Siv Mørkved

Effect of adding biofeedback to pelvic floor muscle training to treat urodynamic stress incontinence

OBJECTIVE To compare the effect of individual pelvic floor muscle training with and without biofeedback in women with urodynamic stress incontinence METHODS The study was a single, blind, randomized trial. All women completed 6 months of pelvic floor muscle training comprising three sets of ten contractions three times per day, supervised by a physical therapist. One group trained with a biofeedback apparatus at home, the other without biofeedback. The primary outcome measures were pad test with standardized bladder volume and self‐report of severity. RESULTS A total of 103 women were randomized, and data from 94 women were analyzed. Mean age (range) was 46.6 (30–70) years, and mean (range) duration of symptoms was 9.7 (1–25) years. Seventy women had urodynamic stress incontinence alone, and 24 women reported additional urge symptoms. Women training with and without biofeedback showed a statistically significant reduction in leakage on pad test (P < .01) after 6 months of pelvic floor muscle training. Objective cure (2 g or less of leakage) in the total group was 58% in women training with and 46% in women training without biofeedback, and in the subgroup of women with urodynamic stress incontinence alone, 69% in women training with and 50% in women training without biofeedback. There was no statistically significant difference between the groups posttreatment in any outcome measure. CONCLUSION Cure rate was high, and the reduction in urinary leakage after treatment was statistically significant in both groups. However, there was no statistically significant difference in the effect of individual pelvic floor muscle training with and without biofeedback.

Effect of postpartum pelvic floor muscle training in prevention and treatment of urinary incontinence: a one‐year follow up

Objective To evaluate the long term effect of a postpartum pelvic floor muscle training course in prevention and treatment of urinary incontinence.

Regular Exercise During Pregnancy to Prevent Gestational Diabetes A Randomized Controlled Trial

OBJECTIVE: To assess whether exercise during pregnancy can prevent gestational diabetes and improve insulin resistance. METHODS: A total of 855 women in gestational week 18–22 were randomly assigned to receiving a 12-week standard exercise program (intervention group) or standard antenatal care (control group). The exercise program followed standard recommendations and included moderate-intensity to high-intensity activity 3 or more days per week. Primary outcomes were gestational diabetes and insulin resistance estimated by the homeostasis model assessment method. For the power calculation, we assumed a gestational diabetes prevalence of 9% in the control group and a prevalence of 4% in the exercise group (risk difference of 5%). Under these assumptions, a two-sample comparison with a 5% level of significance and power of 0.80 gave a study population of 381 patients in each group. RESULTS: At 32–36 weeks of gestation there were no differences between groups in prevalence of gestational diabetes: 25 of 375 (7%) in the intervention group compared with 18 of 327 (6%) in the control group (P=.52). There were no differences in insulin resistance between groups when adjusting for baseline values. Only 55% of women in the intervention group managed to follow the recommended exercise protocol. No serious adverse events related to physical exercise were seen, and the outcomes of pregnancy were similar in the two groups. CONCLUSION: There was no evidence that offering women a 12-week standard exercise program during the second half of pregnancy prevents gestational diabetes or improves insulin resistance in healthy pregnant women with normal body mass indexes. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00476567. LEVEL OF EVIDENCE: I

Prevalence of Urinary Incontinence During Pregnancy and Postpartum

Abstract: The purpose of the study was to investigate the prevalence of urinary incontinence during pregnancy and the postpartum, and to examine postpartum pelvic floor muscle strength. Eight weeks postpartum the prevalence of urinary incontinence and pelvic floor muscle strength was registered. All women in a Norwegian community, delivering at the local hospital during a 1-year period, were included in the study. The final study group consisted of 144 women (72%). Data concerning the prevalence of urinary incontinence was collected by a structured interview and clinical assessment (pad test) 8 weeks postpartum. Pelvic floor muscle strength was also measured. The prevalence of urinary incontinence during pregnancy was 42%. Eight weeks after delivery the prevalence of self-reported urinary incontinence was 38%. There was a difference between self-reported symptoms and urinary incontinence as assessed by the pad test. Symptoms of fecal incontinence postpartum were reported by 6 women (4.2%). The prevalence of urinary incontinence was found to be nearly the same 8 weeks postpartum as during pregnancy. This documents the need for a strategy to prevent and treat urinary incontinence during these periods.

A single weekly bout of exercise may reduce cardiovascular mortality: how little pain for cardiac gain? ‘The HUNT study, Norway’

Background The observation that exercise training reduces cardiovascular mortality is robust and consistent, but the amount and intensity of exercise that is required for risk reduction is not yet resolved. Methods We studied the association between the amount and intensity of exercise and cardiovascular mortality in 27 143 men and 28 929 women who were free from known cardiovascular disease at the beginning of follow-up between 1984 and 1986. The relative risk of death was calculated as the rate of death among participants within a given physical activity category compared with the rate of death in the reference category (no physical activity). We used Cox regression analysis to adjust for age and other potentially confounding factors. Results After 16 years (SD 4 years) of follow-up, 2946 men (10.8%) and 2486 women (8.6%) had died from ischaemic heart disease or stroke. A single weekly bout of exercise of high intensity reduced the risk of cardiovascular death, both in men [relative risk (RR) 0.61, 95% confidence interval (CI) 0.49–0.75], and women (RR 0.49, 95% CI 0.27–0.89), compared with those who reported no activity. There was no additional benefit from increasing the duration or the number of exercise sessions per week. The risk reduction related to exercise increased with increasing age in men, but not in women. Conclusion These results challenge the current recommendation that expenditure of at least 1000 kcal per week is required to achieve exercise-induced protection against premature cardiovascular mortality.

RANDOMISED CONTROLLED TRIAL OF PELVIC FLOOR MUSCLE TRAINING DURING PREGNANCY

Abstract Objectives To examine a possible effect on labour of training the muscles of the pelvic floor during pregnancy. Design Randomised controlled trial. Setting Trondheim University Hospital and three outpatient physiotherapy clinics in a primary care setting. Participants 301 healthy nulliparous women randomly allocated to a training group (148) or a control group (153). Intervention A structured training programme with exercises for the pelvic floor muscles between the 20th and 36th week of pregnancy. Main outcome measures Duration of the second stage of labour and number of deliveries lasting longer than 60 minutes of active pushing among women with spontaneous start of labour after 37 weeks of pregnancy with a singleton fetus in cephalic position. Results Women randomised to pelvic floor muscle training had a lower rate of prolonged second stage labour (24%, 95% confidence interval 16% to 33%; 22 out of 105 women were at risk (undelivered) at 60 minutes in the survival analysis) than women allocated to no training (38% (37/109), 28% to 47%). The duration of the second stage was not significantly shorter (40 minutes v 45 minutes, P = 0. 06). Conclusions A structured training programme for the pelvic floor muscles is associated with fewer cases of active pushing in the second stage of labour lasting longer than 60 minutes.

Does Physiotherapist-Guided Pelvic Floor Muscle Training Reduce Urinary Incontinence After Radical Prostatectomy?: A Randomised Controlled Trial

BACKGROUND Urinary incontinence after radical prostatectomy (RP) is a common problem and may lead to reduced quality of life. OBJECTIVE To assess the effects of guided pelvic floor muscle training on continence status and perceived problems with urinary function after RP. DESIGN, SETTING, AND PARTICIPANTS We conducted a randomised controlled trial at St. Olavs Hospital/Trondheim University Hospital in Norway between September 2005 and December 2007. All men with clinically localised prostate cancer who underwent surgery with open RP were invited to participate, until 85 participants were included. Dropout rate was 6%. INTERVENTION Two intervention groups (A and B). Both groups received instructions in correct pelvic floor muscle contractions and were encouraged to train the pelvic floor muscles. Group A was offered additional follow-up training instructions by a physiotherapist throughout the 1-yr period. MEASUREMENTS Primary outcome was continence (0 pads) status, and secondary outcomes were perceived problems with urinary function 6 wk and 3, 6, and 12 mo postoperatively. RESULTS No statistically significant difference in continence status between groups was found at 3 mo; 46% were continent in group A versus 43% in group B (p=0.73). In group A, 97% reported no or only mild problems with urinary function compared to 78% in group B (p=0.010). After 6 mo there was a clinically relevant difference in continence status between groups: 79% were continent in group A and 58% in group B (p=0.061). Twelve months postsurgery the difference was clinically and statistically significant (p=0.028) in favour of group A; 92% were continent in group A and 72% in group B. CONCLUSIONS Continence rates were similar 3 mo after RP in groups performing intensive pelvic floor muscle training with or without follow-up instructions by a physiotherapist. However, in the following period up to 1 yr, the group receiving physiotherapist-guided training reduced urinary incontinence significantly more compared to patients training on their own.

Evidence for benefit of transversus abdominis training alone or in combination with pelvic floor muscle training to treat female urinary incontinence: A systematic review.

Pelvic floor muscle training (PFMT) has Level A evidence to treat female urinary incontinence (UI). Recently, indirect training of the pelvic floor muscles (PFM) via the transversus abdominis muscle (TrA) has been suggested as a new method to treat UI. The aim of this article is to discuss whether there is evidence for a synergistic co‐contraction between TrA and PFM in women with UI, whether TrA contraction is as effective, or more effective than PFMT in treating UI and whether there is evidence to recommend TrA training as an intervention strategy.

Does group training during pregnancy prevent lumbopelvic pain? A randomized clinical trial

Background. Prevention of lumbopelvic pain in pregnancy has been sparsely studied. One aim of this study was to assess if a 12‐week training program during pregnancy can prevent and/or treat lumbopelvic pain. A randomized controlled trial was conducted at Trondheim University Hospital and three outpatient physiotherapy clinics. Three hundred and one healthy nulliparous women were included at 20 weeks of pregnancy and randomly allocated to a training group (148) or a control group (153). Methods. The outcome measures were self‐reported symptoms of lumbopelvic pain (once per week or more), sick leave, and functional status. Pain drawing was used to document the painful area of the body. The intervention included daily pelvic floor muscle training at home, and weekly group training over 12 weeks including aerobic exercises, pelvic floor muscle and additional exercises, and information related to pregnancy. Results. At 36 weeks of gestation women in the training group were significantly less likely to report lumbopelvic pain: 65/148 (44%) versus 86/153 (56%) (p = 0.03). Three months after delivery the difference was 39/148 (26%) in the training group versus 56/153 (37%) in the control group (p = 0.06). There was no difference in sick leave during pregnancy, but women in the training group had significantly (p = 0.01) higher scores on functional status. Conclusions. A 12‐week specially designed training program during pregnancy was effective in preventing lumbopelvic pain in pregnancy.

Does regular exercise including pelvic floor muscle training prevent urinary and anal incontinence during pregnancy? A randomised controlled trial.

Please cite this paper as: Stafne S, Salvesen K, Romundstad P, Torjusen I, Mørkved S. Does regular exercise including pelvic floor muscle training prevent urinary and anal incontinence during pregnancy? A randomised controlled trial. BJOG 2012;119:1270–1280.