Pelvic Floor Muscle trainingThe role of general exercise

Stephanie KnightAiredale General Hospital

PFMT in treatment of incontinence Abdominal muscles and continence The role of exercise Does general exercise improve continence

status? What should we tell patients?

Introduction

I leak when I run or jump I have stopped going to the gym because of

leakage I can’t play in the park with my children I daren’t jump on the trampoline I don’t go to social functions/dancing

What do patients say?

Prevention and therapy for many chronic diseases

Exercise increases muscle strength & improves cardiovascular fitness

Is exercise a risk factor for incontinence? Can general exercise improve continence?

Physical Exercise

28% nulliparous female athletes reported incontinence (Nygaard et al.1994)

Most common with high impact, jumping, running, trampolining

Possible “continence threshold” High incidence of UI in high impact sports

(Jang et al. 2004)

Is leaking with exercise a common problem?

Barrier to physical activity

Pelvic floor muscles

3 Supportive Layers

Endopelvic fascia Muscle layer (Levator Ani & Coccygeus) Superficial perineal muscles

Additional urethral closure from striated urethral muscle, smooth muscle and vascular system

Anatomy of the Pelvic Floor

Grade A evidence for improvement of stress and mixed urinary incontinence (NICE CG40 2006)

NICE recommend vaginal assessment Need to be performed correctly Incorrect technique may promote

incontinence (straining/Valsalva/using other muscles)

Pelvic Floor Muscle Exercises

Increase urethral pressure Elevate bladder neck Narrow the levator hiatus in AP & transverse

direction Prevent descent of pelvic organs Increase “stiffness” of PFM Improve timing and coordination (the

“Knack”) Improve endurance/reduce fatigue

Bo K. 2004

How do PFM exercises work

Three layers Deepest layer

Transversus Abdominis (TrA)

TrA is part of core stability complex

Synergist of PFM

Abdominal Muscles

Core muscles

Indirect training of PFM via abdominal muscle training (Sapsford 2001)

Abdominals co-contract with PFM No additional benefit of PFM + TrA training (Dumoulin et al.

2003) No RCT’s to show PFM can be trained

indirectly (Hay Smith et al. 2009)

“Paula” method also not effective (Bo et al. 2011)

Abdominal muscle training

Unable to provide pelvic organ support Unable to increase urethral closure pressure Unable to prevent bladder neck/urethral

descent Potential to increase incontinence

Anatomical position

Joseph Pilates 1883-1967

Pilates Method is an exercise system focused on improving flexibility and strength for the total body

The Pilates method relies on strengthening core postural muscles and developing body alignment

Exercise instruction should always start with pelvic floor contraction

No claims to treat incontinence

Pilates

In normal activity PFM & TrA show synergistic activity to stabilise the spine

Intra-abdominal pressure also increases Lee & Lee 2004 If continent urethral closure pressure

increases simultaneously with IAP If PFM weak stress leak occurs Muscle imbalance “Timing” is important

Working together

Instructors focus on Abd, back,adductors, PFM

Hypothesis: Pilates strengthens PFM if taught in conjunction

62 women little or no pelvic floor dysfunction

2 groups: PFMT/Pilates Strength measured with perineometer in

both groups PFM symptoms/QoL improved in both-no

significant difference Culligan et al. 2010

PFMT vs Pilates exercise

Grade A evidence that obesity increases risk for incontinence (Subak et al. 2009)

Weight loss can improve continence status(Subak et al. 2002)

Exercise promotes weight loss!

Obesity and incontinence

Supervised Maximal contractions? Train for function Encourage long term adherence Make it FUN! Combine with other exercises Vaginal examination to ensure correct

contraction NICE CG40 2006

Intensive PFM training

PFMT is long term commitment

Need fun ways to maintain motivation

Using other muscle groups can improve concordance

Adherence

To avoid this……..

Try this………

Dancing

Or this………….

No evidence that abdominal or physical exercise alone improves continence status

PFMT does improve continence Teach correct PFM contraction to combine

with general exercises Weight loss important Any fun activity to improve long term

adherence Patients need motivation

In conclusion