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

Neurourology and Urodynamics 30:746–753 (2011) Determining the Optimal Pelvic Floor Muscle Training Regimen
for Women with Stress Urinary Incontinence
Chantale Dumoulin,1Cathryn Glazener,2§ and David Jenkinson2
1Faculty of Medicine, School of Physiotherapy, University of Montreal, Montreal, Canada 2Health Services Research Unit, University of Aberdeen, Aberdeen, UK Pelvic floor muscle (PFM) training has received Level-A evidence rating in the treatment of stress urinary incontinence(SUI) in women, based on meta-analysis of numerous randomized control trials (RCTs) and is recommended in manypublished guidelines. However, the actual regimen of PFM training used varies widely in these RCTs. Hence, to date,the optimal PFM training regimen for achieving continence remains unknown and the following questions persist: howoften should women attend PFM training sessions and how many contractions should they perform for maximal effect?Is a regimen of strengthening exercises better than a motor control strategy or functional retraining? Is it better toadminister a PFM training regimen to an individual or are group sessions equally effective, or better? Which is better,PFM training by itself or in combination with biofeedback, neuromuscular electrical stimulation, and/or vaginal cones?Should we use improvement or cure as the ultimate outcome to determine which regimen is the best? The questions areendless. As a starting point in our endeavour to identify optimal PFM training regimens, the aim of this study is (a) toreview the present evidence in terms of the effectiveness of different PFM training regimens in women with SUI and(b) to discuss the current literature on PFM dysfunction in SUI women, including the up-to-date evidence on skeletalmuscle training theory and other factors known to impact on women’s participation in and adherence to PFM training.
Neurourol. Urodynam. 30:746–753, 2011. 2011 Wiley-Liss, Inc.
Key words: pelvic floor muscle training; stress urinary incontinence; women
INTRODUCTION
PFM TRAINING ALONE VERSUS NO TREATMENT STUDIES
National and international clinical practice guidelines recom- The effects of PFM training for women with urinary incon- mend supervised pelvic floor muscle (PFM) training as a first-line tinence (UI) as compared to no treatment, a placebo or sham treatment for stress urinary incontinence (SUI) in women (Level treatment were recently evaluated in a Cochrane Review.2 The of evidence A).1--4 The goal is to improve the functioning Cochrane Incontinence Group’s Specialised Trials Register and of the PFMs.2 Essentially, PFM training can be prescribed to the reference lists of relevant articles were searched (February 18, 2009). Randomized and quasi-randomized trials and the tar-geted population (women with stress, urgency, or mixed UI) • PFM strength (the maximum force generated by a muscle in a were among the selection criteria. In this review, at least one component of each trial had to include PFM training. The com- • PFM endurance (the ability to perform repetitive contractions parators were no treatment, a placebo or a sham treatment, or or to sustain a single contraction over time), and another type of inactive control treatment.
• PFM coordination (muscular activity prior to effort and on Fourteen trials involving 836 women met the inclusion cri- teria. Within the 14 trials, only 8 (370 women) contributed data exclusively for women with SUI and were also suitablefor analysis (Table I). There were considerable variations in the Supervised by a trained health professional, progressive PFM exercise regimens and often their descriptions were not exten- training involves various PFM exercises either with or without sive. Generally, the exercise programmes consisted of strength, adjunctive biofeedback, electro-neurostimulation, intra-vaginalresistance, and/or a bladder diary.1 The uncertainty aboutwhich of these strategies are most effective in training womento use their PFM to cure or improve symptoms of SUI has beenidentified by a wide panel of patients and experts to be one of Linda Brubaker led the review process.
the key clinical questions which needs to be prioritized.5 In order to determine the best regimen for treating SUI in The work was performed at ICI-RS 2010.
§ women, this study begins with a review of the up-to-date evi- Professor of Health Research.
Research Fellow.
dence of the effectiveness of PFM training regimens alone as ∗Correspondence to: Chantale Dumoulin, Ph.D., Associate Professor, Facult´e de compared to no treatment or a placebo treatment, the evi- M´edecine, ´Ecole de R´eadaptation, Universit´e de Montr´eal, C.P. 6128 Succ. Centre- dence for the comparative effectiveness of different types of PFM ville, Montr´eal, Qu´ebec, Canada H3C 3J7. E-mail: chantal.dumoulin@umontreal.caReceived 3 February 2011; Accepted 15 February 2011 training regimens and, finally, the evidence for PFM training in Published online 15 June 2011 in Wiley Online Library (wileyonlinelibrary.com).
combination with various adjunct therapies.
Optimal Training For Women With Stress Incontinence TABLE I. PFM Training Programs From RCTs Comparing PFM Training to a Control
Short programme aimed at improving coordination between a VPFMC and a rise in intra-abdominalpressure Set: 8--12 high-intensity maximal VPFMC with a 6- 8 sec hold followed by 3--4 fast contractions at the end of each, and a 6 sec rest between maximal contractions Exercises done in different body positions included supine, kneeling, sitting, and standing—all with thelegs apart Set: 10 VPFMC, with 5 sec hold and 10 sec rest. Progressed at 2 weeks to 10 sec hold and 20 sec rest VPFMC confirmed by surface electromyography with Set: not stated (not clear if 30 total or 30 each), taking Strength: burst of intense activity lasting a few secondsEndurance: 6 sec holds progressed by 1 sec/week to 12 secSets per day: 30 VPFMC Set: 10 VPFMC with 3 sec hold, and 10 VPFMC with 10 sec hold. Progressed by 10 per set to daily maximum of 200 Weekly clinic visits with nurseDrop out: 10 group not Sets: 5 VPFMC with 10 sec hold, 10 VPFMC with 5 sec hold, 20 PFMC with 2 sec hold, 20 VPFMC with 1 sec hold, 5 Sets: 10 VPFMC with 3 sec hold, 10 VPFMC with 10 sec hold in sitting, lying, and standing positions with the PFM, pelvic floor muscle; VPFMC, voluntary PFM contraction; PFMT, PFM training; Set, one episode or sequence of PFM contractions or training, including lengthof time of holding contraction, positions while performing contractions and number of repetitions of contractions.
endurance or coordination training, or a combination of these: Despite these difficulties, the review found that PFM-trained women with SUI were about 17 times more likely to report cure 1. Programmes with a low number of repetitions and high of incontinence compared to those having non-active control loads (maximal effort) were classified as strength training.
management in one trial (RR 16.8, 95% CI: 2.4--119.0). Addition- 2. Those that included a high number of repetitions ally, PFM-trained women with SUI were 17 times more likely to or prolonged contractions with low-to-moderate loads report improvement or cure of their symptoms (RR 17.33, 95% CI: (submaximal contractions) were classified as endurance 4.31--69.64, in two trials). Moreover, they experienced between 0.8 and 3 fewer leakage episodes per 24 hr compared to women 3. Those that employed the repeated use of a PFM contraction in non-active treatments. Finally, PFM-trained women with SUI in response to a specific situation (e.g., prior to cough, “The were 5--16 times more likely to be continent on a short pad test Knack”) were classified as coordination training.
4. For the most part, PFM training programmes were diffi- Overall, the best conclusion that could be derived from the cult to categorize because they described either a mixed review is that PFM training is better than no treatment, placebo (e.g., strength and endurance) programme or omitted a key drug, or inactive control treatments for women with SUI. Vari- training parameter (e.g., the amount of voluntary effort per ations in the PFM training programmes were a major source contraction, number or duration of contractions per set, dura- of clinical heterogeneity, preventing a comparative analysis of tion or frequency of sets per day, Table I).
the training programmes and their potential effectiveness. The Neurourology and Urodynamics DOI: 10.1002/nau study trials, however suggested that treatment effects (in terms to cure incontinence than no treatment (Fig. 1). Furthermore, of self-reported cure/improvement) might be greater in women all of the interventions examined (with the exceptions of PFM with SUI participating in a supervised PFM training programme training with vaginal cones and biofeedback, and PFM training with Duloxetine), were significantly better than no treatmentat improving SUI (HTA monograph18 Fig. 32, p. 105). Moreover,there was also clear evidence that when women attended forPFM training in more than 2 sessions per month it was more COMPARISON OF DIFFERENT PFM TRAINING REGIMENS
effective than 2 or fewer sessions per month (cure: medianodds ratio 8.36, 95% credible interval 3.74--21.7; improvement: Twelve trials comparing different PFM exercise regimens in median odds ratio 5.75, 95% credible interval 2.11--16.2). There- SUI women were found in the literature review, very few of fore, PFM training reinforced with biofeedback or PFM provided which compared the same regimens. In most trials, the partici- in extra sessions appear to be the most effective interventions, pant numbers were few; consequently the confidence intervals although there is some uncertainty surrounding this.18 were wide and the results were inconclusive (Table II).6--17 So in summary, in terms of treatments specifically targeting Because of this limitation, the review of the available data was women with SUI, the up-to-date evidence does not clearly iden- unable to discern clear differences between the following train- tify an optimal PFM training regime. However, the evidence does suggest that supervised PFMT programmes delivered more often (more than 2 sessions per month) or augmented with maximal versus submaximal strength training,6 biofeedback appear to be more effective. In order to identify strength/motor relearning versus motor relearning alone,7 the parameters of an optimal PFM training, rigorous adequately PFM training with and without deep abdominal muscle powered RTCs must be conducted in which different models of exercises in the supine position versus a combination of posi- This being said, there are, however, certain elements in the literature pertaining to (a) the biological rationale for PFM train- direct PFM training versus indirect or imitation PFM training ing, (b) PFM dysfunction in women with SUI, (c) skeletal muscle through the hip abductor muscles,10,11 or training theory as progressive overload, and (d) behavior and adherence strategies which impact on women’s participationand adherence to PFM training programmes. These are dis- cussed in detail below and must be taken into consideration cure/improvement if PFMT was taught and supervised by when designing optimal PFM training regimens which might a health professional versus self-administered.14 Further, be amenable to testing by randomized control trial (RCT).
self-reported cure or cure/improvement in SUI women wasmore likely with more health professional contact during PFMTversus less health professional contact (Table II).15,16 BIOLOGICAL RATIONALE FOR PFM TRAINING
The biological rationale for using PFM training is twofold.
PFM TRAINING IN COMBINATION WITH VARIOUS ADJUNCT
Firstly, a voluntary contraction before and during a cough (a THERAPIES STUDIES
maneuver termed “The Knack”) has been shown to effectivelyreduce urinary leakage during a cough.19 Hence, simply learn- More recently, the effectiveness of PFM training combination ing to contract the PFM before a cough may be, in and of itself, with various adjunct therapies has been studied using mixed sufficient treatment for those women who experience leakage treatment comparison models. These are sophisticated meta- during coughing; and as such should be included in all PFM analyses that handle evidence about several interventions from training regimens for SUI women. Secondly, improving PFM many trials in one analysis, producing comparisons between strength is thought to build up long-lasting structural support all pairs of interventions, including those which have not been of the pelvis by elevating the levator plate to a higher location in directly compared in any trial.18 The Cochrane Incontinence the pelvis: this is also enhanced by hypertrophy of the muscles Group’s Specialised Trials Register and the reference lists of which will increase the stiffness of the PFMs and connective relevant articles were searched (up to June 2008). Randomized tissues.20 Thus, improving PFM strength could prevent perineal and quasi-randomized trials where more than 50% of partic- descent during increased intra-abdominal pressure and facil- ipants had SUI were eligible. The primary outcome measures itate PFM before and during effort, thereby reducing SUI in were (1) cure and (2) improvement of the symptoms of SUI.
women. Given the above biological rationale, when treating SUI These outcomes were measured in the trials as either patient- the focus of any PFM training should be to improve the timing reported (where available), or clinician-reported (as a proxy for (of the contraction relative to a stressor), strength, and stiffness the patient-reported outcome when this was not reported).
Eighty-eight trials were identified (9,721 women).18 The mixed treatment comparison analysis compared 14 interven-tions (including “no active treatment”) and included data from55 trials (6,608 women) that reported cure or improvement.
PFM DYSFUNCTION LITERATURE IN WOMEN WITH SUI
Interventions were on average more effective than no treat-ment. Further, there was clear evidence that PFM training either Further to the biological rationale, a growing body of liter- with extra sessions (more than 2 per month) or combined with ature focuses on the differences in PFM function in continent biofeedback, was better than no treatment, for cure of incon- and SUI women. Using instruments such as dynamometers, tinence, while a basic frequency of PFM training sessions (2 which can provide direct measurements of PFM function (mus- or less per month) was not. Vaginal cones, bladder training, cle tone, strength, coordination, and endurance), and other PFM training with electrical stimulation and PFM training with innovative technologies such as ultrasound (US) and magnetic both bladder training and biofeedback were also more likely resonance imaging (MRI), these studies have provided a unique Neurourology and Urodynamics DOI: 10.1002/nau Optimal Training For Women With Stress Incontinence TABLE II. PFM Training Programs From RCTs Comparing Different Programs
Course: sets of 8--12 VPFMC with 6--8 sec rest, 3 times a day, at least 3 days a week VPFMC with 1--2 sec hold, 4 daysweekly + Knack contraction for 6- 8 sec with feet crossed at the ankles. 3 sets of long and 2 sets of Neurourology and Urodynamics DOI: 10.1002/nau TABLE II. (Continued )
PFMT: 1/4 (25%)Modified pilates: 3/6 (50%)RR 0.5 (95% CI: 0.08--3.27), Supine PFMT: 12/22 (55%)Different position PFMT: Standard care: given a leaflet + 4 clinic Standard care: 53/75 (71%)RR 0.86 (95% CI: 0.69--1.09), contractions daily in lying, sitting, and PFM, pelvic floor muscle; VPFMC, voluntary PFM contraction; PFMT, PFM training; HP, health professional; Set, one episode or sequence of PFM contractions ortraining, including length of time of holding contraction, positions while performing contractions and number of repetitions of contractions.
Neurourology and Urodynamics DOI: 10.1002/nau Optimal Training For Women With Stress Incontinence Fig. 1. Mixed treatment comparison: odds ratio for cure of urinary incontinence for each treatment versus no
treatment. Posterior distributors median (circle) with 95% central credible intervals. The horizontal axis is plotted
on the log scale. PFMT basics: ≤2 sessions per month; PFMT basics: >2 sessions per month; VC, vaginal cones; SNRI,
Duloxetine; BF, biofeedback; BT, bladder training; ES, electrical stimulation.
way of studying PFM function, displacement, and morpholog- nal support to the urethra, reducing displacement, velocity, and ical integrity in continent women versus those with SUI. Such acceleration. In women with SUI, this PFM pre-contraction did studies have already increased our understanding of SUI patho- not occur; consequently, the urethras of women with SUI had to physiology, determined the causes of functional abnormalities, move further and faster for a longer duration.
and might, in future, enable us to identify and better tailor PFM Finally, using MRI, Hoyte25 found differences between conti- training regimens to SUI women. Some examples include: nent and SUI women in terms of the position of the levator plate In a cohort study evaluating PFM function in 59 pre- at rest, which is indicative of stiffness; the levator plate being menopausal women, using dynamometry, Morin et al.21 demonstrated that incontinent women as compared to con- All these findings indicate that PFM function is deficient in tinent women had lower passive force at rest (muscle tone), SUI women at rest (in terms of tone and stiffness), during showed lower endurance, and were unable to produce as many a maximal voluntary contraction (maximal strength, rapid- rapid contractions in 15 sec; indicative of PFM dysfunction at ity, and endurance), and during effort (timing and maximal rest and during an active contraction.
strength). Therefore, PFM assessments could be used to identify In another study by the same author, which evaluated PFM which aspects of structure or function are deficient; subsequent function in 34 continent women and 33 post-menopausal training regimens could then be designed to address these dys- women with SUI, incontinent women showed a reduction of functions by using a diversity of exercises, possibly tailored the PFM involuntary response during a maximal cough such as to individual women’s abilities. Ultimately, the development a lower PFM-contraction rapidity, a decrease in maximal PFM of clinical prediction rules based on such assessments could force, and a reduction of the PFM force measured at peak max- improve clinical practice, enabling SUI women to be matched imum intra-abdominal pressure. This indicates abnormalities to the optimal intervention for their condition.
in the involuntary responses of the PFM during coughing inwomen with SUI.22 Conversely, Verelst and Leivseth,23 in a study evaluating PFM function using dynamometry on 26 control and 20 SUI parous SKELETAL MUSCLE TRAINING THEORY AS PROGRESSIVE
women, concluded that normalized strength differed between OVERLOAD
continent and SUI women; the incontinent women had weakerPFMs.
The American College of Sports Medicine recently issued a Further, in Lovegrove et al.24 used US to characterize the dis- special communication on evidence-based progression models placement, velocity, and acceleration of the PFM during a cough for resistance training in healthy adults.26 These recommen- in 23 asymptomatic and 9 SUI women. They found that dur- dations could be used to elaborate exercise regimen protocols ing a cough, PFM activation in continent women produced a aimed at improving timing, strength, and stiffness. The arti- timely compression of the PFMs and provided additional exter- cle sets out the basic principles, including progressive overload, Neurourology and Urodynamics DOI: 10.1002/nau specificity, and periodization, that need to be incorporated into ing into their lives using either a routine or ad hoc approach.
any resistance-training programme in order to achieve maxi- Those participants who used a routine approach were 12 times more likely (than those employing an ad hoc approach) to have a PFM training regimens should also adhere to these principals.
high adherence level at 3 months (OR = 12.4, 95% CI = 4.0--38.8, For example, in relation to PFM training, progressive overload P < 0.001) and were significantly more likely to have maintained implies that the intensity of the exercises and the number of that level 12 months post-intervention (OR = 2.7, CI = 1.2--6.0, repetitions should be gradually increased throughout the exer- P < 0.014). Practicing bladder training was also related to high cise programme, the speed or tempo of the repetitions with submaximal loads should be adjusted according to the desired Finally, two trials have investigated the use of adherence goal (i.e., to train for either endurance or strength), the rest peri- strategies as a means of rendering PFM training more effec- ods should be shortened for endurance-improvement training tive in women with SUI. In both trials, two groups followed the or lengthened for strength and power training, and, finally, the same daily home-based PFM training programme, but one was overall volume of training should be increased gradually.
provided with an adherence strategy.30,31 In the Sugaya study, Further, in order to increase muscle strength, the progression participants were provided with a device emitting a rhyth- model suggests using a repetition range of 8--12 maximum con- mic beep, signaling them to undertake a contraction; they also tractions at moderate velocity, a 1- to 2-min rest between sets, pressed a button on the device to record each contraction.30 an initial training frequency of 2--3 times per week progressing Participants in the Gallo study were given an audiotape of to 4--5 times, and the application of a 2--10% increase in load exercise instructions that counted out 25 consecutive PFM when an individual can perform the current workload for 1--2 contractions.31 Participants who used the beeping device to repetitions over the targeted number.
cue PFM contractions were more compliant and more likely For endurance training, the progression model suggests the to be satisfied with the treatment outcome, compared to the need for light to moderate loads (40--60% of maximal load) control group (RR 3.17, 95% CI: 1.02--9.88).30 Those who used with high repetitions (>15) and short rest periods (<90 sec). In the audiotape of exercise instructions were more likely to per- PFM training this can be achieved by changing positions from form the exercises twice daily, as per instruction (RR 7.05; 95% gravity-free to anti-gravity (i.e., from lying to sitting to standing) CI: 2.78--17.88).31 Whether these adherence strategies impact or through the introduction of cones into the exercise sessions.
on objective continence outcomes remains inconclusive, as the Finally, rapidity and coordination training (“The Knack”) results were not significant in Sugaya’s study and impact was would include the use of repetitive, voluntary PFM contrac- tions in response to specific situations; for example, prior to Interestingly, the ability to incorporate an exercise regime and during coughing, lifting an object, or jumping.
into one’s daily routine or using an adherence strategy wereboth facilitators for adherence to the home-based exerciseprogramme, including its continuation post-treatment. Resultsfrom these studies should be taken into consideration whendefining protocols for PFM training regimens to achieve optimal TYPES OF BEHAVIOR AND ADHERENCE STRATEGIES FOR
participation during training, at home and, most importantly, EFFECTIVE PFM TRAINING
A few studies have examined factors that impact on women’s participation in and adherence to a PFM training regimenduring treatment (in class and at home), as well as in the long-term, post-treatment.27--29 In a qualitative descriptive study CONCLUSION
using individual and focus-group interviews, In 2006, Milneand Moore27 studied the self-care strategies employed by PFM training has been shown to be effective in treating SUI in community-dwelling individuals to adhere to the PFM train- women. However, to date there are only limited indications as ing regimen at home. Factors that facilitated home-based PFM to which type of PFM training is the most effective. While super- training included realistic goals and expectations, positive affir- vised PFM training which is delivered more often (more than 2 mations, follow-up, and a regular exercise routine. Barriers sessions per month) or augmented with biofeedback appear to noted were insufficient information about the exercise, the be more effective, data and hence consensus are lacking as to characteristics of the exercises, competing interests, financial which elements of a PFM training regimen are most effective, such as the strength and duration of the muscle contractions, In 2007, Martin and Dumoulin28 also studied factors that the type of training employed, the number of contraction rep- facilitate or impede the participation of women with UI in a etitions used, the positions in which exercises are performed, weekly PFM-exercise classes and their adherence to a daily, the inclusion or exclusion of the use of ancillary muscles home-based PFM exercise programme. Four facilitating fac- (such as abdominal ones), and the treatment session approach tors in terms of participation in a weekly PFM exercise classes (e.g., individual versus a class approach), among many others.
were identified: a desire to reduce UI, a sense of responsibility Moreover, factors and treatment strategies that affect compli- towards the programme, close supervision by a physiother- ance and long-term adherence are only just beginning to be apist, and group support. Impediments were illness, medical appointments, and planned social activities. Facilitators for the It is no longer a question of whether PFM training pro- home-based PFM exercise programme were a desire to reduce grammes work but what components (including adjunct UI and commitment to making exercises part of a daily routine.
therapies) and combinations thereof are most effective. Nor Impediments were a busy schedule, the length of the exercise can PFM training be studied without due consideration of PFM dysfunction, resistance training and adherence factors Hines et al.29 conducted a survey 1-year post-treatment of and strategies, derived from physiological theory and innova- 164 community-dwelling, post-menopausal women to identify tive technological investigations. Future RTCs which incorporate predictors of long-term adherence to PFM and bladder training methods and strategies that have been shown to be effective, exercises. Results indicated that women incorporated PFM train- both for treatment for and to encourage long-term adherence, Neurourology and Urodynamics DOI: 10.1002/nau Optimal Training For Women With Stress Incontinence are needed to address some of the uncertainties in how best to 14. Zanetti MR, Castro RA, Rotta AL, et al. Impact of supervised physiotherapeutic pelvic floor exercises for treating female stress urinary incontinence. Sao Paulo PFM training programmes work but the how and for whom is 15. Bo K, Hagen RH, Kvarstein B, et al. Pelvic floor muscle exercise for the treatment still ill understood. In order to improve treatment for SUI women of female stress urinary incontinence: III. Effects of two different degrees of more studies in the following areas are required: pelvic floor muscle exercises. Neurourol Urodyn 1990;9:489--502.
16. Konstantinidou E, Apostolidis A, Kondelidis N, et al. Short-term efficacy of 1. Which PFM components impact, and to what degree, on the group pelvic floor training under intensive supervision versus unsupervisedhome training for female stress urinary incontinence: a randomized pilot study.
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Neurourology and Urodynamics DOI: 10.1002/nau

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