Ijerph 19 11073

International Journal of
Environmental Research
and Public Health
Protocol
Effect of Pelvic Floor Workout on Pelvic Floor Muscle Function
Recovery of Postpartum Women: Protocol for a Randomized
Controlled Trial
Hongmei Zhu 1,2,3 , Di Zhang 1,3 , Lei Gao 1,3 , Huixin Liu 1,3 , Yonghui Di 2 , Bing Xie 1,3 , Wei Jiao 2, *,†
and Xiuli Sun 1,3, *,†
1 Department of Obstetrics and Gynecology, Peking University People’s Hospital, No. 11,
Xi-Zhi-Men South Street, Xi Cheng District, Beijing 100044, China
2 Department of Sports medicine and rehabilitation, Beijing Sports University, No.48, Xin Xi Road,
Hai Dian District, Beijing 100084, China
3 The Key Laboratory of Female Pelvic Floor Disorders, Beijing 100044, China
* Correspondence: jiaowei@bsu.edu.cn (W.J.); sunxiuli@pkuph.edu.cn (X.S.)
† These authors contributed equally to this work.
Abstract: Background: There is a risk of pelvic floor dysfunction (PFD) from baby delivery. Many
clinical guidelines recommend pelvic floor muscle training (PFMT) as the conservative treatment for
PFD because pelvic floor muscles (PFMs) play a crucial role in development of PFD. However, there
is disagreement about the method and intensity of PFM training and the relevant measurements.
To pilot the study in PFM training, we designed a Pelvic Floor Workout (PEFLOW) for women to
Citation: Zhu, H.; Zhang, D.; Gao, L.; train their pelvic through entire body exercises, and we planned a trial to evaluate its effectiveness
Liu, H.; Di, Y.; Xie, B.; Jiao, W.; Sun, X. through comparing the outcomes from a group of postpartum women who perform PELFLOW at
Effect of Pelvic Floor Workout on home under professional guidance online with the control group. Methods/design: The randomized
Pelvic Floor Muscle Function controlled trial was projected to be conducted from November 2021 to March 2023. A total of
Recovery of Postpartum Women:
260 postpartum women would be recruited from the obstetrics departments of the study hospital
Protocol for a Randomized
and women would be eligible for participation randomized into experimental or control groups
Controlled Trial. Int. J. Environ. Res.
(EG/CG) if their PFM strength are scaled by less than Modified Oxford grading Scale (MOS) to be less
Public Health 2022, 19, 11073.
than grade 3. Women in EG would perform a 12-week PEFLOW online under the supervision and
https://doi.org/10.3390/
ijerph191711073
guidance of a physiotherapist, while women in CG would have no interventions. Assessments would
be conducted at enrollment, post intervention (for EG) or 18th to 24th week postpartum (for CG), and
Academic Editors: Milan Terzic,
1 year postpartum. Assessment would be performed in terms of pelvic floor symptoms, including
Antonio Simone Laganà,
MOS, cough stress test, urinary leakage symptoms, pelvic organ prolapse quantitation (POP-Q), and
Antonio Sarria-Santamera and
vaginal relaxation, clinic examinations including Pelvic floor electrophysiological test, Pelvic floor
Ugo Indraccolo
ultrasound and Spine X-ray, overall body test including trunk endurance test, handgrip test, body
Received: 6 July 2022 composition test, and questionnaires including International Physical Activity Questionnaire Score-
Accepted: 2 September 2022 Short Form(IPAQ-SF), Pelvic Floor Distress Inventory Questionnaire-20 (PFDI-20), Pelvic Floor Impact
Published: 4 September 2022
Questionnaire-7 (PFIQ-7), the 6-item Female Sexual Function Index (FSFI-6), and the Pittsburgh Sleep
Publisher’s Note: MDPI stays neutral Quality Index (PSQI). Primary analysis will be performed to test our main hypothesis that PEFLOW
with regard to jurisdictional claims in is effective with respect to strengthen PFM strength. Discussion: This trial will demonstrate that
published maps and institutional affil- pelvic floor-care is accessible to most women and clinical practice on PFD may change relevantly
iations. should this study find that Online PEFLOW approach is effective to improve PFMs. Trial registration:
ClinicalTrials.gov, NCT05218239.
Keywords: pelvic floor muscle training; pelvic floor workout; pelvic floor muscle; pelvic floor
Copyright: © 2022 by the authors.
dysfunction; postpartum; rehabilitation
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
1. Introduction/Background
creativecommons.org/licenses/by/ Pelvic floor dysfunction (PFD) is a series of symptoms of dysfunction caused by
4.0/). injuries on pelvic floor muscle, nerve, ligament, and fascia injury. PFD has a serious
Int. J. Environ. Res. Public Health 2022, 19, 11073. https://doi.org/10.3390/ijerph191711073 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2022, 19, 11073 2 of 14
negative impact on the common life of woman, who would experience different degrees of
urinary incontinence, pelvic organ prolapse, chronic pelvic pain, sexual dysfunction, etc.
Although not clinically emergent, PFD brings a heavy economic burden to the women
who suffers from this problem. The latest updated data show that the prevalence of
urinary incontinence in Chinese women reaches 30.9%, the incidence of symptomatic
pelvic organ prolapse is up to 9.6% [1], and the prevalence of sexual dysfunction is
about 29.7% [2]. Pelvic floor diseases are more prevalent among women who have
multiple births.
Pregnancy and vaginal delivery have independently been proved to be the risk factors
for the development of severe urinary incontinent (SUI) as they could obviously weaken
the pelvic floor muscle (PFM) strength. However, it was hard to evaluate patients’ muscle
strength objectively; therefore, it was hard to validate whether a measure could be effective
to have the weakened pelvic floor muscles be recovered before Modified Oxford scale
(MOS) for muscle strength was published [3]. MOS provides quantitative scales for muscle
strength, and it is simple and easy to apply clinically. It is becoming widely accepted
method for pelvic floor muscle strength assessment since it was published. Literately and
clinically, MOS 4 and 5 is identified as having “good” or “strong” muscle contraction which
represents a normal condition of the pelvic floor muscles; relevantly MOS ≤3 indicates a
weak contraction or no contraction being felt [4]. Some studies suggested that pelvic floor
muscle strength be correlated with the incidence of pelvic organ prolapse (POP). Thus,
Pelvic Organ Prolapse Quantification (POP-Q) was developed for evaluation of the pelvic
floor muscle [5]. Borello-France et al. [6] used POP-Q to evaluated women’s pelvic floor
muscle in their studies and argued that women with stage II of prolapse were better than
those with stage III or IV in elevating their pelvic floor, and also would be easier to get
benefit from PFM training than those over stage III. Scientific evidence showed that 10–20%
of patients who were not intervened for the clinically confirmed POP got progressed in
term of POP-Q scoring in 2-year follow-up [7,8], so early prevention or treatment should
have high priority. The incidence rate of POP is higher in middle aged and elderly women.
PFM training is recommended to women postpartum for it reduces the incidence of PFD
during 6–12 months postpartum [9] and should possibly reducing the incidence of diseases
from muscle dysfunction related to the anatomical changes with aging [10]. A program of
supervised PFM training was recommended as a first option for women with symptomatic
POP-Q stage I or stage II [11]. MOS and POP-Q can be the objective indicators be used to
validate the effectiveness of any measure in improving PFM.
PFM training is the most popular conservative intervention for PFD. Its role in PFM
improvement is becoming more and more important along with the rapid development of
rehabilitation medicine and it is more and more acceptable by women as their requirements
for improvement of quality of life are getting stronger. There are many kinds of programs
for post-delivery exercises that are commercially available for women. Formulating a
rehabilitation program after childbirth is certainly an effective strategy for most women
to benefit from the post-delivery recovery. However, PFM rehabilitation relied on the
synchronous recovery of both type I and type II muscle fibers, and, as it is difficult to
identify type I and type II of the muscle fibers accurately by nonprofessionals during
pelvic floor muscle contraction, exercises are usually not properly programmed, and
the effectiveness of such programs are not easy to gain. Formulating a science-based
rehabilitation program that can trained type I and type II muscle fibers for their synchronous
rehabilitation after childbirth is certainly an effective strategy for most women to benefit
from the post-delivery recovery.
Many pelvic floor rehabilitation methods were explored in previous studies. In 1948,
Kegel training was first proposed and adopted as the gold standard of pelvic floor muscle
training (PFMT) [12]. PFMT refers to the conscious exercise via autonomic contraction
of the pelvic floor muscles that are dominated by pubococcinate muscles. The American
Urogynecologic Society evaluated PFMT as the wisest exercise choice for women and
recommended it as the first-line treatment for PFD [13]. Kegel exercise has rarely been
used alone until now. The human body is an organic whole, so PFMT should not be
limited to the local pelvic floor. In 1980, abdominal hypopressive technique (AHT) [14] was
invented. It emphasizes PFMT to be combined with activation of transverse abdominis
muscle and diaphragmatic breathing [14]. Some studies found that training of the core
muscles, including rectus abdominis, transversus abdominis, internal or external oblique,
lumbar multifidus, and erector spinae muscles [15] for their stability, such as Yoga exercises,
can strengthen PFM [16,17]. A French therapist, Philippe, proposed a concept of Global
Postural Re-education (GPR) [18,19] and demonstrated that GPR was advantageous in
improving respiratory muscle strength and reducing urinary incontinence since GPR
was projected to correct postural misalignments by stretching the muscle chains [19]. In
consideration that the spine is a continuous boney structure that is closely associated with
pelvic dynamics [20], some investigators in recent years focused their research on restoring
the balance of anatomic mechanical systems through adjustment of the posture. It was
found that therapeutic exercise on posture adjustment (diaphragm and lumbar position)
for patients with poor respiration and posture can improve the neuromuscular control
on muscles of deep abdomen, diaphragm, and pelvic floor, and promote the stability of
lumbar and pelvic floor. In addition, a significant correlation between overall posture and
PFD was also demonstrated in several studies [20,21].
In 2020, the Canadian Society of Obstetricians and Gynecologists (SOGC) recom-
mended that, to gain effectiveness, PFMT should be performed under supervision for at
least 3 months [22]. Some previous studies [23–26] in alleviation of symptomatic ureter leak-
age demonstrated that physical exercise with PFMT was effective on the pelvic floor muscle.
In referring to the above published studies and concepts and based on the previous
study [27] of our team, our team from Peking University Peoples Hospital (PKUPH)
developed a Pelvic Floor Workout (also named as PKUPH-PEFLOW), which focuses on
training to improve the strength, endurance, flexibility, stability, and flexibility of core
muscles, including diaphragmatic, abdominal, pelvic floor, and lower back muscles. We
also designed a randomized controlled clinical trial to demonstrate the effectiveness of
PEFLOW. The trial was designed on hypothesis that (1) a 12-week Global Pelvic Floor
Workout would improve the pelvic floor muscle strength of postpartum women; (2) the
12-week Global Pelvic Floor Workout would positively impact on the overall function of
postpartum women, including pelvic floor function, body posture, pain, etc.; and (3) body
posture, physical activity level, trunk muscle endurance and strength would have beneficial
effects on maternal overall function.
2. Methods
2.1. Study Design
This is a randomized controlled trial to be conducted from November 2021 to March
2023. Participants are recruited from the obstetrics departments of Peking University
People’s Hospital. The study was approved by Peking University Institutional Re-
view Board (number: 2021PHB254-001) and registered in Clinical.Trials.gov (number:
NCT05218239).
2.2. Inclusion Criteria

Postpartum women will be eligible for enrollment if they are: (1) in 6th to 12th
week postpartum; (2) without history of clinically confirmed systematic diseases, such as
neurological conditions and cardiac insufficiency, currently not wearing cardiac pacemaker
or receiving hormone therapy, and/or not been treated with radical surgery for pelvis
and sling or surgery for prolapse before pregnancy, and with no pregnant complications;
(3) willing to participate signing informed consent form; and (4) able to read without
cognitive problem from poor education or diagnosed mental problem.
2.3. Exclusion Criteria

Participants will be excluded if they are: (1) confirmed by postpartum pelvic exam-
ination to be >grade 3 of pelvic floor muscle strength by Modified Oxford Scale (MOS);
(2) ≥stage III for Pelvic Organ Prolapse Quantification (POP-Q); (3) symptomatically con-
firmed to have severe urinary incontinence (Women with more than one incontinent episode
per day AND an important volume of urine loss [28] or urine leakage occurred in a quiet
state were classified as having severe urinary incontinence); or (4) any limb dysfunction
that unenabled women to take this training. A participant will be recorded as“ drop off
from trial” if she becomes pregnant during the follow-ups.
2.4. Site Investigators and Roles

To conduct and evaluate the project, the study should assign the following persons to
play roles: (1) a gynecologist (can be the chief investigator) who would conduct baseline
examination and evaluation for eligible women, and another two gynecologists who would
conduct examinations at the second and third follow-up visits, respectively, who was
unaware of the data from the last follow-up. The examinations would include MOS,
POP-Q, cough stress test, and vaginal relaxation.
(2) A research coordinator who is responsible for informed consent, study record and
data management, contacting with and be accompanied with the participants during the
examinations.
(3) A physiotherapist who would apply the designed intervention to participant in
experimental group (EG).
(4) A physiotherapist assistant who would be responsible for correcting actions of
EG during training and record Borg’s Rating of Perceived Exertion 6-20 (RPE) Scale after
each session of training. (5) Clinic examiners who would be responsible for pelvic floor
surface electromyography (sEMG), pelvic floor ultrasound examination, and Spine X-ray.
2.5. Randomization and Allocation Concealment

Eligible women would be randomized into two groups, the experimental group (EG)
and the control group (CG), at a ratio of 1:1. A randomization list would be created
by a statistician from Peking University for each center before the start of the research.
Randomization would be performed using SAS 9.4 (SAS Institute, Cary, NC, USA). The
randomization lists would be concealed until a woman is confirmed eligible for partic-
ipation. Then, the research coordinator in the site would assign the eligible participant
to EG or CG. With such a randomization, the numbers of participants in EG and CG are
expected to be statistically balanced. Participants and the physiotherapists engaging in the
intervention are not blind to the randomized assignment because it is not feasible to do.
However, to minimize the risk of assessor’s unblinding, participants are blind to other’s
assignments and encouraged not to discuss their treatment with the independent assessor
in the informed consent procedures and at the time of each assessment.
2.6. Assessment Schedule

Each participant would experience three assessments to go through the whole pro-
cedures in this study. The first assessment is for enrollment and would be given when
women is confirmed eligible for participation. The second assessment would be conducted
after 18th week postpartum but not later than 24th week. The final assessment would be
performed in one year after delivery (Figure 1).
Int. J. Environ. Res. Public Health 2022, 19, x FOR PEER REVIEW 5 of 14
Figure 1.1.Flowchart
Figure Flowchartofofthe
thetrial.
trial.
2.7. Interventions
2.7. Interventions
All participants in EG and CG would be undergo postpartum pelvic floor evaluation
All participants
according to standard incomical
EG andprocedures,
CG would whichbe undergo
includespostpartum
instructions pelvic floor
for PFM evaluation
strengthen-
according
ing with Kegel [12] and Knack [29] methods to improve voluntary contraction of thestrength-
to standard comical procedures, which includes instructions for PFM pelvic
ening
floorwith Kegel
muscles, [12] and
as well Knack
as daily [29]
living methods
habits to improve
and posture voluntary
education, contraction
such as of the
reducing stool
pelvic floor muscles, as well as daily living habits and posture education,
time, avoiding heavy lifting, etc. No extra intervention would be given to the participants such as reducing
stool time, avoiding heavy lifting, etc. No extra intervention would be given to the partic-
in CG.
ipants In
in addition
CG. to the clinical standard pelvic floor evaluation, participants in EG would
be In
provided
addition with
to thea Pelvic Floor
clinical Workout
standard (PEFLOW).
pelvic PEFLOW
floor evaluation, is a general
participants inprogram
EG would
for physical training of the pelvic floor via entire body
be provided with a Pelvic Floor Workout (PEFLOW). PEFLOW is a general programexercise. PEFLOW trains onfor
coordination of breathing and muscle movement, maximum contraction
physical training of the pelvic floor via entire body exercise. PEFLOW trains on coordina- of PFM, quick
contraction
tion of breathingof the
andPFM,muscle andmovement,
enduring contraction of PFM. The
maximum contraction of frequency
PFM, quickofcontraction
exercise
offollowing
the PFM,PEFLOW
and enduring is 2 sessions a week
contraction for 12The
of PFM. weeks. It should
frequency be performed
of exercise under
following PE-
the guidance of the professional physiotherapist for the whole process. It is designed
FLOW is 2 sessions a week for 12 weeks. It should be performed under the guidance of
for offline and online exercise. Due to COVID-19 pandemic prevention, PEFLOW in this
the professional physiotherapist for the whole process. It is designed for offline and online
study would be performed by the participants in EG at home under the online guidance of
exercise. Due to COVID-19 pandemic prevention, PEFLOW in this study would be per-
2 physiotherapists. In order to keep the training effective, we would conduct the training
formed by the [26]
in grouping participants
with eachinincluding
EG at home lessunder
than 10thepersons
online guidance
and ensure ofthat
2 physiotherapists.
no woman is
Inover
order to 12
than keep
weeksthe postpartum
training effective, wesession
at her first wouldofconduct
PEFLOW. the training in grouping [26]
with each
The including less than 10 personsPEFLOW
Physiotherapist-online-guided and ensure that no woman
(OG-PEFLOW) is over
would than 12 weeks
be performed by
postpartum at her first session of PEFLOW.
participants in EG twice sessions a week for 12 weeks (Figure3). OG-PEFLOW would be
The Physiotherapist-online-guided PEFLOW (OG-PEFLOW) would be performed by
participants in EG twice sessions a week for 12 weeks (Figure3). OG-PEFLOW would be
provided via Zoom and in the form of live broadcasting. To monitor the performance of
provided via Zoom and in the form of live broadcasting. To monitor the performance of the
participants, the participants would be requested to turn on the camera on their playing
devices during the whole sessional procedures; however, they would be fully informed
that no video or picture would be recorded or shot to protect their privacy. In each session
of the OG-PEFLOW, a physiotherapist would perform exercise guidance, while another
physiotherapist would monitor the performance of the participants and take notes. Details
of the PEFLOW will be published in another manuscript.
During the 12 weeks of intervention, participants in EG group would be requested
to record their training load using RPE scale [30] every time after each training session.
RPE quantitative evaluation of exercise load is calculated by “RPE score times x Exercise
duration”. RPE scale indicates the exercise intensity in a specific time and the participants’
subjective psychological response to the stimulation from the exercise loads. In addition,
Both EG and CG needs to record their training or exercise (if any) from the 6th week to
1 year postpartum. All of those records would be used for post-intervention assessment
after 12-week intervention of EG.
The PEFLOW (Tables 1 and 2) is a multimodal exercise program including moderate-
intensity, aerobic, resistance, balance, and stretching exercise combined with PFMT, and the
duration of each training session is about 60 min. Included in this program are ten sections,
one for pelvic floor warm-up, eight for global exercises, and one for cooling down.
All participants in EG are informed to claim to the medical providers involved if any
experiencing symptoms related to sport injury (e.g., knee pain, elbow pain, etc.). Any
patients claiming to have such injury would be referred to the obstetric department or the
physio therapist for treatment followed by an assessment for whether they should continue
the training or not. An anticipated adverse event log would be prepared and sent to the
principal investigator (PI) when such injury happens.
Table 1. The 12-week Pelvic Floor Workout and the sectioning.
Week 8-Scetion Program Week 8-Scetion Program

Pelvic floor perception, try to feel the contraction of pelvic floor muscles at different positions, including standing, lying and
Warm-ups
sitting position.
1. Walking squeezing
2. Sitting on Swiss ball: pelvic with
up-limb dancing
1. Standing squeezing
3. Lying: new respiratory exercise
2. Sitting on Swiss ball: pelvic dancing
with balloon
4. Lying: hip isometric curling with balloon
4. Lying: hip curling
1 7 5. Lying with neck bending: leg clip ball+
5. Lying: dynamic hand-knee resistance
isometric hand-ball resistance
6. Side lying: knee bending side bridge
6. Side lying: knee extension isometric
7. Lying: alternating knee extension
side bridge
8. Four-foot kneeling: alternating
7. Lying: four-foot dynamic extension with
knee extension
elastic belt
8. Four-foot kneeling: four-foot dynamic
Main extension with elastic belt
Progressive 1. Walking squeezing
Exercises 2. Sitting on Swiss ball: pelvic with
up-limb dancing
1. Standing squeezing
with balloon
4. Lying: Hip isometric curling with
4. Lying: hip curling
balloon
2 5. Lying: dynamic hand 8 5. Lying with neck bending: leg clip ball+
-knee resistance
isometric hand-ball resistance
6. Side lying: knee bending side bridge
6. Side lying: knee extension isometric
7. Lying: four-foot dynamic extension
side bridge
8. Four-foot kneeling: four-foot
dynamic extension
elastic belt
8. Four-foot kneeling: four-foot isometric
extension with elastic belt
Table 1. Cont.
Week 8-Scetion Program Week 8-Scetion Program

1. Walking squeezing +Arm large swing
2. Sitting on Swiss ball: pelvic with up-limb
1. Calf raising squeezing
dancing using elastic belt
with balloon
4. Lying: Hip curling
4. Lying: hip isometric curling with balloon
5. Lying with neck bending: dynamic
3 9 5. Lying: neck bending +Leg Clip Ball+
hand -knee resistance
Side ball shot
6. Side lying: knee bending “clam”
6. Side lying: knee extension side bridge
side bridge
with arm cross swing
7. Lying: four-foot dynamic extension
elastic belt
dynamic extension
extension with elastic belt
1. Walking squeezing +Arm large swing
dancing using elastic belt
1. Calf raising squeezing
with balloon
4. Lying: hip dynamic curling with Swiss
4. Lying: hip curling with balloon
ball and balloon
5. Lying with neck bending: dynamic
4 10 5. Lying with neck bending: Leg Clip Ball+
hand -knee resistance
Side ball shot
6. Side lying: knee bending clam
6. Side lying: knee extension side bridge
side bridge
with arm cross swing
7. Lying: four-foot isometric extension
7. Side Lying: Four-foot isometric extension
with elastic belt
isometric extension
extension with elastic belt on
Main
unstable support
Progressive
Exercises 1. Walking squeezing with arm small swing
1. Single leg squeezing dancing using elastic belt
2. Sitting on Swiss ball: pelvic and 3. Lying: new respiratory exercise
up-limb dancing with balloon
3. Lying: new respiratory exercise 4. Lying: hip dynamic curling with Swiss
4. Lying: hip curling with balloon ball and balloon
5 5. Lying with neck bending: isometric 11 5. Lying with neck bending: leg clip ball+
hand -knee resistance side ball shot
6. Side lying: knee extension dynamic 6. Side lying: four-foot extension
side bridge side bridge
7. Lying: four-foot isometric extension 7. Lying: four-foot isometric extension with
8. Four-foot Kneeling: four-foot elastic belt
isometric extension 8. Four-foot kneeling: four-foot isometric
unstable support
1. Walking squeezing with Arm
small swing
1. Single leg squeezing dancing using elastic belt
2. Sitting on Swiss ball: pelvic and 3. Lying: new respiratory exercise
up-limb dancing with balloon
3. Lying: new respiratory exercise 4. Lying: hip dynamic curling with Swiss
4. Lying: hip curling with balloon ball and balloon
6 5. Lying with neck bending: isometric 12 5. Lying with neck bending: leg clip ball+
hand -knee resistance side ball shot
6. Side Lying: knee extension dynamic 6. Side lying: four-foot extension side
side bridge bridge with upper leg abducted (if not,
7. Lying: four-foot isometric extension the same as week 11th)
8. Four-foot Kneeling: four-foot 7. Lying: four-foot isometric extension with
dynamic extension with elastic belt elastic belt
unstable support
Dynamic stretching, including upper and lower limbs, waist, back, and abdomen stretching and pelvic floor muscle relaxation
Cooling Down
with mini foam axis.
sion upper leg abducted (if not, the same as week 11th)
8. Four-foot Kneeling: four-foot dy-
7. Lying: four-foot isometric extension with elastic
namic extension with elastic belt belt
8. Four-foot kneeling: four-foot isometric extension
Int. J. Environ. Res. Public Health 2022, 19, 11073 with elastic belt on unstable support 8 of 14
ling Dynamic stretching, including upper and lower limbs, waist, back, and abdomen stretching and pelvic
wn floor muscle relaxation with mini foam axis.
Table 2. Data collection and follow-up instruments.
Table 2. Data collection and follow-up instruments.
EG CG
EG EGCG CGEG EGCG CGEG CG
Baseline screen, BaselineInformed screen, consent,
Informed Randomization
consent,EG Randomization
EG EG CGCG EG CG EG CG EG EG EGEG
CG CG CG CGCG EG EG CG EGCG CG
visitsEG
CG CG EG EG EGCG EG The Third CG
EG EG EG CG CG EG CG CG EG CG EGEG CG CG EG CG EGEG CG CG EG CG EGEG CG CGCG
Baseline
Baseline screen, screen,The
Informed
Baseline follow-up
Informed
screen,
consent, Informed The visits
consent,
Randomization follow-up
Randomization
consent, Randomization The First The First The Second The Second The Third
Baseline
eline screen, Baseline
Informed screen,
screen, Informed
Baseline
consent, Informed
screen,
consent, Informed
Baseline
Randomizationconsent,
Randomizationscreen,
consent, Informed
Baseline
Randomization screen,
EG consent, Informed
Baseline
Randomization
CG screen,
EG consent,EG Informed
Baseline
Randomization
CG CG screen,
EG consent,EGInformed
EGRandomization
CG CG EG consent,
CG EGEGRandomization
CG CG EG CG EGEG CG CG EG CG EGEG CG CGCG
Demographic
The follow-up The follow-up
visitsDemographic
data
The follow-up collection
visits visits data collection ◯
The First The First ◯
TheThe ◯FirstSecond ◯
The Second The The Second ThirdThe Third The Third
Baseline screen,The Randomization
follow-up
Informed
Baseline screen,
consent,visits
The follow-up
Informed
Baseline
Randomizationscreen, visits
consent, The follow-up
Informed
Baseline
Randomization Thevisits
screen,
EG consent, The
First follow-up
Informed
Baseline
Randomization
CG Thevisits
screen,
EG consent, The
EGThe
First Second
follow-up
Informed
Baseline
Randomization
CG CG Thevisits
screen,
EG consent, The
EG The
First The
Second
Informed
EG follow-up
Third
Randomization
CG CG EG Thevisits
consent,
CG EGThe
First
EG The
Second Third
Randomization
CG CG EG TheEG
CG The
First
EG The
Second
CG Third
CG EG CGTheEGThe
First
EGThe
Second
CGThird
CGCG
The Demographic
follow-up
Demographic visits
Demographic
dataDemographic
collection
The MOS data collection
data
Thecollection
MOS ◯ The First ◯
●◯ ◯ ◯ ●● The ◯ ●Second ● ● ● ● The ● Third ● ● ●
Baseline screen, The
The follow-up
follow-up
Informed
Baseline data
screen,
consent, visits
Demographic
collection
visits
The follow-up
Informed
Baseline
Randomizationdata Demographic
screen, collection
visits
Informed
Baseline
Randomization ◯
data The
screen,
EG The
Demographic
consent,visits
The
First First
collection
Informed
Baseline◯ EG
follow-up
Randomization
CG ◯
data Demographic
screen,
consent,collection
Thevisits
The
EGThe
First
Informed
Baseline ◯ CG
Second
follow-up
Randomization
CG ◯
data
screen,
EG The
Demographic
The
consent,EG Second
collection
visits
The
The
First The
Informed
EG ◯ Third
Second
follow-up
Randomization
CG CG ◯
data
EG consent,
CG collection
Thevisits
EGThe
First
EGThe ◯ Third
Second
Randomization
CG CG ◯
EG The
CG The
EGThe
First
EGThird
The ◯ Third
Second
CG CG ◯
EG CGTheEGThe
First
EGThe ◯ Third
Second
CG CGCG
Demographic data The MOS The MOS MOS stage #◯
The POP-Q ● ● ●◯ ● ●●● ◯● ◯ ● ● ●● ● ● ● ◯● ●
Baseline Demographic
Demographic
screen, The Thecollection
follow-up
Informed
Baseline MOSdata
data
screen,
consent,POP-Q
collection
Demographic
collection
visits
The
Informed
Baseline stage
follow-up
The
Randomizationdata
MOS Demographic
screen, collection
visits
Informed
Baseline The EG
Randomization ◯
data
MOS Demographic
●consent,
screen,EG
The collection
visits
The
First ●
◯● CG
follow-up
Informed
Baseline The
Randomization
CG #
◯
data
●consent,
MOS ●
Thevisits
screen,
EG ●
Demographic
collection
The
EGThe EG
First ● CG
Second
follow-up
Informed
Baseline The
Randomization
CG ●EG●consent,
data
●
MOS CG● visits
Demographic
The
screen, collection
●
The
EG The
First●The●follow-up
◯●●Third
EG
Second
Informed
EG The
Randomization
CG CG ◯
data
●EG●CG
MOS ● ●CG
The
consent, ●
collection
●
visits
EGThe ●The
First
EG ●●Third
Second ●
Randomization
CG CG ●◯
EG●CG
●
TheEG ●
The
First
EG●●The ◯
● Third
Second
CG CG ◯
●EG●CG
●TheEG●
The
First
EG●The◯
● Third
Second
CG ● CG
CG ●
● ● ● ●●
Baseline
Baseline Demographic
The
screen,
screen, The MOS TheMOS
POP-Q
Informed
follow-up
The
Informed
Baseline
POP-Q
MOS
data
screen,
consent,
stage
POP-Q
stage
Cough
Demographic
collection
consent,
visits
The
Informed
Baseline stage
POP-Q
stress
follow-up
The Cough
Randomization
POP-Q test
data
MOS stage
Randomization
screen,
consent,
stage stress
Demographic
collection
visits
TheInformed
Baseline test EG
follow-up
The
Randomization
POP-Q ◯
data
●
MOS ●
●Demographic
•consent,
screen,
● stage collection
Thevisits
The
First
Informed
Baseline◯
●
CG●● EG
follow-up
The
Randomization
●
POP-Q ●◯
data
●
MOS
●
●Demographic
•consent,
Thevisits
screen,
stage ●
The
EG
●
●Informed
The ●
collection
● First ◯●●●CG
Second
follow-up
Baseline
CG
POP-QThe
Randomization
● ● ◯●
•consent,
●
data
●EG
MOS
● ● visits
Demographic
The
screen,
stage The
EG
● The ●
●Informed
collection
● First
EG●
●
●The ◯
●follow-up
●●Third
Second
CGThe
Randomization
●
POP-Q CG● ◯●
•CG
data
●EG●
MOS
● ●
●
●
●
The●visits
consent,
stage EG ●
collection
●
The
● First
EG
●
●
●The ◯
Second ●Third
Randomization
CG● CG●●
●◯
EG•CG
●
● ● ● EG
The
● ●
The
● First
EG●●The
● ◯
● Third
Second
CG
● CG● ◯
●EG•CG
●
● ●
●TheEG●
The
●First
EG●The
● ◯
● Third
Second
CG
● ● CG
CG
● ●
●
Demographic
Baseline screen, The POP-Q
The
Cough follow-up
follow-up
The
Informed
Baseline data
stress
MOS stage
Cough
Demographic
screen,
consent, visits
collection
test
visits
The
Vaginal stress
Cough
follow-up
Informed
Baseline test
data
The Vaginal
Randomization
relaxity MOS Demographic
stress
screen, collection
test
visits
Informed
Baseline The MOS
Randomization
relaxity ◯•consent,
data
● The
●Demographic
collection
Thevisits
screen, The
First ◯
●
First
●● MOS
follow-up
Informed
Baseline The
Randomization
● ◯•consent,
data
● Thevisits
screen, ●
●Demographic
The
The
First
● The
●Informed
collection
● ◯●●
Second Second
follow-up
Baseline
● The
Randomization ◯•consent,
●
data
●MOS Demographic
The
screen,
● collection
●
visits
The
The
First●The●
●Informed
● ◯●●
SecondThe
follow-up
The Third
Randomization
● ◯•consent,
● Third
data
●MOS ● ●
The
● collection
●
visits
The
●First ●
●The ◯●●
Second ●◯
Third
Randomization
● •●The
● ● ● ●
The
First●●The ◯
Second ●◯
● Third •●The●
● The
First●The◯
● Third
Second● ● ●
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
•● ● ●● stress ● ●visits
● ● ● ●●●
POP-Q stage POP-Q stage POP-Q ● stage POP-Q
● stress ● stage ● Cough POP-Q ●● stage ● Cough POP-Q
● ● stress ●● stage
POP-Q Cough
TheCoughstage
Demographic
Demographic
stress
follow-up
The MOSstress
data
test
data
Demographic
Cough stress testCough stress
test
visits
The collection
collection follow-up
The data
MOS Demographic
collection
visits
Thetest follow-up
The MOS ◯
data
● The
testCough
◯visits
Demographic
collection
The
FirstPOP-Q ◯●● ◯MOS
follow-up
●The ◯
data
●
test
• Demographic
collection
●
Thevisits
The
The
First
● ◯●● ●
Second
follow-up
The ◯
data
●MOS
● The
test
• Demographic
collection
●
visits
The
The
First●The ◯●◎Third
Second
● follow-up
The ◯•●
data
●MOS
● ●The
test
collection
●
The ●The
First ◯●◎
Second ● ●◯
Third •●
● ●
The
● ● ● ●●
●
The
First● The ◯ ●◯
● Third
Second •●
● ●The●
● ● ● ● ●
●
The
First●The◯
● Third
Second● ●
Vaginal
Pelvic
POP-Q
Cough floor Vaginal
relaxity
stage
stress relaxity
Vaginal
electrophysiological
Pelvic
testCough POP-Qfloor relaxity
stage POP-Q ●
● ●
stage test ◎●
● stress ●
● ●
stage ●◎ ●◎
● Cough POP-Q●
● stress
●●◎●
● ◎
stage ● ●
● Cough●
● ◎
● ●
POP-Q ●
● stress
●● ●
● ● ◎●
stage
● test ●◎
● ● ●
● ●● ●
● ● ◎●
●● ●
● ● ●
● ● ●
● ● ◎
●
● ● ●
● ● ●
●● ●
● ●
● ● ● ● ●
● ● ●
● ● ●
● ● ●
Vaginal
Vaginal relaxity
relaxity Vaginalstress relaxity testCough
Vaginalstress ●
•●
relaxity testCough
Vaginal● ● test
●
• Demographic
relaxity Vaginal ● ● test
●
• Demographic
relaxity ●
Vaginal ● ● •●
relaxity ● •● •● ●
Demographic
Cough
Pelvic stress
floor TheThe
Pelvic
POP-Q data
test
MOS
floor MOS
Demographic
stage collection The data
MOS
ultrasound
Pelvic
Pelvic floor POP-Q Demographic
floor
stage collection
test test The test
ultrasound
POP-Q ◯
data
●
MOS
● ◎
stage ●collection
Demographic ◯
◎●◎ ●●
The
●
POP-Q ◯
data
●
MOS
● ◎ collection
stage ●◎
● ◎ ◎ ●POP-Q◯●●
The
● ◯
data
●MOS
◎ stress
● ◎●
● ◎
stage ●◎●
● collection
● ●◎
● ◎ ◯●
The
●◎ stress
POP-Q ● ◯
data
●MOS
◎●
● ●◎
●
stage●collection
●●
●◎● ●◎◯
● ●◎ ◎
● ●●
● ◯●
● ●◎ ●
● ● ● ◎◯
● ● ●
● ●◯ ●
●●● ●
● ● ● ● ◯ ●
● ● ● ●
● ●
Pelvic
Pelvic floorCough
floorVaginal stress
relaxity
Pelvic test
floorCough
Vaginal stress
relaxity test
testfloor
test
Pelvic Cough
Vaginal ◎●
stress
●
relaxity
test
Pelvic test
floorCough ◎
Vaginal●
● test ◎●
stress
●
relaxity
Pelvic ◎●
test
floor Cough
● Vaginal ◎●
● test◎●
●◎ ●
●
relaxity
Pelvic ◎●
test
● ◎
floor ●
Cough
●
Vaginal◎●
● test◎●
●◎ ●
● ●
● ◎
◎
relaxity
electrophysiological ●
test
● ◎ ● ◎ ●
● test◎●
●◎ ●
●◎●
● ◎ ●
● ◎ ●
● ◎ ●
● ◎ ●
●◎ ●
●◎● ◎ ●
● ◎ ●
● ◎ ●
● ◎ ● ◎ ●
●
The MOS
POP-Q
Pelvic Spine
stage
floor The
X-ray MOS
ultrasound Spine X-ray The ●
MOS
●stage ●
◎ testCough ◎●
The ●
●◎ stress ●
MOS ◎ test
●stage ●◎ ◎
●◎Cough ● ●
The ●
●◎ stress
●●◎●
MOS ◎●
●stage ●
●◎Cough●
●◎ ◎ ●◎
The ●
●◎ ●
MOS ● ◎
●stage
● test ●●◎
● ● ●
●◎ ● ●◎
● ● ◎●
●● ●
●●●
●◎ ● ●
● ● ●
◎
● ● ●
● ● ●
●● ●
●●●
● ● ●
● ● ●
● ● ●
● ● ●
● ● ●
●
Vaginal
Pelvic
Pelvic
floor
POP-Q
Cough
Vaginal
Pelvic
Pelvic
floor
relaxity
floor
floor stressultrasound
stage
relaxity
Pelvic
test
ultrasound
ultrasound
Pelvic Cough
Pelvic
floor
POP-Q
Vaginal
floor
floor stressultrasound
stage
relaxity test
ultrasound
test
Pelvic Pelvic
floor CoughPOP-Q
Vaginalfloor ●
stress
◎● ● Pelvic
relaxity
ultrasound
test
Pelvic floor
POP-Q
◎
Vaginal●
●
floor ●◎●
●
relaxity
ultrasound
test
Pelvic ◎●
●
Pelvic
floor◎
POP-Q
Vaginal◎●
●● test
floor ◎●
● ◎●
relaxity
ultrasound
Pelvic ◎
●
test
◎●
Pelvic
floor ●
◎●
●
POP-Q
Vaginal◎● test
●
floor ◎●
● ●
stress
◎● ●
◎
● ●◎
relaxity
ultrasound
◎
●
●
◎
◎● ◎ ● test◎
◎
●●◎●◎● ◎ ● ◎ ● ◎
◎
● ◎ ●◎ ●◎● ◎ ● ◎ ● ◎ ● ◎ ● ◎ ●
Spine
POP-Q
Cough Cough Body
X-ray
stage
stress Spine
stress
test
Composition
test
Cough X-ray
POP-Q Body
Spine stage
stress
Composition
X-ray test CoughPOP-Q ●
stress◎
●stage ● test Cough ◎
POP-Q
●◎
● stress
● ● ◎
●stage ●◎◎
● Cough
test ● POP-Q● ◎
● stress
●●
● ◎●stage
● ● ◎
● Cough
test ●◎ ◎
● POP-Q ● ●●
● ◎
stress● ◎
●stage
● test ●● ●
● ◎
● ● ◎
● ● ●● ●● ◎
● ● ● ● ● ● ● ● ●● ●●● ● ● ● ● ● ● ● ● ● ●
◎ ◎ ◎ ◎ ◎ ◎●◎ ◎ ◎ ◎ ◎●◎ ◎
●◎◎ ◎ ◎ ◎ ●◎ ●◎● ◎ ● ◎ ◎ ◎◎◎ ◎ ● ◎ ● ◎
● ● Pelvic ● ● ◎Vaginal ● test ● ●◎ ● ●◎test ● ●◎ ●◎ ●◎test ◎ ● ●●● ● ◎
● ● ◎ ●
Pelvic Spine
Vaginal
Spine
floor X-ray
relaxity
X-ray
ultrasound
Pelvic Spine
Vaginalfloor X-ray
relaxity
ultrasound
Pelvic Spine
Vaginalfloor X-ray
relaxity
ultrasoundPelvic Spine
Vaginal
floor X-ray
relaxity
floor X-ray
relaxity
ultrasound Spine
Vaginal X-ray
relaxity
Pelvic floorPelvic floor electrophysiological
electrophysiologicalPelvic
Body Composition Body floor
Hand electrophysiological
test
grip
Composition
Body
test
Pelvic
test
Hand
Composition
floor
grip test ◎
test
Pelvic floor
◎ testCough ◎
◎◎test ◎ test
floor
◎◎Cough ◎ ◎ stress
◎ ◎ Pelvic
Pelvic floor
◎Cough◎ ◎
floor
◎
ultrasound
◎test ◎
◎ ◎● ●
Cough
Body stress
Composition
Vaginal test Cough
Body
relaxity stress
Composition test Cough
Body ●
stress
◎
Composition
◎● ● Body ◎
◎● ● ●
stress
◎
Composition
● test ◎● ◎
◎●
●◎ Body● ◎
◎● ◎● ◎●
Composition
● test◎●◎ ● ● ◎●
test
◎● ◎ ◎●
Body
● ◎
◎● ◎● ●
stress
◎
Composition
◎●◎ ● ●
◎
● ◎ ◎●●
● ◎●
● ◎ ◎●
● ◎ ◎●
●◎◎●
●◎●
◎
● ◎ ◎ ● ● ◎ ●
◎
● ◎ ◎●
●◎◎●
●◎●
◎
● ◎ ◎●
● ● ◎◎● ●
◎
● ◎ ● ●
●
◎ ◎
●
◎◎◎ ◎◎ ◎ ◎ ◎◎
Body
Pelvic Pelvic
floor Spine
Vaginal
floor X-ray
relaxity
Composition
ultrasound
Pelvic Pelvic
floor Spine
Vaginalfloor X-ray
relaxity
ultrasound
test
Pelvic Pelvic
floor Spine
Vaginalfloor X-ray
relaxity
Vaginal
floor X-ray
relaxity
◎Vaginal floor X-ray
relaxity
ultrasound
◎ Pelvic Spine
Vaginalfloor X-ray
relaxity
ultrasound
Pelvic floor ultrasound
Hand Trunk
grip Hand
testendurance
grip
Hand Trunk
test
griptest test electrophysiological
endurance test
Pelvic
test ◎ floor electrophysiological
◎ ◎ ◎Pelvic
◎ ◎ floor ◎ electrophysiological
◎ ◎Pelvic◎ floor
◎◎◎ ◎ electrophysiological
◎test ◎ ◎ ◎test ◎
◎
Pelvic
Pelvic floor Hand
Body Spine
floor
Vaginal
Pelvic Hand grip
Composition
X-ray test Body
floor relaxity
grip
ultrasound
Pelvic test
Pelvic
floor HandSpine
Vaginalfloor grip
Composition
X-ray
testtest
relaxity
ultrasound
test
Pelvic Body
Pelvic Hand
Spine
Vaginalfloor ◎
grip
Composition
◎●
X-ray test
◎
relaxity
ultrasound Body
Pelvic Hand ◎
◎
Vaginal●
Spine
floor ◎ ◎
grip
Composition
◎●
X-ray
relaxity
ultrasound◎
test
◎●
Pelvic ◎
BodyHand
Vaginal◎
◎●
Spine
floor ◎● ◎
grip
Composition
◎ ◎● ◎
X-ray
relaxity
ultrasound◎
test
◎●
Pelvic ◎
Body
◎●Hand
Vaginal◎
◎●
Spine
floor ◎
◎● ◎
grip
Composition
◎● ◎
◎
●
X-ray
relaxity
ultrasound◎
test
◎
◎ ● ◎
◎● ◎
◎● ◎
◎● ◎
◎● ◎
◎
● ◎
◎ ● ◎
◎● ◎
◎
● ◎
◎● ◎
◎● ◎
◎
● ◎
◎● ◎
◎● ◎
◎
● ◎
● ◎
◎ ●
◎
Trunk Trunk
endurance endurance
Trunk
test endurancetestfloor electrophysiological
PFDI-20
test test
Pelvic◎ floor
PFDI-20 electrophysiological
◯◎test
◎ Pelvic ◎ floor
◯
◎◎ ◯ electrophysiological
◎ test
Pelvic
◯◯ floor
◎ ◎ ◎ ◯
◎ electrophysiological
◯test ◎ ◯◯ ◎ ◎
◎ ◯test◯ ◎ ◯
Spine
Trunk
Body X-ray
Hand
Pelvic
Trunk
Pelvic Pelvic
floor endurance
grip
Composition
Spine floor
X-ray
endurance
floor ultrasound
Pelvic Trunk
test test
BodyHand
ultrasound
Pelvic
floor test endurance
Spine grip
Composition
floor X-ray
ultrasound
test
Pelvic Trunk
test test
Body
Pelvic
floor Hand
Spine ◎
endurance
grip
◎ ◎◎
Composition
floor X-ray test
ultrasound
test
Pelvic Trunk
test
Body
Pelvic
floor Hand ◎
◎ ◎ ◎
endurance
◎grip
◎
Composition
Spine
floor X-ray
ultrasound
test
Pelvic ◎Trunk
test
◎ test
◎
Body
Pelvic
floor Hand ◎
◎◎
Spine ◎ ◎
endurance
◎grip
◎
Composition
floor ◎
X-ray
ultrasound
test
Pelvic ◎Trunk
test
◎ ◎◎
test
◎
Body
Pelvic
floor Hand ◎
◎
Spine
floor ◎ ◎
endurance
◎grip
◎
Composition◎
◎
X-ray ◎
ultrasound
test ◎
◎
test
◎ ◎
test
◎ ◎
◎ ◎
◎
◎
test◎
◎ ◎
◎ ◎
◎ ◎
◎ ◎
◎ ◎
◎ ◎
◎ ◎
◎ ◎
◎ ◎
◎ ◎
◎ ◎
◎ ◎
◎
PFDI-20 PFDI-20 PFIQ-7PFDI-20 ◯ PFIQ-7 ◯◯ ◯ ◯ ◯ ◯ ◯ ◯◯ ◯ ◯ ◯◯ ◯ ◯ ◯ ◯ ◯◯ ◯ ◯
Body Pelvic
Composition
TrunkHand
Body endurance
Spine grip
Spine
Composition
floor X-ray Trunk
test
X-ray
ultrasound
Questionnaires test
Body
Pelvic HandSpine
PFDI-20
floor
Questionnaires
PFDI-20
endurance
grip
Composition
X-ray Trunk
test
ultrasound
PFIQ-7
test
Body
Pelvic Hand
Spine
floor
FSFI-6
PFIQ-7
◯
◎
PFDI-20
endurance
grip
◎ ◎
Composition
#
X-ray ◎
test
ultrasound
◯ Pelvic
PFIQ-7
Trunk
test
Body
FSFI-6Hand ◯
◎
◎
Spine
floor
◯ ◯
◎ ◯
◎
PFDI-20
◎
endurance
grip
◎
Composition
#X-ray ◯
◎Trunk
test
ultrasound
◯ Pelvic◎ ◯◯
◎
test
Body
◯ Hand ◯
◎
◎◎
Spine
floor
◯
◯
◎
◎ ◯
◎
PFDI-20
endurance
grip
◎
Composition
#
◯ ◎
◯test
X-ray
ultrasound◯
◎
◎Trunk
Pelvic
◯
◎◯
◎
test
◎
BodyHand
◯ ◯
◯
◎
◎
Spine
floor
◯
◯
◎
◎ ◯
◎
PFDI-20
endurance
grip
◎
Composition
#
◯
◯
◎
◎◯
X-ray ◎ ◯
◎
◎
test
ultrasound◎ ◯
◎
◯test
◎◯EG ◯
◎ ◎
◯
◎
◎◯PFDI-20
◎
◯
◯
#◯
◎
◎ ◎◯ ◯
◎ ◎
◎ CG◯ ◎
◎◯◎
◯
◎ ◯ ◎
◎ ◯
#◯
◎
EG
◎ ◎ ◯
◎ ◎◯
◎ ◎
◎ CG◯◎ ◯
◎ ◎◯
◎ ◎
◎E
Trunk endurance
Body
Hand Composition
grip Trunk
test
testBody Hand PFIQ-7
PFDI-20
endurance
grip Trunk
test
testBody Hand ◯
PFIQ-7
◎
PFDI-20
endurance
grip ◎ ◎ Trunk
Baseline test ◯
◎ ◎ ◯
PFIQ-7
◎
PFDI-20
◎
endurance
screen, ◯
◎Trunk
Informed ◎
test ◯
◎◎ ◯ ◯
PFIQ-7
◎ ◎
PFDI-20
endurance
consent, ◎ ◯
◎Trunk◎◯
◎
test
Randomization ◯
◎ ◯ ◯
PFIQ-7
◎ ◎
PFDI-20
endurance ◯
◎ ◎ ◯
◎
◎ ◯
◎
test ◯
◎ ◯ ◯
PFIQ-7
◎ ◎
PFDI-20
◎ ◯
◎ ◯
◎ ◯
◎ ◯
◎ ◯
◎ ◯
◎ ◯
◎ ◯
◎ ◯
◎ ◯
◎ ◎◯
◎ ◯
◎ ◎
Hand Body
grip
Questionnaires Composition
Spine testX-ray
Questionnaires
Questionnaires Composition
PFIQ-7
Spine X-ray
FSFI-6 Spine
IPAQ-SF
FSFI-6 ◎
# ◯ test
Composition
X-ray
FSFI-6 Body
IPAQ-SF Hand ◎◯
Spine
◯ grip
◎
Composition
# ◯ test
X-ray ◎ ◯◯ ◯Hand
Body ◎
Spine ◯ ◎grip
◎
Composition
#
◯ ◯test
X-ray ◎◯ ◎
BodyHand
◯ ◯ ◎
Spine
◯ ◎grip
◎
Composition
#
◯ ◎◯
X-ray test
◎ ◯◎◯◎◯◎ ◯ ◎
#◎◯ ◎ ◎ ◯ ◎ ◎◎ #◎ ◎
Questionnaires Questionnaires FSFI-6
Questionnaires
PFIQ-7 ◯
FSFI-6
Questionnaires
PFIQ-7
◎ ◎Trunk ◯
◎ ◯
FSFI-6
◎ ◯
Questionnaires
PFIQ-7
◎ ◎ ◎ ◯
◎ ◯ ◯
FSFI-6 ◯
Questionnaires
#◎
PFIQ-7
◎ ◎ ◎ ◯
◎ ◯ ◯ ◯
#◯
FSFI-6
PFIQ-7 ◯
◎ ◯
◎◯◯ ◯ ◯
FSFI-6
PFIQ-7◯
◎◯ ◯◎◯ ◯ ◯◯ ◯ ◯
◎◯ ◎ ◯ ◎ ◯ ◎◯
Trunk
Questionnaires
Trunk Hand
Body
endurance
Hand
endurance
grip
Composition grip
test Trunk
test test
BodyHand FSFI-6 PFDI-20
endurance
grip
Composition
IPAQ-SF Trunk
test test
Body Hand
PSQI
IPAQ-SF PFDI-20
endurance
grip
#◎ ◯ test
Composition
IPAQ-SF test
Body
PSQI Hand ◯ ◯
PFDI-20
#The
endurance
grip
Composition
◎ ◯ test
follow-up
Trunk
◯◯ test
Body
◯ Hand
◎ ◯
PFDI-20
visits
endurance
grip
Composition
◯ ◯test Trunk
◯ test
Body
◎ ◯◎
Hand
◯ ◯ ◎ ◎
PFDI-20
endurance
grip
Composition
◯ ◎◯
◎ ◎
test ◯test ◎◯ The ◎
◯
◎ ◎
PFDI-20
#First ◎◯ ◎ ◎◎ # ◎ Second
The ◎
Questionnaires
TrunkTrunk
Hand Questionnaires
endurance
endurance
grip Trunk
test test
Handtest
IPAQ-SF IPAQ-SF
FSFI-6
Questionnaires
PFIQ-7
PFDI-20
endurance
grip Trunk
test testHand ◯
IPAQ-SF
FSFI-6
◎
PFDI-20
endurance
#
grip ◎
Questionnaires
◯
PFIQ-7 testTrunk
testHand ◯
◯
◎ ◯
IPAQ-SF
◎
FSFI-6
PFIQ-7
◎
PFDI-20
endurance
#
grip ◯
Questionnaires
◯
Demographic ◯
◎Trunk
test ◎
testHand ◯
◯
data
◎ ◯ ◯
IPAQ-SF
FSFI-6
◯
PFIQ-7
◎ ◎
collection
◎
PFDI-20
endurance
#
grip ◯
Questionnaires
◯ ◯
◎Trunk
test ◯
◯
◎
testHand ◯
◯
◎ ◯
◯ ◯
IPAQ-SF
FSFI-6
◯
PFIQ-7
◎ ◎
PFDI-20
endurance
#
grip ◯
◯
◎ ◯
◎
◯
◎
test ◯
◯
◎
test ◯◯
◯
◎ ◯ ◯
IPAQ-SF
FSFI-6
◯ ◯
PFIQ-7
◎ ◎
PFDI-20
# ◯
◯
◎ ◯
◯
◎ ◯ ◯
◯
◎ ◯
◯
◎ ◯
◯
◎ ◯
◯
◎
# ◯
◯
◎ ◯
◯
◎ ◯
◯
◎ ◯
◯
◎ ◯
◯
◎ ◯
◯
◎
PSQI PSQI PSQI ◯ ◯◯ ◯ ◯ ◯ ◯ ◯ ◯ ◯◯ ✷（if
◯ ◯ ◯◯ ✷（if◯ ◯ ◯
PFDI-20 ◯ ◯ test ◯
◯ ◯ ✷◯ ◯ ✷ ◯ ◯
# ◯ ◯ ◯ ◯ ◯ ◯ ◯ ◯ ◯ ◯ ◯ ◯ ◯ ◯ ◯ ◯ ◯ ◯ ◯ ◯ ◯ ◯ ◯ ◯
Training recordTraining
PSQI record PSQI PSQI PSQI PSQI PSQI ◯ ◯
Questionnaires
Trunk endurance Questionnaires
Trunk
test PSQI IPAQ-SF
FSFI-6
Questionnaires
PFDI-20
PFIQ-7
PFDI-20
endurance Trunk
test # ◯Trunk
IPAQ-SF
◯
FSFI-6
Questionnaires
PFIQ-7
◎
PFDI-20
endurance ◯
◎ ◯
IPAQ-SF
◯
FSFI-6
PFDI-20
endurance ◯
Questionnaires
PFIQ-7
◎ ◎ The
Trunk ◯MOS
test ◯
◎ IPAQ-SF
◯
◎ ◯
FSFI-6
◎
PFDI-20
endurance
✷（if# ◯
Questionnaires
PFIQ-7 ◎Trunk ◯
◎
test
✷（if
any） ◯
◎ IPAQ-SF
◯
◎ ◯
FSFI-6
PFIQ-7
◎
PFDI-20
endurance
✷（if# ◯
◎ ◯
◯
◎
any） ◯
◎
test ◯
◎
● IPAQ-SF
◯
◎ ◯
FSFI-6
PFIQ-7
◎
PFDI-20
# ◯
◎ ◯
◎ ● ◯
◎ ◯
◎ ◯
◎ ◯
◎
●
# ◯
◎ ◯
◎ ◯
◎ ● ◯
◎ ◯
◎ ◯●
◎
Questionnaires Training
Training
Training
Training
record
Questionnaires
record
record RPE
Training
record
PFIQ-7
Training PSQI
IPAQ-SF
FSFI-6
PFDI-20 record
PFIQ-7
Questionnaires
PFIQ-7record RPETraining ◯◯
◯
PSQI
IPAQ-SF
FSFI-6 ◯
Questionnaires
PFIQ-7
PFDI-20 record Training
◯ ◯◯
◯ IPAQ-SF ◯
PSQI
◯record
FSFI-6 ◯✷◯
◯
Questionnaires
PFIQ-7
PFDI-20 ✷
POP-Q
◯
◯◯
Training
✷（if◯
◯ ✷◯ ◯
◯
PSQI
IPAQ-SF
◯
FSFI-6 ◯✷◯
Questionnaires
PFIQ-7
PFDI-20
any）
stage ✷record ✷
◯
◯
any）
◯
◯
Training
✷（if◯
◯ ◯
◯◯
PSQI
✷IPAQ-SF
FSFI-6
PFIQ-7
PFDI-20
(if
any） ◯ ◯◯
any)
record
◯
◯◯
✷ ◯ ● ◯✷（if
◯ ◯
◯
◯ ◯
◯◯
PSQI
IPAQ-SF
FSFI-6
PFIQ-7
PFDI-20◯ ✷ ◯
◯●◯ ◯ ◯ ◯✷（if◯
◯◯ ◯ ◯
●◯ ✷
◯ ◯◯ ◯●◯ ◯✷（if
◯
◯◯ ◯●
◯ ◯ ◯ ◯ ◯ ◯ ◯ ◯ ✷（if
any）◯ ◯ ◯ ◯ ◯ ◯ ✷（if
any）◯ ◯ ◯ ◯
◯ ◯ ◯ ✷（if
any）◯ ◯ ◯ ◯ ◯ ◯ ✷（if
any）
◯ ◯ ◯ ◯ ◯ ◯ ✷（if
any）
◯ ◯
Training◯ ◯record ◯ test ✷✷◯ ◯✷ ◯ ✷●
Questionnaires
Questionnaires
Questionnaires Training Questionnaires
RPE Adverse FSFI-6 PSQI
IPAQ-SF
FSFI-6 FSFI-6
Questionnaires
PFIQ-7
Event Adverse PSQI
IPAQ-SF
◯
FSFI-6
Questionnaires
PFIQ-7 ◯ PSQI
IPAQ-SF
◯
FSFI-6 ◯
Questionnaires
PFIQ-7 ◯ ◯ PSQI
IPAQ-SF
◯
FSFI-6 ◯
Questionnaires
PFIQ-7
record
✷ ◯  ◯ ◯ PSQI
IPAQ-SF
◯
FSFI-6
PFIQ-7 ◯ ◯  ◯ ◯ ◯ PSQI
IPAQ-SF
◯
FSFI-6
PFIQ-7◯ ◯ ◯ ◯ ◯ ◯ ◯ ◯ ◯ ◯
RPE record RPE
Training RPE record Event record Training ✷✷ Training Training record ✷ ●
Questionnaires RPE
Questionnaires RPE IPAQ-SF
PSQI
IPAQ-SF
FSFI-6
Questionnaires RPE◯ ◯
PSQI
IPAQ-SF
FSFI-6
Questionnaires RPE
◯
◯ IPAQ-SF ◯ Cough
PSQI
FSFI-6 ◯◯stress
✷
Questionnaires ✷（if
◯any） RPE
◯ ◯
PSQI
IPAQ-SF
FSFI-6 ◯✷ ◯◯◯any）
Questionnaires ✷（ifRPE
◯ ◯
◯
PSQI
IPAQ-SF
FSFI-6 ◯◯ ●
✷
◯ ✷（if
◯any） ◯ ◯◯ ✷
PSQI
IPAQ-SF
FSFI-6 ◯ ◯ ◯any） ✷（if ●
◯◯◯ ✷ ◯ ◯ ◯any） ◯ ◯●
✷（if
●: DataAdverse
Adverse
would
Training
Adverse
Adverse
Event
Event
●:record
Data
be collected
RPEEvent Adverse
would
Training Event
IPAQ-SF
Adverse by
be Eventfloor
collected
pelvic
record
Event
Training
Adverse
◯
by professionals
pelvic floorTraining
record
Event Adverse
◯
professionals
via vaginal record
Event
✷

✷
palpation.
via ◯
vaginal
Training
Adverse 
◎: record
Event
✷
palpation.
Data

✷
◯ would
Training
Adverse
◎:  Data
be ◯ ✷
collected
record
Event
would
✷ by
be ◯
collected
 ✷
✷ by  ✷

✷  ◯●
RPE
PSQI
IPAQ-SF PSQI RPE◯
PSQI
IPAQ-SF ◯ ◯
RPE
◯ IPAQ-SF ◯ ◯
PSQI Vaginal ◯ ✷（ifRPE
relaxity
any）
◯ IPAQ-SF
◯ ◯ ◯◯
PSQI ◯ ◯ ✷（if
any）RPE
◯ ◯
◯◯ ◯ ◯ ◯ IPAQ-SF
PSQI
IPAQ-SF ● ✷（if
any）◯ ●
◯◯ ◯ ◯ ◯ ◯◯◯ ◯ ◯ ◯ ◯
PSQI ✷（if
any） ● ● ✷（if
any）
●: Data
●: Dataexperienced
would be●:would
Training
collected
Data
experienced
General beby
record
would collected
Training
pelvic
be
specialists
General
PSQI byasrecord
collected
floor pelvic
specialists
the floor
Training
professionals
byexaminers.
pelvic as floor
the ◯
professionals
record
◯:
via professionals
vaginal
examiners.
dataAdverse via
Training
would ◯:◯
vaginal
palpation. record
via
be
data ✷ palpation.
vaginal
collected
 would Data◯
Training
◎:Adverse ◎:
palpation.
by
be would record
collected
requesting ✷
Data
 be ◯
◎: would
Training
collected
by Data
all would
requesting by◯
berecord
participants
 ✷
collected
 be toby
allcollected ◯
participants
give by ✷ to give  ✷
  by
●: Data would be Adverse
DataRPE
●:collected Event
would Adverse
by pelvic
be●:collected:RPE
•floor
Data Data
PSQI Event
would
professionals
by
would Adverse
●:collected
pelvic
be Data
be RPE
floor◯
viaEvent
would
collected
PSQI professionals
vaginal
by pelvic
be
by ◯
Pelvic RPE
●:collected ◯
palpation.
Data
floor
pelvic via Event
would
floor
PSQI ✷
◯ ◎:
professionals
floorvaginal
by ●:collected
pelvic
beData ◯ ✷（if
any）RPE
◯
palpation.
Data
floor
professionals would✷（if
◯
via
PSQI Event
would ✷
◯ ◎: ◯
professionals
vaginal
by
be
via Adverse
pelvic
collected
beData
test
vaginal ◯ ✷（if
any）RPE
◯
collected ◯
palpation.
floor
would
via
byEvent
◯ ✷
◯ ◎: ◯
professionals
vaginal
palpation.
PSQI by
be pelvic ◎◯
collected
Data ✷（if
any）◯
palpation.
:floor◯
would
via
Data ◯
by
PSQI ✷
◯ ◎collected
◎: ◯
professionals
vaginal
be
would Data ◯ ✷（if
any）
◯ ◎
◯
palpation.
be would
via◯
by
collected ✷
◯ ◎:
vaginal
be ◯ ◎◯ ✷（if
any）
collected
by Data ◯
palpatio
would◯◎
experienced answers
experienced
General Training
Training
through
answers
General
experienced record
specialists record
scanning Training
through theaspecialists
specialists
General
asAdverse QR asrecord
scanning
code.
examiners. the ✷: Training
a◯:QRRecording
examiners.
as the code.
data
examiners.record
◯:
would✷:by databe Training
Recording
all
◯: the
would
collected
data berecord
participants
by
would ✷
all the
collected
by ✷Training
participants
in
requesting
be EG
by
collected onlyrecord
requesting
all by ✷per
in Training
EG
their
participants
requesting allonly
trainingrecord
per
participants
to allgive✷
their
record
participants training
to and
give ✷
torecord
give and ✷
●: Data would
experienced General Adverse
be Data
experienced RPE
●:collected
specialistsEvent
would byasexperienced
Generalpelvic
be
the experienced
●:collected
Data RPE
floor
specialists
examiners. Event
would
professionals
General ◯: theGeneral
Adverse
●:
byasexperienced
pelvic
be data RPE
collected
Data
floorvia
specialists
examiners.
would specialists
Event
would
professionals
vaginal
byas
General
be◯: Adverse
●:data
pelvic
be
experienced
the as
collected RPE
collectedthe
specialists
examiners.
wouldEvent
Pelvic
palpation.
Data
floor viawould
by 
✷
examiners.
◎:
floor
professionals
vaginal
by
General ◯: Adverse
●:data
pelvic
beData
requesting
as
beexperienced
the
collected✷（if
#:
RPE
ultrasound
any）
collected
palpation.
Data
floor
wouldany）
via
specialists
examiners.
would
all data
Event
would
by 
✷✷（if
be would
◎:
professionals
vaginal
by Adverse
pelvic
collected
◯:be
participants
General Data
requesting
as
be the be
✷（if
any） 
RPE
collected
palpation.
collected
data floor
wouldcollected
via
specialists
examiners.
to by
would
all Event ✷ ◎:
professionals
give
by vaginal
by
be by
pelvic ◎
collected
◯:
participants Data
requesting
as
be the ✷（if
any）
requesting
palpation.
collected
data floor
would
via
examiners.
to by
would
all ✷ ◎
◎: all
professionals
vaginal
give
by be collected
◯:
participantsData
requesting
be 
participants
✷（if
any） ◎
palpation.
collected
data would
tovia
by
would
allgive
by 
✷ ◎: to
vaginal
be collected
Data
participants
requesting
be 
◎palpatio
✷（if
any）
would
collected by
toall
gib◎
p
answers Training
answers
through record
Training
through
answers
scanning record
ascanning
throughQR code. Traininga give
scanning ✷: RPE
a QRscore
record
QRRecording
code. ✷:
code. bygiven
Training RPE
Recording by
score
all Recording
✷: the themselves.
recordby allgiven
participants byaby
Training
the all 
participants
in
the EG ✷
themselves.
:record
Optional
participants
 only✷
✷
Training
in 
items
EG
per : Optional
only
their record
inEvent
EG ✷per
training
 onlyitems
Training
their per training
record
theirrecord
and✷ recordrecord
training
 and ✷
and
  ✷
 
●: Data
answers
experienced would
through
General Adverse
be
answers
scanning
experienced RPE
●:collected
Data
specialists RPE
Event
awould
through QR byas
code.
General Adverse
●:collected
pelvic
be
answers
scanning
experienced
the Data
✷: RPE
floor
specialists
examiners. answers
Event
awould
professionals
Recording
throughQR byascode.
General ◯: ●:
pelvic
be
answers through
Adverse
scanning
by
experienced
the all
✷:
data RPE
collected
Data
floorvia
Recording
through
the
specialists
examiners.
would scanning
Event
awould
professionals
QRvaginal
byas
participants
code.
General Adverse
●:
pelvic
be
answers
be scanning
◯: by
experienced
the all
✷:
collected
data QR
RPE
collected
palpation.
Data
floor via code.
Event
awould
Recording
through
in
the
specialists
examiners.
wouldEGQR
by ✷
Spine
◎:
professionals
vaginal
by
participants
only
code.
General ●:
pelvic
beData
answers
scanning
◯:
requesting
as
be by :collected
Adverse
per
experienced
the Recording
X-ray
collected
data any）
all
✷: RPE
palpation.
Data
floor
wouldvia
their awould
Recording
through
in
the
specialists
examiners.
would
all EGQR ✷any）
◎:
training
by onlyby
professionals
vaginal
by
be pelvic
code. all
Adverse
collected
beData
scanning
◯:
participants
General
requesting
as
be the by
per the
any）
record
collected
dataall
✷: RPE
collected
palpation.
floor
would
via
their by
Recording
in
the
specialists
examiners.
to
would
all EG
and
QR ✷
participants
aEvent ◎:
professionals
vaginal
by
be
training
give
by onlypelvic
code.
◯:
participants by
requesting
as
be the ◎
collected
Data
per in
any）
record
all
✷:
collected
data EG
palpation.
floor
would
via
their by
Recording
in
the
examiners.
to EG
would
all and✷
only ◎
◎:
training
give
by only◯: per
professionals
vaginal
be collected
participantsData
requesting
be by
pertheir
any）
record
all
collected
data ◎
palpation.
would
via
their
in
the
to by
EG
would
all and ✷
training◎:
vaginal
be
training
give
by only ◎
per
participants
requesting
be any）
collected
Datapalpatio
would
record
their
in
collected
to Eab◎
by
all
gi p
RPE score
record RPE
given
and score
RPE
by
RPE given
themselves.
score
score Abbreviations:
by
given
given by
themselves.
:by
Optional
themselves.: items
Abbreviations:
themselves.: Optional  :Optional
Optional items items
items.
 Abbreviations: MOS: The modified Oxford Scale [3],
●: Data ●: Adverse
Adverse RPE Event Event
RPE Adverse
●: score RPE Event
given RPE
by Adverse
●: RPE
themselves.
score Event
given  RPE
by Adverse
●:
:experienced
Optional RPE
themselves.
score Body
Event
given
items 
✷◎:
RPE
byComposition
Adverse
●:
:experienced
Optional
themselves.
score 
RPE Event
given
items 
✷◎:
RPE
by Adverse
:pelvic
Optional
themselves.
score 
RPE Event
given
items ✷◎:
RPE
by
:pelvic ◎
Optional
themselves.
score  given
items✷◎
◎:by
:◯:Optional 
themselves.◎ items 
✷◎: ◎
: collected
Optional  ite ◎
answers
experienced would
through
Generalbe
answerscollected
scanningData
experienced
RPE specialists
MOS: The modified would
through
a QR
MOS: The by
General
aspelvic
be
code.
answers
scanningcollected
experienced
the
Oxford Data
✷: floor
specialists
examiners.
modified would
professionals
Recording
through
a QR by
General
ScaleOxford
which
as pelvic
◯:be
code.
answers
scanning
by collected
experienced
the
[3], which
needs
Data
✷:
data floor
all via
specialists
examiners.
toScale
would
beneeds
Abbreviations:
would
[3], professionals
Recording
through
thea QRvaginal
by
General
as
be
whichpelvic
◯:
to be be
participants
code.
answers
scanning
the
Abbreviations:
performed
by collected
palpation.
Data
✷:
collected
data floor
all via
specialists
examiners.
performed
needs
Abbreviations:
by
would
would professionals
Recording
through
in
thea EGQR
by vaginal
by
General
to beby
inserting
pelvic
◯:be
participants
only
code. Data
answers
scanning
requesting
as
be theby
performedper
inserting
two ✷
collected
palpation.
Data
✷:
collected
data floor
would
all via
their
specialists
examiners.
fingers
would
would
allby
twoprofessionals
Recording
through
in
thea EGQR
byvaginal
by
be
training
only collected
◯:be
code.
participants
General Data
scanning
requesting
as
be
inserting
into
the
fingers by collected
per
the vagina
palpation.
✷:
collected
data floor
would
record
all via
their
specialists
examiners.
into to by
would
all
two the professionals
Recording
in
thea EG
and
QR
give
by vaginal
by
be
training
only collected
code.
◯:
participants
fingers Data
by
requesting
as
forvagina
be theperpalpation.
✷:
collected
data
intofor
approximately
floor
record
allwould
via
their
in
the
examiners.
to byprofessionals
EG
would
all vaginal
Recording
andbe
training
give
by
the vagina only collected
participants
4
Data
requesting
be
cm
by palpation.
per would
record
all
collected
data via
their
in
the
to by
EG
would
all
forto feel the FPM andvaginal
be
training
give
by only Datapalpatio
per
participants
requesting
be would
record by
their
in
collected
to E
alla
gibp
answers●: through
●: DataData
experienced would
would Adverse
be●:
answers be
collected
scanning
General Data
experienced Event
collected
would
through
a
specialists QR by by
RPE
code.Adverse
●:
pelvic
be
answers
General
as pelvic
scanningscore
collected
experienced
the Data
✷: floor Event
floor
given
would
professionals
Recording
through
a
specialists
examiners. QR by code.
General
as Adverse
Abbreviations:
professionals
RPE
by ●:
pelvic
be
answersthemselves.
scanning
◯: by score
collected
experienced
the Data
floor
all
✷:
data viaEvent
given
would
Recording
through
the
specialists
examiners.a
would QRvia 
professionals
vaginal
by
participants
code.
General Adverse
Abbreviations:
vaginal
RPE
by
: ●:
Optional
pelvic
be
answers
as
be scanning
◯: by collected
palpation.
experienced
the Data
floor
all
✷:
collected
data via Event
palpation.
themselves.
score given
items
would
Recording
through
in
the
specialists
examiners.a
wouldEGQR
by 
Hand
◎:
RPE
by
:
professionals
vaginal
by pelvic
be
participants
only
code.
Generalanswersgrip
Adverse
◎:
Abbreviations:
●:
Optional
Data
scanning
◯:
requesting
as
be by
per
experienced
the Data
themselves.
score
all
✷:
collected
data 
test
collected
palpation.
floor
wouldvia
their Event
would
given
items
Recording
through
in
the
specialists
examiners.a
would
all EGQR ◎:
RPE
training
by by
:
professionals
vaginal
by
be
only
code. Adverse
Abbreviations:
be
Optional
pelvic
collected
Data
scanning
◯:
participants
General
requesting
as
be the by
perrecord
all
✷:
collected
data 
collected
themselves.
score
palpation.
floor
would
their Event
given
viaitems
by
Recording
in
the
specialists
examiners.
to a
would
all EG
and
QR by◎:
training
give
by RPE
by
:
professionals
vaginal
beonly
code.
◯:
participants by
requesting
as
be the ◎
Abbreviations:
Optional
themselves.
pelvicperscore
collected
Data record
all
✷:
collected
data 
palpation.
floor
would
their given
items
via
by
Recording
in
the
examiners.
to EG
would
all and ◎
◎:
training
give
by onlyAbbreviations:
by
:◯:Optional
professionals
vaginal
be
participants
requesting
be by
per 
themselves.
collected
Data record
all
collected
data ◎
palpation.
would
their
in
the
to items
via
by
EG
would
all and ◎:
:
vaginal
be
training
give
by only ◎
Optional
collected
Data
per
participants
requesting
be 
record ite
palpatio
would
by
their
in
collected
to E
alla
gib◎
p
Adverse
MOS: The approximately
MOS:
modifiedTheEvent
MOS: modified
Oxford approximately
4
The modifiedcm
Scale to
Oxford feel the
4
[3],contraction
Oxford
which cm FPM
Scale [3], to
needs
Scale feel
contraction
which
and the
to give
[3], be FPM
needs
which scale
performedand
contraction
to
needsbe give
ranging to scale
performed
bybe and
from
insertingranging
performed give
by
0 (no scale
inserting
two 
from ranging
0
contraction)
by
fingers (no
two
inserting into 
contraction)
from
fingers
to
the
two 0 (no
into the
5vagina
(strong
fingers contraction)
tofor 5 (strong
vagina
contraction).;
into the◎ to
for POP-Q
vagina 5 (strong
for ◎ [5]: pelvic ◎
organ
◎
MOS:
●: Data
answers The
experiencedmodified
would
through
experienced MOS:
be
answers
scanning
General Oxford
Data The
●:4collected
General
cmthrough
experienced
specialists
contraction).;
approximately
approximately
modified
specialists
toawould
QR Scale
by RPE
code.MOS:
[3],
●:
as
pelvic
be
answers
General
4 as scanning
experienced
the
contraction).;
approximately POP-Q
feel cm
the to
Oxford
the
✷:
[5]:
FPM
which
score The
4collected
Data
floor givenmodified
awould
Recording
through
specialists
examiners.
prolapse
feel
cm pelvic
POP-Q
the QRneeds
examiners.Scale
contraction
to feel
RPE
by
professionals
by code.
General
as MOS:
[3],
pelvic
be
answers to
scanning
◯: by
experienced
the
quantitation;
organ
FPM [5]:
the
be
Oxford
which
Abbreviations:
●: ◯: all
✷:
data
pelvic
The
prolapse
contraction
FPM
and
performed
data
themselves.
score
collected
Data
floor given
via
Recording
through
the
specialists
examiners.
give
modified
aorgan
would QR needs
Scale
would
would  RPE
by
professionals
vaginal
by
participants
code.
General
PFDI-20:
contraction
MOS:
[3],
pelvic
be
answers
as
be to
by
be
:experienced
Optional
scanning
◯: theby
quantitation;
and
scale prolapse
give
be
Oxford
Abbreviations:
●: collected
themselves.
score
collected
palpation.
Data
floor
all
✷:
collected
data
The
ranging
and
Trunk
inserting
which
The
performed
given
aitems
viawould
Recording
through
in
scalethe
specialists
examiners.
wouldEG
Pelvic QR
bymodified
needs
Scale
◎:
by endurance
two
RPE
by
professionals
vaginal
by
participants
only
code. MOS:
[3],
0answers
General to
by
fingers
requesting
:experienced
Optional
pelvic
be
scanning
◯:
requesting
quantitation;
give PFDI-20:
ranging
from as
scalebe
Floor theby
per
collected
(no data
The
be
Oxford
Abbreviations:
●: inserting
which
themselves.
Data score
all
✷: The
collected
palpation.
Data
floor
would
their test
performed
into
0given
Recording
through
in
the
specialists
from
ranging examiners.
Distresswould
all
PFDI-20:
Pelvic
contraction)EG modified
aitems
viawould
QR needs
Scale
all  the
two
◎:
training
participants
by
(no
from only
Generalcode. [3],
vagina
to
by
scanning
requesting
as
be
Inventory
Floor
The the byfingers
participants
RPE
by
:◯:Optional
professionals
vaginal
by
be 0pelvic per be
Oxford
Abbreviations:inserting
which
themselves.
collected
beData score
5collected
record
collected
contraction)
to
(no dataall
✷: performed
palpation.
floor
would
via
their for
by into
to
given
items
Recording
in
the
specialists
examiners.
Pelvic
Distress to aFloor
would
all
contraction)
(strong EG
and
QR needs
Scale

give
trainingthe
two
◎:
RPE
by
participants
give
by
Questionnaire-20;
to only
code.
◯: [3],
vagina
:pelvic
professionals
vaginal
by
5be
to
by
by
requesting
as
be
Inventory the fingers
Optional
per be
inserting
which
Abbreviations:
themselves.
score
collected
Data record
all
✷:
collected
Distress
(strong
to data
5◯
performed
palpation.
floor
would
their for
into
needs
given
items
via
by
Recording
in
the
examiners.
to EG
would
all and  the
two
◎:by
:◯:
training
participants
give
PFIQ-7:by
Inventory
(strong only
requesting
be vagina
to
by
byfingers
Optional
professionals
vaginal
be per be
inserting
Abbreviations:
record
all
collected
Pelvic data performed
themselves.
collected
Data palpation.
would
their
in
the
to
Floor for
into
items
via
by
EG
would
all and the
two
◎:
training
give
by vagina
by
fingers
Data
participants
only
requesting
be
Impact inserti
: collected
vaginal
be Optional
palpatio
per would
record
collected
to by
their
inallab◎
for
Ein
ite
gi p
ta would be
MOS:
answers collected
approximately
The
answers modified
through
through
experienced by
MOS:
answers
scanning
General
experiencedpelvic
4approximately
cm to
Oxford
The
scanning afeel
through
specialists
Questionnaire-20;
contraction).; QR floor
the
modified
Scale
apelvic
QR
RPE
code.FPM
MOS:
[3],
answers
General
as scanning
experienced
Questionnaire-20;
PFIQ-7:
POP-Q the professionals
4code.
approximately
cm
score
✷: contraction
to
Oxford
which
The
✷: afeel
Questionnaire-7;
Recording
through
specialists
examiners.
Pelvic
[5]: QR the
modified
needs
Scale
Recording
given code.
General
PFIQ-7:
pelvic Floor as FPM
and
MOS:
[3],
answers
organ
to
scanning
◯: by
experienced
the
Pelvic
Impact
via
4themselves.
approximately
cmbe
all
✷:
data give
Oxford
which
Abbreviations:
RPE
by by
score The vaginal
contraction
to afeel
FSFI-6: scale
performed
all
given
Recording
through
the
specialists
examiners.
would
Floor
prolapse QR the
modified
needs
Scale
the The
participants
code.
General MOS:
answers
as
be
Questionnaire-7;◯:
Impact the
quantitation;
palpation.
ranging
FPM
and
4themselves.
[3],
to
byapproximately
cmbe
6-item
scanning
by give
all
✷:
collected
data contraction
to
Oxford from
inserting
which
Abbreviations:
participants
RPE
by
:experienced
Optional
score The
specialists
examiners. feel
scale
performed
given
aitems
wouldFemale
Recording
through
in
the EGQR
by
Questionnaire-7;
FSFI-6:
0the
modified
inneeds
Scale

EG two
RPE
General
PFDI-20: by◎:
(no
ranging
FPM
and
MOS:
[3],
to
by
:experienced
◯:Optional
participants
only
code.
answers
scanning
requesting
as
be the
The by
per
The
Data
4themselves.
contraction)
approximately
cm
fingers
be
score
Sexual give
Oxford
Abbreviations:
only inserting
which
per
all
✷:
collected
data The
their would
contraction
to from
feel
given
specialists
examiners.
6-item
scale
performed
into
aitems
Function
Recording
through
in
the
would
FSFI-6:all
Pelvic EGQR
by 0the
modified
theirneeds
Scale
Female
The  :to
(no
the
two
RPE
trainingby
only
Floor◯: PFDI-20
ranging
FPM
5and
[3],
Optional
code.
scanning
participants
General
requesting
as
be the by
6-item
be
vagina
to
by
fingers
be
score
Index;
perrecord
all
✷:
collected
data collected
4themselves.
contraction)
(strong
cm give
contraction
to
Oxford
Abbreviations:
training from
inserting
which
their
specialists
examiners.
Sexual
Distress to feel
scale
performed
for
record into
given
items
IPAQ-SF;
Recording
in
theaFunction
would
all
Female EG
and
QR 0the
needs
Scale

training
give
by :to
(no
the
two
and
RPE
by
only◯:
participants by
ranging
FPM
5and
[3],
vagina
to
by
Optional
code. experi-
contraction)
(strong
fingers
be give
contraction
themselves.
by
requesting
as
be
Sexual
Inventory theperscore from
inserting
which
Abbreviations:
International
record
all
✷:
collected
data their
examiners.
Index; to scale
performed
for
into
given
items
Recording
in
the EG
would
all
Function and
give
by
◯
0requesting
needs
 :to
(no
the
two
by
training
only◯:ranging
5and
vagina
to
by
fingers
Optional
participants
be
Index; be
themselves.
Physical
by
per
record
all
collected
data
◯
contraction)
(strong
givefrom
inserting
Abbreviations:
their
in
the
to scale
performed
for
into
items 
Activity
EG
would
all and the
two
training
give
by only 5◯
0requesting
:to
(no
ranging
contractio
(strong
vagina
by
Optional
per
participants
be from
fingers
inserti
record
collected
to ab◯
for
Ein
ite
their
inall
gi p
contraction).; POP-Qcontraction).;
[5]: POP-Q
organ [5]:
prolapse
pelvic quantitation;
organ prolapse PFDI-20:
quantitation;
The PelvicPFDI-20: Floor The
Distress Pelvic Inventory
Floor Distress Inventory
◯ ◯ ◯ ◯ ◯
contraction).;
approximately
MOS: The modifiedPOP-Q
4
MOS: contraction).;
to[5]:
approximately
cmOxford
The feel pelvic
the
modified
Scale POP-Q
FPM
4organ
MOS:
[3],
RPEcontraction).;
[5]:
prolapse
approximately
cm contraction
to feel
Questionnaire
Oxford
which
The
score pelvic
the
modified
needs
Scale
given POP-Q
quantitation;
FPMorgan
and
4
MOS:
[3],
to
bycontraction).;
[5]:
prolapse
approximately
cm give
contraction
to
Score-Short
be
Oxford
which
The feel
performed
themselves.
Abbreviations: pelvic
scale PFDI-20:
the
modified
needs
Scale
 POP-Q
quantitation;

Form; organ
ranging
FPM
and
4
MOS:
[3],
to
by
: contraction).;
beRPE:The
Oxford [5]:
prolapse
approximately
cm give
contraction
to from
inserting
which
Optional
Abbreviations: The feel Pelvic
pelvic
scale0
Ratings
performed PFDI-20:
the
modified
needs
Scale
 (no
two
items POP-Q
quantitation;
Floor
organ
ranging
FPM
and
4
MOS:of
[3],
to
by contraction).;
The
Distress
contraction)[5]:
prolapse
approximately
cm give
contraction
to from
Perceived
fingers
be
Oxford
Abbreviations:inserting
which
The feel
performedPelvic
pelvic
scale
into 0the
modified
needs
Scale
 to
(no PFIQ-7
PFDI-20:
Inventory
POP-Q
quantitation;
Floor
organ
ranging
FPM
5and
4
Exertion.
the
two [3],
vagina
to
by
fingers
be
Oxford
Abbreviations: The
Distress
[5]:
prolapse
contraction)
(strong
cm give
contraction
tofrom
inserting
which feel
performed
for Pelvic
pelvic
scale
into 0
needs
Scale
 PFDI-20:
the to
the
two Inventory
(no quantitation;
Floor
organ
ranging
FPM
5and
[3],
vagina
to
byfingers
be The
Distress
contraction)
(stronggiveprolapse
Pelvic
contraction
from
inserting
which
Abbreviations: scale
performed
for
into 0 PFDI-20:
needs
 toInventory
(no
the
two quantitation;
Floor
ranging
5and The
Distress
contraction)
(strong
vagina
to
by give
fingers
be from
inserting
Abbreviations: Pelvic
scale
performed
for
into0PFDI-20:
toInventory
(no
the
two Floor
ranging
5 The
Dist
contractio
(strong
vagina
by from
fingers
inserti
for
in
answers through
GeneralQuestionnaire-20;
specialists answers
scanning
as
IPAQ-SF; through
a QR
theInternational
Questionnaire-20; examiners.
IPAQ-SF;
Questionnaire-20;
PFIQ-7: RPE
code.
answers
scanning
PFIQ-7:
Pelvic ✷:◯:
score
International
Physical
Floor Pelvic
PFIQ-7: given
Recording
through
a QR
data
Impact RPE
by
code.
answers
Activity
Floor
Pelvic would themselves.
scanning
by
Physical
Impact score
all
✷: given
Recording
through
thea QR
be collected
Questionnaire
Questionnaire-7;
Floor Activity RPE
by
:
Questionnaire-7;
Impact Optional
participants
code.
answersthemselves.
scanning
by score
all
✷:
Questionnaire by
Score-Short
Questionnaire-7;
FSFI-6: The given
items
Recording
through
in
thea EGQR RPE
by
:
requesting
FSFI-6:
6-item Optional
participants
only
code.
answers
Form；RPE:themselves.
scanning
by
per
Score-Short
The
FSFI-6:
Femalescore
all
✷: their
6-item
The given
allitems
Recording
through
in
thea EGQR RPE
trainingby
: Optional
participants
only
code.
participants
Form；RPE:
Ratings
Female
Sexual
6-item themselves.
scanning
by score
perrecord
all
✷: their
of Perceived
Sexual
Function
Female given
items
Recording
in
thea
RatingsEG
and
QR
trainingRPE
by
:
participants
Function
Sexual
Index; only
to give Optional
code.
of themselves.
by
per
Exertion score
record
all
✷:
Perceived
Index;
Function
◯
their
answers given
items
Recording
in
the EG
and by
:
training Optional
participants
only
Exertion
Index; ◯
themselves.
by
per
record
all
their
in
the
◯
items
EG
and :
trainingOptional
participants
only per
record ite
their
in Ea
Questionnaire-20;
contraction).;
approximately
MOS: Questionnaire-20;
The modified PFIQ-7:
POP-Q
4approximately
MOS: cm to
Oxford
The Pelvic
contraction).;
[5]:feel pelvic
theQuestionnaire-20;
modified
Scale Floor
RPE PFIQ-7:
POP-Q
4organ
FPM
MOS:
[3], Impact
approximately
cm Oxford
which
score The Pelvic
contraction).;
[5]:
prolapse
contraction
to feel
given Questionnaire-7;
pelvic
the
modified
needs
Scale Questionnaire-20;
Floor
PFIQ-7:
POP-Q
FPM
and
MOS: Impact
quantitation;
organ
4themselves.
approximately
cm give
Abbreviations:
[3],
to be
Oxford
which
Abbreviations:
RPE
by score The Pelvic
contraction).;
[5]:
prolapse
contraction
to feel
performed
given pelvic
scale PFDI-20:
the
modified
needs
Scale

Questionnaires
Questionnaire-7;
FSFI-6:
Questionnaire-20;
Floor
PFIQ-7:
POP-Q
ranging
FPM
and
MOS:
[3],
to
by The
beImpact
quantitation;
organ
4themselves.The
Oxford 6-item
inserting
which
:Abbreviations:
RPE
by Optional
score The Pelvic
contraction).;
[5]:
prolapse
approximately
cm give
contraction
to from
feel
performed
given
items Questionnaire-7;
FSFI-6:
Pelvic
pelvic
scale
modified
needs
Scale
 twoQuestionnaire-20;
Female
Floor
PFIQ-7:
PFDI-20:
0the:(noPOP-Q
MOS:
[3],
to
by The
Impact
quantitation;
Floor
organ
ranging
FPM
andfingers
be Sexual
Oxford
Abbreviations:
RPE
by Optional 6-item
inserting
which
score The Pelvic
contraction).;
4themselves. The
Distress
contraction)[5]:
prolapse
approximately
cm give
contraction
to from
feel
given Pelvic
pelvic
scale
performed
into
items PFDI-20:
0the
modified
needs
Scale
 :to
(no
the
two FSFI-6
Questionnaire-7;
FSFI-6:
Function
Female
Floor
PFIQ-7:
Inventory
POP-Q
ranging
FPM
5and The
Impact
quantitation;
Floor
organ
4themselves. Sexual
Index;
The
contraction)
[3],(strong
cm
vagina
to
by
fingers
be give 6-item
Pelvic
Distress
[5]:
prolapse
contraction
to
Oxford
Abbreviations:
RPE
by Optional from
inserting
which
score feel
scale
performed
for
into
given
items Questionnaire-7;
FSFI-6:
Pelvic
pelvicFunction
0the
needs
Scale
 Female
Floor
PFDI-20:
toInventory
(no
the
tworanging
FPM
5and The
Impact
quantitation;
Floor
organ Sexual
Index;
The
contraction)
(strong
[3],
vagina
to
byfingers
be give 6-item
Distress
contraction
from
inserting
which
Abbreviations:
RPE
by
:Exertion
Optional
themselves.
score Questionnaire-7;
prolapse0FSFI-6:
scale
performed
for
into Function
Pelvic
needs
given
items  Female
PFDI-20:
:toInventory
(no
the
two ranging
5and The Sexual
Index;
quantitation;
Floor The6-item
Distress
contraction)
(strong
vagina
to
by give
fingers
be from
inserting
Abbreviations:
by Optional 0FSFI-6:
Pelvic
scale
performed
themselves. for
into
items  :to
(no
the
two 5◯
Function
Female
PFDI-20:
rangingThe
Inventory
Floor Sexu
Inde
The6-i
Dist
contractio
(strong
vagina
by from
fingers
inserti
Optional for
in
ite
◯
IPAQ-SF;
gh scanning a
IPAQ-SF; QR IPAQ-SF;
International
Questionnaire-20;
code.
International ✷:
IPAQ-SF;
International
IPAQ-SF; Physical
Physical
Questionnaire-20;
PFIQ-7:
International
Recording
International
Pelvic
Physical
Activity
Activity
IPAQ-SF; by all
Physical
Activity
Physical
Questionnaire
the
Questionnaire
International
Activity
Questionnaire
Activity
participants
IPAQ-SF;
Score-Short
Questionnaire
Score-Short
Physical
Questionnaire in
International
Score-Short
Activity
IPAQ-SF;
Form；RPE:
EG
Form；RPE:
Score-Short
only
Score-Short
Physical
Form；RPE:
Questionnaireper
International
Ratings
Ratings
Activity
IPAQ-SF;
Form；RPE:
their
Form；RPE:
of Ratings
Perceived
training
Score-Short
of
Physical
Questionnaire
Perceived
International
Ratings
of
Ratings
IPAQ-SF
Activity
Perceived
Exertion
record
Form；RPE:
Exertion
of Perceived
Score-Short
of
Physical and
Questionnaire
Perceived RPE
Ratings◯
Activity
Exertion
Form；RPE:
Exertion score
Score-Short
of ◯
Questionnaire
Perceived RatingsForm；RPE:◯
Exertion
Score-Short
of Perceived ◯
Ratings
Form；R
Exertion
of Pe ◯
contraction).;
MOS:MOS:TheThe
approximately
modifiedPOP-Q
modified
MOS: contraction).;
cm to[5]:
Oxford
4approximately
Oxford
The feel theQuestionnaire-20;
pelvic
modified
Scale Floor
PFIQ-7:
POP-Q
4organ
Scale
FPM
MOS:
[3], Impact
[3],
Oxford
which
The Pelvic
contraction).;
[5]:
prolapse
which
approximately
cm contraction
to feel Questionnaire-7;
pelvic
the
modified
needs
Scale
3. Data Collection Questionnaire-20;
Floor
needsPFIQ-7:
POP-Q
FPM
and
4
MOS:
[3],
to Impact
quantitation;
organbeto
Oxford
which
Abbreviations: be
approximately
cm give
The Pelvic
contraction).;
[5]:
prolapse
performed Questionnaire-7;
FSFI-6:
pelvic
performed
contraction
to feel
scale the
modified
needs
Scale
and Questionnaire-20;
Floor
PFIQ-7:
PFDI-20:
POP-Q
ranging
FPM
and
4
MOS:
[3],
to
by The
Impact
quantitation;
organ by 6-item
approximately
cmbe give Pelvic
contraction).;
The
[5]:
prolapse
contraction
to
Oxford from
inserting
which
Management
Abbreviations: The feel
scale
performed Questionnaire-7;
0FSFI-6:
Pelvic
pelvic
inserting the
modified
needs
Scale Questionnaire-20;
Female
Floor
(no
two PFIQ-7:
PFDI-20:
POP-Q
ranging
FPM
and
4
MOS: The
Impact
quantitation;
Floor
organ
two Sexual
contraction)
approximately
[3],
to
by cm
fingers
begive 6-item
Pelvic
contraction).;
The
Distress
[5]:
prolapse
fingers
contraction
to
Oxford from
inserting
which
The feel
scale
performed
into Questionnaire-7;
0FSFI-6:
Pelvic
pelvicFunction
the
modified
needs
Scale Female
Floor
to
(no
the
two PFIQ-7:
PFDI-20:
into Inventory
POP-Q
ranging
FPM
5and
4 The
Impact
quantitation;
Floor
organ
the Sexual
Index;
The
contraction)
[3],(strong
cm
vagina
to
by
fingers
be give 6-item
Pelvic
Distress
[5]:
prolapse
vagina
contraction
to
Oxford from
inserting
which feel
scale
performed
Abbreviations: Abbreviations: Abbreviations: Abbreviations:for
into Questionnaire-7;
0FSFI-6:
Pelvic
pelvic
for Function
the
needs
Scale Female
Floor
PFDI-20:
toInventory
(no
the
tworanging
FPM
5and The
Impact
quantitation;
Floor
organ Sexual
Index;
The
contraction)
(strong
[3],
vagina
to
byfingers
be give 6-item
Distress
contraction
from
inserting
which Questionnaire-7;
prolapse
scale
performed
for
into 0FSFI-6:
Function
Pelvic
needs Female
PFDI-20:
toInventory
(no
the
two ranging
5and The Sexual
Index;
quantitation;
Floor The6-item
Distress
contraction)
(strong
vagina
to
by give
fingers
be from
inserting FSFI-6:
scale
performed
for
into0 Function
Pelvic Female
PFDI-20:
to
(no
the
two ranging
5 The
Inventory
Floor Sexu
Inde
The6-i
Dist
contractio
(strong
vagina
by from
fingers
inserti
for
in
IPAQ-SF;TheInternational
Questionnaire-20;
approximately
contraction).;
approximately
MOS: modifiedIPAQ-SF;
POP-Q 4 cmPhysical
Questionnaire-20;
PFIQ-7:
4approximately
MOS: cm to
Oxford
The Pelvic
to
contraction).;
[5]:feel feel
pelvic
modified
Scale given
International
Activity
IPAQ-SF;
Floor
PFIQ-7:
the
POP-Q
4organ
FPM
MOS: FPM by
Impact
approximately
[3],cm themselves.
Physical
Questionnaire
International
Pelvic
contraction
contraction).;
[5]:
prolapse
contraction
to
Oxford
which
The feel pelvic
modified
needs
Scale Activity
IPAQ-SF;
Questionnaire-7;
Floor
PFIQ-7:
POP-Q
FPM
and
4to
MOS: Impact
and
quantitation;
organ
approximately
[3], cmbe give 
Physical
give
contraction).;
[5]:
contraction
to
Oxford
which
The feel:
Score-Short
Pelvic
prolapse Optional
Questionnaire
International
scale
performed the
modified
needs
Scale Activity
scale
pelvic IPAQ-SF;
PFDI-20:
POP-QForm；RPE:
Questionnaire-7;
FSFI-6:
Questionnaire-20;
Floor
PFIQ-7:
ranging
FPM
and
4to
MOS:
[3],
by The
Impact
ranging
quantitation;
organ items
Score-Short
Physical
Questionnaire
contraction).;
The
[5]:
approximately
cmbe give International
6-item
Pelvic
prolapse
contraction
to
Oxford from
inserting
which
The feel from
Pelvic
pelvic
scale
performed 0the
modified
needs
Scale Ratings
Activity
(no
two IPAQ-SF;
0MOS:
PFDI-20: Form；RPE:
Questionnaire-7;
FSFI-6:
Questionnaire-20;
Female
Floor
PFIQ-7:
(no
POP-Q
ranging
FPM
and The Score-Short
of
Physical
Impact
contraction)
approximately
[3],
to
by cm
fingers
begive Questionnaire
SexualPerceived
International
6-item
Pelvic
contraction)
quantitation;
4Floor
organ
contraction).;
The
Distress
[5]:
prolapse
contraction
to
Oxford from
inserting
which
The feel
scale
performed
into 0the
modified
needs
Scale Ratings
to
(no
the
two PSQI
Activity
ranging
FPM
5andForm；RPE:
Questionnaire-7;
FSFI-6:
Pelvic
pelvicFunction
Female
Floor
PFIQ-7:
PFDI-20: to
Inventory
POP-Q Exertion
4vagina
[3],
to
by The
fingers
be Score-Short
Oxford
whichof
Physical
Impact Questionnaire
Perceived
Sexual
Index;
6-item
5inserting
quantitation;
Floor
organ Pelvic
(strong
The
Distress
[5]:
prolapse
contraction)
(strong
cm give
contraction
tofrom
feel
performed
for Pelvic
pelvic
scale
intoneeds
Scale Ratings
PFDI-20:
0the to
the
two
◯
Activity
Form；RPE:
Questionnaire-7;
FSFI-6:
Function
Female
Floor Exertion
Inventory
(no The Score-Short
quantitation;
Floor
organ
ranging
FPM
5and
[3],
vagina
to
byfingers
be of
Impact
Sexual
Index;
The6-item
Distress
contraction)
(stronggiveprolapse
inserting
which
◯
Questionnaire
Perceived
Pelvic
contraction
fromscale
performed
for
into Ratings
PFDI-20:
needs to
the
two Form；RPE:
Questionnaire-7;
0FSFI-6:
Function
Female
Inventory
(no The ◯
Exertion
Score-Short
of
quantitation;
Floor
ranging
5and
vagina
to
by
fingers
be The Perceived
Sexual
Index;
6-item
Distress
contraction)
(strong
givefrom
inserting 0FSFI-6:
Pelvic
scale
performed
for
into
◯
Ratings
Function
PFDI-20:
to Form；R
Female Exertion
Inventory
(no
the
two Floor
ranging
5vaginaof
The
Sexu
Inde
The Pe
6-i
Dist
contractio
(strong
by from
fingers
inserti
for
in
◯
IPAQ-SF; International
contraction).;IPAQ-SF;
POP-Q Physical
International
[5]: Activity
IPAQ-SF;
pelvic Physical
organ Demographic
Abbreviations:
Questionnaire
International
prolapse Activity
IPAQ-SF; Score-Short
Physical
quantitation; data,
Questionnaire
International including
Activity
IPAQ-SF;
Form；RPE:Score-Short
Physical
Questionnairethe
International
Ratingsage,
Activity
IPAQ-SF;
Form；RPE: height,
Score-Short
of
Physical
Questionnaire
Perceived
International weight,
Ratings
Activity
Form；RPE:
Exertion body
Score-Short
of
Physical
Questionnaire
Perceived mass
Ratings
Activity
Form；RPE:
Exertion index
Score-Short
ofQuestionnaire
Perceived (BMI),
Ratings prenatal
Form；RPE:
Exertion
Score-Short
of Perceived ✷（if
Ratings
Form；R
Exertion
of Pe
Questionnaire-20;
contraction).;
approximately Questionnaire-20;
PFIQ-7:
POP-Q
4approximately
cm Pelvic
contraction).;
to[5]:feel pelvic
Floor
PFIQ-7:
POP-Q
FPM cmImpact
4organ
approximatelyPelvic
contraction).;
to[5]:
prolapse
contraction
feel Questionnaire-7;
pelvic
the Questionnaire-20;
Floor
PFIQ-7:
POP-Q
FPM
and Impact
quantitation;
4organ
approximately
cm give Pelvic
contraction).;
to[5]:
prolapse
contraction
feel pelvic
scale the 4PFDI-20:
Questionnaire-7;
FSFI-6:
Questionnaire-20;
Floor
PFIQ-7:
PFDI-20:
POP-Q
ranging
FPM
and The
Impact
quantitation;
organ
contraction).;
The
[5]:
approximately
cm give The
6-item
Pelvic
prolapse
contraction
to from
feel Pelvic
pelvic
scale0the Pelvic
Questionnaire-7;
FSFI-6:
PFDI-20:
(no
Training POP-Q
ranging
FPM
and Floor
Questionnaire-20;
Female
Floor
PFIQ-7: The
Impact
quantitation;
4Floor
organ Sexual
contraction).;
The
Distress
contraction)[5]:
approximately
cm give
contraction
to
record from
feelDistress
6-item
Pelvic
prolapse
scaleQuestionnaire-7;
FSFI-6:
Pelvic
pelvicFunction
0the Female
Floor
to
(no PFIQ-7:
PFDI-20:
Inventory
POP-Q Inventory
The
Impact
quantitation;
4Floor
organ
ranging
FPM
5and Sexual
Index;
The6-item
Pelvic
Distress
[5]:
prolapse
contraction)
(strong
cm give
contraction
tofrom
feel Questionnaire-7;
FSFI-6:
Pelvic
pelvic
scale Function
Female
Floor
PFDI-20:
0the toInventory
(no The
Impact
quantitation;
Floor
organ
ranging
FPM
5and Sexual
Index;
The6-item
Distress
contraction)
(stronggive Questionnaire-7;
prolapse0FSFI-6:
Function
Pelvic
contraction
fromscale Female
PFDI-20:
toInventory
(no The Sexual
Index;
quantitation;
Floor
ranging
5and The6-item
Distress
contraction)
(strong
givefrom
✷ 0FSFI-6:
Function
Pelvic
scale Female
PFDI-20:
to The
Inventory
(no 5Floor
ranging Sexu
Inde
The6-i
Dist
contractio
(strong
from
Questionnaire-20;
Questionnaire-20;
contraction).; POP-Q PFIQ-7:
IPAQ-SF; Physical
Questionnaire-20;
PFIQ-7: Pelvic
contraction).;
[5]: Pelvic
International
pelvic Activity
IPAQ-SF;
POP-Q
organ maximum
Floor
Questionnaire-20;
Floor
PFIQ-7: Impact Impact
Physical
Questionnaire
contraction).;
[5]: International
Pelvic
prolapse
pelvic weight,
Questionnaire-7;
Activity
IPAQ-SF;
Questionnaire-7;
Questionnaire-20;
Floor
PFIQ-7:
POP-Q Score-Short
quantitation;
organ Physical
Impact Pelvic
contraction).;
[5]:
prolapse physical
Questionnaire
pelvic FSFI-6:
International
Activity
IPAQ-SF;
Questionnaire-7;
FSFI-6:
PFDI-20:
POP-Q activity
Form；RPE:
Questionnaire-20;
Floor
PFIQ-7: The
Impact
quantitation;
organ The
Score-Short
Physical
6-item
Pelvic
contraction).;
The
[5]:
prolapse 6-item
Questionnaire
Pelvic
pelvic during
International
Ratings
Activity
PFDI-20:
POP-Q Female
IPAQ-SF;
Form；RPE:
Questionnaire-7;
FSFI-6:
Questionnaire-20;
Female
Floor
PFIQ-7: The
Impact
quantitation;
Floor
organ pre-pregnancy
Sexual Sexual
Score-Short
of
Physical
Questionnaire
Perceived
International
6-item
Pelvic
contraction).;
The
Distress
[5]:
prolapse Function
Ratings
Activity
Form；RPE:
Questionnaire-7;
FSFI-6:
Pelvic
pelvicFunction
Female
Floor
PFIQ-7:
PFDI-20:
Inventory
POP-Q Exertion
The
Impact
quantitation;
Floor
organ Sexual
Index;
The and
Index;
Score-Short
of
Physical
Questionnaire
Perceived
6-item
Pelvic
Distress
[5]:
prolapse pregnancy,
Ratings
Activity
Form；RPE:
Questionnaire-7;
FSFI-6:
Pelvic
pelvicFunction
Female
Floor
PFDI-20: Exertion
Inventory The Score-Short
of
Impact
quantitation;
Floor
organ Sexual
Index;
The6-item
Distress and
Questionnaire
Perceived Ratingsbackground
Form；RPE:
Questionnaire-7;
prolapse FSFI-6:
Function
Pelvic Female
PFDI-20: Exertion
InventoryTheScore-Short
of Perceived
Sexual
Index;
quantitation;
Floor The6-item
Distress any）
Ratings
FSFI-6:
Function
Pelvic Form；R
Female
PFDI-20: Exertion
of
The
Inventory
Floor Sexu
Inde
The Pe
6-i
Dist
S: The modified Oxford Scale [3], which needs to be performed by inserting RPE
two fingers into the vagina for ap- ✷
IPAQ-SF;
IPAQ-SF;
Questionnaire-20;International
International
IPAQ-SF;
PFIQ-7:Physical
Questionnaire-20; Physical
International
Pelvic Activity
IPAQ-SF; data
Activity
Questionnaire-20;
Floor
PFIQ-7: Physical
Impact including
PelvicQuestionnaire
Questionnaire
International
Activity
IPAQ-SF;
Questionnaire-7;
Questionnaire-20;
Floor
PFIQ-7: the
Impact working
Score-Short
Score-Short
Physical
Questionnaire
International
Pelvic Activity
IPAQ-SF;
Questionnaire-7;
FSFI-6: position,
Form；RPE:
Form；RPE:
Questionnaire-20;
Floor
PFIQ-7: The Score-Short
Physical
International
6-item
Pelvic smoking,
RatingsRatings
Activity
IPAQ-SF;
Form；RPE:
Questionnaire-7;
FSFI-6:
Questionnaire-20;
Female
Floor
PFIQ-7: The Score-Short
of
Physical
Impact
Sexual
6-item
Pelvic alcohol
ofQuestionnaire-7;
Perceived
Questionnaire
Perceived
International
Ratings
Activity
FSFI-6:
Function
Female
Floor
PFIQ-7: Theconsumption,
Form；RPE: Exertion
Exertion
Score-Short
of
Physical
Perceived
Sexual
Index;
6-item
Pelvic Ratings
Activity
Questionnaire-7;
FSFI-6:
Function
Female
Floor The urine
Form；RPE:
Exertion
Score-Short
Impact
Sexual
Index;
6-item leakage,
ofQuestionnaire
Perceived RatingsForm；RPE:
Questionnaire-7;
FSFI-6:
Function
Female The ofasthma,
Exertion
Score-Short
Perceived
Sexual
Index;
6-item Ratings
FSFI-6:
FunctionForm；R
Female Exertion
of6-i
The
Sexu
IndePe
mately 4 cm to feel the FPM contraction and give scale ranging from 0 Adverse (no contraction) Event to 5 (strong contraction).;  
IPAQ-SF; Physical
International
Activity
IPAQ-SF; constipation,
Physical
Questionnaire
International
Activity
IPAQ-SF; family
Score-Short
Physical
Questionnaire history
International
Activity
IPAQ-SF;
Form；RPE: of
Score-Short
Physical PFD,
Questionnaire
International
Ratingsdelivery
Activity
IPAQ-SF;
Form；RPE: Score-Short
of
Physical history
Questionnaire
Perceived
International
Ratings
Activity
Form；RPE: of
Exertion pregnancy,
Score-Short
of
Physical
Questionnaire
Perceived Ratings
Activity
Form；RPE:
Exertion weight
Score-Short
ofQuestionnaire
Perceived Ratingsgain ofduring
Form；RPE:
Exertion
Score-Short
Perceived Ratings
Form；R
Exertion
of Pe
Q [5]: pelvic organ prolapse quantitation; PFDI-20: The Pelvic ●: Data Floor would Distress
be collected Inventoryby pelvicQuestionnaire-20;
floor professionals viaPFIQ-7: vaginal palpation. ◎: Data would be c
pregnancy, and fetal weight, would be collected at the enrollment visit of the study; while
Floor Impact Questionnaire-7; FSFI-6:the Thefollowing
6-item Female questionnaires would be filled by all participants Physi-
Sexual
experienced Function
General Index;
specialists asIPAQ-SF;
the examiners. International
◯: data would
at be collected by requesting all partic
baseline and at all
cal Activity Questionnairefollow-up Score-Short answers through
Form；RPE: Ratings of Perceived Exertion scanning a QR code. ✷: Recording by all the participants in EG only per their traini
visits: RPE score given by themselves. : Optional items
(1) The International Physical Activity Questionnaire Score-Short Abbreviations: Form (IPAQ-SF), which
3. Data Collection and Management
were recommended as a cost-effective method to assess physical by
MOS: The modified Oxford Scale [3], which needs to be performed insertingby
activity two fingers into th
nine
Demographic data, including the age,
approximately height, 4 cm weight,
to
questions recording the activity of four levels of intensities in short forms: vigorous-feel the body FPM mass
contraction index and (BMI),
give prena-
scale ranging from 0 (no contraction) to
tal maximum weight, physical contraction).;
activity during POP-Qpre-pregnancy
[5]: pelvic organ prolapse and quantitation; PFDI-20:
pregnancy, and The Pelvic Floor Distress I
intensity, moderate-intensity, walking, and sitting [31];
Questionnaire-20; PFIQ-7: Pelvic Floor Impact Questionnaire-7; FSFI-6: The 6-item Female Sexual Fu
(2) The Pelvic Floor IPAQ-SF; DistressInternational Inventory PhysicalQuestionnaire-20
Activity Questionnaire (PFDI-20)
Score-Shortand Form；RPE: Pelvic Ratings Floor of Perceiv
Impact Questionnaire-7 (PFIQ-7), which were designed to comprehensively evaluate
1 1 to what extent the lower urinary tract, lower gastrointestinal tract, and pelvic organ
1 1 1
1 1 1 prolapse1symptoms affect1 the quality
1 of life of women who suffer from PFD [32];
1 1 (3)
1 The Female1 Sexual Function
1 Index (FSFI-6)
1 [33], a common tool that has been validated
1 1 1 for clinical use for evaluating female sexual function in six terms [34,35];
1 1 1
1 1 1
(4) 1
The Pittsburgh 1
Sleep Quality 1
Index (PSQI), which was developed in 1989 and accepted
1 1 1 1 1 1 1 quality [36].
as the most common measure of sleep
1 1 1 1 1 1
Baseline demographic data, IPAQ-SF, PFDI-20, PFIQ-7, FSFI-6, and PSQI were inte-
grated into a WeChat mini program and can be filled by the Participants themselves by
scanning a QR code on WeChat, a social App that is commonly used by the public in China.
The body mass index (BMI) among the demographic data and all the scores or grades for
all the questionnaires can be automatically come out by the configured formulas in the
WeChat mini program.
Following the questionnaires in each of the visits would be the physical examination
including PFM strength evaluation by Modified Oxford Grading (MOS) [3], pelvic organ
prolapse quantitation (POP-Q) stage [5], vaginal relaxtity, symptomatic SUI detection and
grading, pelvic floor surface electromyography (sEMG) based on Glazer protocol [37],
pelvic floor ultrasound examination, quantitative measurement of pelvic sagittal rotation
degree by X-ray, and evaluation of the overall body composition and strength.
Pelvic floor surface electromyography (sEMG) would be tested based on Glazer proto-
col. The participants would be taught to contract the pelvic floor muscle correctly and will
have one practice before testing.
SUI is defined by SUI symptoms or a positive result of the cough stress test. Before the
cough stress test, participants are suggested to keep fully bladder. Positive result of the test
is defined as involuntarily urinary leakage when asked to cough in the lithotomy position.
Pelvic floor ultrasound indicators, which include LAM thickness, diameter of the
levator hiatus, and levator hiatus area, were measured using the proprietary software 4D
View via transperineal ultrasound(GE Kretz Medizintechnik), a reproducible and reliable
measurement of vaginal support [38].
The quantitative measurement of pelvic sagittal rotation degree on Spine X-ray
(Definium7000, General Electric Company, Boston, MD, USA) was analyzed which in-
cludes the pelvic tilt angle, the sacral slope angle, the difference of sacral slope and pelvic
tilt, the ratio of the pelvic tilt angle to the sacral slope angle, the ratio of the pelvic tilt angle
to the pelvic incidence angle and sacral-femoral distance.
The change of the overall body composition would be analyzed through body compo-
sition analyzers (Inbody 770), and overall strength which would be measured through hand
grip strength test and trunk endurance test. Body composition analyzers would analyze
data regarding waist hip ratio, basal metabolic rate, body fat rate, etc. Hand grip strength
would be measured by JAMAR Plus+ grip gauge. The measurement accuracy is 0.1 kg.
The participants should not have visible hand defects. The grip gauge should be adjusted
before measurement. When the participants hold the grip gauge, the second knuckle of the
index finger should be at 90 degrees. At the same time, mark the best position of each hand
on the grip meter. Before measurement, the participants should remove wrist jewelry to
avoid injury. The left and right hand are measured alternately three times. Trunk endurance
would be tested using the Plank test, Side bend test, and Biering–Sorensen Test [39]. All the
participants were encouraged to keep the positions as long as possible. Time as recorded in
seconds with a maximal length of 90 s.
4. Outcomes of the Study

The primary outcome will be the comparison of participants’ pelvic floor muscle
strengths using MOS scale at the enrollment baseline and post intervention. The secondary
outcomes will be: (1) the occurrence of SUI, (2) the change of the Pelvic floor ultrasound
indicators, (3) change of the Pelvic Organ Prolapse Quantitation measured by callipers,
(4) change of the pelvic sagittal rotation degree, and (5) the change of the overall body
composition and strength. The list of data collection instruments and time of data collection
is presented in Tables 2 and 3.
Table 3. Outline of Soring for general pelvic floor function.
Testing Items Indicators Compute Value Score Value

Stage 0 0
Stage I 1
POP-Q Stage II 2
Stage III 3
Stage IV 4
Yes 1
Cough stress test
No 0
≥4 fingers 4
>3 fingers, and <4 fingers 3
Vaginal relaxation
=3 fingers 2
>2 fingers, and <3 fingers 1
≤2 fingers 0
Pelvic floor <20 cm2 Hg 1

electrophysiological test [40] ≥20 cm2 Hg 0
* Total Score 1
PFDI-20 - Comprehensive score
PFIQ-7 - Comprehensive score
FSFI-6 - Comprehensive score
* Total Score 2
* The total score 1 means the sum of all above score values which represents objective indicators for pelvic floor
function. The lower the total score, the better the pelvic floor function; the total score 2 means the sum of the
above three comprehensive score which represents women’s subjective evaluation by themselves for pelvic floor.
The other secondary outcome measures involved in the Table 2 will be calculated and
discussed separately.
4.1. Sample Analysis

Sample size was calculated according to the improvement rate of MOS grade after
12-week training using PASS 2019 software. According to the preliminary experiment,
the improvement rate of MOS in the CG was 20% and that of women in EG was 60% at
6 months postpartum. Group sample sizes of 106 in each group achieve 90.248% power
to detect a difference between the group proportions of 0.4. The CG proportion is 0.2.
The EG proportion is assumed to be 0.4 under the null hypothesis and 0.6 under the
alternative hypothesis. The test statistic used is the one-sided Z test (unpooled). However,
in considering 20% of the possible dropout, a total of 260 women will be randomized.
4.2. Statistical Analysis

Data will be analyzed using SPSS version 26.0 (SPSS, Inc., Chicago, IL, USA) and
the statistically significant difference will be identified if p < 0.05. Descriptive statistics
including numbers and proportions, means and standard deviations, or medians (P25, P75)
will be used. Group differences in the primary and secondary outcomes will mainly use
chi-square and student’s t tests. For primary outcome, we will count the rate of pelvic
muscle strength reaching grade 4 at 6 months postpartum between EG and CG by chi-
square test or Fisher’s exact test as appropriate. Analysis of the primary and secondary
outcomes will be based on an intention-to-treat basis in consideration of the drop-offs from
the follow-ups and be conducted by the statistician at Peking University Clinical Research
Institute. For comparison between groups of quantitative data, the analysis of variance
or Wilcoxon rank sum test will be used according to the data distribution; chi square test
or exact probability method is used for counting data (if chi square test is not applicable),
Wilcoxon rank sum test or CMH test is used for grade data, and logistic regression analysis
is used for correlation analysis. Repeated ANOVA will be used to assess within-patient
correlation. and multivariable linear regression models if potential confounders were
imbalanced.
5. Discussion
Pelvic floor rehabilitation is becoming more and more important due to the rapid de-
velopment of rehabilitation medicine and the improvement of the life quality of demanded
by women. PFMT is one of the widely adopted exercise therapies in the clinic for female
pelvic floor rehabilitation.
Although medical societies realize that rehabilitative exercises to be the currently
demonstrated effective way to improve PFM, consensus on the standard for PFMT is still
lack. Many issues are remaining; questions, such as “what is the right to exercise correctly?”
and “what is the proper frequency and duration for PFM training?”, and reports on the
efficacy of PFMT are much confusing. Due to the positional particularity and abstractness
of pelvic floor muscles, it is difficult for a non-medical backgrounded woman to exercise
pelvic floor muscle fiber I and fiber II directly, accurately, and/or effectively. PFMT has not
been skilled for public populization, although many investigators have efforted exploring
more convenient and effective pelvic floor rehabilitation methods.
In referring to comprehensive literature related to our previous research [20], we
developed 12-week PEFLOW, with emphases on training of the entire muscle system.
PEFLOW is composed of 10 sections as shown in Table 1. The warm-up section
was setup to have the participants percept the pelvic floor contractions in different body
positions via self-feeling to the pelvic floor movements. In this section, participants are
instructed to practice quick contraction (1”) and relaxation (2”) for perception of type II
muscle fiber (fast-twist fiber) and hold-on contraction (8-10”) and relaxation (8-10”) for
perception of type I muscle fibers (slow-twist fiber). The training of multiple repetitions for
fast-twist fibers is also a way of targeting slow-twist fiber [41]. Section 1 was integrated
in the program to train the pelvic contractions corelating to the movements of standing,
heel lifting, single feet standing, and walking. According to the literature, feet play roles
in control and adjustment of postures, and exercises corelated with the movement of feet
can improve body balance and simulate feedback perception [42]. Section 2 was setup to
improve the flexibility and mobility of the lumbar vertebrae and pelvic, so as to make them
adapt the changes in woman’s body postures that is the unavoidable outcome of pregnancy
and delivery due to the changes in lumbar vertebrae bulge, pelvic width and tilt, and
the relevant muscle tension [43]. With Section 3, we tend to train the movements of PFM
with correlating to breaths. It was programed based on a rational from multiple studies
that exhaling maximizes PFM tension and strength [14,44]. Sections 4–8 were programed
to train joint contractions of the core muscles, surrounding muscles and PFMs as what
more and more scientific evidence demonstrated that PFM contraction can be optimized by
joint contractions of the core muscles such as abdominal, lumbar dorsal, and diaphragm
muscles [40], and surrounding muscles such as hip abductors [45,46].
Optimal and long-term therapeutic effects are anticipated. We made PEFLOW be
performed at home due to the meeting restrictions in COVID-19 pandemic. However, we
anticipate that home exercise with the facilitation of online guidance and encouragement
will increase the participation rate and the concordance of the women in taking correct
exercise. The requirement for participants to report the RPE score after each training session
is not only an encouragement to the participants, but a guarantee of the appropriate training
intensity being kept training effectively and safely [47].
The possible limitation of this trial might be that we lack more precise measurements
for physical activity level, such as wrist or waist accelerometers to monitor heart rate during
daily physical activities and trainings.
6. Conclusions
In conclusion, this study is expects that the 12-week online PEFLOW is a cost-effective
training for the recovery of Pelvic floor muscle function, which is suitable for future clinic
trails and also for clinical promotions.
Author Contributions: X.S. and W.J. are responsible for study design, conceptualization, and super-
vision. H.Z. is responsible for data management, writing articles, PEFLOW designs, and instructions
for exercises. H.Z., D.Z., L.G. and B.X., are responsible for writing—review and editing. H.L. is re-
sponsible for software and methodology. Y.D. is responsible for data collection and exercises assistant.
X.S. is responsible for funding acquisition. All authors have read and agreed to the published version
of the manuscript.
Funding: This research was supported by the National Key Technology R&D Program of China (number:
2018YFC2002204) and the Chinese Association of Plastics and Aesthetics (number: 2020-Z-27).
Institutional Review Board Statement: This study protocol has been approved by the Ethics Com-
mittee of Peking University People’s Hospital (number: 2021PHB254-001).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: Not applicable.
Acknowledgments: We thank all the participants in the study, all investigators in the project, and all
clinical examiners from Peking University People’s Hospital for their contributions.
Conflicts of Interest: The authors declare no conflict of interest.
References
1. Zhu, L.; Wenjia, L.O.U. Current situation of female pelvic floor rehabilitation in China. Chin. J. Fam. Plan. Gynecotokol. 2020, 12,
3–4, 8. (In Chinese)
2. Lan, Z.H.U.; Wenjia, L.O.U. Pay attention to female sexual dysfunction diseases. J. Pract. Obstet. Gynecol. 2018, 34, 401–402.
(In Chinese)
3. Ferreira, C.H.J.; Barbosa, P.B.; Souza, F.D.O.; Antônio, F.I.; Franco, M.M.; Bø, K. Inter-rater reliability study of the modified Oxford
Grading Scale and the Peritron manometer. Physiotherapy 2011, 97, 132–138. [CrossRef] [PubMed]
4. El-Haieg, D.O.; Madkour, N.M.; Basha, M.A.A.; Ahmad, R.A.; Sadek, S.M.; Al-Molla, R.M.; Tantwy, E.F.; Almassry, H.N.; Altaher,
K.M.; Mahmoud, N.E.M.; et al. Magnetic resonance imaging and 3-dimensional transperineal ultrasound evaluation of pelvic
floor dysfunction in symptomatic women: A prospective comparative study. Ultrasonography 2019, 38, 355–364. [CrossRef]
5. Bump, R.C.; Mattiasson, A.; Bo, K.; Brubaker, L.P.; DeLancey, J.O.; Klarskov, P.; Shull, B.L.; Smith, A.R. The standardization of
terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am. J. Obstet. Gynecol. 1996, 175, 10–17. [CrossRef]
6. Borello-France, D.F.; Handa, V.L.; Brown, M.B.; Goode, P.; Kreder, K.; Scheufele, L.L.; Weber, A.M.; Pelvic Floor Disorders
Network. Pelvic-floor muscle function in women with pelvic organ prolapse. Phys. Ther. 2007, 87, 399–407. [CrossRef]
7. Gilchrist, A.S.; Campbell, W.; Steele, H.; Brazell, H.; Foote, J.; Swift, S. Outcomes of observation as therapy for pelvic organ
prolapse: A study in the natural history of pelvic organ prolapse. Neurourol. Urodyn. 2013, 32, 383–386. [CrossRef]
8. Miedel, A.; Ek, M.; Tegerstedt, G.; Maehle-Schmidt, M.; Nyren, O.; Hammarstrom, M. Short-term natural history in women with
symptoms indicative of pelvic organ prolapse. Int. Urogynecol. J. 2011, 22, 461–468. [CrossRef]
9. Sigurdardottir, T.; Steingrimsdottir, T.; Geirsson, R.T.; Halldorsson, T.I.; Aspelund, T.; Bo, K. Can postpartum pelvic floor muscle
training reduce urinary and anal incontinence?: An assessor-blinded randomized controlled trial. Am. J. Obstet. Gynecol. 2020,
222, 247.e1–247.e8. [CrossRef]
10. Min, L.; Chunxue, Y.; Qiubo, L.; Xudong, D.; Yan, Z.; Guifang, Z.; Kejia, H.; Tianzi, G.; Qing, F. Effectiveness of intravaginal
electrical stimulation combined with electromyography biofeedback-mediated pelvic floor muscle training for postpartum
symptomatic pelvic organ prolapse: Protocol for the PROSPECT randomized trial. Trials 2022, 23, 131. [CrossRef]
11. Bo, K.; Angles-Acedo, S.; Batra, A.; Braekken, I.H.; Chan, Y.L.; Jorge, C.H.; Kruger, J.; Yadav, M.; Dumoulin, C. International
urogynecology consultation chapter 3 committee 2; conservative treatment of patient with pelvic organ prolapse: Pelvic floor
muscle training. Int. Urogynecol. J. 2022. [CrossRef] [PubMed]
12. Kegel, A.H. Progressive resistance exercise in the functional restoration of the perineal muscles. Am. J. Obstet. Gynecol. 1948, 56,
238–248. [CrossRef]
13. Iglesia, C.B.; Smithling, K.R. Pelvic Organ Prolapse. Am. Fam. Physician 2017, 96, 179–185.
14. Zachovajeviene, B.; Siupsinskas, L.; Zachovajevas, P.; Venclovas, Z.; Milonas, D. Effect of diaphragm and abdominal muscle
training on pelvic floor strength and endurance: Results of a prospective randomized trial. Sci. Rep. 2019, 9, 19192. [CrossRef]
[PubMed]
15. Oliva-Lozano, J.M.; Muyor, J.M. Core Muscle Activity During Physical Fitness Exercises: A Systematic Review. Int. J. Environ. Res.
Public Health 2020, 17, 4306. [CrossRef] [PubMed]
16. Brennen, R.; Lin, K.Y.; Denehy, L.; Frawley, H.C. The Effect of Pelvic Floor Muscle Interventions on Pelvic Floor Dysfunction After
Gynecological Cancer Treatment: A Systematic Review. Phys. Ther. 2020, 100, 1357–1371. [CrossRef] [PubMed]
17. Tenfelde, S.; Logan, R.; Abernethy, M. Yoga from the pelvic floor. Beginnings 2014, 34, 24–26.
18. Fozzatti, C.; Herrmann, V.; Palma, T.; Riccetto, C.L.; Palma, P.C. Global Postural Re-education: An alternative approach for stress
urinary incontinence? Eur. J. Obstet. Gynecol. Reprod. Biol. 2010, 152, 218–224. [CrossRef]
19. Fozzatti, M.C.; Palma, P.; Herrmann, V.; Dambros, M. Impact of global postural reeducation for treatment of female stress urinary
incontinence. Rev. Assoc. Med. Bras. 2008, 54, 17–22. [CrossRef]
20. Liu, T.; Hou, X.; Xie, B.; Wu, J.; Yang, X.; Sun, X.; Wang, J. Pelvic incidence: A study of a spinopelvic parameter in MRI evaluation
of pelvic organ prolapse. Eur. J. Radiol. 2020, 132, 109286. [CrossRef]
21. Teodori, R.M.; Negri, J.R.; Cruz, M.C.; Marques, A.P. Global Postural Re-education: A literature review. Rev. Bras. Fisioter. 2011,
15, 185–189. [CrossRef] [PubMed]
22. Dufour, S.; Wu, M. No. 397—Conservative Care of Urinary Incontinence in Women. J. Obstet. Gynaecol. Can. 2020, 42, 510–522.
[CrossRef] [PubMed]
23. Talley, K.M.C.; Wyman, J.F.; Bronas, U.; Olson-Kellogg, B.J.; McCarthy, T.C. Defeating Urinary Incontinence with Exercise Training:
Results of a Pilot Study in Frail Older Women. J. Am. Geriatr. Soc. 2017, 65, 1321–1327. [CrossRef] [PubMed]
24. Virtuoso, J.F.; Menezes, E.C.; Mazo, G.Z. Effect of Weight Training with Pelvic Floor Muscle Training in Elderly Women with
Urinary Incontinence. Res. Q. Exerc. Sport 2019, 90, 141–150. [CrossRef]
25. Bo, K. Physiotherapy management of urinary incontinence in females. J. Physiother. 2020, 66, 147–154. [CrossRef]
26. Dumoulin, C.; Morin, M.; Danieli, C.; Cacciari, L.; Mayrand, M.H.; Tousignant, M.; Abrahamowicz, M. Group-Based vs Individual
Pelvic Floor Muscle Training to Treat Urinary Incontinence in Older Women: A Randomized Clinical Trial. JAMA Intern. Med.
2020, 180, 1284–1293. [CrossRef]
27. Gao, L.; Zhang, D.; Wang, S.; Jia, Y.; Wang, H.; Sun, X.; Wang, J. Effect of the App-Based Video Guidance on Prenatal Pelvic
Floor Muscle Training Combined with Global Postural Re-education for Stress Urinary Incontinence Prevention: A Protocol for a
Multicenter, Randomized Controlled Trial. Int. J. Environ. Res. Public Health 2021, 18, 12929. [CrossRef]
28. Gasquet, I.; Tcherny-Lessenot, S.; Gaudebout, P.; Bosio, L.G.B.; Klein, P.; Haab, F. Influence of the severity of stress urinary
incontinence on quality of life, health care seeking, and treatment: A national cross-sectional survey. Eur. Urol. 2006, 50, 818–825.
[CrossRef]
29. de Andrade, R.L.; Bo, K.; Antonio, F.I.; Driusso, P.; Mateus-Vasconcelos, E.C.L.; Ramos, S.; Julio, M.P.; Ferreira, C.H.J. 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, 91–96. [CrossRef]
30. Arney, B.E.; Glover, R.; Fusco, A.; Cortis, C.; de Koning, J.J.; van Erp, T.; Jaime, S.; Mikat, R.P.; Porcari, J.P.; Foster, C. Comparison
of RPE (Rating of Perceived Exertion) Scales for Session RPE. Int. J. Sports Physiol. Perform. 2019, 14, 994–996. [CrossRef]
31. Craig, C.L.; Marshall, A.L.; Sjostrom, M.; Bauman, A.E.; Booth, M.L.; Ainsworth, B.E.; Pratt, M.; Ekelund, U.; Yngve, A.; Sallis, J.F.;
et al. International physical activity questionnaire: 12-country reliability and validity. Med. Sci. Sports Exerc. 2003, 35, 1381–1395.
[CrossRef]
32. Barber, M.D.; Walters, M.D.; Bump, R.C. Short forms of two condition-specific quality-of-life questionnaires for women with
pelvic floor disorders (PFDI-20 and PFIQ-7). Am. J. Obstet. Gynecol. 2005, 193, 103–113. [CrossRef]
33. Isidori, A.M.; Pozza, C.; Esposito, K.; Giugliano, D.; Morano, S.; Vignozzi, L.; Corona, G.; Lenzi, A.; Jannini, E.A. Development
and validation of a 6-item version of the female sexual function index (FSFI) as a diagnostic tool for female sexual dysfunction. J.
Sex. Med. 2010, 7, 1139–1146. [CrossRef] [PubMed]
34. Chedraui, P.; Perez-Lopez, F.R.; Sanchez, H.; Aguirre, W.; Martinez, N.; Miranda, O.; Plaza, M.S.; Schwager, G.; Narvaez, J.;
Quintero, J.C.; et al. Assessment of sexual function of mid-aged Ecuadorian women with the 6-item Female Sexual Function
Index. Maturitas 2012, 71, 407–412. [CrossRef]
35. Sonbahar, A.E.; Culha, M.G.; Jannini, E. The validity and reliability of the Turkish version of the 6-item female sexual function
index (FSFI-6) and the relationship between climacturia and female sexual dysfunction. Int. J. Impot. Res. 2021, 1–4. [CrossRef]
[PubMed]
36. Mollayeva, T.; Thurairajah, P.; Burton, K.; Mollayeva, S.; Shapiro, C.M.; Colantonio, A. The Pittsburgh sleep quality index as a
screening tool for sleep dysfunction in clinical and non-clinical samples: A systematic review and meta-analysis. Sleep Med. Rev.
2016, 25, 52–73. [CrossRef] [PubMed]
37. Oleksy, L.; Wojciechowska, M.; Mika, A.; Antos, E.; Bylina, D.; Kielnar, R.; Pruszczynski, B.; Stolarczyk, A. Normative values for
Glazer Protocol in the evaluation of pelvic floor muscle bioelectrical activity. Medicine 2020, 99, e19060. [CrossRef]
38. Kobak, W.H.; Rosenberger, K.; Walters, M.D. Interobserver variation in the assessment of pelvic organ prolapse. Int. Urogynecol. J.
Pelvic Floor Dysfunct. 1996, 7, 121–124. [CrossRef]
39. Martinez-Romero, M.T.; Ayala, F.; De Ste, C.M.; Vera-Garcia, F.J.; Sainz, D.B.P.; Santonja-Medina, F.; Sanchez-Meca, J. A Meta-
Analysis of the Reliability of Four Field-Based Trunk Extension Endurance Tests. Int. J. Environ. Res. Public Health 2020, 17, 3088.
[CrossRef]
40. Blomquist, J.L.; Carroll, M.; Munoz, A.; Handa, V.L. Pelvic floor muscle strength and the incidence of pelvic floor disorders after
vaginal and cesarean delivery. Am. J. Obstet. Gynecol. 2020, 222, 62.e1–62.e8. [CrossRef]
41. Deshmukh, A.S.; Steenberg, D.E.; Hostrup, M.; Birk, J.B.; Larsen, J.K.; Santos, A.; Kjobsted, R.; Hingst, J.R.; Scheele, C.C.; Murgia,
M.; et al. Deep muscle-proteomic analysis of freeze-dried human muscle biopsies reveals fiber type-specific adaptations to
exercise training. Nat. Commun. 2021, 12, 304. [CrossRef] [PubMed]
42. Viseux, F.; Lemaire, A.; Barbier, F.; Charpentier, P.; Leteneur, S.; Villeneuve, P. How can the stimulation of plantar cutaneous
receptors improve postural control? Review and clinical commentary. Neurophysiol. Clin. 2019, 49, 263–268. [CrossRef] [PubMed]
43. de Tayrac, R.; Schantz, C. Childbirth pelvic floor trauma: Anatomy, physiology, pathophysiology and special situations—CNGOF
perineal prevention and protection in obstetrics guidelines. Gynecol. Obstet. Fertil. Senol. 2018, 46, 900–912. [CrossRef] [PubMed]
44. Wieland, L.S.; Shrestha, N.; Lassi, Z.S.; Panda, S.; Chiaramonte, D.; Skoetz, N. Yoga for treating urinary incontinence in women.
Cochrane Database Syst. Rev. 2019, 2, CD012668. [CrossRef]
45. Tuttle, L.J.; Autry, T.; Kemp, C.; Lassaga-Bishop, M.; Mettenleiter, M.; Shetter, H.; Zukowski, J. Hip exercises improve intravaginal
squeeze pressure in older women. Physiother. Theory Pract. 2020, 36, 1340–1347. [CrossRef] [PubMed]
46. Gomes, C.S.; Pedriali, F.R.; Urbano, M.R.; Moreira, E.H.; Averbeck, M.A.; Almeida, S.H.M. The effects of Pilates method on pelvic
floor muscle strength in patients with post-prostatectomy urinary incontinence: A randomized clinical trial. Neurourol. Urodyn.
2018, 37, 346–353. [CrossRef]
47. Nygaard, I.E.; Wolpern, A.; Bardsley, T.; Egger, M.J.; Shaw, J.M. Early postpartum physical activity and pelvic floor support and
symptoms 1 year postpartum. Am. J. Obstet. Gynecol. 2021, 224, 193.e1–193.e19. [CrossRef] [PubMed]

Ijerph 19 11073

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ijerph 19 11073

Uploaded by

Copyright:

Available Formats

International Journal of

2.2. Inclusion Criteria

2.3. Exclusion Criteria

2.4. Site Investigators and Roles

2.5. Randomization and Allocation Concealment

2.6. Assessment Schedule

Table 1. The 12-week Pelvic Floor Workout and the sectioning.

Week 8-Scetion Program Week 8-Scetion Program

Week 8-Scetion Program Week 8-Scetion Program

4. Outcomes of the Study

Table 3. Outline of Soring for general pelvic floor function.

Testing Items Indicators Compute Value Score Value

Pelvic floor <20 cm2 Hg 1

4.1. Sample Analysis

4.2. Statistical Analysis

You might also like