Chapter 5 138 Brief name Pelvic floor physical therapy in patients with chronic anal fissure: a randomized controlled trial Treatment PFPT: - 5 sessions of a mean of 45-minutes in a period of 8 consecutive weeks. - Different treatment modalities are combined in one session and all treatments are tailored to the patient. - Intrarectal myofascial techniques: stretching the puborectalis muscle and myofascial release on identified trigger points (first 3 sessions for a maximum of 10 minutes). - Pelvic floor muscle exercises: contraction and relaxation combined with breathing exercises (first 3 sessions maximum of 10 minutes) - Breathing exercises and learn how to push (2 sessions), lying down and sitting - Surface electromyography (s-EMG)- biofeedback with an intraanal probe (MAPLe®). Relaxation with breathing techniques, maximum contractions and sets of endurance contractions are used to achieve the treatment goals (3 sessions for 15-20 minutes). - The therapist monitors the adequate relaxation of the pelvic floor muscles throughout the sessions. - If patients are unable to relax the pelvic floor, neuromuscular electrical stimulation will be applied intra-anally during the biofeedback session (15-20 minutes about 45 contractions; 35Hz/250 µsec fade in, fade out 2 sec, hold 4-6 sec, pause 10-16 sec). - If patients are unable to contract neuromuscular electrical stimulation will be applied intra-anally during the biofeedback session (20 minutes/30-45 contractions; 35Hz/250-600 µsec; fade in, fade out 2 sec, hold 4-6 sec, pause 8-12 sec). Home exercise program: - Stretching the puborectalis muscle during the application of ointment (2-3 times a day, 5 minutes); pelvic floor muscle - and breathing exercises to improve relaxation (2-3 times a day, 15 minutes); thermotherapy with a heat blanket three times a day for 15 minutes, preferable at fixed time points or sitz baths for relaxation. - Information is provided with folders and videos to guide the home exercises. - The collaborating pelvic floor physical therapist will ask the patient about the compliance of home exercises and supports correct behaviour at every visit Changes and improvements are noted the patient file. Patients who are assigned to postponed PFPT will not receive additional treatment besides the use of ointment and fibres/laxatives until first follow-up at 8 weeks and start with the same treatment protocol. 4. Procedures Training before the PAF-study started was carried out by an experienced PF physical therapist/principal investigator at a meeting at the Proctos Clinic in the Netherlands. The training provided general background and the developed further knowledge in the specialty of anorectal dysfunction. In total 12 of the collaborating pelvic floor physical therapists from every part of the country providing the treatment attended the meeting. All pelvic floor physical therapists are certified and trained and have at least 3 years of experience in the field of anorectal problems. They all received the treatment protocol prior treatment and have access to peer consultation when needed. To mentor these meetings, we arranged 3 on-line sessions during the COVID-19 pandemic. Appendix 2. Continued
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