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

Original Editor - Eugenie Lamprecht Top Contributors - Eugenie Lamprecht, Shaimaa Eldib and Kim Jackson

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)[1]

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[2].

The PFM mainly consists of the levator ani and coccygeus muscles[3] and are innervated from the lumbosacral plexus[2].

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[4].

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

https://commons.wikimedia.org/wiki/File:1116_Muscle_of_the_Female_Perineum.png
Muscles of the Pelvic Floor
Sacral and coccygeal plexus.png
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)[5].

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[1]

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)[6]

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[6].

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[6].

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[7].

Modified Pilates (MP) as an addition to standard physiotherapy care seems to be even more beneficial[8].

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.

[9]

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.

[10]
[11]

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.

[12]
[13]

Side-kick kneeling

Elevate the superior leg to hip height and pulse anteriorly and then posteriorly.

(modification: side-ly)

[14]

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.

[15]

Roll down series (seated)

Segmented spinal flexion and back up maintaining PFM activation.

[16]

Assisted Squat

Squat with trunk stabilization and co-contraction of core [6][7].

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.

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[6]

References

  1. 1.0 1.1 Wood LN, Anger JT. Urinary incontinence in women. Bmj. 2014 Sep 15;349:g4531.
  2. 2.0 2.1 Eickmeyer SM. Anatomy and physiology of the pelvic floor. Physical Medicine and Rehabilitation Clinics. 2017 Aug 1;28(3):455-60.
  3. Bharucha AE. Pelvic floor: anatomy and function. Neurogastroenterology & Motility. 2006 Jul;18(7):507-19.
  4. Handa VL, Blomquist JL, Knoepp LR, Hoskey KA, McDermott KC, Muñoz A. Pelvic floor disorders 5-10 years after vaginal or cesarean childbirth. Obstetrics and gynecology. 2011 Oct;118(4):777.
  5. Handa VL. Urinary incontinence and pelvic organ prolapse associated with pregnancy and childbirth. UpToDate2014. 2015.
  6. 6.0 6.1 6.2 6.3 6.4 Pedriali FR, Gomes CS, Soares L, Urbano MR, Moreira EC, Averbeck MA, de Almeida SH. Is pilates as effective as conventional pelvic floor muscle exercises in the conservative treatment of post‐prostatectomy urinary incontinence? A randomised controlled trial. Neurourology and urodynamics. 2016 Jun;35(5):615-21.
  7. 7.0 7.1 Coleman TJ, Nygaard IE, Holder DN, Egger MJ, Hitchcock R. Intra-abdominal pressure during Pilates: unlikely to cause pelvic floor harm. International urogynecology journal. 2015 Aug 1;26(8):1123-30.
  8. Lausen A, Marsland L, Head S, Jackson J, Lausen B. Modified Pilates as an adjunct to standard physiotherapy care for urinary incontinence: a mixed methods pilot for a randomised controlled trial. BMC women's health. 2018 Dec;18(1):16.
  9. Pelvic Clock Pilates Exercise from yoopod.com. Available from: https://www.youtube.com/watch?v=UfTf6FdJ2Ao [last accessed 2/14/2020]
  10. PilatesAnytime. Pilates Chest Lift Exercise Demonstrated. Available from: https://www.youtube.com/watch?v=bOgwn-AwYzs [last accessed 2/14/2020]
  11. PilatesAnytime. Pilates Hundred Explained and Demonstrated. Available from: https://www.youtube.com/watch?v=cO4vb678un8 [last accessed 2/14/2020]
  12. PilatesAnytime. Teaching the Pilates Exercise Leg Circles. Available from: https://www.youtube.com/watch?v=JBGpZAvRUyY [last accessed 2/14/2020]
  13. PilatesAnytime. Demonstration of Pilates Exercise Roll Up. Available from: https://www.youtube.com/watch?v=kdptw8GW5BQ [last accessed 2/14/2020]
  14. PilatesAnytime. Side Kick Kneeling Pilates Exercise - Monica Wilson. Available from: https://www.youtube.com/watch?v=hgLDMHCcw4k [last accessed 2/14/2020]
  15. 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]
  16. Howcast. How to Do the Half Roll Down | Pilates Workout. Available from: https://www.youtube.com/watch?v=zTqCd39YcbE [last accessed 2/14/2020]