Diaphragmatic breathing exercises and pelvic floor retraining in children with dysfunctional voiding.

Zivkovic, et al. Eur J Phys Rehabil Med. 2012 Sep;48(3):413-21.
Michelle Spicka, DPT Pelvic PY Distance Journal Club Dec 5, 2012

 

Primary Aim: To investigate the role of abdominal and pelvic floor muscle (PFM) retraining in children with dysfunctional voiding (DV).

Subjects: 43 patients (65% girls) aged 5-13.  All patients had a diagnosis of dysfunctional voiding and were treated by pediatricians in primary care with timed voiding, hydration and constipation management for 3 months with no significant success. 

Methods: The patients underwent the following treatment program (therapy sessions were monthly for up to 12 months):

1.       Education in the normal function of the bladder, voiding charts and importance of regular fluid intake, as well as toileting positions

2.       Diaphragmatic breathing exercises to relax the abdominal muscles

a.       Strong abdominal holding was noted in the patients

b.      Exercises performed in supine with children using their hands on their abdomen for feedback along with cuing from the therapist

3.       Pelvic floor muscle exercises

a.       3 second contraction with 30 second relaxation after proper technique was insured with external palpation/cuing

4.       Constipation was treated with education, toileting schedules, toileting posture, dietary changes and laxatives

5.       Patients with no PVR (post void residual) were prescribed anticholinergics and an antidiuretic hormone was prescribed to be taken 1 hour before bedtime. 

Results: One year after the beginning of the program the patients were re-evaluated.  Treatment result was classified as “cured” in children in whom urinary incontinence and nocturnal enuresis disappeared; “improvement” was a decrease in wetting episodes by 50% and “unchanged” was improvement less than 50%. 

1.       Urinary incontinence was present in 24 out of 43 patients (56%) before treatment with 20 patients “cured”.  Improvement in 3 patients.

2.       Nocturnal enuresis was present in 21 patients prior to treatment and cured in 14 patients upon re-evaluation; improvement in 4 patients

3.       Chronic UTIs were present in 19 children prior to treatment; cured in 13 patients upon re-evaluation

4.       Constipation was resolved in all 15 patients that had constipation prior to treatment.

5.       Improved voiding pattern in 31 of 37 patients to a “normal” pattern.

Discussion:

1.       Many patients with dysfunctional voiding have an overactive abdominal wall that is not released to allow PFM relaxation, given the pelvic floor and the TA muscles act synergistically. 

2.       This study is the first one that has included abdominal muscle relaxation in the treatment of children with DV.

3.       Diaphragmatic breathing exercises are easy to learn and served to teach the children abdominal relaxation

a.       Diaphragmatic breathing has been shown to decrease urethral pressure in health women and facilitates voiding and defecation.

4.       A protocol of pelvic floor exercises reported in children with DV has not been standardized and there is significant variability between other research studies.

a.       The aim of this study was to use pelvic floor exercises to teach children to relax their pelvic floor not strengthen it

5.       This program provides treatment without using EMG biofeedback and the success rates of this study are comparable to prior reports in which EMG biofeedback was used.

Conclusion: Abdominal muscle and pelvic floor retraining is beneficial in the majority of children with DV for curing urinary incontinence, nocturnal enuresis, constipation and UTIs.  These exercises do not require special equipment to be successful

Points from similar research:

1.       Sapsford et al (Man Ther 2004) discussed a rehabilitation program for SUI that utilized abdominal muscle action to initiate tonic PFM activity.

2.       Sapsford et al (Arch Phys Med Rehabil 2001) found in healthy subjects, voluntary activity in the abdominal muscles results in increased pelvic floor muscle activity and abdominal muscle training to rehabilitate the PFM may be useful in treatment UI and FI.

a.       PFM EMG increased with contraction of the abdominal muscles.   With strong abdominal contraction, the PFM activity did not differ from that recorded during a maximum PFM effort alone.

3.       Sapsford and Hodges et al (Neurourol Urodyn 2001) found abdominal muscle activity is a normal response to PFM exercise in subjects with no symptoms of PFM dysfunction and their results provided preliminary evidence at the time that specific abdominal exercises activate the PFM.

4.       Hodges et al (Neurourol Urodyn 2007) noted the PFM contributes to both postural and respiratory functions.

5.       Talasz et al (Int Urogynecol J Pelvic Floor Dysfunct 2011) found in health women, real time dynamic MRI demonstrates parallel cranio-caudal movement of the diaphragm and the PFM during breathing and coughing and synchronous changes in abdominal wall diameter.