Determining the optimal pelvic floor muscle training regimen for women with stress urinary incontinence.

Dumoulin C, Glazner, C, Jenkinson D. Neurourol and Urodynam 2011;30:746-753.

Beth Shelly November 9, 2011

Second International Consultation on Incontinence Research Society Bristol June 2010 – experts in the field chosen to present and debate and eventually summarize selected topics. 

“It is no longer a question of whether PFM training programs work but what components (including adjunct therapies) and combinations there of are most effective.” Page 752

Comparing PFM exercises for SUI to no treatment

·         Women who were treated were 17 times more likely to report cure or improvement

·         They experienced between 0.8 and 3 few leaks per 24 hours

·         Were 5 to 16 times more likely to be continent on pad test

Mixed treatment comparison analysis

·         14 interventions

·         55 trials, 6,608 women

Results

·         No clear optimal training regime

·         Supervised PFM training programs more than 2 times per month or augmented with biofeedback appear to be more effective

·         Figure one page 751

Studies of note

·         Ramsay and Thou – Direct vs indirect (hip abductor) PFM exercises. No sig difference

·         Ghoneim – PFMT vs imitation (hip abductor) PFM exercises. No sig difference

·         Dumoulin – PFMT vs PFMT with TrA training. No sig difference

·         Borello-France – supine PFMT vs supine, sit and stand PFMT. No sig difference

·         Johnson – maximal PFMT vs submaximal PFMT. No sig difference

Biological rational for PFMT

·         Voluntary contraction before and during cough (the knack) should be included in all PFMT regimes

·         Improving PFM strength is thought to elevate levator plate, enhance hypertrophy of PFM and increase stiffness of the PFM thus resisting perineal descent with increased IAP

·         Therefore PFMT should focus on

o   Improving timing of contraction

o   Strength

o   Stiffness

PFM dysfunction

·         Abnormalities of the involuntary response of the PFM during coughing

o   Decreased PFM contraction speed

o   Decreased PFM contraction force

o   Decreased PFM force at peak increased IAP

o   No pre-contraction of the PFM

·         Women with UI had weaker PFM

·         Women with UI had lower levator plate indicating decreased stiffness

·         Summary – PFM is deficient

o   At rest – tone and stiffness

o   During MVC – maximum strength, rapidity, endurance

o   During effort – timing and maximal strength 

·         Evaluations should test for these parameters and exercise routines should address as needed

American college of sports medicine evidenced based progression models for resistance training

·         Intensity of exercises and # of repetitions should increase

·         Endurance training – 40 to 60% load more than 15 repetitions, less than 90 second rest.

·         Strength training – 8 to 12 repetitions at moderate velocity and maximum load with longer rest (1 to 2 minutes) between sets. 2 to 3 times per week building up to 4 to 5 times per week

·         Not sure I see the evidence for this in PFMT???

Behavior and adherence strategies

	Factors that facilitated	Barriers / impediments
Home-based PFMT	Realistic goals and expectations Positive affirmations Follow-up Regular exercise routine Desire to decrease UI Commitment to making exercise part of a daily routine	Insufficient information about the exercises Characteristics of the exercises Competing interests / busy schedule Financial costs Minor psychosocial impacts Illness Length of exercise program
Participation in PFM weekly exercise class	Desire to decrease UI Sense of responsibility towards the program Close supervision by PT Group support	Illness Medical appointments Planned social activities

·         Those using a routine approach to PFMT adherence and practicing bladder training where 12 x more likely to maintain adherence

·         Those using audiotaped instructions were more likely to perform exercises 2x / day.