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This book focuses on particular mental and physical aspects of women’s health, presenting topics concerning the pelvis and pelvic floor dysfunction and the breast during a woman’s life, such as rehabilitation for pelvic and breast disorders, and the benefits of biomechanical analysis in treating these conditions. With each chapter providing a brief survey of a major research area related to the theme, the book offers an integrated overview of topics such as the bio-psycho-social model of women’s health, pelvic floor evaluation in sports, the breast, pregnancy and delivery. It is a valuable resource for a wide range of readers, including researchers, graduates and professionals.



Women’s Health


Improving Women’s Health via the Biopsychosocial Model: Fibromyalgia as a Case Study to Explore Opportunities for Engineering Applications

The biopsychosocial model of health provides a framework to assess and/or treat various medical disorders and is the most heuristic approach to managing chronic pain. Fibromyalgia (FM) is a chronic pain disorder primarily affecting women characterized by widespread musculoskeletal pain, abnormal pain processing, sleep disturbance, fatigue, and often cognitive difficulties and psychological distress. Evidence-based management guidelines in different countries recommend biopsychosocial, lifestyle-oriented intervention to include exercise, cognitive-behavioral therapy, and multicomponent intervention. State-of-the-art evaluation and treatment approaches in FM illustrate the application of the biopsychosocial model to improve women’s health. Engineering applications are beginning to be developed, that, within the context of this model, have the potential to further advance management of the disorder and improve quality of life for those (primarily women) who suffer from it. Users of existing online multicomponent treatment module platforms experience improved pain and physical functioning. Those who use FM symptom tracking systems report improvements in a number of debilitating core FM symptoms beyond pain and physical function. Areas of engineering application showing particular promise include advances in gaming using commercially available motion-controlled video games, mobile activity and symptom data collection with or without feedback via smartphone devices, and integration of these technologies with clinical oversight.
Heather Lynn Rogers

Physical Activity and Women’s Mental Health

Women are twice as likely as men to develop certain mental health conditions such as depression, eating disorders, and anxiety disorders. A multimodal care, including psychotherapies as adjuncts to antipsychotic medications, is acknowledged to be crucial in teaching individual strategies and providing patients with tools to deal with these illnesses. In this scenario, physical activity has become increasingly relevant to promote physical and mental health in women with mental illness. However, it appears that women have unique experiences, risks, and needs that must be taken into account for the treatment strategies. For this reason, the provision of rehabilitation for women with mental illness has been challenging for the mental health systems reform. This underlines the importance of understanding the modern scientific and nonscientific literature about the link between physical activity and mental health in women. This chapter will present research on the relationship between physical activity and mental illness, trying to list female particularities and the advantages of exercise for their health.
Eluana Gomes, Raquel Costa, Tânia Bastos, Michel Probst, Rui Corredeira

The Role of Ultrasound Imaging of Musculotendinous Structures in the Elderly Population

Ultrasound (US) is a noninvasive and real-time method that allows the evaluating muscles and tendons. The enhanced echo-intensity (EI) on ultrasonography images of skeletal muscle is believed to reflect changes in muscle quality (MQ), and these changes accompany aging. Also related to aging, and that may more severely affect women than men, is the well-known loss of skeletal muscle mass. Often associated with the accumulation of connective tissues (e.g., adipose), it affects muscle strength and MQ and causes functional impairment. This chapter demonstrates the potential use of US imaging for assessing muscle changes associated with aging and functional decline.
Luis Carrão, Rute Santos, Margarida Espanha, Paulo Armada-da-Silva, Ana Amaral, Sandra Amado, Henrique A. Almeida, Paula Faria, António Veloso

Bridging Clinical and Biomechanical Aspects of Breast Surgery


Diffusion-Weighted Breast Imaging: Beyond Morphology

Diffusion-weighted imaging (DWI) is a magnetic resonance imaging (MRI) technique that explores the molecular diffusivity of water in biological tissues to probe its microstructure. Its application to the study of breast lesions has been shown to improve their detection, characterization, and the diagnostic accuracy of breast lesions using MRI. In this chapter, the biophysical basis of diffusion is presented, including the model currently used for DWI in the clinical setting; the concept of apparent diffusion coefficient (ADC) is introduced. A theoretical framework of DWI in healthy conditions and in tissues affected by pathological processes is presented, followed by a literature review on the application of DWI to breast imaging. As the technique has only recently been used in breast imaging studies, controversial issues regarding its application have arisen, namely related to its technical challenges. Therefore, we detail the main technical issues associated with the implementation of DWI in the clinical setting and present potential approaches for obtaining good-quality images. Finally, we identify relevant future research needs involving hardware and software optimization as well as clinical issues which need to be addressed to improve breast lesion diagnosis.
Luísa Nogueira, Rita G. Nunes, Sofia Brandão, Isabel Ramos

The Effects of Mastectomy and Breast Reconstruction on Body Posture and Biomechanical Aspects

The purpose of this chapter is to highlight the main changes on the biomechanical aspects focused in posture, body balance and gait of women with breast cancer after surgical treatment of mastectomy, with or without placement of the breast prosthesis. In summary, women with mastectomy showed posture changes, such as asymmetry of trunk and shoulder girdle and greater forward leaning of the trunk. Furthermore, were observed asymmetry of the pelvis, scapula and shoulder one year after the mastectomy with radiotherapy. Women’s with mastectomy showed lymphedema, head rotation to the right, protrusion of the left shoulder, and trunk inclination angle smaller on the operated side, besides bilateral elevation of the scapula. However, women’s post immediate breast reconstruction, with abdominal flaps, demonstrated asymmetry in the vertical alignment of the trunk with greater asymmetry between the acronyms and greater trochanters, which can change trunk balance. The weight of external breast prosthesis can also contribute to posture changes in women post mastectomy, such as asymmetry of the head due to erector spinal muscle activity imbalance in women with mastectomy. Changes in the gait parameters-velocity, cadence, time and step length also were observed with and without prosthesis. These clarifications may provide reliable information for the prescription of physical exercise, such as intervention protocols with exercise for posture and upper kinetic chain, as well as feet motion-control during gait for better postural balance after mastectomy or placement of the prosthesis.
Ana Paula Ribeiro, Thalissa Maniaes, Adriana Naomi Hamamoto

The Role of Physiotherapy in Female Breast Cancer

Breast cancer is a prevalent disease in women and complications following breast cancer treatment are frequent, compromising health condition of this population. This chapter describes physiotherapy applied to motor and functional rehabilitation in women with breast cancer. The implementation of therapeutic activities is important for prevention and health promotion of these women, as for treatment, when changes are installed. Physiotherapy aims to assist the patient recovering the skills to perform daily life activities, wellness and quality-of-life during the whole treatment. It will present the main details for adequate evaluation, care and couseling, and proper physiotherapy to prevent pre- and post-operative complications.
Soraia Cristina Tonon da Luz, Gesilani Júlia da Silva Honório

Breast Implants: Far Beyond Just Aesthetic Surgery

For decades, women have undergone breast implant surgery either for health or aesthetic reasons. Some adverse effects have made their history full of events, showing the complex factors involved in the interaction of the device with the human body. Understanding the adverse outcomes is a key factor to improve the breast implants. This will help to increase the safety of the procedure. It is also important to stress some new concerns as well as the lack of evidence of involvement on specific long-term health outcomes in women with silicone gel breast implants, such as cancer; connective tissue, rheumatologic, and autoimmune diseases; neurologic diseases; reproductive issues, including lactation; offspring issues; and mental health issues. The development of the National Breast Implant Registry (NBIR), since 2012 by the American Society of Plastic Surgeons in collaboration with the FDA was a huge step to understand these issues. In this database, it is possible to collect and tracks important information on patients and devices, maximizing data extraction from clinical cohorts and directing more meaningful analyses. Researchers could finally obtain clarification of the long-term health outcomes of silicone gel breast implants.
Nilza Ramião, Fabiana Zanata, Tomas Fortoul, Fabio X. Nahas, Lydia M. Ferreira, Pedro Martins, Antonio Augusto Fernandes, Maria da Luz Barroso, Diana Costa Santos

The Biomechanics of the Reproductive Period


Anthropometrics and Ergonomics in Pregnant Women

Pregnancy is a women life event that impacts her own and offspring’s life; surprisingly, few systematic and scientific maternal information is available in the literature for anthropometric and ergonomic purposes. Regarding ergonomics, some authors state that guidelines should be design for pregnant women. These guidelines may consider anthropometric issues such as changes in weight and distribution of mass, which influence mobility, home and labour performance, mood and cognition. Anthropometrics allows the body measurement, but in pregnancy women are sparingly characterized, besides Body Mass Index and few other parameters. Ergonomics not only aids in the design process of work or home layouts, but also contains several evaluation tools to determine the level of risk of musculoskeletal disorders of daily or labour tasks. Some of these tools are very specific and others have certain conditions that should be met before using them. The purpose of this study is to present an overview of guidelines and discuss which anthropometric and ergonomic evaluation tools may be used, and under which conditions can be implemented in pregnant women.
Henrique A. Almeida, Rita M. T. Ascenso, Eunice Oliveira

Increased Step Width During Walking as Pregnancy Progresses: Functional or Mechanical Adaptation?

Women change their gait as pregnancy progresses. It is known biomechanical adaptions occur; however, the etiology of these adaptations is unknown. A common suggestion is that the adaptations, such as increased step width, are a functional response to control stability. Nevertheless, step width is also affected by trunk segment kinematics which are themselves also altered as pregnancy progresses. Step width is also affected by mechanical obstruction when the girth of the thigh is increased. Therefore, the changes seen in step width may be of mechanical rather than functional origins. The objective of this chapter is to investigate the etiology of the step width adaptation as pregnancy progresses and its resolution post-birth. It includes discussion on the temporospatial and trunk segment kinematic adaptions as pregnancy progresses and the effect of parity. The mechanical obstruction by increased thigh girth is a likely explanation for increased step width in late pregnancy. The mechanical effect of altered trunk mechanics may also affect step width as pregnancy progresses. Thus, increased step width as pregnancy progresses is a mechanical adaptation rather than a functional adaptation to increase stability. The effect from previous pregnancy may be less important than the individual’s differences in adaptations.
Wendy L. Gilleard

Diastasis Recti During Pregnancy and Postpartum

Diastasis recti abdominis (DRA) or increased inter-rectus distance (IRD) is characterized by the separation of the rectus abdominis muscles. It has its onset during pregnancy and the first weeks following childbirth. The reliability of the instruments used to assess this condition is unclear. There is scant knowledge on the prevalence and risk factors for development of the condition. There is little evidence on which exercises are most effective in reduction of DRA. The aims of our studies were to establish a reliable method for the assessment of the morphology of the abdominal wall, describe DRA prevalence, risk factors, and evaluate the acute response on the IRD induced by drawing-in and abdominal crunch exercises. The results of three methodological studies showed ultrasound imaging to be a reliable method for measuring IRD. The ultrasound transducer can be held relatively stationary in a clinical setting, to evaluate IRD. DRA is prevalent at 6 months postpartum, with a prevalence rate of 39%. The acute response on IRD produced by drawing-in exercise was a widening of the IRD in postpartum, while the abdominal crunch exercise induced an acute narrowing response of the IRD in pregnancy and in postpartum.
Patrícia Mota, Augusto Gil Pascoal, Cristiana Vaz, Filipa João, António Veloso, Kari Bø

Biomechanical Analysis of the Damage in the Pelvic Floor Muscles During Childbirth

The vaginal birth is the leading cause of pelvic floor muscle injuries compromising its function, which can lead to pelvic organ prolapse, urinary incontinence, and other pelvic disorders. These conditions affect many women’s quality of life. As such, biomechanical models emerge to analyze the impact of pregnancy and childbirth in the biomechanics of the pelvic floor, and determine features that potentially contribute to complications during vaginal delivery. Computer models allow structural hypotheses to be analyzed, such as the influence of the shape of the fetal head and its position at delivery, the consequence of specific obstetrical procedures, among others. Damage analysis is especially important to understand the pathophysiology of the associated dysfunctions. The continuous developments in imaging techniques, and the increased computing power, make possible for these frameworks to be clinically valuable, with customized computer models and subject-specific mechanical properties, both in useful time.
Dulce Oliveira, Marco Parente, Teresa Mascarenhas, Renato Natal Jorge

Clinical Approach on the Female Pelvic Floor


Pelvic Floor in Female Athletes: From Function to Dysfunction

Despite the benefits derived from exercise practice, some adverse effects have been described in female athletes. Regarding the problems associated with the pelvic floor, the most commonly reported is urinary incontinence (UI). However, menstrual irregularity, anal incontinence, sexual dysfunction, and eating disorders are also demonstrated among athletes. Practicing sports always involves increased intra-abdominal pressure, but the wide prevalence range of UI found between each sport suggests that some sports could be associated with higher risk than others. Regarding the relation between exercise and pelvic floor dysfunctions, two opposite theories have been suggested: (i) female athletes have strong pelvic floor muscles (PFM); and (ii) female athletes may overload, stretch, and weaken the PFM. Both theories are supported by the results of different studies, suggesting that the mechanism behind exercise-induced UI is not yet completely understood. Rather than a single factor, it is more likely that several environmental and individual factors interact to contribute to pelvic floor dysfunctions. UI negatively affects the quality of life of incontinent women in several domains, which reinforces the need to implement preventive strategies in order to counteract the negative effects of exercise.
Alice Carvalhais, Thuane Da Roza, Cinara Sacomori

Toward the Development of a Vaginal Finger-Cot Device for Measuring Pelvic Floor Muscles Strength

Stress urinary incontinence (SUI) refers to the involuntary leakage of urine on effort or exertion, like sneezing or coughing and is a common problem in female population. Pelvic floor muscle (PFM) training has been demonstrated to be effective in the prevention and treatment of SUI. Vaginal squeeze pressure (VSP) is the most commonly used parameter on PFM strength, measured by vaginal palpation, by pressure transducers or by self-reported to the physiotherapist. Vaginal palpation is clinically relevant to evaluate PFM activation and to guide patient about correct PFM contraction. Vaginal palpation is questionable as a reliable method to quantify PFM strength nevertheless some detailed palpation scoring systems exist to quantify PFM strength. No single measurement instrument gives an overall view of PFM function. A combination of the advantages of vaginal palpation with a reliable measure of the VSP, in a single instrument, is a challenging purpose. This chapter reports the responsiveness and validity of a customized adjustable finger-cot (vaginal finger-cot device) with an embed strain gauge pressure transducer that allows to measured VSP in a time base. The finger-cot, developed by our research according to women’s health physiotherapists’ specifications, kept preserved the properties of vaginal palpation, minimizing the measurement artifacts inherent to intravaginal probe.
Augusto Gil Pascoal, Patrícia Silva, Fátima Sancho

Physiotherapeutic Diagnostic Process for Female Urinary Incontinence

The International Consultation on Incontinence (ICI) recommendations for initial management of female urinary incontinence, including pelvic physiotherapy, are based on presumed (medical) diagnosis, so indication, not (yet) diagnosis. This chapter demonstrates the role of a physiotherapeutic diagnostic process (PDP) for female urinary incontinence in clinical (research) practice. Furthermore, the technique and a practice protocol for the PDP including troubleshooting and interpretation are presented. Based on the PDP including the analysis, evaluation and based on that, the formulation of hypotheses, if indicated, optimal and adequate pelvic physiotherapy treatment can be selected.
Bary Berghmans, Maura Seleme

Psychological Morbidity, Sexual Satisfaction, Coping, and Quality of Life in Women with Urinary Incontinence in Rehabilitation Treatment

This chapter focuses on the relationships between psychological morbidity, sexual satisfaction, coping, and quality of life in women with urinary incontinence in rehabilitation treatment, taking into consideration the women's perception of the severity of the urine loss and the type of urinary incontinence. Women that consider their incontinence symptoms as moderate reported better quality of life, and those with mild symptoms reported greater sexual satisfaction. Women with severe symptoms relied on religion and used more self-blame coping, expression of feelings, denial, and self-distraction strategies. Women with stress urinary incontinence used active coping while women with urge urinary incontinence used behavioral disinvestment, as coping strategies. Given the impact of urinary incontinence in women’s lives, it would be important to develop health promotion strategies in order to help women cope and, as a result, improve their quality of life and the associated psychological symptoms.
M. Graça Pereira, Susana Pedras, Cláudia Senra

Biomechanical Analysis of the Female Pelvic Floor


Searching for the Tissue Mechanical Properties in Pelvic Floor Dysfunction by Computational Modeling

The mechanical characteristics of the female pelvic floor are relevant to understand the pelvic disorders. These disorders can be associated with different risk factors, as hormonal changes, vaginal delivery, and obesity among others, and thus will affect their mechanical response. Urinary incontinence and pelvic organ prolapse are the main pelvic disorders and have been studied by using different methods, through experimental tensile using fresh female cadavers or tissues collected at the time of transvaginal hysterectomy and by applying imaging techniques, such as magnetic resonance imaging and ultrasound. But, the experimental analysis is important to determine biomechanical properties that can be used in pelvic modeling. The inverse Finite Element Analysis (FEA) allows estimating the in vivo biomechanical properties of the pelvic floor muscles for a specific subject—woman without pathology, with stress urinary incontinence, or pelvic organ prolapse–using input information acquired noninvasively.
Elisabete Silva, Sofia Brandão, Marco Parente, Teresa Mascarenhas, Renato Natal Jorge

Computational Analysis of Pelvic Floor Dysfunction

Pelvic floor dysfunction (PFD) is characterized by the failure of the levator ani (LA) muscle to maintain the pelvic hiatus, resulting in the descent of the pelvic organs below the pubococcygeal line. This chapter adopts the modified Humphrey material model to consider the effect of the muscle fiber on passive stretching of the LA muscle. The deformation of the LA muscle subjected to intra-abdominal pressure during Valsalva maneuver is compared with the magnetic resonance imaging (MRI) examination of a nulliparous female. Numerical result shows that the fiber-based Humphrey model simulates the muscle behavior better than isotropic constitutive models. Greater posterior movement of the LA muscle widens the levator hiatus due to lack of support from the anococcygeal ligament and the perineal structure as a consequence of birth-related injury and aging. Old and multiparous females with uncontrolled urogenital and rectal hiatus tend to develop PFDs such as prolapse and incontinence.
Aroj Bhattarai, Ralf Frotscher, Manfred Staat


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