Chapter 7 182 Discussion Principal findings Health related quality of life measured by the RAND-36 significantly improved in all dimensions in all patients at 20-week follow-up and confirm the efficacy of PPFT on quality of life in patients with CAF from the PAF-trial. The literature on the RAND36 shows that very small differences in the range of 3-5 points on the survey could be interpreted as clinically important.23,24 In all domains of the RAND-36, the minimal clinical importance was higher than 3 points, which could be interpreted as indicating that the treatment was meaningful to the patient. Furthermore, compared to the reference values of the general Dutch population, patients with CAF and pelvic floor dysfunction reported an impaired QoL in 8 of 9 domains of the RAND-36. After treatment significant lower scores were found in 2 out of 9 domains. The positive effect of PFPT on QoL in patients with other anorectal complaints25,26 is already known but has never been investigated in patients with CAF. In our study, the PFPT group significantly improved in 5 of 9 domains of the RAND36 at 8-week follow-up. Interestingly, the postponed PFPT group also improved on 5 of 9 domains. An important aspect of treatment is re- education and improving understanding of defecation disorders.27 It is likely that the information all patients receive about their complaints, instruction about toilet behaviour and lifestyle advice also are reflected in an improvement in quality of life in the postponed PFPT group, explaining our results. Neither group improved in the domains, general health, vitality, and emotional role at 8-and 20-week follow-up. One of the reasons could be that RAND-36 is not sensitive enough to pick up changes in these domains in a relative short period of time (i.e., 20 weeks). More studies with a long-term follow-up are needed to confirm this. In the domain bodily pain, all patients significantly improved post-treatment compared to baseline. The same results were found for VAS pain scores. Reduction of pain is likely to have a positive reflection on QoL. Results from a study by Griffin et al.4 in patients with CAF who were treated with topical ointment, confirm this assumption. Higher VAS-pain scores were associated with worse outcome in all aspects of healthrelated QoL, with pain influencing many psychosocial and functional activities. A study by Tsunoda et al.28 examining the treatment of CAF with diltiazem found that pain had a negative impact on the domains bodily pain and social functioning at
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