Chapter 8 204 reported outcome measures in 37 patients with CAF, an association was found with a statistically significant change in social impact, stool related aspects and the mean score of global functioning. The patients received counselling including fiber supplementation, toileting strategies and the use of ointment but were not treated with PFPT. These baseline strategies were also effective in the patients from the postponed PFPT who also improved on Proctoprom-scores.12 In the PAF-trial we found significant improvements in all nine domains of the RAND36 at 20-week follow-up and this result sustained in eight of nine domains at 1-year follow-up, except for the domain vitality. The domain vitality measures energy/ fatigue. It is possible that this domain is less influenced by this anorectal disease. On the other hand, when patients improve with 5 points on the RAND-36, this could be interpreted as clinically relevant.34 Strengths This is the first study of the long-term results of using PFPT in the treatment of CAF. The main strengths of this study are, the well powered, prospective randomized control trial design, and the design of the study in which all patients received the same treatment of PFPT with a long-term follow-up. The willingness to participate and adherence of the patients to the trial procedures and the intervention was high, which can be seen by a relatively low rate of loss of followup (29%) even during the COVID-19 pandemic. Limitations First, the pelvic floor physical therapist was also the principal investigator and consequently investigator’s bias could not be ruled out. Secondly, COVID-19 did have some influence on our study. During the pandemic a small number of patients were lost to follow-up because they were diagnosed with COVID-19 at the follow-up appointment. Some of our patients were lost to follow-up because they were treated with surgery or for personal circumstances. This may have caused non-response bias. Clinical implications Clinical guidelines of leading societies do not recommend PFPT as a treatment option for CAF. Our findings provide strong evidence that also in the long run, PFPT is effective in the treatment of CAF and pelvic floor dysfunction.
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