Key words
pelvic floor - pelvic floor disorders - physiotherapy - sports - women
Introduction
According to the International Continence Society (ICS) and the International
Urogynecological Association (IUGA), urinary incontinence (UI) is defined as the
involuntary loss of urine [1]. The most prevalent type
of UI among young and physically active women is the stress UI (SUI), which occurs
during increases in intra-abdominal pressure (IAP) [2]. High-impact sports, such as those involving jumping and/or
running, have as characteristics the repetitive impacts on the pelvic floor
generated by ground reaction forces and/or increases in IAP [3]
[4]. Due to these
characteristics, studies show that those women who practice high-impact sports have
2.77 times more likely to present complaints of UI when compared to sedentary women
in the same age group [3]. Besides, their UI rates are
greater when compared to women who practice low-impact sports (58.10 and
12.48%, respectively) [5].
Recent studies have shown that UI symptoms are most prevalent in young and
high-impact sports practitioners [6], ranging from
25.9 to 70% [7]
[8], and SUI symptoms rates range from 69 to 72.7% [9]
[10]. Regarding SUI
prevalence by sport, the most prevalent high-impact sports are volleyball and
trampoline [6]
[8]
[11], as well as running activities [11]. Incontinent athletes can also present impairments
in their quality-of-life (QoL), such as restrictions on sports and/or social
activities [12], and even leading to the abandonment
of exercise [4].
Currently there are two opposing hypotheses that explain how strenuous exercise can
affect PFM [13], the first believes that an increased
IAP during the exercise can lead to a PFM strengthening due to a co-contraction of
these muscles. The opposite hypothesis explains that exercise can overload, stretch,
and weaken PFM due to constant increases in IAP. Thus, according to the second
hypothesis, strenuous exercise can lead to a reduction in the maximum voluntary
contraction (MVC) [14], which means loss of a
muscle’s ability to generate force [15], and
in support of pelvic organs [16]. Moreover, PFM
fatigue can influence the development and/or worsening of SUI symptoms;
however, studies addressing fatigue are scarce and conclusions are limited [17].
The PFM training (PFMT) is considered the first-line treatment for SUI in the general
population [18]. Compared with no treatment or
inactive control treatments, women with SUI are eight times more likely to report a
cure with PFMT at the end of treatment [19]. In
addition, the PFMT promotes significant improvement in QoL, influencing the
physical, mental and social aspects of these women [19]
[20]. Currently, we have validated
questionnaires available to assess QoL in women with UI, published with strong
scientific evidence [21]. Few clinical trials
demonstrate the effect of PFMT on UI symptoms in women who practice high-impact
sports, as well as on the QoL and PFM function in these women.
Therefore, this study aims to systematize the scientific evidence that assesses the
effect of PFMT on UI symptoms in women who practice high-impact sports. The
secondary objective was to assess the influence of PFMT on PFM function and the
impact of UI on women’s QoL.
Materials and Methods
This systematic review was registered in PROSPERO and has followed the Preferred
Reporting Items for Systematic Reviews (PRISMA) guidelines. The PICOT strategy was
used to define the participants (P), intervention (I), comparison (C), outcomes (O)
and types of studies (T), and to assist in the construction of the following
research question: what is the effect of PFMT on UI symptoms in women who practice
high-impact sports? The inclusion criteria were: trials women who practice
high-impact sports (sports involving running and/or jumping) [4], the interventions including PFMT, and studies with
a primary or secondary aim to assess UI symptoms. The articles should compare their
results with control groups (inactive) or with other interventions. These studies
should be available in English, Portuguese or Spanish and in full text. Pregnant
women and/or with comorbidities such as obesity, heart disease, orthopedic,
rheumatologic, immunological, respiratory and/or neurological conditions
were excluded. Also, all the studies included in this systematic review, excluded
women unable to correctly contract the PFM or women with pelvic organ prolapse
symptoms.
All studies cited within EMBASE, PubMed, SciELO and Scopus databases from inception
to November 2020 were included. The search strategies used in each database are
described in [Table 1].
Table 1 Database search strategies.
|
Database
|
Search strategies
|
|
PubMed
(https://pubmed.ncbi.nlm.nih.gov/)
|
(women OR athletes OR “female athlete” OR
“sports women”)
AND
(“high-impact” OR sports OR exercise OR
“physical activity”) AND
(“pelvic floor” OR “pelvic floor muscle
training” OR physiotherapy) AND
(“urinary incontinence” OR “stress
urinary incontinence” OR “urge urinary
incontinence” OR “pelvic floor
disorders” OR “athletic
incontinence”).
|
|
Embase (https://www.embase.com)
|
|
SciELO (https://search.scielo.org/)
|
|
Scopus
(https://www.scopus.com/search/form.uri?display=basic)
|
(sportwomen OR athletes OR female AND athlete)
AND ("high-impact" OR sports OR
exercise) AND ("urinary
incontinence" OR "stress urinary
incontinence" OR "urge urinary
incontinence" OR "pelvic floor
disorders").
|
The primary outcome of this review was the UI symptoms (amount and frequency of
urinary losses), while secondary outcomes were the PFM function and the impact of UI
on women’s QoL. Two independent researchers (FSF and ERMA) performed the
selection according to the eligibility criteria. After the duplicate removal, two
reviewers independently screened titles and abstracts of identified articles under
the initial search strategy. Potentially relevant trials were then retrieved for
independent full-text evaluation. A second search was performed by manually
selecting the bibliographic references of articles already included in the review.
The same two researchers performed data extraction using a standardized table format
containing the following information: author, year of publication and country;
number of participants; the primary objective; the outcome measures to assess the UI
symptoms, the PFM function, and the impact of UI on women’s QoL; the
interventions used in the study; and the main results regarding the primary and
secondary outcomes.
The risk of bias of randomized controlled trials (RCTs) was assessed by two
researchers (FSF e ERMA) using the Physiotherapy Evidence Database (PEDro) scale
[22]. In cases of disagreement, a third researcher
(TR) made the final decision in a consensus meeting. The PEDro scale proved to be a
valid measure of the methodological quality of clinical trials [23] The total score ranges from 0 to 10. Studies with
scores less than 4 are considered “poor”, 4 to 5 are considered
‘fair’, 6 to 8 are considered ‘good’ and 9 and 10
are considered ‘excellent’ [24].
The Risk of Bias in Non-Randomized Studies – of Interventions (ROBINS-I) tool
was used for non-RCTs [25] and the same researchers
performed the analysis. This tool assesses the risk of bias in estimates of the
efficacy or safety (benefit or harm). It consists of seven domains, where the first
two (confounding and selection of participants for the study) address
pre-intervention issues, the third domain (classification of interventions) deals
with the issues of the intervention itself and the last four domains (deviations
from the intended interventions, missing data, measurement of the outcome, and
selection of the reported result) address post-intervention issues. At the end, each
domain can be classified into: “Low Risk”, “Moderate
Risk”, “Serious Risk” and “Critical Risk” of
bias.
For the assessment of the PFMT protocols, the Consensus on Exercise Reporting
Template (CERT) was used [26]. The CERT provides
guidance on a minimum set of key items considered essential for reporting replicable
exercise programs. It consists of a total of 19 items and sub-items, listed in seven
domains: what – materials; who – provider; how – delivery;
where – location; when how much – dosage; what, how –
tailoring; and how well - compliance/planned or actual. For the score, one
point is added to each item described in the study. The two researchers applied the
CERT, and the discrepancies were resolved through discussion between the
authors.
Results
A search of the selected databases returned 3,210 articles for screening, among which
676 were removed as duplicates, 2,166 articles were excluded based on title, and 362
based on abstract. Six articles were reviewed for eligibility, and one was excluded,
with reason listed in [Fig. 1]
Fig. 1 PRISMA Flowchart (PRISMA=Preferred Reporting Items for
Systematic Reviews and Meta-Analyses) [43].
[Table 2] shows the study characteristics, primary
aim, outcome measures and interventions of the five studies included. The PEDro
Scale score was also included [27]
[28]
[29]. All articles
included women with at least one UI symptom. A total of 104 participants were
included, with ages ranging from 16 to 46 years, and only two studies did not
present the age range [30]
[31]. The most prevalent sport was volleyball with 46 women participants
[27]
[28]. The
studies were published between 1997 and 2020.
Table 2 Study characteristics, primary aim, outcome measures and
interventions of the five studies included in the review, and the risk
of bias (PEDro Scale) of the three randomized clinical trials.
|
Author, year (country)
|
Sample size/age/sports played
|
Primary aim
|
Outcome measures for UI symptoms
|
Intervention
|
PEDro score
|
|
DA ROZA et al., 2012 (Portugal)
|
7 female athletes/20.0±0.8/Gymnastics,
trampoline, figure skating, synchronized swimming and
handball.
|
To evaluate the effect of a comprehensive PFMT program on UI
symptoms in nulliparous and sportsmen youth.
|
ICIQ-UI SF
|
Intervention: PFMT+DVD with educational
material
|
–
|
|
PFMT protocol: It consisted of four steps conducted for 2
weeks each (8 weeks): (1) PFM awareness, (2) PFM contraction in
different positions with progressive weights, (3) PFM attempts
during exercise activities. running and walking and (4) attempts
to contract PFM during sports activities. The meetings with the
participants were held every 15 days, where the physiotherapist
showed the new exercises for the next step and instructed them
to perform them every day until fatigue. An explanatory DVD
illustrating the exercise program has been provided for use at
home. All participants were instructed to write an exercise
diary, reporting their progress and adherence to the
project.
|
|
FERREIRA et al., 2014 (Portugal)
|
32 female athletes: experimental group (EG)=16 and
control group (CG)=16/EG: 19.4±3.24 and
CG: 19.1±2.11/Clube Atlético de
Voleibol.
|
Verify the effectiveness of a PFMT program in federated
nulliparous athletes.
|
Pad test: amount of urinary losses in the first
15 minutes of volleyball practice.
|
Intervention: PFMT+educational action vs control
group that only had access to the leaflet with a summary of the
educational action.
|
5/10
|
|
Voiding diary: daily frequency of UI episodes for 7
consecutive days.
|
PFMT protocol: Exercises were performed at home, included
30 slow contractions and 4 fast contractions after each slow
contraction, in different positions and daily for 3 months.
Weekly visits were made to the club during the study period to
ensure motivation and adherence to PFMT both at home and after
training.
|
|
PIRES et al., 2020 (Portugal)
|
14 elite athletes were randomized, 13 were analyzed: experimental
group (EG)=7 and control group
(CG)=6/EG: 22.71±4.99 and CG:
21.83±5.19/Federação Portuguesa
de Voleibol.
|
To investigate the effects of PFMT in elite volleyball athletes
and whether it is an effective therapy for SUI.
|
2-hour pad test
|
Intervention: PFMT+educational action and app
illustrating the exercise program to use at home vs control
group (inactive).
|
7/10
|
|
PFMT protocol: consisted of 3 phases that lasted 16 weeks:
awareness/stabilization, strength and strength training.
The first phases were carried out at home and for 2 weeks. The
1st phase started in the lying position and gradually evolved to
the standing position, 10 slow contractions of
10 seconds were performed with the same relaxation time.
In the 2nd phase, the contraction time was greater than the
relaxation time, progressively increasing the degree of
difficulty over time.
|
|
The 3rd phase was carried out at the athlete’s training
site and for 12 weeks (divided into 2 parts, the 1st with 4 and
the 2nd with 8 weeks) in general (1st part) and specific (2nd
part) exercises. In the 2nd part, fast and strong contractions
(1–2 seconds) were performed before and during
any increase in intra-abdominal pressure, however, the number of
sets depended on what was requested by the trainer
|
|
SHERMAN; DAVIS; WONG, 1997 (United States)
|
44 women were randomized, 39 were
analyzed/28,5±7,2/Active duty
soldiers.
|
Determine whether PFMT exercise (Kegel) can help female soldiers
overcome exercise-induced incontinence with minimal therapeutic
intervention.
|
Number and amount of urinary loss, degree of urinary urgency and
enuresis episodes.
|
Intervention: PFMT+biofeedback, educational
action, bladder training and voiding urgency control (group 1)
vs PFMT+educational action, bladder training, voiding
urgency control and biofeedback as a stopwatch only (group
2).
|
5/10
|
|
PFMT protocol: During supervised practice, group 1
performed 5 contractions of 10 seconds with
10 seconds of relaxation and an interval of
30 seconds between each attempt for 2 months for both
groups. The study did not make it clear how the PFMT protocol
for group 2 was performed.
|
|
For home practice, patients in both groups were instructed to
practice 10-second contractions with 10-second relaxation, for
20 min, twice a day.
|
|
SOUSA et al., 2015 (Portugal)
|
7 nulliparous young athletes: supervised group=4 and
unsupervised
group=3/21,7±3,6/Athletics and
football.
|
To evaluate the effect of a comprehensive PFMT protocol on UI
symptoms in young nulliparous athletes using biomechanical
models.
|
Pad test
|
Intervention: Supervised PFMT+DVD with educational
material vs PFMT unsupervised and at home+DVD with
educational material.
|
-
|
|
PFMT protocol: Both groups underwent 8 weeks of treatment
and received a DVD with biomechanical models that helped in the
location, action and how to perform a correct PFM contraction.
The DVD also featured the PFMT protocol divided into 4 phases:
(1) stabilization, (2) strength, (3) power and (4) PFM
contraction during sports activities, each phase lasting for 2
weeks.
|
ICIQ-UI SF: International Consultation on Incontinence Questionnaire-Urinary
Incontinence Short Form; PFM: pelvic floor muscles; PFMT: pelvic floor
muscle training; SUI: stress urinary incontinence; UI: urinary
incontinence.
The UI symptoms were assessed using three different methods: International
Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI
SF) [30], the Pad test [27]
[28]
[31],
and a seven-day voiding diary [27]. Sherman, Davis and
Wong [29] evaluated the UI symptoms through questions
elaborated by the authors. Regarding the Pad test, the authors used the 2-hour Pad
test [28], or during the first 15 minutes of
sports practice [27]. The study by Sousa et al. [31] did not specify the duration of the Pad test.
The PFMT was compared with other interventions in four of the five studies. The PFMT
was compared to educational activities [27]
[29], to the PFMT associated with biofeedback [29], to an unsupervised home-based PFMT protocol [31], and with a control group without intervention
[28]. Da Roza et al. [30] applied the same PFMT protocol to all sample.
[Table 3] shows the main results from selected
studies. Three studies demonstrated a significant reduction in the UI frequency in
the PFMT group [27]
[29]
[30], and there was a significant
decrease in frequency when compared to the control group [27].
Table 3 Main results of urinary incontinence (UI) symptoms of the
five studies included in the review.
|
Outcome
|
Author/year
|
Intra and/or intergroup analysis
|
|
Frequency of urine loss
|
DA ROZA et al., 2012
|
PFMT: P1 mean 1.6 (SD 1.5); P2 mean 0.1 (SD 0.4)*
|
|
FERREIRA et al., 2014#
|
PFMTa: mean -0.3 (SD 0.50)* vs control
group: mean -0.1 (SD 0.44)
|
|
SHERMAN; DAVIS; WONG, 1997
|
PFMT without biofeedback: P1 mean 15.72 (SD 10.71); P2 mean 5.25
(SD 7.24)* vs PFMT with biofeedback: P1 mean 7.27
(SD 7.44); P2 mean 2.90 (SD 6.53)*
|
|
Amount of urine loss
|
DA ROZA et al., 2012
|
PFMT: P1 mean 2.6 (SD 1.5); P2 mean 0.3 (SD 0.8)*
|
|
FERREIRA et al., 2014#
|
PFMTa: mean -2.0 (SD 1.28)* vs control
group: mean -0.2 (SD 0.41)
|
|
PIRES et al., 2020#
|
PFMT: P1 mean 2.71 (SD 2.14); P2 mean 1.29 (SD 1.70)*
vs group control: P1 mean 1.83 (SD 2.40); P2 2.00 (SD
1.67)
|
|
SOUSA et al., 2015
|
PFMT with supervision: P1 mean 1.34 (SD 0.4); P2 mean 0.93 (SD
0.3)$
vs PFMT without supervision:
P1 mean 1.08 (SD 0.1); P2 mean 1.07 (SD 0.2)
|
|
Enuresis episodes
|
SHERMAN; DAVIS; WONG, 1997
|
PFMT without biofeedback: P1 mean 1.19 (SD 1.28); P2 mean 0.25
(SD 0.45)* vs PFMT with biofeedback: P1 mean 0.65 (SD
0.94); P2 mean 0.26 (SD 0.54)*
|
# Statistically significant difference between groups
(p<0.05); * Statistically significant difference within
groups (p<0.05); $ Statistically significant
difference within groups (p=0.05); SD: standard deviation;
a Mean and SD of the variation (final-initial) of the values;
P1: pre-intervention; P2: post-intervention; PFMT: pelvic floor muscle
training.
Regarding the UI amount, five studies showed a significant decrease in pre- and
post-PFMT group [27]
[28]
[29]
[30]
[31] and two studies showed a
significant decrease in PFMT group when comparing with the control group [27]
[28]. Sherman, Davis
and Wong (1997) [29] evaluated the amount of UI and
the degree of urinary urgency, through ordinal variables that have a classification
of the severity of the symptom elaborated by the authors themselves. The study found
significant decrease in both groups (PFMT with and without biofeedback) in the pre-
and post-intervention comparisons for the two variables, but without significant
differences between groups.
The enuresis episodes were evaluated in one study through a question created by the
authors and found a significant reduction in both study groups (PFMT with or without
biofeedback) [29]
[Table 4] presents the results of the PFM function and
QoL. From the five selected studies, three assessed the function of PFM. Three
different tools were used: manometer [28]
[30]
[31], modified Oxford
Scale [31] and Self-Efficacy Scale of Broome (score A,
B and total) [31]. Two studies found a significant
increase in MVC of the PFM in the PFMT group when comparing before and after
treatment [28]
[30], and
one study found a significant increase in PFMT group when comparing with the control
group [28]. The same two studies assessed the VRP
[28]
[30], where Da
Roza et al. found a significant increase in the PFMT group after the intervention.
In the evaluation using the modified Oxford Scale and the Self-Efficacy Scale of
Broome (score A, B and total), no significant differences were found in intra- and
inter-group comparisons [31].
Table 4 Main results of pelvic floor muscle (PFM) function and
quality of life (QoL) of the three studies included in the review.
|
Outcome
|
Author/year
|
Intra and/or intergroup analysis
|
|
PFM function - manometry (MVC, cmH
2
O)
|
DA ROZA et al., 2012
|
PFMT: P1 mean 73.4 (SD 24.9); P2 mean 89.8 (SD 19.1)*
|
|
PIRES et al., 2020#
|
PFMT: P1 mean 60.80 (SD 19.72); P2 mean 78.75 (SD 18.36)*
vs control group: P1 mean 55.68 (SD 29.12); P2 55.13
(SD 30.97)
|
|
SOUSA et al., 2015
|
PFMT with supervision: P1 mean 34.61 (SD 0.5); P2 mean 54.59 (SD
11.2) vs PFMT without supervision: P1 mean 41.23 (SD
0.0); P2 mean 48.23 (SD 0.0)
|
|
PFM function - manometry (VRP, cmH
2
O)
|
DA ROZA et al., 2012
|
PFMT: P1 mean 38.4 (SD 15.7); P2 mean 55.8 (SD 9.0)*
|
|
PIRES et al., 2020
|
PFMT: P1 mean 17.33 (SD 7.74); P2 mean 12.31 (SD 3.70) vs
control group: P1 mean 16.18 (SD 15.71); P2 13.67 (SD 8.00)
|
|
PFM function – vaginal palpation (modified Oxford
Scale)
|
SOUSA et al., 2015
|
PFMT with supervision: P1 mean 3.50 (SD 0.7); P2 mean 4.50 (SD
0.7) vs PFMT without supervision: P1 mean 4.00 (SD 0.0);
P2 mean 4.00 (SD 0.0)
|
|
PFM function – questionnaire (Broome Self-efficacy
Scale)
|
SOUSA et al., 2015
|
Score A=PFMT with supervision: P1 mean 46.25 (SD 48.1);
P2 mean 75.71 (SD 17.9) vs PFMT without supervision: P1
mean 61.90 (SD 45.0); P2 mean 71.43 (SD 25.1)
|
|
Score B=PFMT with supervision: P1 mean 69.45 (SD 17.5);
P2 mean 75.00 (SD 12.5) vs PFMT without supervision: P1
mean 71.48 (SD 17.2); P2 mean 65.93 (SD 25.7)
|
|
Total score=PFMT with supervision: P1 mean 57.85 (SD
32.2); P2 mean 75.36 (SD 15.0) vs PFMT without
supervision: P1 mean 66.69 (SD 30.5); P2 mean 68.68 (SD
25.2)
|
|
Quality of life
|
PIRES et al., 2020
|
Global score (KHQ)=PFMT: 6.35 (5.19) vs control
group: 8.80 (4.62)
|
|
Personal limitations and daily life (KHQ)=PFMT: 17.86
(14.17) vs control group: 24.31 (12.20)
|
|
Emotions and personal relationships (KHQ)=PFMT: 1.19
(2.03) vs control group: 2.08 (3.49)
|
|
Urinary symptoms (KHQ)=PFMT: 0.00 (0.00) vs
control group: 0.00 (0.00)
|
|
Symptom Severity Scale (KHQ)=PFMT: 6.93 (5.16) vs
control group: 6.06 (3.32)
|
|
General perceptions of health (KHQ)=PFMT: 7.14 (12.20)
vs control group: 8.33 (12.91)
|
|
Impact of incontinence (KHQ)=PFMT: 19.05 (17.82)
vs control group:16.67 (27.89)
|
|
SOUSA et al., 2015
|
CONTILIFE total score=PFMT with supervision: P1 mean 9.45
(SD 1.0); P2 mean 9.79 (SD 0.4) vs PFMT without
supervision: P1 mean 9.26 (SD 1.2); P2 mean 9.45 (SD 0.9)
|
|
SOUSA et al., 2015
|
CONTILIFE question 28=PFMT with supervision: P1 mean 1.50
(SD 0.6); P2 mean 1.30 (SD 0.6) vs PFMT without
supervision: P1 mean 1.30 (SD 0.6); P2 mean 1.67 (SD 1.2)
|
# Statistically significant difference between groups
(p<0.05); * Statistically significant difference within
groups (p<0.05); CONTILIFE: Questionnaire
d’évaluation de la Qualité de Vie liée
à l’incontinence urinaire de la femme; KHQ: King’s
Health Questionnaire; MVC: maximum voluntary contraction; P1:
pre-intervention; P2: post-intervention; PFM: pelvic floor muscles; SD:
standard deviation; VRP: vaginal resting pressure.
Two studies assessed the QoL of the incontinent women [28]
[31]. The King´s Health
Questionnaire (KHQ) and the CONTILIFE Questionnaires were the assessment
questionnaires. None of them found a significant difference in intra- and
inter-group comparisons in any domain or total score.
[Table 2] demonstrate the PEDro scale scores applied
to the selected RCTs. The score ranged from 5 to 7 points, where two studies scored
5 [27]
[29] and one study
scored 7 [28]. Only one study [28] was considered to have good methodological quality. For the two
non-RCTs, the ROBINS-I scale was used ([Table 5]),
where one of the studies was classified as having a serious overall risk of bias
[30] and the other as a critical overall risk of
bias [31].
Table 5 Risk Of Bias In Non-randomized Studies – of
Interventions (ROBINS-I) scores of the two non-randomized intervention
studies.
|
Confounding
|
Selection of participants
|
Classification of interventions
|
Deviations from intended interventions
|
Missing data
|
Measurement of outcomes
|
Selection of the reported result
|
General
|
|
DA ROZA et al., 2012
|
Moderate
|
Low
|
Serious
|
Moderate
|
Low
|
Serious
|
Serious
|
Serious
|
|
SOUSA et al., 2015
|
Moderate
|
Low
|
Critical
|
Moderate
|
Low
|
Serious
|
Serious
|
Critical
|
Low risk: comparable to a well-executed randomized trial; Moderate
risk: valid for a non-randomized trial but cannot be considered comparable
to a well-performed randomized trial; Serious risk: has some major
problems; Critical risk: too problematic in this domain to provide
any useful evidence on the effects of the intervention; Overall risk of
bias: equal to the most severe level of bias found in any
domain.
The CERT scores ranged from 5 to 9 ([Table 6]). The
highest scores were obtained by Da Roza et al. [30]
and by Sherman, Davis and Wong [29] with 9 out of 19
points, followed by Pires et al. [28], Ferreira et al.
[27] and Sousa et al. [31] with 7, 6 and 5 points, respectively. None of the authors scored in
six items (6, 11, 14b, 15, 16a and 16b) and only four items (3, 4, 12 and 14a) were
scored by all authors.
Table 6 Consensus on Exercise Reporting Template (CERT) scores of
the five studies included in the review.
|
|
DA ROZA et al., 2012
|
FERREIRA et al., 2014
|
PIRES, et al., 2020
|
SHERMAN; DAVIS; WONG, 1997
|
SOUSA et al., 2015
|
|
1
|
Detailed description of exercise equipment (e. g.
weights, treadmill, ergometer, etc.)
|
Y
|
NA
|
N
|
Y
|
N
|
|
2
|
Detailed description of instructor expertise, qualifications,
and/or training
|
Y
|
N
|
N
|
Y
|
N
|
|
3
|
Describe whether exercises are performed individually or in a
group
|
Y
|
Y
|
Y
|
Y
|
Y
|
|
4
|
Describe whether exercises are supervised or unsupervised;
how they are delivered
|
Y
|
Y
|
Y
|
Y
|
Y
|
|
5
|
Detailed description of how adherence to exercise is measured
and reported
|
Y
|
N
|
N
|
N
|
N
|
|
6
|
Detailed description of motivation strategies
|
N
|
N
|
N
|
N
|
N
|
|
7a
|
Detailed description of decision rule(s) for determining
exercise progression
|
Y
|
N
|
N
|
N
|
N
|
|
7b
|
Detailed description of how exercise program was
progressed
|
Y
|
N
|
Y
|
N
|
N
|
|
8
|
Detailed description of each exercise to enable
replication
|
N
|
N
|
Y
|
N
|
N
|
|
9
|
Detailed description of any home program component
|
N
|
N
|
N
|
Y
|
N
|
|
10
|
Describe any non-exercise components, e. g.
education, cognitive behavioral therapy, etc
|
N
|
Y
|
N
|
Y
|
Y
|
|
11
|
Describe the type and number of adverse events that occur
during exercise
|
N
|
N
|
N
|
N
|
N
|
|
12
|
Describe the setting in which the exercises are performed
|
Y
|
Y
|
Y
|
Y
|
Y
|
|
13
|
Detailed description of exercise intervention, e. g.
reps, sets, sessions
|
N
|
Y
|
Y
|
Y
|
N
|
|
14a
|
Describe whether the exercises are generic (one size fits
all) or tailored
|
Y
|
Y
|
Y
|
Y
|
Y
|
|
14b
|
Detailed description of how exercises are tailored to the
individual
|
N
|
N
|
N
|
N
|
N
|
|
15
|
Describe the decision rule for determining the starting
level, e. g. beginner, intermediate, advanced,
etc
|
N
|
N
|
N
|
N
|
N
|
|
16a
|
Describe how adherence or fidelity to the intervention is
assessed/measured
|
N
|
N
|
N
|
N
|
N
|
|
16b
|
Describe the extent to which the intervention was delivered
as planned
|
N
|
N
|
N
|
N
|
N
|
N: no; NA: not applicable; Y: yes.
[Table 2] shows that all published studies used
different PFMT protocols. The duration of the training protocol ranged between eight
and 16 weeks. The number of slow PFM contractions per day ranged from five to 30
times, they were sustained for five to 10 seconds and the relaxation time
between contractions ranged from two to 10 seconds. The number of rapid
contractions per day ranged from 120 to the number of series requested by the coach
during training. Only Da Roza et al. [30] study asked
the participants to perform the PFM contractions until fatigue.
All five studies associated educational actions or materials with PFMT [27]
[28]
[29]
[30]
[31]. The educational actions consisted of health
education focused on the PFM [27], explanation about
the PFMT [28], an education book and instructions on
urination [29], or a DVD with biomechanical models
that explain anatomy and the PFM contraction [30]
[31]. In addition, one study associated the PFMT with
bladder training and urinary urgency control, to be used when applicable [29]. This training consisted of a urination schedule
that started every one hour and went on to every two hours. Regarding the control of
voiding urgency, the participants were taught to perform three-second CVM to
suppress urgency.
All studies applied PFMT protocol at home [27]
[28]
[29]
[30]
[31], two studies
applied supervised PFMT [29]
[31] and one associated the home environment with the athletes’
training location in the protocol [28]. One study held
meetings with participants every 15 days, where the physiotherapist showed the new
exercises for the next step [30]. To assess the
participants’ progress and adherence to the home-based treatment, one study
requested the completion of an exercise diary [30] and
another performed weekly visits, both at home and after training [27].
Three studies progressed the PFMT protocol in phases [28]
[30]
[31].
The intensity of the PFMT protocols progressed according to the positions adopted,
reducing the interval time between each contraction, increasing the number of
repetitions and/or sustained contraction time.
Discussion
Despite the heterogeneity in the outcome measures used to assess UI symptoms, all
five studies showed a reduction in the amount [27]
[28]
[29]
[30]
[31],
and three studies showed a decrease in the frequency of UI [27]
[29]
[30]
in the PFMT group after the intervention. The symptoms of urinary urgency and the
enuresis episodes were evaluated in one study, and the authors found a significant
decrease in both groups (PFMT with and without biofeedback) [29].
Regarding the PFM function, two of the five studies [28]
[30] found a significant increase in MVC
pre-and-post-PFMT group, and the first study also demonstrated a significant
increase in MVC when compared with the control group [28]. The same two studies assessed the VRP, and one found a significant
VRP increase in the PFMT group [30]. Indeed, several
studies with women of the general population demonstrated an increase of the PFM
maximal strength after PFMT [32]
[33]
[34]. It is known that
a strong pelvic floor positioned at an optimal level within the pelvis can be a
crucial factor in counteracting the increases in IAP that occur during high-impact
activities [13]. The rationale for using the PFMT is
that enhanced by hypertrophy of the muscles which will increase the stiffness of the
PFM and connective tissue. Associated to that, Pires et al. [35] found that the higher the MVC values, the better the QoL in
sportswomen. So, PFMT will enhance the PFM structurally and also improve the QoL of
athletic women.
Studies in the literature demonstrated [11]
[36]
[37] significantly
worse QoL in incontinent women who practice high-impact sports. Pires et al. [38] found that women who practice high-impact sports
had a greater impact on the QoL than those who practice low-impact ones. Dakic et
al. [39] also demonstrated that women with symptoms of
PFM disorders in high-impact sports are the most interrupted exercise (42%)
when compared to women engaged in low-impact sports (21%). These results may
be related to the fact that athletes consider that UI has implications for their
sports performance. They end up using strategies to hide urine loss and omit the
symptoms of this dysfunction to health professionals, impacting their QoL [40]. Curiously, the two studies that assessed the QoL
[28]
[31],
demonstrated a high QoL among the incontinent women pre and post-intervention. These
results can be explained due to the women report their bladder problem as little
affect their exercise [28], or due to the little
amount of UI [31]. In addition, a systematic review
[41] demonstrated that physical activity
practitioners generally have a better perception of QoL.
The studies included feature a variety of study designs, PFMT protocols, comparison
groups, and outcome measures. The CERT score ranged from 5 to 9, which represents
that most RCTs were described in insufficient detail to allow their optimal
translation into clinical practice. In our review, the period of the PFMT
intervention ranges from eight to 16 weeks. García-Sánchez et al.
[42] in their meta-analysis, found that six to 12
weeks or≥24 sessions are ideal to achieve an decrease in urine loss because
there is an improvement in muscle tone and automatic motor control of PFM. All
studies included in this review were carried out at home and some characteristics of
the PFMT protocol were not described, such as the duration and/or weekly
frequency of sessions, number of series and repetitions, contraction and relaxation
time, and adopted positions. The absence of this information makes it difficult to
replicate the protocol and discuss whether the characteristics of the training are
adequate or insufficient to improve the UI symptoms in female athletes.
Among the studies included, only one added an adjuvant treatment to PFMT [29]. This study used biofeedback and found significant
improvement in the group that associated PFMT with biofeedback in UI symptoms
(frequency and amount of UI, enuresis episodes, and degree of urinary urgency). A
recent systematic review [42] demonstrated greater
effectiveness in SUI treatment when using biofeedback, and they recommend applying
PFMT with biofeedback or accessories to treat SUI.
This systematic review has some limitations, the first being that the studies
selected for review had different study designs, where three are RCTs, and two are
non-RCTs. In addition, some PFMT information (number of repetitions, contraction and
interval time, exercises performed, use of accessories, among others) are not
described in the methodology of the included articles, making it difficult to
properly replicate the PFMT protocol and verify the real effect in UI symptoms in
these women. Also, only five studies were included, the results of this study should
be interpreted with caution. There is a need to carry out more studies in this area,
to clarify the best way to apply the PFMT in incontinent women who practice
high-impact sports.
Conclusion
PFMT can significantly reduce UI symptoms and the frequency and amount of UI, and
improve the PFM function in female athletes. The urinary urgency and enuresis
episodes can also be significantly reduced with PFMT associated or not with
biofeedback. At the end of the PFMT, the MVC and the VRP were significantly increase
in these women, however, the function of the PFM assessed by palpation or
questionnaire did not improve. Despite evidence showing that UI symptoms can
negatively impact the QoL of female athletes, two studies assessed the QoL and they
demonstrated that UI does not affect their lives. There is still a need for RCTs
with high methodological quality that investigate the effect of PFMT in women who
practiced high-impact sports.
