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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 30  |  Issue : 5  |  Page : 501-506

Contraction techniques adopted for pelvic floor muscle exercise education by Nigeria-based physiotherapists: A preliminary study


1 Department of Medical Rehabilitation, College of Medicine, University of Nigeria, Nsukka, Enugu, Nigeria
2 Department of Medical Rehabilitation, College of Medicine, University of Nigeria, Nsukka, Enugu, Nigeria; Department of Gerontology, Faculty of Social Sciences, University of Southampton, Southampton, UK
3 Department of Gerontology, Faculty of Social Sciences, University of Southampton, Southampton, UK
4 Department of Physiotherapy, Federal Teaching Hospital, Abakaliki, Ebonyi, Nigeria

Date of Submission18-May-2021
Date of Decision22-Jun-2021
Date of Acceptance22-Jun-2021
Date of Web Publication11-Oct-2021

Correspondence Address:
Dr. Sylvester Emeka Igwe
Department of Medical Rehabilitation, College of Medicine, University of Nigeria, Nsukka, Enugu
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/NJM.NJM_93_21

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  Abstract 


Objective: The objective of the study is to investigate contraction techniques adopted for pelvic floor muscle (PFM) exercise education and their perceived efficacies among physiotherapists in Nigeria. Materials and Methods: Two hundred and eight conveniently selected physiotherapists in various clinical specialties, working in different hospitals across Nigeria, responded to a structured questionnaire that investigated contraction techniques adopted for PFM exercise education and their perceived efficacies. The data was analyzed with the SPSS software version 20.0 at P = 0.5. Results: 111 male and 97 female physiotherapists (mean age of 34.2 ± 10.3 years) participated in this study. “Imagination of urinating and suddenly interrupting urine flow” (85.9%) and “gripping of therapist's fingers or vaginal electrodes with the vagina” (44.6%) were the commonly utilized contraction techniques. “Imagination of urinating and suddenly interrupting urine flow” (28.8%) and “imagination of gripping the penis with the vagina” (26.4%) were perceived as the most effective methods by the physiotherapists while “imagination of releasing flatus while attempting to obscure its sound” (0.96%) emerged as the least effective methods. Conclusion: “Imagination of urinating and suddenly interrupting urine flow” is the most common contraction technique utilized for PFM education by Nigerian physiotherapists as well as the perceived most effective method, as compared to others.

Keywords: Nigeria, pelvic floor muscle exercise, perceived efficacy, physiotherapists, teaching method


How to cite this article:
Ojukwu CP, Orji PC, Ede SS, Ezeigwe A, Uchenwoke CI, Anekwu E, Igwe SE. Contraction techniques adopted for pelvic floor muscle exercise education by Nigeria-based physiotherapists: A preliminary study. Niger J Med 2021;30:501-6

How to cite this URL:
Ojukwu CP, Orji PC, Ede SS, Ezeigwe A, Uchenwoke CI, Anekwu E, Igwe SE. Contraction techniques adopted for pelvic floor muscle exercise education by Nigeria-based physiotherapists: A preliminary study. Niger J Med [serial online] 2021 [cited 2021 Dec 5];30:501-6. Available from: http://www.njmonline.org/text.asp?2021/30/5/501/327967




  Introduction Top


The superficial and deep layers of the pelvic floor muscles (PFMs)[1] support the abdomen and pelvic viscera, maintain fecal and urine continence, allow voiding and defecation, promote sexual activity and delivery,[2] and preserve pelvispinal stability.[3] PFM anatomy and function are critical components of physiotherapy practice, notably in the prevention and treatment of pelvic floor diseases. Pelvic diseases may arise as a result of a combination of neuropathic alterations, muscle, fascia, or connective tissue injury linked with the pelvic floor.[4],[5],[6],[7] Pelvic floor disorders encompass a wide range of diseases, including incontinence, pelvic organ prolapse, sexual dysfunctions, and pelvic discomfort. Facilitation of voluntary PFM contractions is a key component of PFM training exercise regimens in the context of pelvic floor diseases. PFM strengthening exercises are the most prevalent and one of the most efficient techniques for treating such illnesses. These exercises' efficacy has been shown in numerous trials, and they are frequently suggested as first-line therapy for pelvic floor problems.[8],[9],[10],[11]

Physiotherapists, among others, play critical roles in the prescription, instruction, monitoring, and assessment of PFM exercises and their effects.[12] Adoption of PFM exercises as therapy regimens necessitate thorough education programs to educate the client on the location and function of the PFMs, as well as to assist isolation and correct activation of these muscles.[13],[14] In contrast to other exercises involving most muscle groups, which generally entail the therapist physically demonstrating the movements to supplement verbal instructions for a better comprehension, PFM exercises cannot be taught in this manner. It is tough to teach PFM exercises.[15] The anatomical placement of these muscles is the most difficult problem in PFM exercise teaching. Because these muscles are situated inside and the visibility of their contraction is not easily noticed, physiotherapists find it challenging to educate clients about the functions of the PFMs as well as proper strengthening procedures.[15] This difficulty, on the other hand, extends to the client's comprehension and enjoyment of the PFM and their exercise plans. These difficulties are not only limited to the instruction of PFM exercises but also to their implementation by the client and the physiotherapist's appraisal of development. Incorrect execution of these exercises renders them useless and may possibly exacerbate the client's symptoms of pelvic floor problems.[15],[16] Adoption of PFM exercises necessitate four steps in a continuous process: education, comprehension, implementation, and assessment. Any shortcoming at any step, particularly the first three, results in the inadequacy of the entire process.[17] A recent study found that teaching women to execute “the Knack” maneuver of the PFMs increased women's awareness of the pelvic floor but had no effect on voluntary contraction of the PFMs and their functions.[13] These emphasize the need for adequacy in all stages of the PFM exercise process.

To achieve the best outcome, physiotherapists and associated professionals have used several contraction techniques of instructing PFM exercises[14] to enable clients' better comprehension and application. Contextually, the contraction technique refers to the expressions used to urge clients to isolate and contract their PFMs. Some strategies were described, such as asking the client to envision stopping the flow of urine midstream, preventing the passage of wind, or a combination of the two.[14] In a recent systematic review, Mateus-Vasconcelos et al.[18] outlined other techniques, including instruction regarding the anatomy and function of the PFM, vaginal palpation, palpation on the central perineal tendon, interruption of urine flow, biofeedback using a perineometer, proprioceptive technique with a vaginal cone, hypopressive exercise, PFM contraction associated with diaphragmatic breathing and visualization using a mirror, and coactivation of the anterolateral abdominal muscles.

Asides from these, anecdotal observations show that other techniques are being conceptualized and utilized by physiotherapists and related personnel in Nigeria but lack empirical documentation. It has also been observed that utilization of these techniques is dependent on the physiotherapist's perception of proper client understanding and application as well as positive treatment outcomes.[19] Investigating available techniques for facilitating contraction of the PFMs and their perceived efficacies are extremely necessary as this will offer valued information to physiotherapists as well as guide their clinical decision-making processes. Therefore, this survey aimed to investigate contraction techniques adopted by Nigerian physiotherapists for PFM exercise education as well as the perceived efficacies of the reported techniques.


  Materials and Methods Top


Design

This cross-sectional descriptive survey constitutes the first phase of an ongoing project (Evaluating Contraction Techniques Adopted for Pelvic Floor Muscle Exercise Education), designed to review and evaluate the efficacies of instructions utilized for educating clients on the location and contraction of the PFMs. This first preliminary phase sought to investigate the instruction-based contraction techniques adopted by physiotherapists for Kegel exercise education and their perceived efficacies. This information will influence the design and contents of the follow-up observational and experimental phases of this study.

This study was approved by the University of Nigeria Research Ethics Committee with the approval number: NHREC/05/01/2008B-FWA00002458-1RB00002323.

Participants

A minimum sample size of 171 respondents was calculated according to Yamane[20] with an estimated population size of 300 physiotherapists, who attended two major physiotherapy conferences hosted by the only two Nigerian professional Associations for physiotherapists in October and November 2018. Therefore, 300 questionnaires were distributed to the conference participants and 208 eligible participants filled and returned theirs, yielding a response rate of 69.3%. The study inclusion criteria included physiotherapy training and practice in Nigeria as well as clinical experience in the management of patients that required PFM training. Physiotherapists with less than or equal to six months of working experience and no clinical experience in the management of conditions requiring prescription of PFM strengthening exercises were excluded from this study.

The conference attendees were not the most appropriate but best fit representative of Nigerian-based physiotherapists as the conferences had delegates from across the entire states of Nigeria.

Procedure

Questionnaire

A structured self-administered questionnaire was utilized for this study. This questionnaire was face and content validated by four experts. Its reliability was assessed in a pilot study by a test-retest method among 10 physiotherapists, before the conferences. Seven days were observed between the test and retest activities. The correlation coefficient of the test-retest reliability was r = 0.967 (P = 0.001).

This seven-item questionnaire has three sections (A, B, and C). Section A contained questions on the demographic and occupational characteristics of the respondents. Section B investigated the contraction techniques utilized by physiotherapists for educating clients on PFM exercises while Section C sought information on respondents' perceptions of the utilized contraction techniques in improving patient outcomes.

One hundred and eighty copies of the questionnaire were printed and distributed to the respondents by the end of the first day of each conference. At the end of the last day of each conference, the filled copies of the questionnaires were collected for data collation and analysis. Respondents who could not submit theirs by the end of the conference had them mailed to the researchers.

Data analysis

Data was analyzed with the SPSS software version 20.0 for data analysis (SPSS Inc., Chicago, IL, USA). Descriptive statistics of mean, standard deviation, frequencies, and percentages were used to summarize physiotherapists' responses.


  Results Top


One hundred and eleven male and 97 female physiotherapists (mean age of 34.2 ± 10.3 years) participated in this study [Table 1]. The majority of the respondents specialized in orthopedics (29.3%) and women's health (21.6%) [Table 1]. Most (64.9%) of the respondents had greater than five years of clinical experience as physiotherapists.
Table 1: Demographic and occupational characteristics of the respondents (n=208)

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In descending order, the five commonly utilized contraction techniques adopted for educating PFM exercises are “imagination of urinating and suddenly interrupting urine flow” (85.9%), “gripping of therapist's fingers or vaginal electrodes with the vagina” (44.6%), “imagination of releasing flatus while attempting to obscure its sound” (43.5%), “tightening of the abdomen with hip adduction” (37.0%), “imagination of gripping the penis with the vagina during sexual intercourse” (37.0%) [Table 2].
Table 2: Contraction techniques utilized by physiotherapists for educating Kegel's exercises (descending order)

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The majority of the respondents perceived “imagination of urinating and suddenly interrupting urine flow” (28.8%) and “imagination of gripping the penis with the vagina during sexual intercourse” (26.4%) as the most effective methods while “imagination of releasing flatus while attempting to obscure its sound” (0.96%) was rated the least effective methods [Table 3].
Table 3: Physiotherapists' perceived efficacy of the contraction techniques (Descending order)

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  Discussion Top


This novel study reported the contraction techniques utilized by physiotherapists for PFM education. The effectiveness of PFM exercises is partly dependent on the instructions provided.[15] Verbal instruction is a key element in PFM contraction education.[21],[22] This study showed that Nigerian physiotherapists predominantly utilized “imagination of urinating and suddenly interrupting urine flow” and “gripping of therapist's fingers or vaginal electrodes with the vagina” for PFM education. Simulating an attempt to pause urine flow has been considered as one of the verbal instructions for educating PFM contractions in previous studies.[14],[23],[24],[25] Although we could not ascertain reasons guiding physiotherapists' preferences of the reported contraction techniques, the utilization of “imagination of urinating and suddenly interrupting urine flow” in other geographical areas[21],[23],[24],[25] suggests that it is a widely accepted technique.

Physiotherapists in the present study perceived “imagination of urinating and suddenly interrupting urine flow” as the most effective method for educating PFM exercises. The fact that it was the preferred method of PFM education in previous studies[21],[23],[24],[25] further suggests its perceived efficacy by other authors. However, these inferences are not absolute as there is a paucity of data on the comparative effects of available contraction techniques on PFM activation. The reported efficacy in our study is largely subjective but can serve as an interim guide to related clinicians, pending the conclusion of other phases of this study. In subsequent phases, these reported contraction techniques would be evaluated to delineate more objective guidelines supported with empirical evidence.

Nevertheless, other contraction techniques were also reported in our study. The second most utilized method is the “gripping of therapist's fingers or vaginal electrodes with the vagina” technique. Logically, this approach looks to be fairly objective, as the client should be able to focus the activity on the PFMs by gripping a physical instrument (therapist's finger, vaginal electrode, or penis). These “gripping” techniques are typically used as improvised biofeedback procedures to enhance the PFMs. Such approaches allow for the provision of oral or tactile input to the client, providing rapid feedback on the strength of the contraction created. Biofeedback is a powerful tool for increasing muscle activation and training strength in the PFMs.[24],[26],[27] Although these studies[26],[27],[28] reported additional positive outcomes of PFM training with the inclusion of biofeedback regimens, others have shown contradicting findings.[29],[30]

”Tightening the abdominal muscles with hip adduction” was also reported as a contraction technique by physiotherapists in the present study. The synergistic activation of the PFMs and each of the abdominal[31],[32],[33] and hip adductor[7],[34] muscles is generally the foundation of this approach. Because of their anatomical arrangement, the PFMs can be activated with abdominal or hip adduction movements and vice versa. As such, the adoption of abdominal and hip exercises for PFM rehabilitation has been recommended and utilized in previous studies.[35],[36],[37],[38],[39],[40]

Comparing the outcomes of this study with previous studies showed some distinctions among contraction techniques used to facilitate PFM contractions in Nigeria and other climes. According to Elaine et al.,[18] common techniques used in other climes include PFM anatomy and function instruction, vaginal palpation, palpation on the central perineal tendon, interruption of urine flow, biofeedback with a perineometer, proprioceptive technique with a vaginal cone, hypopressive exercise, PFM contraction associated with diaphragmatic breathing, and visual stimulation. Asides from the interruption of urine flow and proprioceptive technique with a vaginal cone, the other techniques were not reported as contraction techniques utilized by physiotherapists in this study. Although it is known that the other techniques are utilized for evaluation and treatment purposes in most Nigerian clinical settings, it is obvious that they are not adopted for the facilitation of PFM contractions. All the studies reviewed by Elaine et al.[18] utilized vaginal palpation to facilitate PFM contractions. The efficacy of this technique in facilitating PFM contraction in women who had difficulties isolating the PFMs was shown in several studies.[41],[42],[43]

This study had some limitations including the use of a small sample size and the absence of information on the contraction techniques taught to the respondents during their academic and clinical training. This would have informed us of the options available to them through physiotherapy training. It is common for clinicians to adopt only clinical practices that were passed on to them during training, irrespective of the known efficacies of such practices.

Implications for practice and policy

Physiotherapists in Nigeria utilized various methods for educating PFM exercises and their perceived efficacy of each method varied based on their clinical experiences. This provides a wide spectrum of options available for physiotherapists during the education and prescription of PFM exercises. Especially, the three most used approaches to educating the PFMs including holding urine or stool along with putting a finger in the vagina or rectum to contract muscle over it are the most commonly cited in the literature.[21],[23],[24],[25] However, the efficacy of these methods in achieving the aims of PFM rehabilitation needs to be further investigated objectively, preferably in an experimental approach.


  Conclusion Top


Eight contraction techniques were reported by physiotherapists in this study. “Imagination of urinating and suddenly interrupting urine flow” and “gripping of therapist's fingers or vaginal electrodes with the vagina” were the most frequently utilized techniques. The former was scaled as the perceived most effective method, as compared to others.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Raizada V, Mittal RK. Pelvic floor anatomy and applied physiology. Gastroenterol Clin North Am 2008;37:493-509.  Back to cited text no. 1
    
2.
Mantle J, Haslam J, Barton S, Polden M. Physiotherapy in Obstetrics and Gynaecology. Edinburgh, Scotland: Butterworth-Heinemann; 2004.  Back to cited text no. 2
    
3.
Sapsford R, Bullock-Saxton J, Markwell S. Women's Health: A Textbook for Physiotherapists. London: WB Saunders; 1999.  Back to cited text no. 3
    
4.
Ashton-Miller J, DeLancey JOL. Functional anatomy of the female pelvic floor. In: Bo K, Berghmans B, Morkved S, Van Kampen M, editors. Evidence Based Physical Therapy for Pelvic Floor – Bridging Science and Clinical Practice. UK: Elsevier; 2007.  Back to cited text no. 4
    
5.
Petros PE. The Integral Theory System. A simplified clinical approach with illustrative case histories. Pelviperineology 2007;29:37-51.  Back to cited text no. 5
    
6.
Shafik A, Ahmed I, Shafik AA, El-Ghamrawy TA, El-Sibai O. Surgical anatomy of the perineal muscles and their role in perineal disorders. Anat Sci Int 2005;80:167-71.  Back to cited text no. 6
    
7.
Smith MD, Coppieters MW, Hodges PW. Postural response of the pelvic floor and abdominal muscles in women with and without incontinence. Neurourol Urodyn 2007;26:377-85.  Back to cited text no. 7
    
8.
Alves FK, Riccetto C, Adami DB, Marques J, Pereira LC, Palma P, et al. A pelvic floor muscle training program in postmenopausal women: A randomized controlled trial. Maturitas 2015;81:300-5.  Back to cited text no. 8
    
9.
Bø K. Pelvic floor muscle training is effective in treatment of female stress urinary incontinence, but how does it work? Int Urogynecol J Pelvic Floor Dysfunct 2004;15:76-84.  Back to cited text no. 9
    
10.
Dumoulin C, Hay-Smith J, Habée-Séguin GM, Mercier J. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women: A short version Cochrane systematic review with meta-analysis. Neurourology and urodynamics 2015;34:300-8.  Back to cited text no. 10
    
11.
Hagen S, Stark D, Glazener C, Dickson S, Barry S, Elders A, et al. Individualised pelvic floor muscle training in women with pelvic organ prolapse (Poppy): A multicentre randomised controlled trial. Lancet 2014;383:796-806.  Back to cited text no. 11
    
12.
Dumoulin C, Hunter KF, Moore K, Bradley CS, Burgio KL, Hagen S, et al. Conservative management for female urinary incontinence and pelvic organ prolapse review 2013: Summary of the 5th International Consultation on Incontinence: Conservative Management for UI and POP. Neurourol Urodyn 2016;35:15-20.  Back to cited text no. 12
    
13.
de Andrade RL, Bø K, Antonio FI, Driusso P, Mateus-Vasconcelos EC, Ramos S, et al. An education program about pelvic floor muscles improved women's knowledge but not pelvic floor muscle function, urinary incontinence or sexual function: A randomised trial. J Physiother 2018;64:91-6.  Back to cited text no. 13
    
14.
Polden M, Mantle J. Physiotherapy in Obstetrics and Gynaecology. Oxford: Butterworth-Heinemann; 1990.  Back to cited text no. 14
    
15.
Mason L, Glenn S, Walton I, Hughes C. The instruction in pelvic floor exercises provided to women during pregnancy or following delivery. Midwifery 2001;17:55-64.  Back to cited text no. 15
    
16.
Sampselle C. Effect of pelvic muscle exercise on transient incontinence during pregnancy and after birth*1. Obstet Gynecol 1998;91:406-12.  Back to cited text no. 16
    
17.
Woodley SJ, Boyle R, Cody JD, Mørkved S, Hay-Smith EJ. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database Syst Rev 2017;12:CD007471.  Back to cited text no. 17
    
18.
Mateus-Vasconcelos EC, Ribeiro AM, Antônio FI, Brito LG, Ferreira CH. Physiotherapy methods to facilitate pelvic floor muscle contraction: A systematic review. Physiother Theory Pract 2018;34:420-32.  Back to cited text no. 18
    
19.
Bernardo-Filho M, Barbosa Júnior ML, da Cunha Sá-Caputo D, de Aguiar Ede O, de Lima RP, Santos-Filho SD, et al. The relevance of the procedures related to the physiotherapy in the interventions in patients with prostate cancer: Short review with practice approach. Int J Biomed Sci 2014;10:73-84.  Back to cited text no. 19
    
20.
Yamane T. Statistics: An Introductory Analysis. 3rd ed. New York: Harper and Row; 1973.  Back to cited text no. 20
    
21.
Neels H, De Wachter S, Wyndaele JJ, Van Aggelpoel T, Vermandel A. Common errors made in attempt to contract the pelvic floor muscles in women early after delivery: A prospective observational study. Eur J Obstet Gynecol Reprod Biol 2018;220:113-7.  Back to cited text no. 21
    
22.
Vermandel A, De Wachter S, Beyltjens T, D'Hondt D, Jacquemyn Y, Wyndaele JJ. Pelvic floor awareness and the positive effect of verbal instructions in 958 women early postdelivery. Int Urogynecol J 2015;26:223-8.  Back to cited text no. 22
    
23.
Deindl FM, Vodusek DB, Hesse U, Schussler B. Activity patterns of pubococcygeal muscles in nulliparous continent women. Br J Urol 1993;72:46-51.  Back to cited text no. 23
    
24.
Deindl FM, Vodusek DB, Hesse U, Schüssler B. Pelvic floor activity patterns: Comparison of nulliparous continent and parous urinary stress incontinent women. A kinesiological EMG study. Br J Urol 1994;73:413-7.  Back to cited text no. 24
    
25.
Miquelutti MA, Cecatti JG, Makuch MY. Evaluation of a birth preparation program on lumbopelvic pain, urinary incontinence, anxiety and exercise: A randomized controlled trial. BMC Pregnancy Childbirth 2013;13:154.  Back to cited text no. 25
    
26.
Glavind K, Nøhr SB, and Walter S. Biofeedback and physiotherapy versus physiotherapy alone in the treatment of genuine stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 1996;7:339-43.  Back to cited text no. 26
    
27.
Mørkved S. Effect of adding biofeedback to pelvic floor muscle training to treat urodynamic stress incontinence. Obstet Gynecol 2002;100:730-9.  Back to cited text no. 27
    
28.
Glavind K, Nøhr SB, Walter S. Biofeedback and physiotherapy versus physiotherapy alone in the treatment of genuine stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 1996;7:339-43.  Back to cited text no. 28
    
29.
Berghmans LC, Frederiks CM, de Bie RA, Weil EH, Smeets LW, van Waalwijk van Doorn ES, et al. Efficacy of biofeedback, when included with pelvic floor muscle exercise treatment, for genuine stress incontinence. Neurourol Urodyn 1996;15:37-52.  Back to cited text no. 29
    
30.
Bumsz PA, Pranikoff K, Nochajski TH, Hadley EC, Levy KJ, Ory MG. A comparison of effectiveness of biofeedback and pelvic muscle exercise treatment of stress incontinence in older community-dwelling women. J Gerontol 1993;48:M167-74.  Back to cited text no. 30
    
31.
Critchley D. Instructing pelvic floor contraction facilitates transversus abdominis thickness increase during low-abdominal hollowing. Physiother Res Int 2002;7:65-75.  Back to cited text no. 31
    
32.
Hung HC, Hsiao SM, Chih SY, Lin HH, Tsauo JY. An alternative intervention for urinary incontinence: Retraining diaphragmatic, deep abdominal and pelvic floor muscle coordinated function. Manual Ther 2010;15:273-9.  Back to cited text no. 32
    
33.
Tajiri K, Huo M, Maruyama H. Effects of co-contraction of both transverse abdominal muscle and pelvic floor muscle exercises for stress urinary incontinence: A randomized controlled trial. J Phys Ther Sci 2014;26:1161-3.  Back to cited text no. 33
    
34.
Ptaszkowski K, Paprocka-Borowicz M, Słupska L, Bartnicki J, Dymarek R, Rosińczuk J, et al. Assessment of bioelectrical activity of synergistic muscles during pelvic floor muscles activation in postmenopausal women with and without stress urinary incontinence: A preliminary observational study. Clin Interv Aging 2015;10:1521-8.  Back to cited text no. 34
    
35.
Sapsford RR, Hodges PW, Richardson CA, Cooper DH, Markwell SJ, Jull GA. Co-activation of the abdominal and pelvic floor muscles during voluntary exercises. Neurourol Urodyn 2001;20:31-42.  Back to cited text no. 35
    
36.
Arab AM, Chehrehrazi M. The response of the abdominal muscles to pelvic floor muscle contraction in women with and without stress urinary incontinence using ultrasound imaging. Neurourol Urodyn 2011;30:117-20.  Back to cited text no. 36
    
37.
Madill SJ, McLean L. Relationship between abdominal and pelvic floor muscle activation and intravaginal pressure during pelvic floor muscle contractions in healthy continent women. Neurourol Urodyn 2006;25:722-30.  Back to cited text no. 37
    
38.
Betsy DF, Chorny WC, Brahler J, Ingely A, Kennedy J, et al. A comparison of two Pelvic floor muscle training programs in female with stress urinary incontinence: A pilot study. J Appl Res 2012;11:73-83.  Back to cited text no. 38
    
39.
Kim JS, Choi JD, Shin WS. Effect of different contraction methods on pelvic floor muscle contraction in middle-aged women. Phys Ther Rehabil Sci 2015;4:103-7.  Back to cited text no. 39
    
40.
Augustina J, Ponmathi P, Sivakumar SP. A study to compare three types of assisted pelvic floor muscle training programmers in women with pelvic floor muscle weakness. Int J Pharm Clin Res 2016;8:1446-50.  Back to cited text no. 40
    
41.
Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, et al. The standardization of terminology of lower urinary tract function: Report from the standardisation sub-committee of the international continence Society. Am J Obstet Gynecol 2002;187:116-26.  Back to cited text no. 41
    
42.
Bø K, Finckenhagen HB. Vaginal palpation of pelvic floor muscle strength: Inter-test reproducibility and comparison between palpation and vaginal squeeze pressure. Acta Obstet Gynecol Scand 2001;80:883-7.  Back to cited text no. 42
    
43.
Bø K, Morkved S. Motor learning. In: Bø K, Berghmans B, Morkved S, Van Kampen M, editors. Evidence-Based Physical Therapy for the Pelvic Floor. Philadelphia: Elsevier; 2007. p. 113-9.  Back to cited text no. 43
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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