Journal of Womens Health Physical Therapy 19

Copyright 2014 Section on Womens Health, American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
Research Report
ABSTRACT
Objective: The purpose of this study was to investigate the
effect of variations in forced expiration effort on the auto-
matic activation of pelvic oor (PF) muscles.
Study Design: Quasiexperimental repeated measures.
Background: The PF activates automatically, both squeez-
ing and lifting, during times of increased intra-abdominal
pressure for postural stability and continence. Expiration
additionally produces automatic activation of the PF mus-
cles. No study to date has investigated the effects of forced
expiration on PF displacement and squeeze pressure.
Methods and Measures: A convenience sample of pre-
menopausal, nulliparous, continent women was recruited
and instructed on 3 variations in forced expiration effort:
(1) minimum; (2) moderate; and (3) maximum. Pelvic oor
automatic activation measurements were taken using peri-
neometry (squeeze pressure) and transperineal ultrasound
imaging (PF displacement) during each type of expiration.
Chi-square test was used to analyze the direction of PF
displacement, and Friedman analysis by ranks was used
to analyze the magnitude of the squeeze pressure and PF
displacement.
Results: Data of 18 women, aged 24.8 2.5 years, were
analyzed. There was a signicant difference in the vaginal
squeeze pressure ( P < .001) and magnitude of displace-
ment in the horizontal plane ( P < .001) and the vertical
plane ( P < .001) of the PF between the 3 variations of
INTRODUCTION
The pelvic oor (PF) is a dynamic and complex
structure that serves many functions, including pelvic
organ support, continence, respiration, and lumbo-
pelvic postural stability.
1-3
A volitional contraction
of the PF muscles displaces the PF cranially and
ventrally, closing the urethral opening and sup-
porting the bladder neck from descending.
4-10
This
cranial-ventral displacement with sphincteric closing
forces supports continence. Successful rehabilitation
for individuals with stress and mixed urinary incon-
tinence involves instruction and procient practice
of a volitional PF contraction that demonstrates
the proper cranial-ventral displacement and squeeze
pressure.
3

,

11

The PF muscles automatically activate during
respiration, with greater activation during expiration
than during inspiration.
2
Moreover, PF displace-
ment, measured by magnetic resonance imaging, has
been objectied during inspiration (caudal direction)
and expiration (cranial direction).
12
The PF addi-
tionally automatically activates during increases in
intra-abdominal pressure (IAP).
13

,

14
This automatic
activation functions in a feedforward fashion to resist
the caudal pressure of the intra-abdomen, stabilize
posture, and support continence.
2

,

3

,

10

,

15

1
Clinical Musculoskeletal Research Laboratory, Center
for Rehabilitation Research, Texas Tech University Health
Sciences Center, Lubbock.
2
Atlas Physical and Hand Therapy, Atlas Womens Health
Physical Therapy, Eugene, Oregon.
3
College of Pharmacy and Health Sciences, Campbell
University, Buies Creek, North Carolina.
The primary investigator supplied private funding.
The authors declare no institutional funding or conicts of
interest.
DOI: 10.1097/JWH.0000000000000005
Effect of Variations in Forced Expiration
Effort on Pelvic Floor Activation
in Asymptomatic Women
Lenore J. Kitani , PT, ScD
1

Gail G. Apte , PT, ScD
2

Gregory S. Dedrick , PT, ScD
3

Phillip S. Sizer , PT, PhD
1

Jean-Michel Brisme , PT, ScD
1

expiration. Minimum effort of forced expiration created
the most consistent PF displacement in a cranial-ventral
direction.
Conclusions: Minimal forced expiration effort resulted in
the most consistent PF cranial-ventral displacement with
vaginal squeeze pressure. These ndings provide basic
science information on PF activation applicable to PF train-
ing programs.
Key Words: pelvic oor , rehabilitation , respiration
JWHPT-D-13-00012.indd 19 3/18/14 10:01 PM
20 Volume 38 Number 1 January/April 2014
Research Report
Copyright 2014 Section on Womens Health, American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
Automatic PF activation patterns have been
measured with electromyography (EMG).
2

,

15

,

16
Electromyography, however, does not quantify the
functional squeezing pressure of the PF, nor does
it qualify the direction of PF displacement during
muscle activation. Pelvic oor closing forces are mea-
sured as a vaginal squeeze pressure, with manometry
or perineometry demonstrating reliability appropriate
for clinical research.
17-21

Ultrasound imaging (USI) has gained popularity
as a relatively inexpensive and clinically accessible
method for assessing the PF muscle activity and posi-
tion.
22-24
It provides information on PF displacement,
represented by changes in the position of the bladder
base (transabdominal USI) or bladder neck (trans-
perineal [TP] USI) during a Valsalva maneuver
25-27
or volitional PF contraction.
22

,

23

,

25

,

28-30
Together,
squeeze pressure and displacement are measures that
offer qualitative and quantitative information on the
functional aspects of PF activation.
6,7,9

,

31-36

In PF rehabilitation programs, a volitional contrac-
tion of the PF muscles can be taught with expiration,
based on the understanding that expiration facilitates
PF muscle activation and cranial displacement. A
more forceful expiration results in even greater cra-
nial displacement than quiet expiration, as well as
greater PF EMG activity.
12

,

13
However, forced expira-
tion additionally results in increases in IAP with max-
imum forced expiration against a closed glottis, or
Valsalva maneuver, resulting in PF descent and pos-
sible disruption of continence mechanisms.
3

,

13

,

25-27

,

37
Although forced expiration facilitates PF activation, it
is still unknown how the PF automatically responds
to gradations of forced expirations. Specically, no
investigator to date has measured automatic activa-
tion of the PF muscles as squeeze pressure and PF
displacement using TP USI to a standardized varia-
tion in forced expiration effort. It was hypothesized
that minimum and moderate forced expiration efforts
would result in facilitation of automatic PF muscle
squeeze pressure and lift. Therefore, the purpose of
this study was to quantify automatic PF activation
measured as PF squeeze pressure and PF displace-
ment, in response to variations in forced expiration
effort in healthy, nulliparous women.
METHODS AND MEASURES
Participants
Using a quasiexperimental repeated-measures design,
a convenience sample of 26 young (age 18-35 years),
nulliparous, premenopausal women was recruited.
Exclusion criteria included atypical PF muscle activity
(caudal descent during a PF maximum volitional con-
traction [MVC]), pregnancy, history of lower back
or pelvic pain and/or surgical procedures, urinary
incontinence, history of PF dysfunction (bowel incon-
tinence, pelvic pain, prolapse), diabetes, endometrio-
sis, and neuromuscular or connective tissue disease.
Urinary continence status was assessed using
the International Consultation on Incontinence
Questionnaire (ICIQ). This questionnaire was chosen
for its brevity and reliability.
38
Participants scoring
more than zero on questions 1 and 2 on the ICIQ
were excluded.
The study was approved by the local univer-
sity institutional review board. Informed consent was
obtained for each subject. Medical history and demo-
graphic information included age, weight, height, and
questions specic to exclusionary medical conditions.
Instrumentation
A breathing device was used to create forced expira-
tion using a Portex EzPAP positive airway pressure
system, with a breathing lter attached to ensure no
contamination between subjects (Smiths Medical
ASD, Inc, Keene, New Hampshire). The device was
modied by interchangeable tubes of differing length
that provided 3 variations in resistancemeasured
in a laboratory with spirometryat a constant ow
rate. The ow rate was set at a level that would allow
5-second expiration for clinical testing.
Expiration pressure was measured in centimeters
of water (cm H
2
O) by a manometer attached to the
Portex EzPAP device and was used as an indication
of effort (Instrumentation Industries, Inc, Bethel
Park, Pennsylvania). The manometer measured pres-
sure up to a maximum of 120 cm H
2
O in increments
of 4 cm. There was a resettable pointer on the dial
that was used to set the target pressure for each
condition.
To standardize the maximum forced expiration
effort for individual participants, each was instructed
to breathe out as forcefully as possible, get to your
most forceful breathing out as quickly as possible,
and continue to breathe out at this force for 5 sec-
onds. Participants practiced until they were able
to perform a sustained maximum forced expiration
effort for 5 seconds 3 times in a row. The mean of
the 3 trials was used for each participants maximum
forced expiration effort. Minimum and moderate
efforts were then calculated as 33% and 66% of each
subjects maximum effort, respectively. To practice
moderate and minimum forced expiration efforts, the
investigator set the pointer on the manometer to the
desired effort. Both the participant and the investiga-
tor visualized the manometer to ensure expiration at
the appropriate effort. Participants were instructed to
stay within 1 tick mark above and below the desired
effort, which was 8 cm H
2
O of variability. The inves-
tigator also monitored and cued participants on the
5-second expiration duration.
JWHPT-D-13-00012.indd 20 3/18/14 10:01 PM
Journal of Womens Health Physical Therapy 21
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Copyright 2014 Section on Womens Health, American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
investigator 1 was caudal to participants, instruct-
ing and assessing proper PF MVC performance
and recording the perineometer and USI measure-
ments. Investigator 2 was cranial to the participants,
instructing the expirations, monitoring expiration
effort, and monitoring and cueing the 5-second timer.
After consent was collected, bladder volume was
standardized as detailed. Weight, height, and medical
history were then taken. Participants were familiarized
with instrumentation and then investigator 2 instruct-
ed maximum forced expiration effort. Moderate
and minimum expiration efforts were calculated as
detailed. Participants practiced the 3 variations of
forced expiration until they were able to consistently
expire at each desired effort for 5 seconds. Then, they
were asked to undress from the waist down and lay
down in the testing position.
Pelvic oor MVC was then instructed as squeeze
the PF muscles as if you were trying to close all
your openings, and lift the PF toward the top of
your head. Visual and palpatory assessments were
performed to ensure that no accessory muscles were
used and no motions through the lumbopelvic area
or thorax were performed during PF contraction.
Investigator 1 ensured that there was no gross caudal
descent of the PF by palpation assessment using the
dorsum of the hand. Participants were allowed to
practice PF MVC until they were able to adequately
perform the contraction as indicated by visual and
palpation assessment.
Data Collection: PF Squeeze Pressure
For standardization purposes, vaginal squeeze pres-
sure was rst taken at rest and during a PF MVC.
Pelvic oor MVCs were held for 5 seconds, and the
peak pressure was recorded. Consecutive readings
were taken 3 times at rest and then 3 times during a
PF MVC, with a 30-second rest after each PF MVC.
Participants were then instructed to exhale at
their maximum, moderate, and minimum forced
expiration efforts in a randomized order. Participants
performed 3 trials each of maximum, moderate,
and minimum forced expiration efforts (a total of 9
trials), and no instruction was given on whether to
relax or squeeze the PF during the forced expiration.
Expirations were 5 seconds in duration, and the rest-
ing and peak vaginal squeeze pressures were recorded
during each expiration. There was a 30-second rest
between each 5-second expiration.
Data Collection: PF Position
Pelvic oor position data were taken after PF squeeze
pressure data collection was completed. For exclusion
and reliability purposes, the PF position was taken at
rest and during a PF MVC, using the on-off method
described earlier. Pelvic oor MVCs were held for
The squeeze pressure of the PF muscles was mea-
sured using a Peritron 9300A perineometer with
a silicone vaginal sensor probe (Cardio Design Pty
Ltd, Lara, Victoria, Australia). This manometer has
demonstrated good test-retest
17
and intra-
18
and
interrater
20
reliability in clinical studies. The sensor
probe with a protective covering and a small amount
of gel was inserted in the vagina by the subject to
a standardized depth of 7 cm. According to the
manufacturer, the optional ination of the vaginal
sensor probe decreases the sensitivity of the sensors
response, so the sensor was used uninated.
Pelvic oor position was measured by 2-dimensional
TP B-mode USI using MyLab25 (Biosound Esaote,
Indianapolis, Indiana) with a 2.5- to 5-MHz curvilin-
ear transducer (CA621). The transducer was applied
translabially in the sagittal plane according to the
method of Schaer et al
37
to capture an image of the
bladder, bladder neck, urethrovesical junction, and
pubic symphysis.
For USI, the intrarater reliability to reproduce a con-
sistent image for each participant was analyzed by using
the on-off method. Three images each were taken of
the PF at rest and during an MVC for 22 participants.
The transducer was displaced and replaced on the PF
between each image. The same 6 images of each par-
ticipant were taken again by the same rater using the
same method, at least 24 hours later. The images were
analyzed using the coordinate system (described in the
Data Reduction section) at a later time.
The intrarater reliability to consistently locate the
urethrovesical junction using the coordinate system
(described in the Data Reduction section) on the
ultrasound image was analyzed by 1 rater locating
the structure 5 times each on 10 randomly selected
images. The structure was located again on the same
10 images, 5 times each, by the same rater at least
24 hours later.
Bladder Volume Standardization
Bladder volume was standardized by asking par-
ticipants to void their bladder and then drink 24
ounces of water. Approximately 20 minutes passed
between drinking 24 ounces of water and the USI
data collection.
Testing Position
All procedures were performed with the participant
in the supine position with hips exed to 60 , knees
exed, and a 2-inch towel roll placed under the par-
ticipants lumbar spine to provide support and allow
for mild lordosis during testing.
18

,

22

,

29

,

39

Testing Sequence and Data Collection
The same 2 female investigators instructed par-
ticipants and collected data. During data collection,
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22 Volume 38 Number 1 January/April 2014
Research Report
Copyright 2014 Section on Womens Health, American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
5 seconds. The PF position was recorded consecu-
tively 3 times at rest and then 3 times on the third
second of a PF MVC. There was a 30-second rest
after each PF MVC.
Participants were then instructed to exhale at
their maximum, moderate, and minimum forced
expiration efforts in a randomized order. Participants
performed 3 trials each of maximum, moderate, and
minimum forced expiration efforts (a total of 9 trials),
and no instruction was given on whether to relax or
squeeze the PF during forced expiration. Expirations
were 5 seconds in duration, and the PF position was
recorded on the third second of each expiration.
There was a 30-second rest between each 5-second
expiration.
For the reliability study, participants were asked
to return at least 24 hours later. Investigator 1 took
6 images of the PF position, using the on-off method
described earlier. Pelvic oor MVCs were held for
5 seconds. The PF position was recorded consecutive-
ly at rest and then on the third second of a PF MVC,
with a 30-second rest after each PF MVC.
Data Reduction
For TP USI, the pubic symphysis was localized and
a coordinate system was created with the x -axis fol-
lowing the central axis of the pubic symphysis and the
y -axis at the caudal-inferior tip of the pubic symphysis
and perpendicular to the x -axis
28

,

37
( Figure 1 ). The
bladder neck was located at the proximal ventral
urethrovesical junction. Resting position was estab-
lished as x
1
, y
1
and end position as x
2
, y
2
. Change in
the bladder neck position was calculated as follows:
(1) horizontal displacement in a dorsal-ventral
direction ( x
1
x
2
); (2) vertical displacement in a cra-
nial-caudal direction ( y
1
y
2
); and (3) a total change
in bladder neck position calculated as vector length a
( a = b
2
+ c
2
, b = y
1
y
2
, c = x
1
x
2
).
28

,

37

Using this coordinate system, negative values in the
horizontal plane denoted PF displacement in the ven-
tral direction, whereas positive values indicated dor-
sal displacement. In the vertical plane, negative val-
ues indicated cranial displacement whereas positive
values indicated caudal displacement. The vertical
and horizontal positions of the PF were calculated as
the average of the 3 trials. The distance function on
MyLabDesk program and a manual protractor were
used to draw the coordinate system directly onto the
ultrasound image after data collection. Investigator
1 performed all data reduction while blinded to the
expiration effort condition.
Data Analysis
The following descriptive statistics (means, standard
deviations, and minimum and maximum values)
were recorded for each participant: (1) age; (2) body
mass index; (3) maximum expiration effort; (4)
vaginal squeeze pressures during PF MVC; (5) vaginal
squeeze pressures during the 3 variations in forced
expiration effort; (6) direction of PF displacement
during PF MVC and the 3 variations in forced expi-
ration effort; and (7) magnitude of PF displacement
during PF MVC and the 3 variations in forced expira-
tion effort.
Inferential statistics were conducted using the SPSS
statistical software (version 15.0, SPSS, Inc, Chicago,
Illinois). Intraclass correlation coefcient (ICC 3,3)
was used to assess intrarater reliability to reproduce
Figure 1. Coordinate system of measurement. Ultrasound image (A). Representation of ultrasound image (B). Each image is
labeled with the following: x , horizontal axis following the central axis of the pubic symphysis; y , vertical axis perpendicular
to horizontal axis at the caudal-dorsal tip of the pubic symphysis; a, pubic symphysis; b, bladder; c, bladder neck; and d,
proximal ventral urethrovesical junction. Horizontal position is distance from d to y. Vertical position is distance from d to x.
JWHPT-D-13-00012.indd 22 3/18/14 10:01 PM
Journal of Womens Health Physical Therapy 23
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Copyright 2014 Section on Womens Health, American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
were analyzed ( Figure 2 ). Participants took 6 to 11
trials to consistently expire at their maximum effort
for a 5-second duration. Moderate and minimum
expiration efforts were achieved in 1 to 2 practice
trials. Maximum expiration effort was 45.0 11.7
(24-67) cm H
2
O. Each subject remained within 8 cm
H
2
O with respect to her target expiration effort for
each trial per the manometer.
Intrarater reliability to consistently locate the ure-
throvesical junction using the coordinate system (ICC
3,5) was 0.99 (95% condence interval [CI] = 0.97-
1.00) in the horizontal plane and 1.00 (95% CI =
1.00-1.00) in the vertical plane. Intraclass correlation
(ICC 3,3) of intrarater reliability to reproduce the
same PF TP ultrasound image on each subject was
0.93 (95% CI = 0.86-0.97) in the horizontal plane
and 0.84 (95% CI = 0.68-0.92) in the vertical plane.
Descriptive statistical results for squeeze pres-
sure (perineometry), PF displacement direction (USI),
and mean PF displacement magnitude (USI) during
MVC and 3 conditions of forced expiration efforts
are summarized in Table 1 . A PF MVC produced
a mean squeeze pressure of 46.2 16.8 cm H
2
O,
wherein 100% of the participants displaced the PF
in a cranial-ventral direction. A PF MVC resulted in
a mean horizontal displacement of 0.60 0.33 cm
ventrally and a mean vertical displacement of 0.20
0.15 cm cranially.
the same ultrasound image on each subject. Intraclass
correlation coefcient (ICC 3,5) was used to assess
intrarater reliability to produce consistent measure-
ments using the coordinate system. A
2
test was
used to analyze the frequency distribution of direction
of PF displacement during the variations of forced
expiration effort. Alpha adjustments were made
using the multiplicative correction for 3 pairwise
comparisons to maintain a family-wise level of
.0167. Because the sample size was small and the data
did not meet parametric assumptions, 2 Friedman
1-factor repeated-measures analyses of variance for
ranked data were used to compare (1) differences in
PF squeeze pressure and (2) differences in magnitude
of PF displacement during variable expiration efforts.
Wilcoxon signed rank tests with a Bonferroni correc-
tion ( = .0167) were used post hoc to locate signi-
cant differences.
RESULTS
Of the 26 women recruited, 4 were excluded because
they did not meet the urinary continence criteria per
the ICIQ. After data reduction, 4 more participants
were excluded because they produced an atypical
caudal displacement of the PF during an MVC.
3

,

9

,

36

,

40
The data of 18 women aged 24.9 2.5 (21-30) years
and body mass index 22.3 2.3 (18.2-26.6) kg/m
2
Figure 2. Study owchart. Abbreviations: PF, pelvic oor; USI, ultrasound imaging.
JWHPT-D-13-00012.indd 23 3/18/14 10:01 PM
24 Volume 38 Number 1 January/April 2014
Research Report
Copyright 2014 Section on Womens Health, American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
variations, there was a signicant difference between
minimum versus maximum ( P < 0.001) and moderate
versus maximum ( P = 0.006) conditions. There was
no signicant difference in horizontal displacement
between minimum and moderate efforts ( Table 2 ).
Pelvic oor ventral displacement occurred most often
during minimum effort (94.4% of participants), fol-
lowed by moderate (61.1% of participants) and maxi-
mum forced expiration efforts (16.7% of participants)
( Table 1 ). In the vertical plane , PF cranial displacement
occurred in 61.1% of participants during minimum
forced expiration versus 33.3% and 22.2% for mod-
erate and maximum forced expiration efforts, respec-
tively ( Table 1 ), which were not signicant ( Table 2 ).
When comparing PF displacement in the cranial-
ventral versus not cranial-ventral direction, minimum
forced expiration effort produced a signicantly
greater frequency of cranial-ventral displacement
than moderate ( P = .002) and maximum forced expi-
ration efforts ( P < .001). There was no signicant
difference in the frequency of cranial-ventral displace-
ment when comparing moderate versus maximum
expiration effort ( Table 2 ). Minimum forced expira-
tion effort produced cranial-ventral PF displacement
in 55.6% of the participants compared with moder-
ate (22.2%) and maximum forced expiration efforts
(5.6%) ( Table 1 ). Maximum forced expiration effort
resulted in a large percentage of participants (66.7%)
displacing the PF in a caudal-dorsal direction.
Vaginal Squeeze Pressure
When comparing vaginal squeeze pressure measure-
ments, there was a signicant difference between all 3
expiration conditions ( P < .001) ( Table 2 ). Maximum
forced expiration effort demonstrated the highest
mean squeeze pressure (12.4 7.9 cm H
2
O), whereas
moderate and minimum efforts were 7.57 5.02 and
3.67 2.84 cm H
2
O, respectively ( Table 1 ).
PF Displacement: Magnitude
When comparing PF displacement magnitude in the
horizontal plane , the 3 expiration efforts produced
signicantly different mean displacements ( P < .001)
( Table 2 ). Maximum forced expiration produced
the greatest mean displacement of 0.23 0.34 cm.
Minimum and moderate forced expiration efforts
produced mean displacements of 0.15 0.23 and
0.09 0.35 cm, respectively ( Table 1 ).
There was also a signicant difference in PF dis-
placement magnitude in the vertical plane between all
3 expiration efforts ( Table 2 ). Maximum forced expi-
ration again produced the greatest mean displacement
of 0.27 0.29 cm. Minimum and moderate expiration
efforts produced a mean displacement of 0.03
0.13 and 0.08 0.20 cm, respectively ( Table 1 ).
PF Displacement: Direction
When comparing the displacement direction in the
horizontal plane produced by the 3 forced expiration
Table 1. Squeeze Pressure (Perineometry), Direction, and Magnitude of Pelvic Floor (PF) Displacement (USI) During PF Maximum
Voluntary Contraction (MVC), Minimum, Moderate, and Maximum Expiration Efforts
MVC,
Mean SD (Range)
Minimum,
Mean SD (Range)
Moderate,
Mean SD (Range)
Maximum,
Mean SD (Range)
Perineometry (pressure in cm of H
2
O), Mean SD
(Range)
46.21 16.75
(15.4-76.4)
3.67 2.84
(0.68-10.70)
7.57 5.02
(3.37-19.98)
12.35 7.90
(3.65-29.82)
USI (PF horizontal displacement, magnitude in cm)
( ) = ventral, Mean SD (Range)
( + ) = dorsal, Mean SD (Range)
0.60 0.33
( 0.09 to 1.31)
0.15 0.23
( 0.49 to 0.57)
0.09 0.35
( 0.32 to 1.01)
0.23 0.34
( 0.20 to 1.34)
USI (PF horizontal displacement, direction), % 100% ventral 94.4% ventral 61.1% ventral 16.7% ventral
USI (PF vertical displacement, magnitude in cm)
( ) = cranial, Mean SD (Range)
( + ) = caudal, Mean SD (Range)
0.20 0.15
( 0.02 to 0.64)
0.03 0.13
( 0.24 to 0.20)
0.08 0.20
( 0.31 to 0.48)
0.27 0.29
( 0.16 to 0.98)
USI (PF vertical displacement, direction), % 100.0% cranial 61.1% cranial 33.3% cranial 22.2% cranial
USI (overall PF displacement, magnitude in cm),
Mean SD (Range)
0.66 0.32
(0.19-1.39)
0.29 0.12
(0.14-0.57)
0.36 0.24
(0.17-1.06)
0.47 0.35
(0.14-1.66)
USI (overall PF displacement, direction), % 100.0% CRV
55.6% CRV 22.2% CRV 5.6% CRV
38.9% CV 38.9% CV 11.1% CV
5.6% CRD 27.8% CD 66.7% CD
11.1% CRD 16.7% CRD
Abbreviations: CD, caudal-dorsal; CRD, cranial-dorsal; CRV, cranial-ventral; CV, caudal-ventral; MVC, maximum voluntary contraction.
JWHPT-D-13-00012.indd 24 3/18/14 10:01 PM
Journal of Womens Health Physical Therapy 25
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Copyright 2014 Section on Womens Health, American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
However, these investigators did not incorporate a
standardized forceful expiration. Neumann and Gill
13
measured the PF response using surface EMG dur-
ing a standardized forced expiration of 40 mm Hg
(54.4 cm H
2
O) and observed a PF muscle response at
57% of maximum activation. They did not objectify
the displacement of the PF during forced expiration,
so it is impossible to know whether the increased
EMG activity was concurrent with PF descent or
ascent. Their forced expiration value was higher
than the mean value of maximum forced expiration
effort produced by our participants. These authors
found a minimal increase in IAP during isolated PF
and abdominal contractions (6-9 mm Hg) whereas
forced expiration produced a 36-mm Hg increase
in IAP. In concert with their ndings, there was
likely an increase in IAP in our participants during the
maximum and moderate forced expiration efforts,
which appeared true on the basis of PF displacement
recorded in our study. Maximum forced expiration
effort predominantly led to a caudal-dorsal displace-
ment (66.7%), whereas minimum forced expiration
effort predominantly resulted in a cranial-ventral
PF displacement. At the minimum forced expiration
effort, participants were most likely to demonstrate
an automatic PF muscle activation that may have
resisted the effort of forced expiration, leading to PF
displacement in the ventral (94.4%), cranial (61.1%),
and cranial-ventral (55.6%) directions.
Vaginal squeeze pressure is 1 of 2 important PF
mechanisms that create continence.
3

,

8
Most inves-
tigators have demonstrated a signicant difference
between participants with stress urinary incontinence
(SUI) and controls in resting vaginal closing pres-
sure,
33

,

41
maximum closing pressure,
33

,

42
and PF
muscle endurance.
41
Our ndings showed signicant
increases in vaginal squeeze pressure as effort of
forced expiration increased. However, intravaginal
pressure measurements can be affected by increases in
IAP.
43

,

44
Because many of our participants depressed
the PF in a caudal-dorsal direction, especially during
maximum (66.7%) and moderate (27.8%) forced
expiration efforts, there is an assumption of signi-
cantly increased IAP. We hypothesized that minimum
and moderate forced expiration efforts would result
in facilitation of automatic PF muscle squeeze pres-
sure and lift. Because so many participants depressed
the PF during the moderate and maximum efforts,
the vaginal squeeze pressure data had little descrip-
tive value in these expiration conditions. For this
reason, also, vaginal squeeze pressure in all expiration
conditions was expressed as raw data, rather than a
standardized percentage of each participants MVC.
Knowledge of basic and applied physiology of PF
muscle activation is valuable in PF training programs,
which have strong support in the literature as an
COMMENT
In this preliminary investigation, PF squeeze pres-
sure and displacement in response to a standardized
variation in forced expiration effort were measured.
Because we were interested in gaining normative data
on these measures, we used an asymptomatic popu-
lation that had no indication of atypical PF muscle
activation during an MVC.
Overall, a cranial-ventral PF displacement was
observed most often during minimum forced expi-
ration effort. It supports the use of minimum
forced expiration effort during PF training pro-
grams aimed at enhancing PF displacement in an
optimal and protective direction. The use of such
strategy should rst be evaluated using PF palpation
or USI, as 45% of the participants did not display
a cranial-ventral PF displacement during minimum
forced expiration effort.
Talasz et al
12
reported a PF cranial displacement
(0.51 0.47 cm) in response to forceful expiration.
Table 2. Comparisons of Squeeze Pressure, Direction of Pelvic
Floor (PF) Displacement, and Magnitude of PF Displacement by
Expiratory Efforts

2
df Z-value P-value
Squeeze pressure
a

Min vs mod
b

Min vs max
b

Mod vs max
b

30.333

3.636
3.724
3.463
< .001 *
< .001 *
< .001 *
.001 *
Direction of PF displacement
c

Min vs mod (Hor)
Min vs max (Hor)
Mod vs max (Hor)
Min vs mod (Vert)
Min vs max (Vert)
Mod vs max (Vert)

4.018
d

22.050
7.481
2.786
5.600
0.554

1
1
1
1
1
1

.045
< .001 *
.006 *
.095
.018
.457
Direction of PF displacement
c

Min vs mod (CV vs not CV)
Min vs max (CV vs not CV)
Mod vs max (CV vs not CV)

9.402
17.577
0.929
d

1
1
1

.002 *
< .001 *
.335
Magnitude of PF displacement
(Hor)
a

Min vs mod (Hor)
b

Min vs max (Hor)
b

Mod vs max (Hor)
b

21.778

3.332
3.680
2.722
< .001 *
.001 *
< .001*
.006*
Magnitude of PF displacement
(Vert)
a

Min vs mod (Vert)
b

Min vs max (Vert)
b

Mod vs max (Vert)
b

23.408

2.635
3.724
3.053
< .001 *
.008 *
< .001 *
.002 *
Abbreviations: CV, cranial-ventral; Hor, horizontal; max, maximum;
min, minimum; mod, moderate; Vert, vertical.

a
Friedman 1-way analysis of variance by ranks.

b
Wilcoxon signed rank test post hoc with Bonferroni adjustment.

c

2
test.

d
With Yates correction.
*Statistically signicant.
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26 Volume 38 Number 1 January/April 2014
Research Report
Copyright 2014 Section on Womens Health, American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
activation, so we did not believe that their automatic
PF activation would provide normative data.
Because this was an investigation of asymptomatic
women, it lacks generalizability to other populations
and provides limited information on rehabilitation
applications to symptomatic populations. Further
investigations with larger sample sizes and using
symptomatic individuals are needed.
Intra-abdominal pressure was not monitored or
measured because it was beyond the scope of this
study. On the basis of the ndings of this preliminary
investigation, further studies are warranted to objec-
tify therapeutic levels of forced expiration with IAP
quantication in symptomatic populations.
CONCLUSION
Forced expiration resulted in PF activation. Minimal
forced expiration effort resulted in the most consis-
tent cranial-ventral displacement with vaginal closing
pressure of the PF. This provides important clinical
information on the use of forced expiration in PF
training programs.
ACKNOWLEDGMENTS
The authors thank Texas Tech University Health
Sciences Center for providing equipment and labora-
tory space for the completion of data collection for
this study.
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SUI. Investigations have demonstrated improvements
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45-51
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45

,

46

,

52
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training program participants. The mechanism of
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34

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atic populations.
Methodological Considerations
We used a small, convenience sample of women
because of the invasive component of this study. In
addition, we excluded 18% of our participants (4/22)
because they were unable to demonstrate typical
PF activation during an MVC. This exclusion was
justied because we were interested in automatic PF
activation in a normal population that demonstrated
typical PF activity. Participants who demonstrated
PF caudal displacement during a volitional contrac-
tion were already outside the limits of typical PF
JWHPT-D-13-00012.indd 26 3/18/14 10:01 PM
Journal of Womens Health Physical Therapy 27
Research Report
Copyright 2014 Section on Womens Health, American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
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