The effect of Pilates on pelvic floor muscle strength in women with urinary incontinence
- 1 Introduction
- 2 Clinically Relevant Anatomy and Physiology
- 3 Mechanism of pelvic floor Injury
- 4 General UI management plan
- 5 Pelvic Floor Muscle Training and Pilates
- 6 Examples of Pilates Exercises
- 6.1 Activation (supine/ crook-ly)
- 6.2 Pelvic Clock (supine/ crook-ly)
- 6.3 Bridging (supine/ crook-ly)
- 6.4 Chest-lift (supine/ crook-ly)
- 6.5 Hundred (supine)
- 6.6 Roll-up (supine)
- 6.7 Leg-circles (supine)
- 6.8 Side-kick kneeling
- 6.9 Adductor Squeeze (supine/ crook-ly)
- 6.10 Bent Knee fall out (supine/ crook-ly)
- 6.11 Supine Arm series (supine/ crook-ly)
- 6.12 4 point kneeling position
- 6.13 Roll down series (seated)
- 6.14 Assisted Squat
- 7 Conclusion
- 8 References
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
- Higher body-mass-index (BMI)
- advanced age
- family history
- urinary tract infections (UTI)
Clinically Relevant Anatomy and Physiology
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.
- 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
- reduce fluids, caffeine and carbonated drinks
- regular and timed urination
- treating constipation
- reduce BMI (<25)
- pelvic floor muscle training (PFMT)
Pharmacology (urgency urinary incontinence)
- Beta 3 agonist
Surgery (stress urinary incontinence)
- injectable bulking agents
- Burch colpo-suspension
- fascial slings
- mid-urethral synthetic slings
- 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
Activation (supine/ crook-ly)
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
legs at table-top, Cx and Tx spine in flexion with bilateral arms pumping up and down by the sides of the trunk
segmental flexion of Cx -, Tx and Lx spine
unilateral perpendicular leg circles clockwise and anti-clockwise while maintaining a stable pelvis
elevate the superior leg to hip height and pulse anteriorly and then posteriorly
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
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.Adding Pilates exercise to standard Physiotherapy care has been found to lower financial strain on the healthcare system, providing less discomfort (no internal devices) and can be used as an alternative for individuals disliking conventional PFM exercises
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- Pelvic Clock Pilates Exercise from yoopod.com. Available from: https://www.youtube.com/watch?v=UfTf6FdJ2Ao [last accessed 2/14/2020]
- PilatesAnytime. Pilates Chest Lift Exercise Demonstrated. Available from: https://www.youtube.com/watch?v=bOgwn-AwYzs [last accessed 2/14/2020]
- PilatesAnytime. Pilates Hundred Explained and Demonstrated. Available from: https://www.youtube.com/watch?v=cO4vb678un8 [last accessed 2/14/2020]
- PilatesAnytime. Teaching the Pilates Exercise Leg Circles. Available from: https://www.youtube.com/watch?v=JBGpZAvRUyY [last accessed 2/14/2020]
- PilatesAnytime. Demonstration of Pilates Exercise Roll Up. Available from: https://www.youtube.com/watch?v=kdptw8GW5BQ [last accessed 2/14/2020]
- PilatesAnytime. Side Kick Kneeling Pilates Exercise - Monica Wilson. Available from: https://www.youtube.com/watch?v=hgLDMHCcw4k [last accessed 2/14/2020]
- Royal Free London NHS Foundation Trust. Four point to two point kneeling. Available from: https://www.youtube.com/watch?v=huOASwAQmUM [last accessed 2/14/2020]
- Howcast. How to Do the Half Roll Down | Pilates Workout. Available from: https://www.youtube.com/watch?v=zTqCd39YcbE [last accessed 2/14/2020]