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

Original Editor - User:EugenieLamprecht Top Contributors - Eugenie Lamprecht, Shaimaa Eldib, Kim Jackson and Vidya Acharya

Introduction

The prevalence of Urinary Incontinence (UI) among women varies widely but is approximately 55%. Many women feel embarrassed and believe it's a normal part of womanhood. For this reason, many cases of UI go undiagnosed.

UI has a large impact on the socioeconomic burden worldwide. UI is associated with lower Quality of Life (QoL), depression and extremely high annual medical-care costs.

Risk factors include;

• pregnancy and childbirth
• hysterectomy
• Higher body-mass-index (BMI)
• advanced age
• family history
• smoking
• caffeine
• Diabetes
• constipation
• urinary tract infections (UTI)

Clinically Relevant Anatomy and Physiology

The Pelvic Floor muscles' (PFM) main function is control over bladder, bowel, sexual function, pregnancy in women and providing support to pelvic organs.

The PFM mainly consists of the levator ani and coccygeus muscles and are innervated from the lumbosacral plexus.

Mechanism of pelvic floor Injury

Literature indicates a strong association between vaginal childbirth and pelvic floor disorders however, further research is necessary to determine which aspects of childbirth contribute most.

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

Muscles of the Pelvic Floor

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).
  

General UI management plan

Lifestyle interventions

• reduce fluids, caffeine and carbonated drinks
• regular and timed urination
• treating constipation
• reduce BMI (<25)
• pelvic floor muscle training (PFMT)

Pharmacology (urgency urinary incontinence)

• anticholinergics
• Beta 3 agonist

Surgery (stress urinary incontinence)

• injectable bulking agents
• Burch colpo-suspension
• fascial slings
• mid-urethral synthetic slings

Other

• onabotullinumtoxinA injection
• sacral neuromodulation
• posterior tibial nerve stimulation
• incontinence pessaries

Pelvic Floor Muscle Training and Pilates

It's important to understand that 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)

Therefore, when rehabilitating the PFM, it is important to do so in conjunction with the other muscular groups named above.

Pilates exercise program vs.conventional PFM exercise program

A Pilates exercise - and standard PFM exercise program seems to be equally effective, in improving the recovery time 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.

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.

Clinicians often apply activity restrictions among women suffering from pelvic floor disorders. This is due to the association of increased intra-abdominal pressure (IAP) with pelvic floor loading. Fortunately, a study completed by Coleman et al. (2015), determined no statistically significant difference between the IAP in sit-to-stand and fundamental Pilates exercises and therefore recommends Pilates exercises to women desiring a low intra-abdominal pressure exercise routine.

Modified Pilates (MP) as an addition to standard physiotherapy care seems to be even more beneficial.

Examples of Pilates exercises

Pelvic Clock (supine/ crook-ly)

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

Bridging (supine/ crook-ly)

posterior pelvic tilt pelvis, then elevate the pelvis

Chest-lift (supine/ crook-ly)

hands interlaced behind the head, followed by segmental flexion with cervical and thoracic spine

Hundred (supine)

legs at table-top, Cx and Tx spine in flexion with bilateral arms pumping up and down by the sides of the trunk

Roll-up (supine)

segmental flexion of Cx -, Tx and Lx spine

Leg-circles (supine)

unilateral perpendicular leg circles clockwise and anti-clockwise while maintaining a stable pelvis

Side-kick kneeling

elevate the superior leg to hip height and pulse anteriorly and then posteriorly

(modification: side-ly)

Adductor Squeeze (supine/ crook-ly)

contract muscles by squeezing a ball between knees

Bent Knee fall out (supine/ crook-ly)

unilateral abduction with pelvic stabilization

Supine Arm series (supine/ crook-ly)

arm work in flexion, abduction and rotation with trunk stabilization

4 point kneeling position

elevate one limb with trunk stabilization or maintaining a neutral spine

Roll down series (seated)

segmented spinal flexion and back up maintaining PFM activation

Assisted Squat

squat with trunk stabilization and co-contraction of core

Conclusion

Each patient is different, therefore it is extremely important to individualize each session to the patient's specific needs and abilities. Pilates can be a great addition to standard Physiotherapy care by modifying exercises to ensure the correct technique and contraction of the PFM.