Download pdf - W19: Pre and postpartum pelvic floor muscle …Apart from muscles’ injuries there are also ligaments and nerves that undergo a significant stretch during pregnancy and delivery

W19: Pre and postpartum pelvic floor muscle exercise in

prevention of urinary incontinence - theory and practice Workshop Chair: Siv Morkved, Norway

03 September 2019 16:00 - 17:30

Start End Topic Speakers

16:00 16:05 Welcome and presentation Siv Morkved

16:05 16:20 Pelvic floor anatomy and risk factors of birth injuries to the

pelvic floor

Cornelia Betschart Meier

16:20 16:35 Evidence for pelvic floor muscle exercise

during pregnancy and after childbirth

Siv Morkved

16:35 16:50 Adherence strategies in promotion of pelvic floor muscle

training

Helena Frawley

16:50 17:00 Pelvic floor muscle training included in general pre- and

postnatal exercise classes - an example

Signe Nilssen Stafne

17:00 17:20 Practical exercise class for pre- and postpartum women Kari Bø

17:20 17:30 Discussion Siv Morkved

Cornelia Betschart Meier

Kari Bø

Helena Frawley


Aims of Workshop

The aim of this workshop is to improve the health care for women during pregnancy and after delivery, by facilitating

implementation of evidence based practice.

The workshop includes a practical exercise session, an update on pelvic floor anatomy and possible birth injuries, evidence for

the use of pelvic floor muscle exercises (PFME) in prevention and treatment of urinary incontinence during pregnancy and after

childbirth, and strategies to improve adherence and implementation of PFME.

At the conclusion of this workshop, the participants will know the rationale and evidence behind the use of PFME in pre and

postnatal care, and how they can plan and implement an exercise program in clinical practice.

Learning Objectives

The rationale and evidence behind the use of pelvic floor muscle exercises in the prevention and treatment of pre- and postnatal

urinary incontinence

Target Audience

Urogynaecology, Conservative Management

Advanced/Basic

Intermediate

Suggested Learning before Workshop Attendance

1. Evidence-based Physical Therapy for the Pelvic Floor. Bridging science and clinical practice. Bø K, Berghmans B, Mørkved S,

Van Kampen M. 2015 Elsevier. ISBN 978-0-7020-4443-4

2. Incontinence, 6th Edition 2017. Abrams P, Cardozo, Wagg A, Wein A. Incontinence Ch 12 Adult Conservative Management

6th Edition 2017 ISBN: 978-0-956907-3-3

3. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal

women.Woodley SJ, Boyle R, Cody JD, Mørkved S, Hay-Smith EJC.

Cochrane Database Syst Rev. 2017 Dec 22;12:CD007471. doi: 10.1002/14651858.CD007471.pub3. Review.

Pelvic floor anatomy and risk factors of birth injuries to the pelvic floor

Cornelia Betschart

Anatomy: The pelvic floor is a complex unity that consists of different anatomical structures. There are large, robust muscles on

the pelvic side-wall like the piriformis muscle and the obturator internus muscle that are not prone to birth related injuries. The

obturator muscle gives origin to the fascial structure like levator arch. More caudally a next condensation of connective tissue

forms the fascial arch. Both arches support the levator ani muscle and the endopelvic fascia. The different subdivisions of the

levator ani will be revised with focus on their fibers’ vectors. The functional consequence of levator muscle injury depends on

the region of muscle affected.

The vagina and the cervical ring are anchored within the endopelvic fascia. Most caudally we find the perineal membrane

where the urethra, the vagina and the rectum pass through. We know from imaging studies that 15 to 35% of women giving

birth, have an injury of the levator ani muscle after their first vaginal delivery.

The anatomical structures, subjected to injuries, will be revised by short video clips.

Apart from muscles’ injuries there are also ligaments and nerves that undergo a significant stretch during pregnancy and

delivery. The two most important ligaments are the uterosacral ligament and the cardinal ligament. They both reinforce the

membranes of the pelvic floor. The uterosacral ligament is situated more horizontally, from ventral to posterior, and the cardinal

ligament acts in a vertical way.

In one MRI-model taken at five different time points in pregnancy and up to 1 year postpartum, a significant change during

pregnancy and postpartum of both, the ligaments and levator ani was demonstrated. It was shown that the ligaments and

levator ani one year after delivery remained still longer than at 16 weeks of pregnancy. Within one year, they did not return to

their initial length.

When it comes to pelvic floor nerves we also have a good model of the second stage phase where Lien et al. demonstrated the

effect of passing the baby’s head through the genital hiatus. In their model the posterior branches of the pudendal nerve, that

means the inferior rectal nerve and the anal sphincter nerve were stretched 35% whereas the anterior nerves such as the

urethral sphincter nerve and the labial nerves got stretched less, for about 15%.

Pressure on the pelvic floor: Delivery is not only a spatial issue, it is also a pressure issue. In everyday life the pelvic floor is

subject to different pressures: walking, jogging, coughing, lifting weight. The rise in intraabdominal pressure during these

activities is comparable to the rise of a second stage contraction that is between 60 and 70 cm H2O. The big difference is the

length of the pressure impact. For example, when jogging, the rise of pressure lasts for milliseconds whereas the second stage

contraction lasts for about 90 seconds. This makes a difference in the area under the curve and yields to a more than hundred

times higher impact to the pelvic floor during a second stage contraction than for example jogging or lifting weights.

Literature

- Betschart C, DeLancey JOL, et al. Muscle fiber direction of the levator ani and external anal sphincter muscle in MRI. IUJ

2014

- Jean Dit Gautier E, Rubod C, et al. Pregnancy impact on uterosacral ligament and pelvic muscles using a 3D numerical

and finite element model: preliminary results. IJU 2018

- Lien KC, DeLancey JO, et al. Pudendal nerve stretch during vaginal birth. AJOG 2005

- Bo K, et al. Regular exercisers have stronger pelvic floor muscles than nonregular exercisers at midpregnancy. AJOG

2018

- Shaw JM, Nygaard I, et al. Intra-abdominal pressures during activity in women using an intra-vaginal pressure

transducer. J Sports Sci 2014

- Meyer S, Achtari C, et al. Continuous recording of intrarectal pressures during the second phase of labour: correlations

with postpartum pelvic floor complaints. A biomechanical-clinical study. IUJ 2017

Evidence for pelvic floor muscle exercise during pregnancy and after childbirth

Siv Mørkved, PT, MSc, PhD

Professor, Department of Public Health, Norwegian University of Science and Technology, Trondheim, Norway

Associate medical director Central Norway Regional Health Authority

The role of physiotherapy in avoiding and treating pelvic floor disorders during pregnancy and after delivery

Aim of the presentation is to present literature on the evidence behind the use of pelvic floor muscle training (PFMT) during

pregnancy and after delivery in prevention and treatment of urinary incontinence (UI).

There is evidence that child-bearing results in higher risk of incontinence. The challenge is to find effective and acceptable

methods to avoid injury to the PFM, treat dysfunction early to stop progression, and find strategies to treat and rehabilitate

pelvic floor damage related to pregnancy and delivery. One such strategy is to encourage women to do PFM exercises.

The pelvic floor muscles give pelvic organ support and are an important continence mechanism. It is a strong biological rationale

for PFMT for to treat stress UI and pelvic organ prolapse (POP) (Miller et al -04, Bø & Talseth -97, Peschers -01, Brækken et al -

10). The rationale for PFMT is to perform strength training over time to build up «stiffness» and structural support of the pelvic

floor. In addition, to the women can learn to consciously contract before and during an increase in abdominal pressure– «The

Knack» - to prevent descent to the pelvic floor.

Does pelvic floor muscle exercise during pregnancy and after delivery prevent or treat urinary incontinence?

In The International Consultation on Incontinence 2017; Conservative Management, one Chapter adresses prevention and

treatment in pregnant and postnatal women. The primary outcome of interest was self-reported UI (cure, improvement,

number of leakage episodes). The recommendations are:

Prevention of UI in childbearing women: Offer continent, pregnant women a supervised (including regular health professional

contact) and intensive strengthening antepartum PFMT programme to prevent antepartum and postpartum UI.

Treatment of UI in childbearing women: PFMT should be offered as first line conservative therapy to women with persistent UI

symptoms three months after delivery. An ‘intensive’ PFMT programme (in terms of supervision and exercise content) is likely to

increase the treatment effect.

Where a population approach (groups of women where some did and some did not have prior UI symptoms) is used, the ‘best’

evidence to date suggests the following: (a) an intervention comprising of a daily home PFMT and weekly physiotherapist-led

exercise classes for 12 weeks, starting at 16-24 weeks’ gestation for pregnant women, and (b) an individually taught

strengthening PFMT programme that incorporates adherence strategies for postpartum women who have had a forceps delivery

or a vaginal delivery of a large baby (4000g or more).

Reflections

Knowledge about training principles, functional anatomy and motor learning principles including motivation theory is essential

for physiotherapists dealing with exercise therapy in general. Moreover, this knowledge may be particularly important when

dealing with prevention and treatment of incontinence. Pregnant women and women in the postpartum period seem to need

thorough instructions in correct PFM contractions, strong motivation and close follow up if exercise is to be maximally effective.

Take home message

– To improve clinical management the interventions used should be based on high level evidence

– PFMT is an effective low-threshold treatment with no adverse effects, that should be offered to child-bearing women

– Multidiciplinary teams

Adherence strategies in promotion of pelvic floor muscle training

Helena Frawley

This presentation will cover:

• Why (long-term) exercise adherence is difficult

• How theory helps us understand adherence

• How a patient-centred and context-specific application can maximise adherence

At the end of this presentation you will be able to:

• Identify one or more behaviour change techniques that might support patients’ exercise adherence in your practice

• Record adherence strategies

Phases of adherence: Initial uptake -> Adoption of main routine -> Maintenance routine -> Relapse management.

The core concepts discussed will include:

• Adherence is a process AND an outcome

• Measuring adherence is difficult – no gold standard

• Most people are partially adherent, some are over-adherent

• Certain level of adherence is required to obtain therapeutic benefit

• Treatment adherence typically requires health behaviour change: 4As: Aware, Agree, Adopt, Adhere.

o There is attrition in this pipeline, so that fewer reach adherence than start.

We will consider adherence to PFMT as an ‘exercise behaviour’.

Theories that have been used in PFMT adherence research, or theories that may be applied:

• Health Belief Model

• Social Cognitive Theory: Self-Efficacy Beliefs

• Information Motivation Behavioural Skills Model (IMB)

• Capability, Opportunity, Motivation, determining Behaviour (COM-B model)

We will discuss the research that has looked at:

• factors that modify adherence to PFMT: Knowledge, Feelings about PFMT, Physical skill, Cognitive analysis, planning

and attention, Prioritisation, Service provision.

• Determinants of adherence (Moderators & Mediators) and the strategies that can be used to enable these

determinants, in populations with UI, but not other PFDs.

Adherence is not uni-dimensional, there are interacting dimensions which affect adherence, highlighting the need for an

individualised, context-specific approach. Important to consider the patient perspective, because does not always align with the

clinician perspective.

We will discuss terminology for the exercise behaviour strategies used to promote adherence to PFMT, and optimal recording of

these.

References:

o Albrecht L et al. Development of a checklist to assess the quality of reporting of knowledge translation interventions

using the Workgroup for Intervention Development and Evaluation Research (WIDER) recommendations. Implement

Sci. 2013; 8: 52.

o Behaviour change: http://www.marketingforchange.com.au/great-behaviour-change-mind-map/

o Borek AJ, et al. A checklist to improve reporting of group-based behaviour-change interventions. BMC Pub Health. 2015

15: 963.

o Dumoulin C, et al. Pelvic Floor Muscle Training Adherence: tools, measurements and strategies - 2011 State-of-the-

Science Seminar Research Paper II of IV. Neurourol Urodyn 2015 34(7): 615-621.

o Dumoulin C, et al. Consensus Statement on Improving Pelvic Floor Muscle Training Adherence: International Continence

Society 2011 State-of-the-Science Seminar. Neurourol Urodyn 2015 34(7): 600-605.

o Fisher WA, et al (2003) The Information-Motivation-Behavioral Skills model: A general social psychological approach to

understanding and promoting health behavior. In: Suls J, Wallston KA (eds) Social Psychological Foundations of Health

and Illness. Blackwell Publishing, 82–106.

o Frawley HC, et al. Is pelvic floor muscle training a physical or a behavioral therapy? Physical Therapy (2017) 97 (4): 425-

437

o Frawley, H, et al. (2015) Health Professionals’ and Patients’ Perspectives on Pelvic Floor Muscle Training Adherence –

2011 ICS State-of-the-Science Seminar Research Paper IV of IV. Neurourol Urodynam, 34(7): 632-639.

o Glasziou, P. and R. B. Haynes (2005). The paths from research to improved health outcomes. Evidence-Based Medicine

10: 4-7.

o Grol, R., M. Wensing, et al., Eds. (2013). Improving patient care: the implementation of change in health care. Oxford,

Wiley Blackwell

o Hay-Smith J, et al. Pelvic-Floor-Muscle-Training Adherence ‘‘Modifiers’’: A Review of Primary Qualitative Studies—2011

ICS State-of-the-Science Seminar Research Paper III of IV. Neurourol Urodyn 2015, 34(7): 622-631.

o Hay-Smith, E. J., et al (2015). "Exercise Adherence: Integrating Theory, Evidence and Behaviour Change Techniques."

Physiotherapy 101(Suppl 1): e9-e10

o McClurg D et al. Scoping Review of Adherence Promotion Theories in Pelvic Floor Muscle Training - 2011 ICS State-of-

the-Science Seminar Research Paper I of IV. Neurourol Urodyn 2015 34(7): 606-614

o Michie S et al (2011) The behaviour change wheel: a new method for characterising and designing behaviour change

interventions. Implement Sci 6:42

o Michie S, et al. The Behavior Change Technique Taxonomy (v1) of 93 Hierarchically Clustered Techniques: Building an

International Consensus for the Reporting of Behavior Change Interventions. Ann Behav Med 2103; 46(1): 81-95.

o Rainbird, K et al. (2006) Identifying barriers to evidence uptake http://www.nicsl.com.au/

o Slade SC, et al, and the CERT Panel. Consensus on Exercise Reporting Template (CERT): a modified Delphi study. Phys

Ther. 2016; 96(10): 1514-1524.

o Slade SC, et al. The Consensus on Exercise Reporting Template (CERT): Explanation and Elaboration Statement. Br J

Sports Med. 2016;50:1428–1437

o Spring, B. & Hitchcock, K. (2009) Evidence-based practice in psychology. In I.B. Weiner & W.E. Craighead (Eds.) Corsini’s

Encyclopedia of Psychology, 4th edition (pp. 603-607). New York:Wiley

o https://www.wcpt.org/sites/wcpt.org/files/files/wpt15/fs/FS-09.pdf

o WHO 2003: Adherence to Long-Term Therapies - Evidence for Action

http://apps.who.int/medicinedocs/en/d/Js4883e/7.2.html#Js4883e.7.2.1

Pelvic floor muscle training included in general pre- and postnatal exercise classes - an example

By Signe Nilssen Stafne

In this section I will present how pelvic floor muscle training (PFMT) can successfully be implemented in general pre- and

postnatal exercise classes. The study was done in Trondheim, Norway, in 2007-2009 and was included in my PhD. The study has

been published in BJOG (Stafne et al., Does regular exercise including pelvic floor muscle training prevent urinary and anal

incontinence during pregnancy? A randomized controlled trial. BJOG, 2012). The study was a RCT aiming to study whether

exercise training during pregnancy could prevent pregnancy related diseases as conditions, including urinary incontinence (UI).

Healthy pregnant women with a single live fetus were eligible for study inclusion. In total 855 women were included in mid-

pregnancy. Women randomized to the exercise group were encouraged to follow a 12-week exercise program. Women met for

group training once per week and were encouraged to exercise on their own twice a week. The exercise program followed

recommendations from the American College of Obstetricians and Gynecologists. The exercise groups consisted of 10-15

pregnant women and were led by a physiotherapist. The exercise program was standardized and consisted of both endurance

training and strength training. The strength exercises was for upper and lower limbs, core muscles and the pelvic floor muscles.

All exercise sessisons were ended with light stretching, body awarness and relaxation exercises. More specific, the PFMT

followed the principles for increasing strength of skeletal muscles, and women were encouraged to perform three sets of 8-12

close to maximum contractions of the PFM, and were encouraged to hold the contraction for 6-8 seconds, and if possible to add

three fast contractions at the end of the contraction. Before starting the exercise period, all women met for an individual vaginal

examination with a physiotherapist to ensure that they were able to do a correct voluntary contraction. Women who were

unable to contract were instructed until they managed. All women received written and verbal information in pelvic floor

anatomy and why they should do PFMT. The information were given both individually and repeated in the exercise group

sessions. The exercise program consisted of low impact exercises as it stresses the continence system minimally. PFMT was done

in different positions for variation and we also included functional exercises. After the 12-week exercise period, in late

pregnancy, significantly less women in the exercise group reported UI (42% vs. 53%, p=0.004). At three months postpartum

there was significantly fewer women in the exercise group reporting UI (29% vs. 38%, p=0.008). The implications of the study is

that thorough instruction in correct PFM contractions and a specific PFMT program successfully can be included in exercise

classes for pregnant women.

PELVIC FLOOR MUSCLE TRAINING CLASS/ CORE MUM PROGRAM

Kari Bø, Professor, PhD, exercise scientist, physical therapist, Norwegian School of Sport Sciences, Department of Sports

Medicine.

Table 1. Example of a PELVIC FLOOR MUSCLE EXERCISE CLASS (30 minutes of low impact aerobic exercise can be added to the

below program).

TIME (minutes) EXERCISE

Music 4.00 – 6.00 Warming up; stretch, walk, step

touch, body awareness, posture

3.00 PELVIC FLOOR: STANDING

Music 2.30 Strength: back and abd (TrA);

prone

3.00 PELVIC FLOOR: PRONE, ONE LEG

IN FLEXION

Music 2.30 Strength: arms, back, TrA

“Dog position”

3.00 PELVIC FLOOR: FROG POSITION

Music 2.30 Strength: abdominals, back; crook

lying

Music 2.10 Relaxation, breathing. Neck and

shoulder stretch; sitting position

3.00 PELVIC FLOOR: SITTING POSITION

Music 3.19 Move to standing, stretches,

ergonomics, strength: thigh,

gluteals and back

2.00 PELVIC FLOOR: STANDING & WITH

FLEXED HIPS AND KNEES

Music 3.18 Stretches, breathing relaxation;

standing position

CONTENT:

This model for pelvic floor muscle training consists of two main stages:

STAGE 1: SEARCH, FIND, LEARN AND CONTROL

This is done individually with a trained physical therapist (PT) and includes observation and vaginal palpation with verbal

feedback of muscle performance. If the patient is able to perform a correct contraction, muscle strength is measured, and the

patient can be sent to the exercise class. If she is not able to contract she comes back to the PT, and the PT may use facilitation

techniques (tapping, stretching, massage, el.stim) in order to stimulate ability to contract correctly.

STAGE 2: STRENGTH TRAINING

The strength training can be performed individually in the PT’s office + home training, or in groups. The aim of the strength

training is to build up the muscles in order to make them able to give better structural support to counteract increase in intra-

abdominal pressures. Possible changes to the pelvic floor muscles due to strength training are:

1. lifting of the pelvic floor to a higher anatomical position inside the pelvis

2. increase of the cross sectional area of the muscles (hypertrophy)

3. increase of “stiffness” of the connective tissue within and around the pelvic floor muscles

4. reduction of the area of the levator hiatus

Such changes have been verified in a recent single blind randomized controlled trial.

In the group training class strength training of the pelvic floor muscles is done in 5 different positions with attempts of 8-12

maximum voluntary contractions (MVC) in each position. The participants are instructed to hold each contraction for 6-8

seconds. In addition about half of the contractions in each position are “intensive contractions” meaning that the women are

asked to contract as hard as possible, hold the contraction for 6-8 seconds, and then add 3-4 fast contractions on top of the

prolonged contraction. The instructor is using strong verbal encouragement to stimulate for maximum contractions. The

patients typically exercise in the class once a week, but ideally supervized PFM training classes would be done 3 times/week.

Positions with legs apart are used to avoid strong outer pelvic muscles (hip adductor, gluteals and outer abdominal muscles) to

take over and mask attempts of maximum contraction of the pelvic floor muscles. Co-contractions of the inner abdominal

muscles have always been allowed in this program, as it does not seem to be possible to perform maximum contractions of the

pelvic floor muscles without some co-contraction of the inner abdominals (no visible movement of the pelvis, only a small

tucking in of the abdomen should be observed). When the PFM are contracted first, co-contraction of the abdominals is unlikely

to open the levator hiatus or press the pelvic floor downwards.

In addition to the supervised training the patients are asked to perform 3 sets of 8-12 maximum contractions every day at home

and to report training adherence in a training diary/app/mobile phone.

References

Bø K 2004 Pelvic floor muscle training is effective in treatment of stress urinary incontinence, but how does it work?

International Urogynecology Journal and Pelvic Floor Dysfunction 15:76-84.

Bø K, Hagen RH, Kvarstein B, Jørgensen J, Larsen S 1990 a Pelvic floor muscle exercise for the treatment of female stress urinary

incontinence: III. Effects of two different degrees of pelvic floor muscle exercise. Neurourology and Urodynamics 9:489-

502.

Bø K, Talseth T 1996 Long term effect of pelvic floor muscle exercise five years after cessation of organized training. Obstetrics

and Gynecology 87(2):261-265.

Bø K, Talseth T, Holme I 1999 Single blind, randomised controlled trial of pelvic floor exercises, electrical stimulation, vaginal

cones, and no treatment in management of genuine stress incontinence in women. British Medical Journal 318:487-

493.

Bø K, Kvarstein B, Nygaard I 2005 Lower urinary tract symptoms and pelvic floor muscle exercise adherence after 15 years.

Obstet Gynecol ,105: 999-1005.

Bø K, Berghmans B, Mørkved S, van Kampen M 2015: Evidence based physical therapy for the pelvic floor. Bridging science and

clinical practice. Elsevier 2015

Brækken IHB, Majida M, Engh ME, Bø K: Morphological changes after pelvic floor

muscle training. Obstet Gynecol, 115, 2, Part 1:317-324, 2010

Brækken IHB, Majida M, Engh ME, Bø K: Can pelvic floor muscle training reverse

Pelvic organ prolapse and reduce prolapse symptoms? Am J Obstet Gynecol,

Aug, 203, 170e: 1-7, 2010

Mørkved S, Bø K, Fjørtoft T 2002 Is there any additional effect off adding biofeedback to pelvic floor muscle training? A single-

blind randomized controlled trial. Obstetrics and Gynecology 100(4):730-739.

Mørkved S, Bø K. The effect of postpartum pelvic floor muscle exercise in the prevention and treatment of urinary incontinence.

Int Urogynecol J 1997; 8:217-222.

Mørkved S, Bø K 2000 Effect of postpartum pelvic floor muscle training in prevention and treatment of urinary incontinence: a

one-year follow up. Br J Obstet Gynaecol, 107: 1022-1028.

Mørkved S, Bø K, Schei B, Salvesen K. Pelvic floor muscle training during

pregnancy to prevent urinary incontinence: A single blind randomized controlled trial Obstet Gynecol 2003: 101:313-

319.

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Agenda – Faculty

Welcome and presentation 16.00-16.05 Siv Morkved, Norway

Pelvic floor anatomy and

risk factors of birth injuries 16.05-16.20 Cornelia Betschart Meier, Switzerland

Evidence for PFMT during pregnancy

and after childbirth 16.20-16.35 Siv Morkved

Adherence strategies in promotion

Of PFMT 16.35-16.50 Helena Frawley, Australia

PFMT included in general pre- and

postnatal exercise classes 16.50-17.00 Signe Nilssen Stafne, Norway

Practical exercise class for pre- and

postnatal women 17.00-17.20 Kari Bo, Norway

Discussion 17.20-17.30 All

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ICS, Gothenburg, 3th September 2019

Pre and Postpartum Pelvic Floor Muscle Exercise in Prevention of UrinaryIncontinence - Theory and Practice


Cornelia Betschart, MD Urogynecologist

Department of GynecologyUniversity Hospital Zurich

Switzerland

Nerves

Fascias

Ligaments

Muscles

Orchestra Pelvic Floor

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Dietz HP, et al. Obstet Gynecol 2005Kearney R, et al. Obstet Gynecol 2006

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Anatomy – Muscles and Arches

conceptual

https://vimeo.com/showcase/5853765

symphysis

Levator ani

Levator ani

M. pubovisceralis

M. puborectalis

M. ileococcygeus

M. pubovaginalis

M. puboperinealis

M. puboanalis

Dissection – Levator ani muscle

Dissection – Levator ani muscle

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Anatomy - ligaments

sagittal scheme

conceptual

https://vimeo.com/showcase/5853765

Betschart Somaini Passweg ©

1 2

3 4

5 6

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Dissection - Ligaments

Cardinal ligament Uterosacral ligament

DeLancey © 25.09.2019 8

Changes already during pregnancy

USL and LA muscle more stretched postpartum than in 16th week of pregnancy

C-section at 4cm dilatation

Jean Dit Gautier E, et al. Pregnancy impacton uterosacral ligament and pelvicmuscles using a 3D numerical and finite element model: preliminary results. IJU 2018

USL

USL

LA m

usc

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LA Muscle

25.09.2019 9

from: Thakar and Fenner, Springer Science+Business Media

Pelvic Floor Nerves - delivery

Lien et. al, Pudendal nerve stretch during vaginal birth. Am J Obstet Gynecol 2005

How is it in-vivo?

Schwertner-

Tiepelmann N, et al.

Obstetric levator ani

muscle injuries:

current status.

Ultrasound Obstet

Gynecol.

2012;39(4):372-83.

Betschart ©

MRI: avulsion of pubovisceral muscle left side(28y-old primipara)

re li re li re li

Pannu HK, Genadry R, Gearhart S, Kaufman HS, Cundiff GW, Fishman EK. Focal levator ani eventrations: detection and characterization by magnetic resonancein patients with pelvic floor dysfunction. International urogynecology journal and pelvic floor dysfunction. 2003;14(2):89-93

Betschart ©

Nerves

Fascias

Ligaments

Muscles

Cathrine Winnes, Norvegian music conductorPhysiotherapist

7 8

9 10

11 12

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Perineal trauma - often clinically underdiagnosed

25.09.2019 14

Kimmich N, Zimmermann R, et al. Video analysis for theevaluation of vaginal births: a prospective observational study.

Swiss Med Wkly 2018

Frohlich J, Kettle C. Perineal care. BMJ clinical evidence. 2015

85% of women having a vaginal birth suffer some perineal trauma

United KingdomPain and discomfort at 10-12d:23% to 42%

Long-term pain 3–18 months after delivery:7% to 10%

High demand Macrosomia >4 kg

Gaudet, Ferraro, Wen, Walker. Maternal Obesity and Occurrence of Fetal Macrosomia: A Systematic Review and Meta-Analysis. Biomed Res Int 2014

▪ 30 studies, all upper/middle income countries, 1992-2010

▪ 11 studies used population based databases

▪ 1,443,449 women

▪ For BMI >25kg/m2

OR 2.01 for Macrosomia

> 4kg

Risk Factors

No Defect (n=131)

Defect (n=29) Odds Ratio

P

Age 29.3±4.7 32.8±5.9 -- .001

2nd stage (min) 92.5±67.5 170.5±117.5 -- .0001

Ruptured Sphincter 16.8% 62.1% 8.1 .001

Forceps 4.6% 41.4% 14.7 .001

Vacuum 7.6% 6.9% 0.9 .626

Episiotomy 34.4% 62.1% 3.1 .006

Epidural 68.7% 65.5% 0.9 .448

Kearney, Obstet Gynecol 2006;107:144-9

Risk assessment pre-partum?Personalized?

Delivery: capacity >< demand

Sculpture Vagina, Tübingen. Foto: dpa

13 14

15 16

17 18

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Subjective risk assessmentUR CHOICE – Score

U UI before pregnancy

R Race/Ethnicity

C Child bearing started at what age?

H Height (mother’s height)

O Overweight (mother’s weight)

I Inheritance

C Children (number of children desired)

E Estimated fetal weight

19

Data from longitudinal studies: ProLong und der SWEPOP databases

Scores for urinary and stool incontinence and prolapse [2]

[1] Wilson D, Milsom I, Freeman. UR-CHOICE: can we provide mothers-to-be with information about the risk of

future pelvic floor dysfunction? IUJ 2014

[2] Jelovsek JE, et al. Predicting risk of pelvic floor disorders 12 and 20 years after delivery. AJOG 2018

http://riskcalc.org/UR_CHOICE/

20

Jelovsek JE, et al. Predicting risk of pelvic floor disorders 12 and 20 years after delivery. AJOG 2018

Tracy et al, J BME 2016

75% adequate capacityPuboviseralis Loop

Objective risk assessment Take Home MessagesAnatomy▪ Pelvic Floor Anatomy many different structures▪ How they are orchestrated is not fully elucidated yet

Paula Modersohn-Becker self-portrait 1907mother and child 1904

Risk mechanisms

▪ Pelvic organ prolapse most birth-related

▪ Educate women regarding benefits of weight optimisation

▪ Forceps is largest risk factor (vacuum not)

▪ Estimating women at risk feasible with estimations:▪ UR-CHOICE (patients history)▪ Capacity-Demand Estimates (ultrasound)

▪ Clinical trials next

Thank you very muchfor your attention

19 20

21 22

23

1

Affiliations to disclose†:

Funding for speaker to attend:

Self-funded

Institution (non-industry) funded

Sponsored by:

Siv Mørkved

None

x

† All financial ties (over the last year) that you may have with any business organisation with respect to the

subjects mentioned during your presentation

2

EVIDENCE FOR PELVIC FLOOR MUSCLE

EXERCISE DURING PREGNANCY AND

AFTER CHILDBIRTH

Siv Mørkved, PT, MSc,

PhD

Professor

Department of Public Health,

Norwegian University of

Science and Technology

Trondheim, Norway

Associate medical director

Central Norway Regional

Health Authority

3

Aims of the presentation

• Literature review

▪ Evidence behind the use of

• pelvic floor muscle exercise during pregnancy and

after delivery in prevention and treatment of urinary

incontinence

• Example of an evidence based training protocol

▪ Results

4

• There is evidence

that child-bearing

may cause damage

to the pelvic floor

and higher risk of

incontinence

5

Can we prevent dysfunction of the

PFM?

• Elective Caesarean section ?

• Obstetric management ?

Need for strategies to treat and rehabilitatepelvic floor damage

• Pelvic floor muscle training

6

The pelvic floor muscles

• Pelvic organ

support

• Continence

mechanism

• Strong and fast

contraction

• “Squeeze and lift”

7

Strong biological rationale for PFMT for

SUI and POP

• During voluntary contraction

– Constriction of levator hiatus

– Increase in ↑ MUCP: 11.1 (10.7)-23.2 (8.4) cm H2O

(Miller et al -04, Bø & Talseth -97)

– Resistance to ↓ movement (Peschers -01)

• Morphological changes after PFME: ↓Hiatal area and muscle length during valsalva, indicatingincreased PFM stiffness? (Brækken et al -10)

8

Rationale for PFME

• Learn to consciously contract before and during

an increase in abdominal pressure and continue

to perform such contractions as a behaviour

modification to prevent descent to the pelvic floor

– The «Knack»

• Perform strength training over time to build up

«stiffness» and structural support of the pelvic

floor

9

Does pelvic floor

muscle exercise

during

pregnancy and

after delivery

prevent or treat

urinary

incontinence?

10

The International Consultation on

Incontinence 2017; Conservative

Management

Prevention and treatment in pregnant and postnatal

women

• The primary outcome of interest was self-reported UI

(cure, improvement, number of leakage episodes)

• Other outcomes of interest included adherence measures

11

Is PFMT effective in the prevention of

UI in childbearing women?

Level of Evidence: 1

• Offer continent, pregnant women a supervised (including

regular health professional contact) and intensive

strengthening antepartum PFMT programme to prevent

antepartum and postpartum UI

– Grade of Recommendation: A

12

Is PFMT effective in the treatment of

UI in childbearing women?


• PFMT should be offered as first line conservative therapy

to women with persistent UI symptoms three months after

delivery

– Grade of Recommendation: A

• An ‘intensive’ PFMT programme (in terms of supervision

and exercise content) is likely to increase the treatment

effect

– Grade of Recommendation: B

13

Is PFMT effective in the mixed

prevention and treatment of UI in

childbearing women?


• The characteristics of trials demonstrating reduced UI

prevalence in late pregnancy and six months postpartum

are high adherence to a supervised PFM strength training

program and home exercises.

– Grade of Recommendation antepartum PFMT: A

– Grade of Recommendation postpartum PFMT: B

14

Is PFMT effective in the mixed

prevention and treatment of UI in

childbearing women?

• Where a population approach is used, the ‘best’ evidence

to date suggests the following:

– an intervention comprising of a daily home PFMT and

weekly physiotherapist-led exercise classes for 12 weeks,

starting at 16-24 weeks’ gestation for pregnant women

– an individually taught strengthening PFMT programme that

incorporates adherence strategies for postpartum women

who have had a forceps delivery or a vaginal delivery of a

large baby (4000g or more)

– Grade of Recommendation C

15

Additional PFMT is more effective thanusual antenatal or postnatal care for theprevention and treatment of urinaryincontinence

Cochrane reviewWoodely et al, 2017

16

An example

of a

training

protocolIntervention (12 weeks)

• Instruction in correct

PFM contraction

• Training in groups 60

minutes once per week

• Home training: 10 strong

PFM contractions x 3 per

day

17

Important !!

Intervention based on knowledge about:

• Exercise principles

• Functional anatomy

• Motor learning principles

• Motivation theory (adherence strategy)

18

Motor learning

principles

Instructions

in correct

PFM contraction

19

General recommendation:

- 3 sets of 10 high resistant contractions three times per

week

- Rehabilitation situations – overload not possible – more

frequent training sessions

Exercise principles

20

Motivation (adherence strategies)

21

The myth that pelvic floor muscle training during pregnancy will cause prolonged labour has not

been confirmed.

Salvesen & Mørkved. BMJ 2004

Salvesen, Stafne, Eggebø,

Mørkved. Acta Obstet Gynecol

Scand. 2014

https://www.ncbi.nlm.nih.gov/pubmed/24102423

22

Training in pregnancy (TRIP)

Signe Stafne, Siv Mørkved, Kjell Å Salvesen NTNU and St.Olavs Hospital, Trondheim, Norway

23

RESULTS: Weekly PFME can reduce postpartum AI

The effect is dependent on

•Degree of AI

•Persistant anal sphincter defect

•PFME frequency

24

Take home message

• Pelvic floor muscle exercises: Easily accessible and

effective low-threshold treatment / no adverse effects

• To improve clinical management the interventions

used should be based on high level evidence

• PFMT should be offered as first-line treatment to

women and men with several pelvic floor

dysfunctions

• Multidiciplinary teams

25

25/09/2019

1

Affiliations to disclose†:

Funding for speaker to attend:

Self-funded

Institution (non-industry) funded

Sponsored by:

Helena Frawley

Nil to disclose

X

X

† All financial ties (over the last year) that you may have with any business organisation with respect to the subjects mentioned during your presentation

Adherence and implementation strategies in

promotion of pelvic floor muscle training

ICS Workshop #19, 3 Sep 2019

Helena Frawley, PhD, FACP• Associate Professor, Physiotherapy, • Monash University• Melbourne, Australia

MONASH

Medicine, Nursing,

Health Sciences

Learning objectives

We will cover:• Why (long-term) exercise adherence is difficult

• How theory helps us understand adherence

• How a patient-centred and context-specific application can maximise adherence

• How to maximise implementation of adherence strategies

You will be able to:• Identify one or more behaviour change techniques that might support

patients’ exercise adherence in your practice

• Record adherence strategies

• Implement evidence-based findings

Adherence

Adherence is ‘the extent to which a patient’s behavior matches agreed recommendations/ instructions from the prescriber; it is intended to be nonjudgmental, a statement of fact, rather than to ascribe blame (to patient, prescriber, or treatment method’).

• National Institute for Clinical Effectiveness

• World Health Organisations

Phases of Exercise Adherence➢ Initial uptake

➢Adoption of main routine

➢Maintenance routine

➢Relapse management

Core concepts

• Adherence is a process AND an outcome

• Measuring adherence is difficult – no gold standard

• Most people are partially adherent, some are over-adherent

• Certain level of adherence is required to obtain therapeutic benefit

• Treatment adherence typically requires health behaviour change

• Implementation requires behaviour change

Behaviours: - Behaviours are what people do as a consequence of their inner

state or because of external drivers (environmental cues)- Behaviours are observable by others- An example of a behaviour is exercise or PFMT- For uptake of a new behaviour, CHANGE is required

Physical Therapy-informed

approaches

Psychology-informed

approaches

Exercise behavior

zone

PFMT adherence as an exercise behaviour (Frawley et al 2017)

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• Long term adherence to exercise based interventions typically very poor:• Urinary incontinence

• Short-term: 64% (Sluijs 1991)

• Long-term: 23% (e.g. Borello-France 2013)

• Initial take up (often in a supported treatment setting) does not translate into daily routine

• People relapse and don’t resume their exercises

• ‘knowledge-behaviour’ gap

It’s challenging…

Attrition in the ‘pipeline’ of research to practice (Glasziou & Haynes 2005)

1.Aware 2.Accept 3.Target 4.Able 5. Acted on 6.Agreed 7. Adhere

Valid andrelevant

research

Theories used in PFMT (McClurg 2015)

Health Belief Model(Rosenstock & Becker, 1988: 1974)

Chiarelli and Cockburn (1999)

Gillard and Shamley (2010)

Dolman and Chase (1996)

Sacomori et al (2012)

Theory of Planned Behaviour (Ajzen, 1991)Whitford and Jones (2011)

Social Cognitive Theory: Self-Efficacy

Beliefs(Bandura, 1986)

Chen (2004); Cheng (2010), Lai

(2008), Hallam (2012), Hay-Smith,

Ryan and Dean (2007), Alewijnse

et al. (2003), Messer et al. (2007)

Transtheoretical Model (Prochaska & DiClemente, 1983)

Alewinjse (2002; 2003)

Self-Regulatory Model (Leventhal, Meyer & Nerenz; 1980)

Alewinjse (2002; 2003)

Health Action Process Approach (Schwarzer, 1992)

Hyland (2012)

Health Belief Model (Rosenstock & Becker, 1988: 1974)

10

Social Cognitive Theory: Self-Efficacy Beliefs (Bandura, 1986)

Information Motivation Behavioural Skills Model (IMB) (Fisher et al 2003)

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9 10

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Modifiers of adherence to PFMT (Hay-Smith et al 2015)

• Knowledge

• Feelings about PFMT

• Physical skill

• Cognitive analysis, planning and attention

• Prioritisation

• Service provision

Population

Women with

Urinary

Incontinence (UI)

Alewijnse,

Chen

Men with UI

Ip 2004

Pre & Post natal UI

Chiarelli and Cockburn

(2002)

Pelvic Organ Prolapse

Lower Bowel Dysfunction

Determinants of adherence (Dumoulin et al 2015)

Population Determinants (Moderators & Mediators)

Women with

Urinary

Incontinence (UI)

Alewijnse,

Chen

Positive intention to adhere

Amount of urine lost (i.e. symptom level)

Self efficacy expectations

Attitudes towards the exercises

Perceived social pressure to engage

Dyadic cohesion (i.e. feedback)

Men with UI

Ip 2004

Pre & Post natal UI


(2002)

Pelvic Organ Prolapse

Lower Bowel Dysfunction


Population Determinants (Moderators & Mediators)

Women with

Urinary

Incontinence (UI)

Alewijnse,

Chen







Men with UI

Ip 2004

No studies

Pre & Post natal UI


(2002)

No studies

Pelvic Organ Prolapse No studies

Lower Bowel Dysfunction No studies


Population Determinants (Moderators & Mediators) Strategies

Women with

Urinary

Incontinence (UI)

Alewijnse,

Chen







A structured programme

Enthusiastic physiotherapist

Audio prompts

Use of established theories of

behaviour change

User consultation

Men with UI

Ip 2004

No studies

Pre & Post natal UI


(2002)

No studies

Pelvic Organ Prolapse No studies

Lower Bowel Dysfunction No studies


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15 16

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Population Determinants (Moderators & Mediators) Strategies

Women with

Urinary

Incontinence (UI)

Alewijnse,

Chen







A structured programme

Enthusiastic physiotherapist

Audio prompts

Use of established theories of

behaviour change

User consultation

Men with UI

Ip 2004

No studies Reminders on fridge magnets

Pre & Post natal UI


(2002)

No studies Health belief model tailoring

PFM to function and time

Pelvic Organ Prolapse No studies None

Lower Bowel Dysfunction No studies None

Determinants of adherence (Dumoulin et al 2015) Five interacting dimensions affect adherence (WHO 2003)


Clinical Recommendations (Frawley 2015)

(1)Patient-related factors may be the most important category of barriers to long-term PFMT adherence.

• patient’s perception of minimal benefit of the therapy

• reduced self-efficacy

• poor identification with pelvic anatomy

• poor understanding of the condition

• → low motivation to adhere to PFMT.

• Health professionals need to identify and address these factors.


(2) Patient- and therapy-related factors may optimally facilitate long-term adherence

• → health professionals need to provide tangible evidence or feedback to patients on PFMT benefits

(3) Long-term adherence may be best achieved through follow-up appointments and a re-assessment of factors impeding progress

• determinants may change over time.


(4) An individualized approach to treatment based on a person’s age, sex, and ethnicity is recommended.

(5) The belief that PFMT adherence determinants differ according to condition is not strongly supported

• → therefore, individualized patient-centered, as opposed to condition-centered, approaches are recommended.

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Orientation

Insight

AcceptanceChange

Maintenance

Phases in the process of change (Grol 2013)

26

Behavior change stages (Frawley et al 2017)

Definition/Explanation Example of Application to PFMT

Orientation and insight: awareness or knowledge of the problem;understanding of how the problem or the change affects oneself

Understanding of UI; interest and involvement in managing it effectively

27





Acceptance and agreement of the change: a positive attitude; motivation to change

Agreeing to adopt a conservative therapy that involves active exercise

28







Change: actual adoption of a new behavior; confirmation of its benefit or value

Uptake of PFMT; adherence in the prescribed program

29







Change: actual adoption of a new behavior; confirmation of its benefit or value

Uptake of PFMT; adherence in the prescribed program

Maintenance of the new behavior; integration into one’s routine

Long-term adherence in PFMT

Behaviour change techniques (BCTs) (Michie et al 2013)

• 93 item taxonomy

• Naming active ingredients of delivery

• Choose for context

• many terms in the BCT taxonomy may be used to name and describe elements of PFMT

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27 28

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BCT items (Michie et al 2013)

ITEM Explanation

1.4 Action planning

2.6 Biofeedback

6.1 Demonstration of the behaviour

2.2 Feedback on the behaviour

5.1 Information about health consequences

4.1 Instruction on how to perform the behavior

9.1 Credible source

2.7 Feedback on outcome of behavior

15.1 Verbal persuasion of capability

41 Mental rehearsal of successful performance 32

Consensus on Exercise Reporting Template (CERT) Items (Slade 2016)

Domain Item Abbreviated item description

WHAT 1 Type of exercise equipment

WHO 2 Qualifications & expertise of exercise instructor

HOW 3 Whether exercises are performed individually or in a group

4 Whether exercises are supervised or unsupervised

5 Adherence strategies & measurement

6 Motivation strategies

7a Decision rules for exercise progression

7b How exercises are progressed

8 Each exercise is described so that it can be replicated e.g.

illustrations, photographs

9 Content of home program components

10 Non-exercise components

11 Number & type of adverse events that occur during exercise

33

Domain Item Abbreviated item description

WHERE 12 Exercise setting

HOW

MUCH

13 Detailed description of exercise dosage

TAILORING 14a Generic (one size fits all) or tailored to the individual

14b How exercises are tailored

15 Decision rule that determines the starting level for exercise

HOW WELL 16a How fidelity to the exercise program is measured

16b Extent to which the exercise program is delivered as planned

Consensus on Exercise Reporting Template (CERT) Items (Slade 2016)

34

Items to report behavior change interventions (*Albrecht 2013;

**Borek 2015)DOMAIN Item Abbreviated item description * Explanation **

Detailed description of all interventions

1 Characteristics of those delivering the intervention (facilitator)

E. g qualifications, experience, personal characteristics such as age, gender

2 Characteristics of the recipients (participants)

Personal characteristics e.g. age, gender, occupation, education, work status

3 The setting Reports the type of setting in which the interventions were delivered including e.g. the venue characteristics, room layout/plan

4 The mode of delivery Individual, group, face-to-face

5 Dosage Session duration, number of sessions, frequency of sessions, length of intervention(s)

6 Detailed description of the intervention content provided for each study group

E.g. themes, topics covered, sequencing, materials or tools the participants used during and outside the sessions

7 Change mechanisms or theories of change

Describes how the intervention was intended to work by identifying change mechanisms or underpinning theories of behaviour change

8 Facilitator training Reports the training in delivering the intervention with which the facilitators were provided

9 Adherence/fidelity to delivery protocols

Methods used to check the fidelity of intervention delivery, i.e. methods used to check if the sessions were delivered as designed

35

DOMAIN Item Abbreviated item description *

Explanation **

Clarification of assumed change process & design principles

10 Intervention development

Describes the source (origin) and/or methods used for developing the intervention e.g. based on published work, intervention mapping

11 Change techniques used in the intervention

Describes the techniques used to prompt change. These may be derived from the mechanisms or theories of change, and may use established taxonomies of behaviour change. Explicit description enables replication

12 Causal processes targeted by these change techniques

Describes the processes or pathways of the direct and indirect linkages between interventions and outcomes

Access to intervention manuals & protocols

13 Published intervention protocols or manuals

Protocols and manuals provided as e.g. online appendices, supplementary data

Items to report behavior change interventions (*Albrecht 2013;

**Borek 2015)To summarise

• Promote motivation through • goal setting and action planning

• “if-then” rules

• Boost self-efficacy

• Work out a relapse strategy

• Ensure patient has necessary behavioural skills • correct exercise technique

• a program to follow that allows progression and relapse management

• skills and equipment to self-monitor or review progress

• Aim for sufficient adherence to obtain therapeutic benefit

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REFERENCES

▪ Albrecht L et al. Development of a checklist to assess the quality of reporting of knowledge translation interventions using the Workgroup for Intervention Development and Evaluation Research (WIDER) recommendations. Implement Sci. 2013; 8: 52.

▪ Behaviour change: http://www.marketingforchange.com.au/great-behaviour-change-mind-map/

▪ Borek AJ, et al. A checklist to improve reporting of group-based behaviour-change interventions. BMC Pub Health. 2015 15: 963.

▪ Dumoulin C, et al. Pelvic Floor Muscle Training Adherence: tools, measurements and strategies - 2011 State-of-the-Science Seminar Research Paper II of IV. Neurourol Urodyn 2015 34(7): 615-621.

▪ Dumoulin C, et al. Consensus Statement on Improving Pelvic Floor Muscle Training Adherence: International Continence Society 2011 State-of-the-Science Seminar. Neurourol Urodyn 2015 34(7): 600-605.

▪ Fisher WA, et al (2003) The Information-Motivation-Behavioral Skills model: A general social psychological approach to understanding and promoting health behavior. In: Suls J, Wallston KA (eds) Social Psychological Foundations of Health and Illness. Blackwell Publishing, 82–106.

▪ Frawley HC, et al. Is pelvic floor muscle training a physical or a behavioral therapy? Physical Therapy (2017) 97 (4): 425-437

▪ Frawley, H, et al. (2015) Health Professionals’ and Patients’ Perspectives on Pelvic Floor Muscle Training Adherence – 2011 ICS State-of-the-Science Seminar Research Paper IV of IV. Neurourol Urodynam, 34(7): 632-639.

▪ Glasziou, P. and R. B. Haynes (2005). The paths from research to improved health outcomes. Evidence-Based Medicine 10: 4-7.

▪ Grol, R., M. Wensing, et al., Eds. (2013). Improving patient care: the implementation of change in health care. Oxford, Wiley Blackwell

38

REFERENCES

▪ Hay-Smith J, et al. Pelvic-Floor-Muscle-Training Adherence ‘‘Modifiers’’: A Review of Primary Qualitative Studies—2011 ICS State-of-the-Science Seminar Research Paper III of IV. Neurourol Urodyn 2015, 34(7): 622-631.

▪ Hay-Smith, E. J., et al (2015). "Exercise Adherence: Integrating Theory, Evidence and Behaviour Change Techniques." Physiotherapy 101(Suppl 1): e9-e10

▪ McClurg D et al. Scoping Review of Adherence Promotion Theories in Pelvic Floor Muscle Training - 2011 ICS State-of-the-Science Seminar Research Paper I of IV. Neurourol Urodyn 2015 34(7): 606-614

▪ Michie S et al (2011) The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci 6:42

▪ Michie S, et al. The Behavior Change Technique Taxonomy (v1) of 93 Hierarchically Clustered Techniques: Building an International Consensus for the Reporting of Behavior Change Interventions. Ann Behav Med 2103; 46(1): 81-95.

▪ Rainbird, K et al. (2006) Identifying barriers to evidence uptake http://www.nicsl.com.au/

▪ Slade SC, et al, and the CERT Panel. Consensus on Exercise Reporting Template (CERT): a modified Delphi study. Phys Ther. 2016; 96(10): 1514-1524.

▪ Slade SC, et al. The Consensus on Exercise Reporting Template (CERT): Explanation and Elaboration Statement. Br J Sports Med. 2016;50:1428–1437

▪ Spring, B. & Hitchcock, K. (2009) Evidence-based practice in psychology. In I.B. Weiner & W.E. Craighead (Eds.) Corsini’s Encyclopedia of Psychology, 4th edition (pp. 603-607). New York:Wiley

▪ https://www.wcpt.org/sites/wcpt.org/files/files/wpt15/fs/FS-09.pdf

▪ WHO 2003: Adherence to Long-Term Therapies - Evidence for Action http://apps.who.int/medicinedocs/en/d/Js4883e/7.2.html#Js4883e.7.2.1

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http://www.marketingforchange.com.au/great-behaviour-change-mind-map/

http://www.nicsl.com.au/

https://www.wcpt.org/sites/wcpt.org/files/files/wpt15/fs/FS-09.pdf


1


Physiotherapist, Specialist in Womens Health, MNFFSt.Olavs Hospital, Trondheim University Hospital, Norway

ResearcherDepartment of public health and nursing, NTNU, Trondheim, Norway

Pelvic floor muscle training included in general pre- and postnatal exercise classes - an example

2

3

Study

• Randomized controlled trial (recruited from April 2007 to June 2009)

– General exercise classes including PFMT 3x/week versus usual care

• N=855

• Eligible for study inclusion:

– Healthy pregnant women

– ≥ 18 years

– Singleton live fetus

• Included in gest.week 18-22

4

Aim

• Randomized controlled trial (recruited from April 2007 to June 2009)

– General exercise classes including PFMT 3x/week versus usual care

• N=855

• Eligible for study inclusion:

– Healthy pregnant women

– ≥ 18 years

– Singleton live fetus

• Included in gest.week 18-22

Objective: Are women following a standardized

exercise program including PFMT during

pregnancy less likely to report UI?

5

Exercise group

✓Led by a physiotherapist

✓Group of 10-15 pregnant women

Standardized exercise program:✓30-35 min aerobic activity

✓20-25 min specific strength training▪Upper/lower limbs▪Core muscles▪Pelvic floor muscles

✓10 min stretching, body awarnessand relaxation exercises

6

Pelvic floor muscle training (PFMT)

• 3 sets of 8-12 repetitions

• Close to maximum contractions

• 3 days / week

• Hold of contraction in 6-8 seconds

• End of contraction; add 3 fast contractions

• Different positions

1 2

3 4

5 6

7

Pelvic floor muscle training (PFMT)

Information

and vaginal

examinationLow-impact

exercises

Functional

exercisesDifferent

positions

8

Urinary incontinence (UI)

✓ Outcome measure:

▪ Self-reported questionnaire (Sandviks severity scale)

▪ UI defined as «any involuntary leakage of urine»

9

Baseline characteristics Pregnancy week 18-22

Exercise group

(N = 429)

Control group

(N = 426)

Mean age – years 30.5 ± 4.4 30.4 ± 4.3

Weight – kg 70.4 ± 9.8 70.8 ± 10.3

Body mass index – kg/m2 24.7 ± 3.0 25.0 ± 3.4

Nulliparous 58 % 56 %

Exercise regularly ≥ 3x/week 14 % 12 %

Plus-minus variables are means ± SD

10

Results

Exercise group Control group P-value

Pregnancy week 32-36

UI 42 % 53 % 0.004

PFMT 95 % 79 % <0.001

3 months postpartum

UI 29% 38% 0.008

PFMT 88% 85% ns

UI = any involuntary leakage of urinePFMT = pelvic floor muscle training

11

Implications

Thorough instructions in correct PFM contractions

and a specific PFMT program should be included in

exercise classes for pregnant women

12

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9 10

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