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November 2003


Strength in Practice

By Rhonda Kotarinos, PT


Urinary incontinence is one of the most common health problems affecting women in America. It is estimated that 30% to 50% of community-dwelling older women experience urinary incontinence.1,2 In women age 18 and older, the prevalence of incontinence is estimated to be 8.5% to 47%.3 Treatment options to be considered for managing urinary incontinence should initially be the least invasive, with the fewest possible adverse complications, and should be individualized for the patient.4 This specifically refers to behavioral techniques for treating urinary incontinence.

Behavioral techniques include assisted toileting, bladder retraining, and pelvic floor muscle rehabilitation, which includes pelvic muscle exercise, biofeedback, and pelvic floor electrical stimulation. Randomized controlled trials of behavioral management have indicated that stress and/or urge incontinent episodes can be reduced by 50% to 80% through these methods of therapy.5-8

For physical therapists, behavioral management of urinary incontinence can be divided into two approaches: pelvic floor and musculoskeletal management (see Figures 1 and 2, pages 38 and 39).

Pelvic Floor Management

The pelvic floor algorithm for behavioral management is self-explanatory. It is understood that a thorough history should be taken, followed by a thorough evaluation. Evaluation of the pelvic floor is extremely important. Simplified, the physical therapist needs to determine if the patient can actively contract the pelvic floor. Once this is determined, the therapist can then develop the appropriate treatment plan.

If there is an adequate isolated active contraction, the therapist has several treatment options, which will depend on the strength of the isolated active contraction. If the pelvic floor contraction is of a trace or poor grade, the therapist may utilize facilitation, active assistive exercise, overflow, or biofeedback.

Neurophysio-logical facilitation techniques that could be used include quick stretch, tapping, and/or proprioceptive neuromuscular facilitation (PNF).


Figure 1. Behavioral management algorithm: pelvic floor.

Resistance to the PNF diagonal of extension, adduction, and external rotation neurophysiologically facilitates a pelvic floor contraction.9 To see this normal function in action, look at the local playground where children can be seen standing with their legs crossed at the ankles in an isometric contraction of extension, adduction, and external rotation in hopes of getting the pelvic floor to send a stronger signal to the bladder.

Physical therapists are quite familiar with the theory of therapeutic exercise. When treating a muscle that is below a fair grade of strength, they utilize positions of gravity eliminated or assisted to exercise a muscle of poor or trace strength, respectively. When the pelvic floor is strong enough, progressive resistive exercise would follow. Progressive resistive exercises would be accomplished with vaginal weights or a perineometer. Progressive strengthening could lead to performing various functional activities, such as stair climbing, laundry, and sports (ie, tennis, golf), with vaginal weights in place.

Cross transfer of training is another technique the physical therapist can use to enhance the strengthening process of a weakened pelvic floor. Hellebrandt described cross transfer of training more than 50 years ago.10 Hellebrandt demonstrated that strengthening exercises to a limb will increase the strength in the unexercised contralateral limb. Kannus et al not only found a transfer of muscle strength, but also discovered a transfer of power and endurance.11 Clinically, this means that the physical therapist can establish a progressive resistive, low repetition strengthening program for the hip girdle musculature and facilitate the strengthening of the pelvic floor. Initiating the strengthening process in this manner allows minimal isolated active contractions to develop without excessive inappropriate recruitment.

Once a minimal isolated contraction is present, biofeedback can be utilized to continue the strengthening process. When the pelvic floor strength is at a fair grade, treatment would continue with progressive strengthening exercises.


Figure 2. Behavioral management algorithm: musculoskeletal.

Electrical Stimulation

When there is no palpable active contraction, besides utilizing neurophysiological facilitation and cross transfer of training, the therapist may choose to treat with electrical stimulation. Electrical stimulation has been used to treat gynecologic disorders for well over 100 years.12 The mechanism of action in treating urinary incontinence is not well understood, but two mechanisms are described. When there is an intact neural pathway, electrical stimulation can neurally inhibit inappropriate detrusor contractions. This is the basis for utilizing electrical stimulation to treat urge incontinence. Brubaker et al, in a randomized blinded controlled study, found that electrical stimulation at a frequency of 20 Hz with a 2 second/4 second work rest cycle and a pulse width of 0.1 second cured detrusor instability (urge incontinence/urgency) in 49% of the subjects.13

The second mechanism, which addresses stress incontinence, involves electrical stimulation of neurally intact muscle, which can promote hypertrophy of the pelvic floor musculature. Increased pelvic floor strength is associated with decreased leakage and an increased ability to inhibit inappropriate detrusor contractions. Uncontrolled studies indicate that the improvement rate is 60%.

Physical therapists have the appropriate background to be more holistic in the behavioral management of urinary incontinence. There are several aspects of musculoskeletal dysfunction that can affect the treatment of urinary incontinence. They are postural dysfunction, abdominal dysfunction and generalized weakness, specifically pelvic girdle weakness. Facilitating pelvic floor strengthening with cross transfer of training by strengthening the pelvic girdle muscles has already been described.

Postural Dysfunction

Postural dysfunction has been considered a factor in pelvic floor dysfunction for almost 100 years. Goldthwaite describes in great detail how postural dysfunctions of a flat back and increased lordosis contribute to pelvic organ prolapse, which may be a factor in urinary incontinence. Goldthwaite states that “the physician has a higher function than the mere treatment of local conditions . . . . It means at once that our work must be judged upon the basis of the ultimate cure of general efficiency rather than simply the immediate relief of some local lesion. It means that in the treatment of disturbances or displacements of the pelvic organs, it is only half doing the work if the condition is simply treated locally, while an imperfect posture which may have been largely responsible for the trouble is allowed to go uncorrected.”15

In a retrospective case-control study, Lind et al found that thoracic kyphosis was associated with uterine prolapse.16 An individualized postural corrective exercise program should be developed to address the postural dysfunction noted on evaluation.

The basic tenet of the physical therapy approach to behavioral management of urinary incontinence is to improve the function of the pelvic floor through strengthening or decreasing the tone of the pelvic floor. As already described, this can include pelvic floor exercises, biofeedback, and electrical stimulation.

Other Musculoskeletal Dysfunctions

Why do only 25% to 50% of the conservatively managed patients achieve near dryness? 5-8 There are two musculoskeletal dysfunctions that can significantly impact the pelvic floor that are frequently overlooked and not treated by many health care practitioners. They are diastasis recti and the contracture of the pelvic floor. Diastasis recti is a separation of the rectus abdominis muscles at the linea alba. A weakened abdominal wall with or without a diastasis recti is an important factor in pelvic organ support. Historically, this has been referred to as the retentive power of the abdomen wall.17 Abdominal wall strength must be maintained for it to function properly in supporting the abdominal and pelvic organs. If a diastasis is present, it must be corrected before progressive abdominal strengthening is initiated. More recent research also shows that addressing the abdominal wall facilitates pelvic floor muscle coordination, support, strength, and endurance.18

The gold standard of pelvic floor exercise to treat incontinence is a Kegel or concentric exercise of the pelvic floor. Unfortunately, this may not be the most appropriate exercise for all patients with incontinence. Optimal skeletal muscle function is dependent on a length-tension relationship. The force of a muscle contraction decreases if the muscle is too long or too short.19

The goal of therapy in treating hypertonic muscles is to decrease the excessive electrical activity that is holding the pelvic floor in a shortened state. Hypertonic pelvic floor muscles can develop through protective guarding with pain or with constant recruitment to inhibit urge. In time, the elevated EMG activity will stop, leaving the pelvic floor in a new shortened position.20 In this shortened state, the pelvic floor is no longer at its optimal length-tension relationship to adequately function to inhibit urge with resulting urge incontinence, urgency-frequency syndrome, or interstitial cystitis. The shortened pelvic floor can also be a factor in stress incontinence if it cannot reflexively contract and compress the urethra when there is increased intra-abdominal pressure.

Management of the shortened pelvic floor is multifactoral. Trigger points that may be present need to be released with or without injections. Stretching is appropriate to manage trigger points as well as contractures.

Lengthening a shortened muscle is the initiation of a strengthening program. Proprioceptive neuromuscular facilitation can be utilized to assist in lengthening the shortened pelvic floor through neurological inhibition. As the pelvic floor lengthens, the patient’s proprioception improves and the patient can actively lengthen their pelvic floor from a resting position. Because of tissue memory, it may be prudent for patients who have had pelvic floor contractures to precede their concentric (Kegel) contraction with a lengthening contraction. Success rates of behavioral approaches to incontinence might improve if physical therapists consider addressing diastasis recti and pelvic floor contracture. Much more research is needed to prove that either of these two conditions has an impact on the management of urinary incontinence. Physical therapists must be made aware at least of the possibility that the association exists so that they can begin to consider the conditions in their treatment plans.

Rhonda Kotarinos, PT, is president of Rhonda Kotarinos Ltd, Oak Brook Terrace, Ill.

References
  1. Diokno A, Brock B, Brown M, Herzog AR. Prevalence of urinary incontinence and other urological symptoms in the non-institutionalized elderly. J Urol.1986;136:1022-5.
  2. Thom D. Variation in estimates of urinary incontinence prevalence in the community: effects of differences in definition, population characteristics and study type. J Am Geriatr Soc. 1998;46:473-80.
  3. Herzog AR, Fultz NH. Prevalence and incidence of urinary incontinence in community-dwelling populations. J Am Geriatr Soc. 1990;38:273-81.
  4. Clinical Practice Guideline: Urinary Incontinence in Adults: Acute and Chronic Management. Rockville, Md: US Department of Health and Human Services, Public Health Service; 1996. Agency for Health Care Policy and Research No. 96 - 0682.
  5. Burgio KL, Locher JL, Goode PS, et al. Behavioral vs drug treatment for urge urinary incontinence in elder women: a randomized controlled trial. JAMA. 1998;280:1985-2000.
  6. Fantl JA, Wyman JF, McClish DK, Harkins SW, Elswick RK, Taylor JR. Efficacy of bladder training in older women with urinary incontinence. JAMA. 1991;265:609-13.
  7. Largo-Janssen TL, Debruyne PM, Smits AJ, van Weil C. Controlled trial of pelvic floor exercises in the treatment of urinary stress incontinence in general practice. Br J Gen Pract. 1991;41:445-449.
  8. Subak LL, Quesenberry CP, Posner SF, Cattolica E, Soghikian K. The effect of behavioral therapy on urinary incontinence: a randomized controlled trial. Obstet Gynecol. 2002;100:72-78.
  9. Knott M, Voss DE. Proprioceptive Neuromuscular Facilitation. New York: Harper & Row; 1968.
  10. Hellebrandt FA. Cross education: ipsilateral and contralateral effects of unilateral training. J Appl Physiology. 1951;4:136.
  11. Kannus P, Alosa D, Cook L, et al. Effects of one-legged exercise on strength, power and endurance using isometric and concentric isokinetic training. Eur J Appl Physiol. 1992;64:117-126.
  12. Massey GB. Conservative Gynecology and Electo-Therapeutics. Philadelphia: F.A. Davis Company; 1889.
  13. Brubaker LT, Benson JT, Bent A, Clark A, Shott S. Transvaginal electrical stimulation for female urinary incontinence. Am J Obstet Gynecol. 1997;177:536-540.
  14. Fall M, Lindstrom S. Electrical stimulation: a physiological approach to the treatment of urinary incontinence. Urol Clin North Am. 1991;18:383-407.
  15. Goldthwaite JE. The relation of posture to human efficiency and the influence of poise upon the support and function of the viscera. Boston Medical and Surgical Journal. 1909;161:839-848.
  16. Lind LR, Lucente V, Kohn N. Thoracic kyphosis and the prevalence of advanced uterine prolapse. Obstet Gynecol. 1996;87:605-9.
  17. Penrose CB. Textbook of Diseases of Women. Philadelphia: WB Saunders; 1907.
  18. Sapsford RR, Hodges PW. Contraction of the pelvic floor during abdominal maneuvers. Arch Phys Med Rehabil. 2001;82:1081-88.
  19. Jones DA, Round JM. Skeletal Muscle in Health and Disease. Manchester, England: Manchester University Press; 1990:21.
  20. Exploratory and analytical survey of therapeutic exercise. Northwestern University Special Therapeutic Exercise Project. Am J Phys Med. 1967;46:1-1135.

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