Bulletin of Faculty of Physical Therapy

ORIGINAL ARTICLE
Year
: 2017  |  Volume : 22  |  Issue : 2  |  Page : 67--73

Postnatal rehabilitation of pelvic floor muscles using aerobic and Kegel exercises


Engy M El Nahas1, Marwa A Mohamed1, Hesham M Kamal2,  
1 Department of Physical Therapy for Obstetrics and Gynecology, Faculty of Physical Therapy, Cairo University, Cairo, Egypt
2 Department of Obstetrics and Gynecology, El-Mataria Teaching Hospital, Cairo, Egypt

Correspondence Address:
Engy M El Nahas
Department of Physical Therapy for Obstetrics and Gynecology, Faculty of Physical Therapy, Cairo University, Cairo
Egypt

Abstract

Background Weakness of pelvic floor muscles (PFMs) is the most important consequence of childbirth and is determined by specific alterations in its structure and physiological function. Objective This study was conducted to determine and add evidence on the effect of aerobic exercises and biofeedback-assisted Kegel exercises on PFMs strength and thickness in postnatal women. Participants and methods A total of 50 primiparous women experiencing mild-degree stress urinary incontinence 3 months postnatally participated in this study; their age ranged from 20 to 30 years. They were divided into two equal groups. Study group (group A) (aerobic+Kegel exercises) consisted of 25 primiparous women who performed aerobic exercise in addition to biofeedback-assisted Kegel exercises, and the control group (group B) (Kegel exercise) consisted of 25 primiparous women who performed only biofeedback-assisted Kegel exercises. Assessment of the PFMs’ strength was performed by using the perineometer, whereas assessment of the PFMs’ thickness was performed by using perineal ultrasound at relaxation and during contraction. Results The results of this study revealed a highly statistical significant increase in the PFMs’ strength, as the P was less than 0.001, and a statistical significant increase in the PFMs’ thickness both at relaxation and during contraction, as the P was less than 0.05, in both groups (groups A and B) after treatment, in favor of group (group A). Conclusion It could be concluded that adding aerobic exercise to biofeedback-assisted Kegel exercises would improve PFMs’ strength and thickness than biofeedback-assisted Kegel exercises only.



How to cite this article:
El Nahas EM, Mohamed MA, Kamal HM. Postnatal rehabilitation of pelvic floor muscles using aerobic and Kegel exercises.Bull Fac Phys Ther 2017;22:67-73


How to cite this URL:
El Nahas EM, Mohamed MA, Kamal HM. Postnatal rehabilitation of pelvic floor muscles using aerobic and Kegel exercises. Bull Fac Phys Ther [serial online] 2017 [cited 2018 Jul 20 ];22:67-73
Available from: http://www.bfpt.eg.net/text.asp?2017/22/2/67/226691


Full Text

 Introduction



Stress urinary incontinence (SUI) is defined as the involuntary leakage of urine during increases in abdominal pressure in the absence of a detrusor contraction. SUI is one of the most common conditions among women with a significant effect on the quality of life owing to psychosocial and hygienic problems. Two main etiologic factors have been implicated in the urethral dysfunction leading to SUI, urethral hypermobility and intrinsic sphincter deficiency [1].

In urethral hypermobility, it is the weakness of pelvic floor support that results in a rotational descent of the vesical neck and urethra during increases in abdominal pressure with subsequent leakage. In intrinsic sphincter deficiency, there is malfunction of the urethral sphincter which leads to low urethral closure pressures [2].

The pelvic floor muscles (PFMs) comprise the pelvic diaphragm muscles (pubococcygeus, ischiococcygeus, and iliococcygeus, together known as the levator ani), which can be referred to as the deep layer of the PFMs; the urogenital diaphragm muscles (ischiocavernosus, bulbospongiosus, and transversus perinea superficialis, together known as the perineal muscles), which can be referred to as the superficial layer of the PFMs; and the uretheral and anal sphincter muscles [3].

Pregnancy and childbirth are major risk factors for the development of urinary incontinence (UI) as the muscles of the pelvic floor become stretched and weakened. For some women, such incontinence after childbirth is temporary, but for others, their experience can be of a much longer term duration [4].

Pelvic floor disorders have an established association with childbirth. It was approved that even first delivery can cause this problem [5].

During the gestational period, PFMs experience a growing weight overload imposed by the pregnant uterus. Moreover, specific hormonal alterations during this period reduce muscle tonus and strength, predisposing to PFMs dysfunctions such as UI and sexual dysfunction [6].

Parity − the number of delivery − is a known risk factor for stress incontinence. Primiparous women have three times higher prevalence of stress incontinence than their age-matched nulliparous controls [7], and the risk of stress incontinence surgery increases with increased parity [8]. Recent evidence suggests that mode of delivery has a significant effect. In a retrospective cohort study of parous women, the odds of bothersome symptoms of SUI doubled among women who had experienced at least one vaginal birth compared with women who delivered exclusively through cesarean [9]. In addition, history of operative vaginal birth has been associated with SUI [10].

PFMs strength is significantly reduced after vaginal delivery, both normal and instrumental, 6–12 weeks postpartum. However, cesarean section resulted in significantly less muscle strength reduction [11].

As early as in 1948, the American gynecologist Kegel emphasized the value of PFM exercise in restoring function after childbirth. He claimed that genital relaxation after delivery was because pudendal nerve injury, over stretching of muscles, and tearing of fascias as well; he mentioned that the method of restoring the condition was ‘tightening’ of the PFMs [12].

Pelvic floor exercises are safe and highly effective measures in the prevention of occurrence and treatment of SUI, both antepartum and postpartum. Their performance in the inpatient setting during early puerperium can allow proper physiotherapeutic instruction and supervision without additional admission and costs [13]. The aim of PFM exercises is to strengthen the perivaginal and perianal musculature to increase a woman’s control of urinary leakage [4].

Although strenuous high-impact activity may provoke UI, little is known about relations with moderate physical activity and UI and relation with PFM. The risk of at least monthly UI decreased with increasing moderate physical activity. For stress and urge UI, women with the most physical activity had lower rates of incontinence than those with less activity. So, long-term moderate physical activity was inversely associated with UI, and the role of exercise in weight maintenance may partly explain this association [14].

PFMs are part of the core stability mechanism. Their function is interdependent with other muscles of this system. They also contribute to continence, elimination, sexual arousal, and intra-abdominal pressure. The innovative rehabilitation program should use abdominal muscle action to initiate tonic PFMs activity [15]. So, this study was conducted to determine the effect of postnatal rehabilitation of PFMs strength and thickness using aerobic and Kegel exercises.

 Participants and methods



Participants

This study is a prospective, randomized, parallel group, active controlled study with a 1 : 1 allocation ratio.

A total of 50 primiparous women experiencing mild-degree SUI, 3 months postnatally, were recruited from the outpatient clinic of El-Mataria Teaching Hospital; they all led a sedentary life style.

The women participated in the study after reading and signing an informed consent form before data collection. Recruitment began after approval was received from the Faculty of Physical Therapy Ethics Committee (reference number: P.T.REC/012/001161).

Participants’ ages ranged from 20 to 30 years, and their BMI did not surpass 30 kg/m2. Participants were screened by the obstetrician before inclusion through full obstetrical examination, and the purpose and nature of the study was explained to all participants. The inclusion criteria were as follows: primiparous and mild-degree SUI. The exclusion criteria were as follows: presence of hypertension, diabetes, genital prolapse, and smoking.

Randomization

The participants were randomly assigned to group A (aerobic+Kegel exercises) (n=25) or group B (Kegel exercise only) (n=25) by an independent person who selected blindly from sealed envelopes containing numbers created by a random number generator. The randomization was restricted to permuted blocks to ensure that equal numbers were allocated to each groups A and B. The sequences assigned to the participants were placed in envelopes containing the allocation to each groups A and B.

Outcome measures

The primary outcome was the change in PFM strength measured before and after the treatment by perineometer, whereas the secondary outcome was the change in PFM thickness measured before and after the treatment by perineal ultrasound.

Instrumentation

Weight and height scale

Weight and height were measured for each woman. Thereafter, BMI was calculated by dividing weight (kg) by height squared (m2).

EN-TREAD electronic treadmill (Vega Max 8000 c with serial number AC3208B59) was used to perform aerobic exercise in the form of walking for the study group.

Perineometer: Periton 9300 designed by Cardio Design (Australia), which was supplied with vaginal sensor. It was used for PFM training and to assess all participants in both groups before starting and after the end of the treatment program.

Technical specification of Periton 9300 perineometer

Vaginal sensor

It is composed of 28 mm diameter, 30 mm seamless active surface, and medical-grade silicone rubber sheath. It is autoclavable at 125°/15 min and 137°/3.5 min. It consists of an air-tight seamless silicone rubber sheath over a skeleton that allows the central part of the probe to be pressed in response to a muscular contraction.

Connecting tube with end fittings

Tube Cat 2031 is 80 cm long and has a T connector with one-way valve for optimal air inflation.

Antiseptic solution was used for cleaning the vulva, and jell was used for lubrication of the perineometer probe in addition to condoms, which were used for covering the probe of the perineometer to avoid cross infection. Vaginal probe was covered with a condom lubricated by sterile lubricant and inflated with air from T connector, after which it was inserted into the vagina until only 1 cm of the lower margin of the pressure area of the probe remains outside. Then the woman was asked to contract her PFMs, lift inward, and squeeze on the vaginal probe. The mean value of the five PFM contractions was recorded and considered the evaluative value.

Ultrasound machine

Ultrasound, machine no.33001584, 17. NN, designed by Medison FA 6000C (Korea), with a 6.5 MHz transvaginal probe, was used for evaluation before starting the study and after the end of the treatment program, with consideration that the same investigator performed all perineal ultrasound assessments. Perineal ultrasound was used to measure the thickness of the urogenital diaphragm at relaxation and during contraction for all participants in both groups before and after the end of the treatment program. The muscular layer of the pelvic floor is situated caudal to the pelvic diaphragm and anterior to the anorectum.

Treatment procedure

Study group (group A) (aerobic+Kegel exercises): the treatment sessions were repeated three times per week for 3 months in addition to biofeedback-assisted Kegel exercises for 45 min, three times per week for 3 months as follows.

Each participant was asked to perform aerobic exercise training in the form of walking on the treadmill at 70% of their maximum heart rate=220−age. The training session started by 5 min warm-up period, 20 min exercise at 70% of maximum heart rate, and then followed by 5 min of cool down by gradually decreasing the speed of the treadmill.

After applying perineometer as previously described, participant was asked to contract the anterior fibers of the PFM (pubovaginalis), three repetitions of eight contractions (hold for 10 s. and relax for 10 s.) with 2 min rest between repetitions.

After 2 min rest, the participant was asked to contract the posterior fibers of the PFM (puborectalis), three repetitions of eight contractions (hold for 10 s. and relax for 10 s.) with 2 min rest between repetitions.

After 2 min rest, the participant was asked to contract both anterior and posterior fibers of the PFM (pubovaginalis and puborectalis), three repetitions of eight contractions (hold for 10 s. and relax for 10 s.) with 2 min rest between repetitions.

Control group (group B) (Kegel exercise): each participant in this group performed only biofeedback-assisted Kegel exercises as in group A for 45 min, three times per week for 3 months.

Sample size determination

Based on the pilot study, sample size was calculated according to the difference in the mean value of intravaginal pressure between control (10.1±1.56) and study (11.8±1.03) groups measured post-treatment, with an effect size of 0.81. Assuming α=0.05, power of 80%, so a sample size of 25 patients per group would be required [(G)Power 301; http://www.psycho.uni-duesseldorf.de].

Statistical analysis

Data were expressed as mean±SD. Comparison between mean values of age, weight, height, and body mass index in the two groups (groups A and B) measured pretreatment was performed using unpaired t-test. A two-way analysis of variance [two groups (group A vs. group B)×two times (pretreatment vs. post-treatment)] was performed to compare within and between groups effects for PFMs’ strength and thickness. Statistical package for the social sciences computer program (version 16 for Windows; SPSS Inc., Chicago, Illinois, USA) was used for data analysis. P less than or equal to 0.05 was considered significant.

 Results



A diagram of the participant’s retention and randomization throughout the study is shown in [Figure 1]. A total of 66 participants were initially screened. After the screening process, 50 participants were found to be eligible to participate in the study. In total, 50 (100%) participants completed the treatment program.{Figure 1}

Demographic characteristics of the participants in both groups A and B

[Table 1] represents the general characteristics for women in both groups A and B when enrolled in the study.{Table 1}

Vaginal closer pressure

[Table 2] represents the vaginal closure pressure in both groups A and B. There was a nonstatistical significant difference (P>0.05) between groups A and B in vaginal closer pressure before the treatment, whereas there was a highly statistical significant difference (P<0.01) after treatment in favor of group A.{Table 2}

Pelvic floor muscle thickness at relaxation

[Table 2] represents the PFM thickness at relaxation in both groups A and B. There was a nonstatistical significant difference (P>0.05) between groups A and B in PFM thickness at relaxation before the treatment, whereas there was a statistical significant difference (P<0.01) after treatment in favor of group A.

Pelvic floor muscle thickness during contraction

[Table 2] represents the PFM thickness during contraction in both groups (groups A and B). There was a nonstatistical significant difference (P>0.05) between groups (groups A and B) in PFM thickness during contraction before the treatment, While, there was a statistical significant difference (P<0.01) after treatment in favor of group A.

 Discussion



The results of the present study revealed that adding aerobic exercise to biofeedback-assisted Kegel exercises would improve PFMs’ strength and thickness than biofeedback-assisted Kegel exercises only.

For many women, childbirth brings the embarrassment of UI, as they wet themselves each time they cough, laugh, sneeze, or try to exercise. SUI has a significant effect on quality of life, affecting the social, psychological, physical, and financial aspects of life [16].

SUI is believed to be primarily owing to structural defects of the neuromuscular and connective tissues supporting the bladder neck and urethra, with the effect of the first vaginal delivery as the key etiological factor. However, antepartum incontinence in young age women at the first pregnancy and first delivery is also a significant predictor of later development of SUI, indicating that the inherent qualities of the supportive tissues could be independent risk factors [17],[18].

This study was in line with Danforth et al. [19] who conducted a study to examine the association between physical activity and risk of developing UI, and results revealed that increasing levels of total physical activity were significantly associated with a reduced risk of UI. Walking, which constituted approximately half of total physical activity among the participants, was related to 26% lower risk of developing UI. Specifically, total physical activity and walking were associated with a significant reduction in SUI, but neither was related to incidence of urge UI.

This study was in agreement with Bø and Stien [20] who conducted a study to describe coactivity patterns of the striated urethral wall muscle and the PFMs (PFM) during contraction of outer pelvic muscles. The results showed that the striated urethral wall muscle was contracted synergistically during PFM, hip adductor, and gluteal muscle contraction but not during abdominal contraction. Both gluteal muscle and abdominal muscles contraction gave synergistic contraction of the PFMs. Thus, the urethral wall striated muscle and the PFMs react differently during abdominal contraction.

The results of this study are consistent with that of Mørkved and Bø [21] who investigated the effect of the postpartum PFM exercises in the prevention and treatment of UI, and they found that postpartum PFM exercise is effective in increasing PFM strength and reducing UI in immediate postpartum period.

The results of the current study are also consistent with that of Mørkved and Bø [22] who evaluate the long-term effect of postpartum PFM training in prevention and treatment of UI. They found that at the 1-year follow-up, significantly more women in the control group than in the training group reported SUI and/or showed urinary leakage at the pad test (P<0.01), and a significantly greater (P<0.01) muscle strength increase in the period between 16th week and 1-year postpartum was demonstrated in the training group than in the control group.

This study was in agreement with Abdullah and Arsyad [23] who stated that Kegel exercise had a positive influence in reducing the incident of UI in postpartum primigravida women. Kegel exercise had no positive influence in reducing incident of UI in lower educational group (elementary or lower secondary school) but had positive influence in higher educational group (high school or higher); thus, Kegel exercise may be adapted as a routine antenatal program to prevent postpartum UI.

These results come also in agreement with the study of Sampselle et al [24] who investigated the effect of PFM exercise on postpartum symptoms of SUI and PFM strength in primigravidas during pregnancy. They found that the PFMT group was ∼30% less likely to experience UI at 36 weeks of gestation and ∼40% less likely to be incontinent at 3 months postnatally.

These results are come in agreement with De Oliveira et al. [25] who reported that various PFMT protocols in nonpregnant women have been reported in literature; however, the recommended frequency of PFMT ranges from two to three times a week for not less than 3-month period, which is the amount of time necessary to obtain minimum hypertrophy.

 Conclusion



The addition of aerobic exercise to biofeedback-assisted Kegel exercises would improve PFMs’ strength and thickness than biofeedback-assisted Kegel exercises only. There was a statistically significant increase in PFMs strength and thickness. Accordingly, it was found that aerobic exercise combined with biofeedback-assisted Kegel exercises appeared to be an effective, noninvasive, cheap, and safe method of strengthening the PFMs.

Study limitations

There are some limitations in the present study. The primary limitation was lack of literature on how adding aerobic exercise to biofeedback-assisted Kegel exercises would improve PFMs’ strength and thickness than biofeedback-assisted Kegel exercises only. Another limitation to our study was that it studied short-term results, so we were unable to assess the long-term effect of aerobic exercise on PFM strength and thickness on postnatal women.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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