factors in such studies are selecting articles from a span of time that is too short and restricting the search to specialty journals. This type of bias is absent from our study, as the selected papers were published over a long period of time. Furthermore, before 1983, there were in fact no relevant papers on pelvic floor physiotherapy, except for Kegel’s original report [31], published in 1948 and counting 347 citations as of now (according to the Web of Science website, accessed on 4 July 2017) [32]. Pelvic floor physiotherapy is a relatively new subspecialty, with no specialized journals on the subject as yet. For this reason, our study included all publications in PubMed, not only physiotherapy journals. This is relevant as all of the classic papers on pelvic floor physiotherapy, with the exception of one, were published in medical journals. This could be because of the currently recommended multidisciplinary treatment approach to pelvic floor diseases, or because authors would like to gain more visibility by publishing in medical journals [2]. As for author names and countries of research, we found that 9 out of 20 papers had the participation of one of two authors (Burgio and Bø). Similarly, research on pelvic floor
Bø and Sherburn [19] Sampselle et al. [20]
Miller et al. [21]
Burgio et al. [22]
Chiarioni et al. [23]
Van Kampen et al. [24]
Wyman et al. [25]
Bø [26]
Burgio et al. [27]
Mørkved et al. [28]
118 116
115
113
112
111
109
109
108
101
RCT randomized clinical trial
Berghmans et al. [18]
121
Fall and Lindström [14]
147
Sand et al. [17]
Lindström et al. [13]
158
131
Wald and Tunuguntla [12]
170
Bø et al. [16]
Fantl et al. [11]
186
Norton et al. [15]
Bø et al. [10]
231
142
Burgio et al. [9]
270
141
Authors
Description of the classic papers
Number of citations
Table 1
Pelvic floor muscle exercise for the treatment of female stress urinary incontinence. III. Effects of two different degrees of pelvic floor muscle exercises Pelvic floor electrical stimulation in the treatment of genuine stress-incontinence: a multicenter, placebo-controlled trial Conservative treatment of stress urinary incontinence in women: a systematic review of randomized clinical trials Evaluation of female pelvic-floor muscle function and strength Effect of pelvic muscle exercise on transient incontinence during pregnancy and after birth A pelvic muscle precontraction can reduce cough-related urine loss in selected women with mild SUI The role of biofeedback in Kegel exercise training for stress urinary incontinence Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia Effect of pelvic-floor re-education on duration and degree of incontinence after radical prostatectomy: a randomized controlled trial Comparative efficacy of behavioral interventions in the management of female urinary incontinence Pelvic floor muscle training is effective in treatment of female stress urinary incontinence, but how does it work? Behavioral training with and without biofeedback in the treatment of urge incontinence in older women: a randomized controlled trial Pelvic floor muscle training during pregnancy to prevent urinary incontinence: a single-blind randomized controlled trial
Anorectal sensorimotor dysfunction in fecal incontinence and diabetes mellitus—modification with biofeedback therapy The neurophysiological basis of bladder inhibition in response to intravaginal electrical stimulation Electrical-stimulation. A physiological approach to the treatment of urinary incontinence Randomized controlled trial of biofeedback for fecal incontinence
Behavioral vs drug treatment for urge urinary incontinence in older women: a randomized controlled trial Single blind, randomized controlled trial of pelvic floor exercises, electrical stimulation, vaginal cones, and no treatment in management of genuine stress incontinence in women Efficacy of bladder training in older women with urinary incontinence
Title
Norway/RCT
USA/RCT
Norway/review
2003
2002
2004
1998
2000
Belgium/RCT
USA/RCT
2006
1986
1998
2005 1998
1998
1995
2003 1990
1991
1983
1984
1991
1999
1998
Year
Italy/RCT
USA/clinical trial
USA/clinical trial
Norway/review USA/RCT
Norway/review
USA/RCT
England/RCT Norway/RCT
Sweden/review
Sweden/experimental study
USA/case–control
USA/RCT
Norway/RCT
USA/RCT
Country/design
Obstet Gynecol
Int Urogynecol J Pelvic Floor Dysfunct JAMA
Am J Obstet Gynecol
Lancet
Gastroenterology
Am J Obstet Gynecol
J Am Geriatr Soc
Phys Ther Obstet Gynecol
Br J Urol
Am J Obstet Gynecol
Gastroenterology Neurourol Urodyn
Urol Clin North Am
J Urol
N Engl J Med
JAMA
BMJ
JAMA
Journal
Int Urogynecol J
Int Urogynecol J
physiotherapy was dominated by two countries, Norway and the USA, which accounted for 15 of the 20 papers. This polarization of classic papers published by centers of excellence with a long-standing dedication to research has already been described in the urology field [33] and is now even more evident in an emergent subspecialty. With such a new field of knowledge, few researchers have a structure and foundation that is good enough to develop quality studies, particularly ones with the potential to reach classic paper status. Moreover, it takes a long time for a paper to be cited more than 100 times. Classic papers on pelvic floor physiotherapy represented a great variety of subjects, including all of the main subspecialty areas: behavior therapy, PFMT, biofeedback-assisted PFMT, and neuromuscular electrical stimulation. This demonstrates that all aspects are homogeneously represented within the field. As a limitation of this study, we should consider terminology. Nowadays, the recommended term according to the International Urogynecological Association (IUGA)/ International Continence Society (ICS) joint report [34] is pelvic floor muscle training, or PFMT. However, in 2013, when we performed the first data base search, the terminology was not so clear, and we wanted to include more papers to be more representative. Thus, we searched MeSH descriptive terms and decided that pelvic floor physiotherapy was the most precise term available to describe the conservative treatment of pelvic floor dysfunctions. Pelvic floor muscle training is a relatively recent term; thus, searching this term would not be useful to find classic papers. Pelvic floor physiotherapy is an emergent subspecialty where scientific knowledge is evolving fast. This is seen not only in numbers, as demonstrated by our quantitative results, but also in quality, as seen in the high-level evidence presented by the classic studies analyzed in our research.
Compliance with ethical standards
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Financial disclosure The authors have no financial relationships relevant to this article to disclose. Conflicts of interest None.
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