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Physical therapy interventions improve sexual health in MS

By Jennie Smith

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A range of physical therapy interventions – particularly pelvic floor muscle training and mindfulness training – can help alleviate sexual dysfunction in people with multiple sclerosis (MS), according to a new study.

Research has shown that both men and women with MS report sexual dysfunction at rates more than double that of the general population, and that sexual function and satisfaction are strong quality of life indicators on MS clinical instruments.

Sexual dysfunction in MS can be a direct result of the disease process. Spinal cord lesions, for example, can alter muscle control and sensation in the pelvis. Dysfunction can also be a consequence of disease-linked pain and fatigue, or of emotional and psychological distress.


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Systematic review and meta-analysis looks at nondrug interventions

The authors of the new study, led by Arpita Gopal, PT, DPT, of the University of California, San Francisco, noted that sexual well-being in MS is overlooked both clinically and in research despite available tools to detect and improve it. In the International Journal of MS Care , Dr. Gopal and colleagues reviewed randomized trials of nonpharmaceutical interventions to treat sexual dysfunction that can be delivered by physical therapists.

Participants in the eight included studies (six of them randomized, controlled trials) all had MS and reported sexual dysfunction or pain associated with sex. Patients in the studies were predominantly women. All the studies used one of two clinical instruments as outcome measures: the Multiple Sclerosis Quality of Life–54 (MSQOL-54) or the Female Sexual Function Index (FSFI). Interventions included pelvic floor muscle training (PFMT), intravaginal neuromuscular electrostimulation (NMES), clitoral stimulation, mindfulness, yoga, and aerobic exercise.

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Dr. Gopal and colleagues found the interventions that resulted in the most improvements in patient-reported sexual function were those directly engaging the pelvis, with a combined effect size across six studies that was large, compared with control groups (d = 0.82; 95% confidence interval, 0.57-1.06). Improvements in patient-reported sexual satisfaction were seen in seven studies (d = 0.65; 95% CI, 0.43-0.87). The grouped improvements amounted to increases of 27% and 36% on FSFI scores for sexual function and satisfaction, respectively. Only the improvements in sexual satisfaction reached statistical significance.

Mindfulness training was also found to improve measures of sexual function and satisfaction, suggesting that “clinicians treating sexual dysfunction in individuals with MS should opt for treatment that targets the pelvic region and includes mindfulness training.” Counseling with mindfulness training and PFMT with intravaginal NMES “may be superior to other PT interventions in improving sexual function and sexual satisfaction,” the authors concluded.

Aerobic exercise and yoga, meanwhile, were found associated with improvements in overall emotional well-being of about 17% across studies, though these did not correlate as strongly to sexual improvement. “Although it may not directly affect sexual function and sexual satisfaction, incorporating aerobic exercise as an adjunct treatment for individuals with MS and sexual dysfunction may help decrease depressive symptoms and thus improve [quality of life],” Dr. Gopal and colleagues reported.

Study findings reflect clinical experiences

In an interview, Erin Glace, PT, a pelvic floor specialist who practices in Suffolk, Va., commented that Dr. Gopal and colleagues’ findings – notably the finding that direct pelvic therapies and mindfulness had the greatest effect among the interventions reviewed – “reinforces what I see in clinic, that we can positively impact sexual function in our patients with MS with pelvic floor–directed therapy, mindfulness, and relaxation education.”

Sexual dysfunction is common even in the absence of a neurologic diagnosis, Ms. Glace noted, and is compounded by stressors and lack of physical activity. “People with MS unfortunately will experience both of these risk factors, and this will affect their sexual function even in the absence of a primary cause,” she said.

“With direct pelvic floor therapy we can really see what’s going on. There are many things that can be happening with pelvic floor muscles, not just weakness but spasms and other problems,” Ms. Glace said. But first the patients need to be referred – and referrals to PT are rarer than they probably should be.

“Oftentimes patients are reticent to discuss sexual function,” Ms. Glace said. “But any MS specialist trying to comprehensively treat patients should ask whether they have concerns regarding sex. It is a strong quality of life indicator – not for everybody, but it should be something that should be at least discussed. It is also worth taking a moment to reach out to a local pelvic floor PT specialist to make see if they are interested in treating those patients who would likely benefit.”

The study authors noted a dearth of literature addressing sexual function in women with central nervous system disorders and said their review helped fill this gap. Men with CNS disorders and sexual dysfunction are usually treated with medication, and most studies to date in this patient group have focused on pharmaceutical interventions.

“Men with MS can also be helped by physical therapy,” Ms. Glace said, with or without concurrent pharmaceutical treatment. In addition to mindfulness and overall physical health interventions, “we can ascertain if there is weakness or overactivity” that might be harming sexual well-being, she said, and help correct it.

Dr. Gopal and colleagues noted among the weaknesses of their study that most of the included trials did not capture MS subtype, which can decrease generalizability of the results, and also that trial participants were mostly women, limiting the findings’ relevance for men.

The researchers did not receive outside funding for their study and disclosed no financial conflicts of interest. Ms. Glace disclosed no financial conflicts of interest.

Erin Glace

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