Pelvic floor muscle training to improve urinary incontinence in young, nulliparous sport students: a pilot study

Da Roza t, de Araujo MP, Viana R, Viana S, Jorge RN, Bo K, Mascarenhas T: Int Urogynecol J, 2012; 23:1069-1073.
Ann Dunbar PT, DPT, MS, WCS
June 8, 2016

Introduction: Urinary incontinence (UI) is thought of as a problem with aging however, studies demonstrate young, physically fit nulliparous women also experience UI. Factors that contribute to incontinence in this population of women are not well understood. Studies suggest weak connective tissue, high-intensity and high-impact activities, heavy training, and possible pelvic floor muscle (PFM) fatigue. Though RCTs demonstrate benefit of pelvic floor muscle training (PFMT) for SUI, none assess the intervention for nulliparous sports women.

Primary Aim:  “to evaluate the effect of a comprehensive PFMT program on UI symptoms in young nulliparous sport students.”

Study Design:  Pre-post test pilot study
Methods:

• Questionnaire offered to physically active female university sport students.  Completed by 119, 24 agreed to participate and of those, 16 met inclusion criteria (nulliparous, incontinent, and performing high levels of physical activity according to International Physical Activity Questionnaire-SF). See inclusion/exclusion criteria in study.
• Definition of UI from International Continence Society: any involuntary urine loss.
• Tables 1 and 2 show demographics of subjects and main sports activities, respectively.
• Data collection included
• (1) Questionnaire to gather demographic information
• (2) Administered IPAQ-SF where high level of physical activity defined as at least 3,000 metabolic equivalent (MET)-min/wk  or 4 hrs/wk vigorous-intense activity
• (3) ICIQ UI-SF administered producing score 0-21 from first 3 items and 4^th item assessing symptoms
• Measurement of ability to contract PFMs, vaginal resting pressure, and maximum voluntary contraction (MVC) included:
• Verification of  correctness of PFM contraction by vaginal palpation
• PFM strength assessed using MVC measured by Peritron perineometer
• Exams performed in crook lying position, performing perceived max contraction for 2-3s
• To register effort as valid, probe needed to pull inward
• Intervention consisted of an 8 week exercise program supervised by 3 PTs (with pelvic floor specialization)
• Exercise program included 2 wks each of: (1) Awareness of PFM via feedback from vaginal palpation; (2) Contraction of PFMs in different positions with progressive weights added to LEs; (3) Attempts to contract PFMs during running and walking activities; (4) Attempts to contract PFMs during sport activities
• Participants met with PTs every 15 days and were instructed in exercises for the next level; participants asked to perform exercises every day “until fatigue”; participants were also provided with an instructional DVD to use at home; participants were asked to keep exercise diary recording their adherence to program and their progress
• Statistical Analysis included use of SPSS software; background variables presented as means of SD; comparison between group that left program and group the completed program was analyzed with independent t-test and differences between pre- and post-test were analyzed with Wilcoxon test where p<0 .05="" considered="" o:p="" significant="" statistically="" was="">

Results

• Protocol completed by 7 sport students (9 dropped out), all with SUI and one with MUI
• Found no significant difference in demographic characteristics between groups completed vs. dropped with p>0.05 for age, BMI, age at menarche and hrs of training
• For PFM resting tone and MVC also found no statistical difference between the two groups however ICIQ results showed those who completed study had significantly greater frequency of UI with larger impact on QOL compared with those who dropped out
• All participants performed correct PFM contraction assessed by vaginal palpation; those completing program demonstrated statistically significant increase in resting pressure and MVC
• Impact of UI on QOL was reported to be negative in 5/7 and one participant thought of quitting her sport
• Found no significant difference in QOL pre/post intervention
• Found significant improvement in frequency and amount of UI pre/post intervention
• Of those completing the program, 6/7 were cured according to ICIQ score

Discussion

• Results of pilot study of female university athletes demonstrate that an intensive 8-wk PFMT program including functional training produced significant improvement in vaginal resting pressure and MVC with 6/7 reporting cure from UI
• Authors suggest this population of highly active women may be more difficult to treat due to frequent exposure to increased ground reaction forces and increases in intra-abdominal pressure
• Authors suggest PFMs may need to be much stronger in exercisers and athletes however we have minimal research to support this
• Max vertical ground reaction forces during landing for long jumps may reach 16x athlete’s body weight (Hay, 1993)
• Results of current study demonstrate that elite athletes have higher than average MVC values when compared to university students with similar demographics (73.4 ± 24.9 versus 45.3 ± 17.7)
• Assessing PFM function in sport and PE nulliparous students with and w/o UI, Bø et al (1994) found no significant difference in PFM strength
• Authors report these findings suggest that heavy lifting and strenuous activity may promote SUI in women already at risk (women with weak collagen tissue)
• In this study, severity of urine loss was found to be a predictor of adherence to program
• Authors suggest several reasons for their high dropout rate (9/16)
• Because urine loss was sporadic and small for most students
• Because program was time consuming (60 minutes at each visit) and specific equipment was needed so it had to be done at a gym
• Other limitations include nonrandomized design and small sample size
• Authors cite a case study examining the effect of 4 months of PFMT on UI in 3 female volleyball players; Intervention included individualized PFM rehabilitation program including biofeedback, functional electrical stimulation, and PFMT with and w/o vaginal cones; results were positive for reducing UI
• Prevalence of UI in elite athletes found to be greatest in those performing high impact activities including gymnastics, track and field, trampoline jumping, ball games
• Findings in current study consistent with this where higher ICIQ scores were in those women participating in higher impact sports; subject w/o improvement was gymnast
• UI impacts QOL for all women regardless of physical activity level and for nulliparous women with very high physical activity levels, this study suggests that PFMT may be very effective for reducing or eliminating UI

Clinical Application

1. What do you think are the key components of this PFMT program? 
2. How do you modify your PFMT to make it more difficult, to further enhance strengthening, work to stimulate more force generation of the PFMs?
3. We integrate PFM contractions into ADLs such as coughing, sneezing, lifting using functional training with “The Knack”.  Are there other ways you integrate PFMs into ADLs, not just for the timing of the contraction but how about functional training for strengthening?  What do you think of using LE weighted exercise for PFM strengthening for your population? How about the exercises used in the Tuttle et al  study below?

Supplementary Article for Discussion
The Role of the Obturator Internus Muscle in Pelvic Floor Function
Tuttle LJ, DeLozier ER, Harter KA, Johnson SA, Plotts CN, Swatrz JL. 2016; J WHPT Jan/April: 15-19

Introduction

• PFMT is primary intervention for PFMD; usually includes Kegel’s exercise for strengthening though other mm have been shown to impact the PFMs (abdominals); likewise hip dysfunctions, habits of poor posture, and SI jt dysfunction may also impact PFMs
• Authors suggest obturator internus, with its close proximity and shared fascial attachment with levator may have integral part in PFM function; studies providing more clarity about PFM and hip m relationships are limited by sample size and outcomes of symptom change not m function
• PFM architecture defined by authors as “arrangement of m fibers relative to the axis of force generation and is the primary predictor of m function.”
• Architecture governs amount of force a m can generate and is main predictor of m function as well as its excursion or range
• Authors cite their previous work using the PFM architecture analysis to suggest that the thin PFMs are able to produce enough force to counteract changes in intra-abdominal pressure with less physical ADLs such as standing, abdominal crunch though for more vigorous ADLs such as coughing and jumping, the intra-abdominal pressures generated ‘clearly exceeds the force generated by the PFMs in isolation.”
• If a m is lengthened during a contraction, the force generation could be doubled but even in this situation, the PFMs in isolation could still not withstand the increased intra-abdominal pressure

Study Aim:  “to investigate the effects of OI strengthening on the m strength (peak squeeze pressure) of the pelvic floor and on hip ER strength.”

Methods and Measures

• Subjects: 18 to 35 yo never been pregnant, no current treatment nor prior diagnosis of PFMD, score of <20 and="" any="" control="" current="" documented="" each="" exercise="" group="" groups="" into="" of="" on="" pfdi="" pfm="" randomized="" routines="" section="" span="" style="mso-spacerun: yes;" was=""> 

Procedures: Participants completed PFDI-20

• Lead investigator (blinded to group llocation) measured hip ER strength seated hip/knees at 90/90 (MicroFET3 digital manual m dynamometer placed above lateral malleolus), 3 trials
• Lead investigator assessed PFMs by first visually assessing accurate contraction then also confirming squeeze and lift action with single digit vaginally; also assessed with US imaging confirming superior movement of full bladder
• Also palpated OI vaginally while subject activated hip into ER with resistance
• PFM force production was measured with Peritron perineometer, 3 trials

Exercise Protocol

• Control group: asked to maintain normal level of fitness avoiding adding exercises or activities to their typical routine
• Exercise group: given same instructions as control group except for the addition of the added exercise study protocol which included: clamshell, isometric wall ER and ‘monster walk’ exercises chosen because of simplicity and familiarity; performed 3 sets of 10 reps, 3 days/wk for 12 weeks; weekly during the 12 weeks, each participants performed the exercises in the lab with a lab assistant observing for accuracy and compliance; participants recorded their program in an exercise log

Data Analysis:  Used 2-way group x muscle, repeated-measures analysis of variance (α value of 0.05 to compare ER strength and vaginal pressure)

Results

• All subjects completed the study (20 in each group); Ex. group was 80% compliant with both home exercise based on their log and 80% compliant with meeting the research assistant weekly
• No difference between L and R hip ER peak forces so bilateral average was used for analysis
• No baseline differences found between group with 2-way analysis of hip ER peak force and PFM peak pressure
• Post 12 weeks of protocol revealed significant within-group increases in PFM strength based on vaginal peak pressures and hip m peak force in exercise group but not in control group

Pre-Post Ex Changes	PFM Peak Pressure  in cm H2O	Hip ER Peak Pressure  in pounds
Exercise Group	24.21 ± 3.72 vs 35.43 ±  14.1 **	16.44 ±  1.1 vs 19.95  ± 0.69 **
Control Group	32.16 ±  3.54 vs 27.37 ±  2.5	17.36 ±  0.54  vs 17.45  ±  0.65

**P < 0.05

Author’s Comment

• Authors cite another study including resisted hip rotation with PFMT for women with SUI that demonstrated positive change in symptoms; no measures of strength done to suggest strength change could be possible mechanism for the improvement; intervention for this study included different exercises and for only 6 wks
• Authors cite multiple limitations in their study and suggest the limitations provide consideration for future studies
• Even though there are limitations, this study does provide some evidence that is important to clinical practice: that addressing hip ER muscle function in rehabilitation exercise may provide increases in PFM function
• Their conclusion: “Strengthening the deep rotators of the hip surrounding the PFM, such as OI, improves PFM strengthen in healthy, young women.”