The effect of Pilates on pelvic floor muscle strength in women with urinary incontinence

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Clinically Relevant Anatomy

Urinary incontinence during the rise of abdominal pressure is largely prevented by sphincteric and musculofascial systems.

The bladder, uterus, rectum and the urethral- and anal sphincters are surrounded by a dome-shaped striated muscular sheet. This dome-shaped structure plays an important role in storing and elimination of urine and stool.

This dome-shaped muscular structure mainly consists of the levator ani and coccygeus muscles.

The levator, coccygeus and urogenital diaphragm are innervated by S2, S3, and S4 nerve fibres; while the external anal sphincter is innervated by the pudendal nerve .

(insert pic of bony structures; muscles, sphincters AND nerves)

Mechanism of pelvic floor Injury

Pregnancy and childbirth may lead to pelvic floor injury due to compression, stretching or tearing of nerve, muscle, and connective tissue.

The following pelvic floor-complications may occur due to pregnancy and childbirth;

• neural injury (due to compression during labour and vaginal delivery),
• levator ani and coccygeus muscles injury,
• fascial injury, and
• impaired connective tissue remodelling (increased synthesis of collagen and elastin causes an alteration in soft tissue biomechanics during pregnancy).
  

For further information regarding clinical presentation and diagnostic procedure, please read 'Incontinence'

Pilates-centred Pelvic Floor Muscle Training (PFMT)

*principles of pilates*

It's important to understand that Pelvic Floor Muscles (PFM) function in synergy with abdominal muscles, chest wall and diaphragm, and not in isolation. Throughout each day, the intra-abdominal pressure and trunk muscle activity alternate regularly. The PFM have to respond rapidly to these changes to prevent incontinence or prolapse of pelvic organs.

The pilates concept is based on 'centre'(core) and 'control'. The pilates method focusses on the following muscles when referring to the 'core';

• PFM (inferiorly),
• diaphragm (superiorly),
• transverse abdominis (TrA) and oblique muscles (anteriorly)
• multifidus (posteriorly)[8]

*insert anatomy picture*

Pilates exercise program vs. conventional PFM exercise program

A Pilates exercise - and conventional PFM exercise program seems to be equally effective, in speeding up the recovery of UI, as well as improve quality of life (QoL). However, higher rates of fully-recovered individuals, diagnosed with UI, are found among individuals following Pilates exercise programmes[8].

Why might the Pilates method be better?

1. A lower financial impact on the healthcare system
2. Less discomfort (no internal devices)
3. An alternative for individuals disliking conventional PFM exercises[8]

Current best available evidence states that individuals, diagnosed with UI, can benefit by doing as little as one session per week, for 8 to 52 weeks[8].

Modified Pilates (MP) as an adjunct to conventional physiotherapy care seems to be even more beneficial in improving self-esteem, decreasing social embarrassment and lowering impact on normal daily activities[9].

Examples of Pilates exercises

2. Pelvic Clock (supine/ crook-ly)

moving pelvis like a clock to facilitate spinal flexion, extension, lateral flexion and rotation

3. Bridging (supine/ crook-ly)

posterior pelvic tilt pelvis, then elevate the pelvis

4. Adductor Squeeze (supine/ crook-ly)

contract muscles by squeezing a ball between knees

5. Bent Knee fall out (supine/ crook-ly)

unilateral abduction with pelvic stabilization

6. Supine Arm series (supine/ crook-ly)

arm work in flexion, abduction and rotation with trunk stabilization

7. 4 point kneeling position

elevate one limb with trunk stabilization or maintaining a neutral spine

8. Roll down series (seated)

segmented spinal flexion and back up maintaining PFM activation

9. Standing Leg Pump

1 leg dissociation (hip and knee flexion) with trunk and pelvic stabilization

10. Assisted Squat

squat with trunk stabilization and co-contraction of core [8]

Differential Diagnosis

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Resources

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