Physiotherapy Theory and Practice

An International Journal of Physical Therapy

ISSN: 0959-3985 (Print) 1532-5040 (Online) Journal homepage: http://www.tandfonline.com/loi/iptp20

Physiotherapy methods to facilitate pelvic floor

muscle contraction: A systematic review

Elaine Cristine Lemes, Mateus-Vasconcelos, PT, PhD, Aline Moreira Ribeiro,

PT, MSc, Flávia Ignácio Antônio, PT, PhD, Luiz Gustavo de Oliveira Brito, PhD
& Cristine Homsi Jorge Ferreira

To cite this article: Elaine Cristine Lemes, Mateus-Vasconcelos, PT, PhD, Aline Moreira Ribeiro,
PT, MSc, Flávia Ignácio Antônio, PT, PhD, Luiz Gustavo de Oliveira Brito, PhD & Cristine Homsi
Jorge Ferreira (2017): Physiotherapy methods to facilitate pelvic floor muscle contraction: A
systematic review, Physiotherapy Theory and Practice, DOI: 10.1080/09593985.2017.1419520

To link to this article: https://doi.org/10.1080/09593985.2017.1419520

Published online: 26 Dec 2017.

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 PHYSIOTHERAPY THEORY AND PRACTICE
https://doi.org/10.1080/09593985.2017.1419520

REVIEW

Physiotherapy methods to facilitate pelvic floor muscle contraction: A

systematic review
Elaine Cristine Lemes, Mateus-Vasconcelos, PT, PhDa,b,c, Aline Moreira Ribeiro, PT, MSc a,
Flávia Ignácio Antônio, PT, PhDc, Luiz Gustavo de Oliveira Brito, PhDd, and Cristine Homsi Jorge Ferreira, PT, PhDc
a
Rehabilitation Center of Clinical Hospital of the Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil; bBarão
de Mauá University Center, Ribeirão Preto, SP, Brazil; cDepartment of Biomechanics, Medicine and Rehabilitation of the Locomotor System,
Course of Physiotherapy, Department of Health Sciences - RibeirãPreto Medical School, Ribeirão Preto, SP, Brazil; dDepartment of
Gynecology and Obstetrics, Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto, SP, Brazil

ABSTRACT ARTICLE HISTORY

Aim: To undertake a systematic review of the literature on physical therapy methods to facilitate Received 10 November 2015
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voluntary pelvic floor muscles (PFM) contraction. Methods: The databases consulted were PubMed, Accepted 13 March 2017
the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, PEDro Revised 30 December 2016
and CINHAL. The study included randomized controlled trials, quasi-experimental trials and systematic KEYWORDS
reviews. The GRADE scale was used to assess methodological quality. Results: Six manuscripts were Awareness; muscle
included. The methods investigated included instruction regarding the anatomy and function of the contraction; pelvic floor;
PFM, vaginal palpation, palpation on the central perineal tendon, interruption of urinary flow, biofeed- physical therapy; systematic
back using a perineometer, vaginal cones, hypopressive exercise, PFM contraction associated with review
diaphragmatic breathing; and coactivation of abdominal muscles. The studies showed improvement
in PFM contraction, but most were of low methodological quality. Only one study was characterized as
being of high methodological quality. Conclusion: All the studies observed improvement in PFM
contraction using various methods, but none were superior over the others. The studies revealed no
adverse effects of the interventions used. Patient preferences should be taken into account in clinical
decision-making. More studies of high methodological quality on this topic are needed.

Introduction The literature has established that women with pel-

vic floor dysfunction have poorer PFM strength than
Pelvic floor muscles training (PFMT) is essential for the
asymptomatic women (Amaro, Moreira, De Oliveira
treatment of pelvic floor dysfunctions. It has the highest
Orsi Gameiro, and Cr, 2005; Devreese et al., 2004). A
level of evidence in the treatment of urinary incontinence
study conducted by Amaro, Moreira, De Oliveira Orsi
(UI) (Dumoulin, Hay-Smith and Mac Habée-Séguin,
Gameiro, and Cr (2005) showed that only 25.5% of
2014). There is high prevalence of women, who are
incontinent patients were able to interrupt the urine
unable to correctly contract their pelvic floor muscles
stream by contracting their PFM, compared to 80% of
(PFM). Teaching women how to contract the pelvic
continent women. Furthermore, the assessment of PFM
floor is one of the most difficult tasks required of phy-
contraction by visual observation, vaginal digital palpa-
siotherapists (Bø and Stien, 1994). Even when thoroughly
tion scale and manometry all showed significantly
instructed regarding PFM anatomy and function, a high
higher strength in the group of continent women. A
percentage of women fail to correctly distinguish PFM
study by Devreese et al. (2004) showed better PFM
contraction from other muscle contraction (Hesse,
strength, endurance, and coordination of contractions
Vodusek, and Deindl, 1991). Talasz et al. (2008) found
in continent women compared with incontinent
that 44.9% of the asymptomatic women investigated in
women. The authors suggested that women with UI
their study were unable to perform a voluntary and
tend to have poor control of the PFM.
normal PFM contraction. Tibaek and Dehlendorff
Physical therapists who work with women’s health
(2014) found that 70% of women with pelvic floor dys-
and pelvic floor physiotherapy are often challenged to
function were unable to perform a correct voluntary
use therapeutic methods in their clinical practice to
PFM contraction, and 97% had low PFM strength.
facilitate voluntary and correct PFM contraction.

CONTACT Cristine Homsi Jorge Ferreira cristine@fmrp.usp.br Department of Biomechanics, Medicine and Rehabilitation of the Locomotor System,
Course of Physiotherapy, Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto, SP, Brazil
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/IPTP.
© 2017 Taylor & Francis
 2 E. C. L. MATEUS-VASCONCELOS ET AL.
In clinical practice, the ability to correctly contract
the PFM is essential to training. This skill is at least as
important as muscle strength (Devreese et al., 2004).
Only women who are able to perform correct contrac-
tions are eligible to perform PFMT. Clinically, a correct
PFM contraction is felt during vaginal palpation exam
as a tightening, lifting, and squeezing action under the
examining finger (Messelink et al., 2005). However,
there is no consensus as to the best method to facilitate
PFM contraction. Different physiotherapeutic interven-
tions are recommended in the literature, including
digital palpation, biofeedback, or simply instructions
regarding contraction of the PFM (Bø, Berghmans,
Morkved, and Van Kampen, 2007). Even though this
issue is essential in physiotherapeutic treatment of
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female pelvic floor dysfunctions, a preliminary search
on PubMed revealed no systematic reviews of the lit-
erature regarding the effectiveness of physiotherapy
methods used to promote correct PFM contraction.
Thus, the present study aimed to conduct a systematic
review of physiotherapeutic methods to facilitate volun-
tary PFM contraction.
Materials and methods
Protocol and registry
This systematic review was registered in the
PROSPERO under protocol number CRD42014009694
and followed the recommendations of the PRISMA
Statement for Reporting Systematic Reviews and
Meta-Analyses of Studies (Moher, Liberati, Tetzlaff,
and Altman, 2009).
Eligibility criteria
The research included scientific articles, without restric-
tion as to the date of publication and language, that
addressed physical therapy interventions aimed at facil-
itating voluntary contraction of the PFM in women, as an
isolated intervention or in association with others, and as
a primary or secondary outcome assessed using any
vaginal palpation scale. Only randomized controlled clin-
ical trials (RCT), quasi-experimental trials and systematic
reviews published in full, including a sample consisting of
adult women (above 18 years of age) were eligible to be
included in this systematic review.
We excluded articles which: exclusively addressed sur-
gical treatment of pelvic floor dysfunction; did not use
any outcome measure to evaluate the ability of women to
voluntarily contract the pelvic floor; excluded women
unable to contract their PFM; or did not describe the
use of a method to facilitate PFM contraction.
Sources of information
The databases consulted were PubMed, the Cochrane
Central Register of Controlled Trials and the Cochrane
Database of Systematic Reviews, PEDro and CINHAL.
The computer database search was performed by two
reviewers (ECLMV and AMR) from April 1–7, 2014
and updated on 5th February, 2016. All date ranges
available in each database were used in the search for
manuscripts. The following keywords were used for the
search strategy: “pelvic floor and awareness,” “pelvic
floor and disabled,” “pelvic floor and disability,” “pelvic
floor and absent muscle contraction,” “pelvic floor and
absence of muscle contraction,” “methods facilitate pel-
vic floor muscle contraction,” “methods improve pelvic
floor muscle contraction,” “pelvic floor muscle inability
contraction,” “pelvic floor muscle inefficient,” “non-
contracting pelvic floor muscle,” “underactive pelvic
floor muscle,” “non-functioning pelvic floor muscle”
and “learning pelvic floor muscle contraction.”
Search, selection, and assessment of
methodological quality of the studies
The search for and selection of articles based on the
eligibility criteria were performed by two indepen-
dent reviewers (ECLMV and AMR). The manu-
scripts were selected by the evaluators based on
the titles and abstracts, and final inclusion was
decided upon by agreement between them. Any
discordant ratings were resolved by consensus with
a third evaluator (CHJF).
The assessment of methodological quality of the
studies was based on the Grading of
Recommendations, Assessment, Development and
Evaluations (GRADE) (www.gradeworkinggroup.org).
Table 1 shows the categories assessed by GRADE,
descriptions and scores.
Based on the score received, the articles were sorted
according to methodological quality as described by
Guyatt et al. (2008):
High Moderate Low Very low
High quality: Further research is very unlikely to
change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have
an important impact on our confidence in the estimate
of effect and may change the estimate. Low quality:
Further research is very likely to have an important
impact on our confidence in the estimate of effect and
is likely to change the estimate. Very low quality: Any
estimate of effect is very uncertain.
 PHYSIOTHERAPY THEORY AND PRACTICE 3

Table 1. Grading of recommendations, assessment, development and evaluation – GRADE scale.

Categories Description Score
Risk of bias Refers to the presence of bias in the selection of the study population, distribution of the compared groups, and 0; −1; −2
ways of gauging, measuring or evaluating the results. It relates limitations in the design or conduct of the study,
i.e., the result of methodological evaluation of each design (Guyatt et al, 2011a)
Imprecision When a result is considered inaccurate, when there is doubt about the significance, or a widened confidence 0; −1; −2
interval, which arises from a small number of participants, or small number of events (Guyatt et al., 2011b)
Indirect evidence Evaluates whether there are differences in the populations, interventions, comparisons and outcomes among the 0; −1; −2
included studies and whether the question of interest in the review is called indirect evidence (Guyatt et al., 2011c)
Inconsistency of results/ Refers to heterogeneity or inconsistency of results between different subgroups of patients on the same test or in 0; −1; −2
Heterogeneity different centers of a multicenter study, or from different studies of a review (Guyatt et al., 2011d)
Publication bias Refers to search asymmetry between results that favor one of the treatments evaluated. It also assesses the 0; −1; −2
influence of research funding (Guyatt et al., 2011e)

Synthesis of results Results

Due to the heterogeneity of the studies and lack of Selection of studies
standardized outcome measures, qualitative analysis
A total of 301 publications were identified in PubMed,
was undertaken. Data were summarized in tables.
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115 publications in the Cochrane Central Register of

Definitions and units were reported in the text accord-
Controlled Trials and Cochrane Database of Systematic
ing to the standards jointly recommended by the
Reviews, 20 publications in PEDro and 87 publications
International Continence Society and the International
in CINHAL, for a total of 523 studies. After applying
Urogynecological Association (Haylen et al., 2010). The
the inclusion criteria, six were selected for this review
description of the studies in the tables was reported
(Figure 1).
strictly according to the authors’ terminology.

Figure 1. PRISMA flow diagram with the number of articles identified, excluded and included in the systematic review.
 4 E. C. L. MATEUS-VASCONCELOS ET AL.

Sample, evaluation and methods of facilitating Oxford grading system; 25% of the women were com-
contraction of the PFM pletely unable to contract their PFM at baseline (Talasz,
Kalchschmid, Kofler, Lechleitner, 2012). In another
The characteristics of the articles included are shown in
study, 91% of the sample showed a mean score of < 3
Table 2. Only two studies were RCTs, and one was a
in the Modified Oxford grading system at baseline
pilot study. Sample sizes ranged between 11 and 63,
(Hung et al., 2011). Pinheiro et al. (2012) included
with a mean of 34.2 (7.4) participants. The age ranged
only women with a score of < 3 according to the
was 18 to 65 years old, with a mean of 50.1 (4.3) and
Modified Oxford grading system. In one study, 31%
median of 55. Three different digital vaginal palpation
of the sample had absent or minimal PFM contraction
scales were used to assess PFM contraction including:
at baseline, evaluated using a non-validated palpation
1) the Modified Oxford grading scale (Hung et al.,
scale (Benvenuti et al., 1987).
2011; Pinheiro et al., 2012; Resende et al., 2012; Stüpp
The studies used the following methods to facilitate
et al., 2011; Talasz, Kalchschmid, Kofler, Lechleitner,
PFM contraction: instruction regarding the anatomy
2012); 2) PERFECT Scheme (Pinheiro et al., 2012;
and function of the PFM; vaginal palpation; palpation
Stüpp et al., 2011); and 3) a non-validated scale
on the central perineal tendon; interruption of urinary
(Benvenuti et al., 1987). Additionally, one used peri-
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flow during urination; biofeedback using a perine-

neometry (Hung et al., 2011) and two used surface
ometer; proprioceptive technique with a vaginal cone;
electromyography (Resende et al., 2012; Stüpp et al.,
hypopressive exercise; PFM contraction associated with
2011). Three studies used more than one method for
diaphragmatic breathing and visualization using a mir-
assessment of PFM contraction (Hung et al., 2011;
ror; and coactivation of the anterolateral abdominal
Resende et al., 2012; Stüpp et al., 2011).
muscles (Table 3).
All subjects in the studies exhibited poor PFM func-
As for the mechanism of action of the methods used
tion, including various aspects of muscle contraction, as
to contract the PFM cited above, only two studies
shown in Table 3. In one study, the authors considered
provided an explanation. Resende et al. (2012)
a correct contraction of the PFM when women in the
explained that the use of hypopressive exercise, as
sample received a score of ≥ 3 using the Modified

Table 2. General characteristics of selected studies.

Country
Authors/Year Journal of Origin Study Design Sample/Withdrawal Rates Age
Benvenuti et al. American Journal of Italy Clinical trial. 26 female outpatients with diagnosed stress urinary 50.8 years
(1987) Physical Medicine and Single-group incontinence. (range 36–65)
Rehabilitation pretest-post-test *Withdrawal rate: 4 patients
design There is no data regarding the place of recruitment.
Hung et al. (2011) Physical Therapy Taiwan Single-group 23 women. 51.9 (6.1) years
pretest-post-test *Withdrawal rate: none.
design Participants were recruited from the Life Quality & Health
Promotion Laboratory at National Taiwan University, with
some in the Ultrasonography Room of the Department of
Obstetrics and Gynecology at National Taiwan University
Hospital.
Pinheiro et al. Fisioterapia em Brazil Randomized Eleven women. G1:
(2012) Movimento clinical trial *Withdrawal rate: 1 patient. 55.0 (3.3) years
Urogynecology and Vaginal Surgery Outpatient Clinics of G2:
the Federal University of São Paulo – Paulista Medical 57.8 (1.4) years
School.
Resende et al. Neurourology and Brazil Randomized 63 women with stage II pelvic organ prolapse 55.4 (9.8) years
(2012) Urodynamics controlled *Withdrawal rate: 5 women from the control group
clinical trial Participants were recruited during routine consultation with
a gynecologist
Stüpp et al. (2011) International Brazil Pilot single- 42 women with untreated stage II anterior or posterior 55.0 (8.0) years
Urogynecology blinded vaginal wall prolapse
Journal randomized *Withdrawal rate: 5 women declined to participate in the
controlled trial study (control group)
Women admitted from Division of Urogynecology and
Reconstructive Pelvic Surgery, Federal University of São
Paulo, Brazil.
Talasz, Archives of Austria Cross-sectional 42 nulliparous women 25.0 (5.0) years
Kalchschmid, Gynecology and and *Withdrawal rate: 3 patients (range 18–35)
Kofler and Obstetrics interventional The study was approved by the ethics committee of the
Lechleitner study Medical University in Innsbruck, Austria, and was carried out
(2012) in an affiliated general hospital with departments of
internal and geriatric medicine and neurology.
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Table 3. Objectives, interventions and measurement of results of selected studies.

Authors/Year Objectives Resource used to raise awareness of PFM Outcome Measure Control/Intervention
Benvenuti et al. To demonstrate the effects of Instruction Vaginal palpation Not controlled
(1987) education regarding the Vaginal palpation (absent/minimal, moderate and strong * Brief explanation of the anatomy and physiology of the lower urinary tract
levator ani muscle, in Interruption of urinary stream contraction) and in particular of the pubococcygeous muscles.
particular, the medial portion 3 months of treatment * Specific education was focused on establishing awareness of function of
(pubococcygeus muscles) the pubococcygeus muscles using vaginal palpation.
* To improve awareness of contraction of the PFM, the subjects were
instructed to interrupt the urinary stream when voiding. *30-minute session
daily, 5 days a week for the first 2 weeks,-then once a week for the last two-
and-a- half months.
* Patients were instructed to repeat vaginal exercises as frequently as
possible and at least 10 times per hour.
Hung et al. To investigate the effect of Instruction PFM strength Not controlled
(2011) PFM strengthening Vaginal palpation *Vaginal palpation - Modified Oxford * Individual instruction about the anatomy and physiology of urinary
on bladder neck mobility for Pressure feedback grading system: no contraction, flicker, continence.
women with stress UI or weak, moderate, good, strong. * Participants were taught how to contract the PFM correctly by vaginal
mixed UI. *Vaginal squeeze pressure palpation and pressure feedback.
4-month daily strengthening * Participants were asked to perform 3 to 5 sets of 6 high-intensity (near-
exercise program maximal) contractions daily at home, with the aim of holding each muscle
contraction for 10 sec maximally and with at least a 10 sec rest between
contractions.
*Fast contractions (1 sec maximal contraction plus 1 sec relaxation) were
added after the sustained contractions, with a target of 10 repetitions in
every set.
Pinheiro et al. To compare PFMT with digital Palpation on the central perineal tendon PFM functional assessment: Not controlled
(2012) palpation with PFMT with Vaginal palpation *Vaginal palpation - PERFECT scheme. *G1 (Biofeedback group): Perineal awareness program consisted of
biofeedback for perineal Pressure feedback Modified Oxford grading system was used biofeedback exercises: achieving the same number of rapid and slow
consciousness of for assessment of the PFM strength. contractions of same duration as that achieved during the PERFECT, over 8
women with stress UI. 4 sessions for 2 consecutive weeks. series, with time of contraction/relaxation 1:2.
*G2 (Palpation group):
- First session: the participants were instructed to contract the PFM while the
physiotherapist performed the palpation on the central perineal tendon.
Then held up the myotatic stretch reflex, in which the physiotherapist
introduced the index and middle finger into the vagina and performed a
quick stretch down, at the same time requesting muscle contraction from
the patient. The number of repetitions of this exercise took into account the
evaluation of fast muscle fibers according to the PERFECT test. The series of
contractions was repeated 3 times with rest time of 1:2
- Second session: In addition to the exercises of the first session, awareness
training of slow muscle fiber contraction was initiated, through digital
palpation by the physiotherapist. 8 contractions were performed, with rest
time of 1:2 between each contraction; the series was repeated 3 times.
- Third session: Identical to the second session.
- Fourth and last session: the exercises of the previous sessions were
performed, but the patient performed self-palpation in the perineal area,
touching the perineum externally with the index and middle fingers in an
inverted “V”, and performed the perineal isolated contraction. Slow fiber
training (eight contractions) and fast fiber training (10 contractions) were
PHYSIOTHERAPY THEORY AND PRACTICE

conducted, with rest time of 1:2 between each contraction.

(Continued )
5

Table 3. (Continued).
Authors/Year Objectives
Resende et al. To evaluate the impact of the
(2012) 3-month hypopressive
exercise (HE) routine in
combination with PFMT (HE +
PFMT), vs. a PFMT regimen
only, on PFM strength and
activation, and to compare
these groups with a control
group
Stüpp et al. To investigate the
(2011) effectiveness of PFMT for the
treatment of pelvic organ
prolapse.
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6
Resource used to raise awareness of PFM Outcome Measure Control/Intervention
Instruction MVC and endurance: Control Group:
Proprioceptive technique with a vaginal *Vaginal palpation - Modified Oxford *They attended one appointment and received lifestyle advice and
cone grading system instructions on how to perform PFM contractions, without following a
HE Muscle activation: defined protocol.
*Surface electromyography (sEMG) PFMT Group Protocol:
Each treatment group underwent a 3- *First session: Information about location and function of the PFM; localize
month course of treatment their pelvic floor with help of a mirror and explore the perineum using
touch; start training with diaphragmatic breathing to contract the PFM in
isolation during expiration.
*Second session: PFM awareness was increased using a vaginal cone with
the patient in a supine position. The physiotherapist quickly pulled the cone
out, as the patient attempted to keep it inside the vagina by PFM
contraction, and then the therapist performed a stretching reflex using
vaginal palpation associated with a voluntary contraction of the PFM by the
patient.
E. C. L. MATEUS-VASCONCELOS ET AL.
*Third session: PFMT was performed according to the home exercise
protocol in the supine, sitting and standing positions: performed 3 sets of
8–12 maximum voluntary contractions held for 6 sec, with 12 sec of rest
between each contraction, followed by 3 rapid contractions in a row.
HE + PFMT Group Protocol:
*The patients participated in 3 sessions to learn how to perform the HE
correctly.
*First session: Information about localization and function of the PFM and
transverse abdominis muscle; localized their pelvic floor with the help of a
mirror and examined the perineum using touch.
*Second session: Patients were taught how to perform HE.
*Third session: Study volunteers were taught how to voluntarily contract the
PFM simultaneously with diaphragmatic aspiration: 2 series of 8–10
repetitions daily, 1 in a supine position, and another in a standing position.
The initial time spent holding each contraction was 6–8 sec.
Instruction PFM function assessment: Control group:
PFM contraction associated with *Vaginal palpation - Oxford Grading scale *The control group received instructions on how to perform
diaphragmatic breathing and and PERFECT assessment scheme PFM contractions without a defined protocol and a standardized lifestyle
visualization using a mirror *Surface electromyography (sEMG) advice sheet immediately after evaluation.
Proprioceptive technique with a vaginal Study program of 14 weeks Intervention group:
cone *The protocol consisted of 7 appointments with a specialist women’s health
physiotherapist over a 14-week period; appointments were scheduled at
weeks 0, 1, 2, 6, 10, and 14.
*At the first appointment, instructions were given concerning anatomy and
function of the PFM by using drawings. The training began with
diaphragmatic breathing, and the patients were instructed to contract the
PFM during expiration. A mirror was used to visualize the muscle
contractions in many positions.
*At the second appointment, PFM awareness was increased using a
proprioceptive technique with a vaginal cone. With the patient in a supine
position, the physiotherapist quickly tried to pull out the cone, while the
patient tried to keep it inside the vagina by PFM contraction. Then, the
therapist performed the quick reflex. To elicit the reflex, the central perineal
tendon was pressed.
*The third session consisted of intensive contraction training of the PFM
during an increase of abdominal pressure through the Knack maneuver.
*A 12-week home exercise program was prescribed: 8 to 12 maximum
voluntary contractions, held for 6 to 10 sec, with double-time rest between
each contraction, followed by 3 to 5 fast contractions.
(Continued )
 PHYSIOTHERAPY THEORY AND PRACTICE 7

recommended by Caufriez (1997), relaxes the dia-

*Women were asked to contract PFM with sub-maximal force 10 times for 10
s, with a minimal interval of 6 s between contractions, followed by 10 rapid
contractions. This series to be repeated at least 10 times a week, distributed
over at least 3 days. In addition, women were asked to perform voluntary
well as verbal feedback focusing on strengthening PFM and anterolateral
abdominal muscle co-contraction during forced expiration and coughing.
*Theoretical instruction about pelvic floor anatomy and PFM function, as
phragm, decreases abdominal pressure, and activates

sneezing, nose blowing or during intensive exertion in order to prevent

expiration phase of coughing and forced expiratory maneuvers, such as
the abdominal muscles and PFM via reflex, during

PFM and anterolateral abdominal muscles co-contraction during the

what Caufriez called diaphragmatic aspiration.
Caufriez (1997) suggested that the reduction of abdom-
inal pressure obtained by the hypopressive method
creates type I reflex activity in the muscles of the
abdominal wall and the PFM, with a latency period of
Control/Intervention

HE: hypopressive exercise; MVC: maximal voluntary contraction; PFM: pelvic floor muscles; PFMT: pelvic floor muscles training; sEMG: surface electromyography; UI: urinary incontinence
several seconds, leading to long-term strengthening of
these muscles. Talasz, Kalchschmid, Kofler and
Lechleitner (2012) explained their intervention by
reporting that women who are continent coactivate
the PFM along with the anterolateral abdominal mus-
pelvic floor descent. cles. Also, the anterolateral abdominal muscles play an
important role in generating and modulating intra-
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abdominal pressure when breathing and maintaining

PFMT program:

posture, and in coactivation of the PFM. Table 4 pro-

vides information on the results of the studies included
in this review.
*Digital vaginal palpation - Oxford Grading

Evaluation of methodological quality

The results of the evaluation of methodological quality
Outcome Measure

Study program of 3 months

are summarized in the last column of Table 3. There

PFM function assessment:

was no disagreement between the two reviewers. Only

one study scored positively on all of the validity criteria.
The studies varied from low to high quality. Most of the
studies had low methodology quality according to the
GRADE scale. Only one article achieved a high score
scale

for methodological quality.

Resource used to raise awareness of PFM

Anterolateral abdominal muscle co-

Discussion
oblique and transverse abdominis
contraction (external and internal

The current study aimed to systematically review the

literature related to physiotherapeutic methods to facil-
itate voluntary contraction of the PFM. To this end,
several interventions were examined, including instruc-
tion regarding the anatomy and function of the PFM,
Instruction

muscles)

vaginal palpation, palpation on the central perineal

tendon, interruption of urine flow, biofeedback using
a perineometer, proprioceptive technique with a vaginal
symptoms of PFM dysfunction;

performing correct coughing/

women without self-reported

PFMT with emphasis on co-

*To determine the effect of

cone, hypopressive exercise, PFM contraction asso-

*To assess PFM function in
healthy young nulliparous

anterolateral abdominal
contraction of PFM and

ciated with diaphragmatic breathing and visualization

muscles, and also on
Objectives

using a mirror, and coactivation of the anterolateral

breathing patterns

abdominal muscles.
Vaginal palpation was used in all of the studies to
classify PFM contraction, using the Modified Oxford
Table 3. (Continued).

grading system, PERFECT scheme or a non-validated

scale. The Modified Oxford grading system consists of a
Kalchschmid,

six-point scale: 0 = no contraction; 1 = flicker;

Lechleitner
Kofler, and
Authors/Year

2 = weak; 3 = moderate (with lift); 4 = good (with

(2012)
Talasz,

lift) and 5 = strong (with lift) (Laycock, 1994). This

scale shows variable intra-examiner reliability with
 Downloaded by [Australian National University] at 01:08 27 December 2017

Table 4. Adherence to intervention, results obtained and evaluation of the methodological quality of the studies.
Authors Year Adherence to intervention Results GRADE
Benvenuti et al. (1987) There was no data regarding adherence to the protocol. At baseline (n = 26):
*On vaginal palpation, phasic contractility was found to be absent or minimal in 31% (n = 8), and tonic
contractility lasting less than 15 s was found in 88% (n = 23). 5 patients (23%) had difficulty in stopping the urinary
stream when voiding.
At the end of the treatment (n = 22):
* On vaginal examination, both tonic and phasic contractility were found to be improved.
*After 3-month treatment, the maximum score on the rating scale was achieved for phasic contractility in all but 3
patients, and for tonic contractility in all but 5 patients.
E. C. L. MATEUS-VASCONCELOS ET AL.

Hung et al. (2011) Maintaining an exercise diary was encouraged but not
required. During the 4-month period, the investigators
did not take the initiative to contact the participants, but Modified Oxford grading system
each participant were allowed to make individual
appointments with the training physical therapist to
check her exercise.
Pinheiro et al. (2012) There was no data regarding adherence to the protocol. G1: Biofeedback group - Mean (SD):
At baseline (n = 23):
*PFM strength (n; %): no contraction (1; 4), flicker (8; 35), weak (12; 52), moderate (2; 9), good (0; 0), strong (0; 0) -
* Vaginal squeeze pressure (cmH2O) - Mean (SD): 27 (15.9)
At the end of training (n = 23):
*PFM strength (n; %): no contraction (1; 4), flicker (2; 9), weak (7; 30), moderate (8; 35), good (5; 22), strong (0; 0) -
Modified Oxford grading system
* Vaginal squeeze pressure (cmH2O) - Mean (SD): 41 (24.9)
- Baseline and final PFM strength: p < 0.001
- Baseline and final vaginal squeeze pressure: p < 0.001
At baseline (n = 6):
*Power: 2.0 (0.3) - Modified Oxford grading system
*Endurance: 3.6 (1.2) - PERFECT
*Fast: 5.4 (1.8) - PERFECT
At the end of treatment (n = 5):
*Power: 3.6 (0.4) - Modified Oxford grading system
*Endurance: 5.8 (0.9) - PERFECT
*Fast: 8.0 (1.1) - PERFECT
G2: Palpation group - Mean (SD):
At baseline (n = 5):
*Power: 2.2 (0.2) - Modified Oxford grading system
*Endurance: 2.4 (0.2) - PERFECT
*Fast: 5.4 (1.6) - PERFECT
At the end of treatment (n = 5):
*Power: 3.2 (0.4) - Modified Oxford grading system
*Endurance: 4.0 (0.6) - PERFECT
*Fast: 7.6 (0.8) – PERFECT
- Biofeedback group vs. Palpation group – Power, endurance and fast: no statistical difference between groups.
(Continued )
 Downloaded by [Australian National University] at 01:08 27 December 2017
Table 4. (Continued).
Authors Year Adherence to intervention
Resende et al. (2012) Patients received phone calls every two weeks from the
physiotherapist, and also attended monthly follow-up
appointments. The volunteers also filled out exercise
diaries in which they reported whether they performed
the exercises each day and, if so, how many sets they
performed.
Stüpp et al. (2011) An exercise diary was used to record compliance.
Fortnightly, the same physiotherapist called the patient
to answer questions and monitor the performance of
exercises.
Talasz, Kalchschmid, The training was to be informally documented by the
Kofler, and Lechleitner patients. They were asked about how consistently they
(2012) had carried out their PFM training program, and also
about their subjective experience of the study on the
final visit.
HE: hypopressive exercise; MVC: maximal voluntary contraction; PFMT: pelvic floor muscles training
Results GRADE
PFMT Group (n = 21) - Mean (SD):
*Baseline and final MVC: 2.4 (0.8) and 3.6 (0.7) – p < 0.001- Modified Oxford grading system
*Baseline and final endurance (sec): 3.1 (1.6) and 7.4 (1.8) – p < 0.001
*Baseline and final activation (μV): 10.4 (3.0) and 15.4 (4.1) – p = 0.001 - sEMG
HE + PFMT Group (n = 21) - Mean (SD):
*Baseline and final MVC: 1.7 (0.7) and 3.8 (0.8) – p < 0.001- Modified Oxford grading system
*Baseline and final endurance (sec): 2.9 (0.1) and 6.2 (1.4) – p < 0.001
*Baseline and final activation (μV): 10.0 (2.0) and 17.0 (4.0) – p < 0.001- sEMG
Control Group (n = 16) - Mean (SD):
*Baseline and final MVC: 2.0 (0.8) and 2.1 (0.8) – p = 0.705- Modified Oxford grading system
*Baseline and final endurance (sec): 2.9 (1.1) and 3.0 (1.4) – p = 0.564
*Baseline and final activation (μV): 10.7 (4.8) and 11.0 (4.3) – p = 0.552- sEMG
- PFMT group vs. HE + PFMT group – Modified Oxford grading system and sEMG: no statistical difference between
groups.
- PFMT group vs. HE + PFMT group – Endurance: p = 0.007.
- Control group vs. HE + PFMT group – Modified Oxford grading system, endurance and sEMG: p < 0.001.
- Control group vs. PFMT group – Modified Oxford grading system and endurance: p < 0.001, and sEMG: p = 0.008.
Control Group - Mean (SD)
At baseline (n = 16):
*Modified Oxford grading system: 2.0 (0.8)
*Endurance (sec): 2.9 (1.1)
*MVC (μV): 10.7 (4.8) - sEMG
At the end of treatment (n = 16):
* Modified Oxford grading system: 2.1 (0.8)
*Endurance (sec): 3.0 (1.4)
*MVC (μV): 11.0 (4.3) - sEMG
Intervention Group - Mean (SD)
At baseline (n = 21):
* Modified Oxford grading system: 2.4 (0.8)
*Endurance: 3.2 (1.6)
*MVC: 10.4 (3.0) - sEMG
At the end of treatment (n = 21):
*Modified Oxford grading system: 3.6 (0.7)
*Endurance: 7.4 (1.8)
*MVC: 15.4 (4.2) – sEMG
- Control group vs. Intervention group – Modified Oxford grading system: p < 0.001
- Control group vs. Intervention group – Endurance: p < 0.001
- Control group vs. Intervention group – MVC: p < 0.008
At baseline (n = 40):
* 30 women (75%) were able to perform normal PFM contraction at rest (Oxford scale score ≥3); only 4 (10%)
presented with additional involuntary PFM contraction before and during coughing.
*10 women (25%) were unable to perform either voluntary PFM contraction (Oxford scale score 0–2) at rest or
involuntary PFM contraction before or during coughing.
*Mean Oxford scale score for the entire group was 3.3 (1.7).
After PFM training program (n = 37):
*29 women (78.4%) performed normal PFM contraction (Oxford scale score ≥3) at rest, and before and during
coughing.
*5 women (13.5%) were only able to contract PFM at rest (Oxford scale score ≥ 3) but did not show involuntary
PHYSIOTHERAPY THEORY AND PRACTICE
PFM contraction before and during coughing.
*3 women (8.1%) were still unable to perform either a voluntary PFM contraction (Oxford scale score 0–2) at rest
or before and during coughing.
9
*29 women (72.5%) significantly increased their Oxford scale score - mean (SD): 4.2 (1.0) (p < 0.005).
 10 E. C. L. MATEUS-VASCONCELOS ET AL.
correlations ranging from moderate to very good.
However, interexaminer reliability has been shown to
be just fair in more than one study (Bø and
Finckenhagen, 2001; Ferreira et al., 2011). The variation
in these results can be explained by the subjective
nature of the classification system, which is minimized
by knowledge of anatomy and clinical experience of the
examiner (Frawley, 2006). Variable correlations have
been found between the Modified Oxford grading sys-
tem, perineometry and ultrasound (Ferreira et al., 2011;
Isherwood and Rane, 2000; Thompson, O’Sullivan,
Briffa, and Neumann, 2006). The PERFECT scheme is
an acronym with P representing power; E, endurance;
R, repetitions; F, fast contractions; ECT, every contrac-
tion timed. The power component of the scale was
Downloaded by [Australian National University] at 01:08 27 December 2017
validated by examining perineal lift and vaginal squeeze
pressure using a perineometer during a maximum
voluntary contraction. Laycock and Jerwood (2001)
showed a significant correlation between power and
both lift and vaginal squeeze pressure. The endurance
component was correlated with the area under curve of
the measurement obtained with a perineometer. These
authors found highly significant test-retest reliability
between power and endurance. The interexaminer
reliability analysis showed also highly significant posi-
tive correlations for power, endurance, repetitions and
number of fast contraction (Laycock and Jerwood,
2001). A non-validated scale was used by Benvenuti
et al. (1987), who described the contraction as absent/
minimal, moderate or strong, even though the
“Standardization of Terminology of Pelvic Floor
Muscle Function and Dysfunction” reported by the
Pelvic Floor Clinical Assessment Group of the
International Continence Society recommends the use
of a simple classification of PFM contraction as absent,
weak, normal, and strong (Messelink et al., 2005). In
fact, more than one author considers that there is no
gold standard scale or tool to assess PFM contraction,
and no single tool is capable of measuring all aspects of
it (Bø, Berghmans, Morkved, and Van Kampen, 2007).
Despite the variety of methods to facilitate PFM
contraction that were investigated, the methodological
quality of the studies ranged from low to high accord-
ing to the GRADE scale. There was a predominance of
studies of low methodological quality. Only one study
had high methodological quality (Resende et al., 2012);
it was the only RCT that was not a pilot study among
the six studies included. This study found no additional
benefit of hypopressive exercise associated with PFMT
when compared to isolated PFMT in relation to
improvement in PFM activity, strength and endurance;
however, both interventions provided significant
improvement in these aspects, increasing the number
of women able to correctly contract their PFM com-
pared to control group.
The study by Pinheiro et al. (2012) aimed to com-
pare the effectiveness of digital palpation and biofeed-
back performed with a perineometer in providing
correct voluntary PFM contraction. The strong point
of this study was that it included only women who were
not able to correctly contract their PFM, defined by the
author as having a score of < 3 in the Modified Oxford
grading system. The definition they used was in agree-
ment with the description of correct voluntary contrac-
tion by the International Continence Society (Messelink
et al., 2005). This consensus on terminology states that
a correct contraction needs to be identified not only by
the tightening and squeezing action of the PFM con-
traction under the examining finger, but also by the
lifting component, which coincides exactly with the
score of ≥ 3 according to the Modified Oxford grading
scale. Although the results of the Pinheiro et al. (2012)
study indicated that both interventions (vaginal palpa-
tion and biofeedback) improved PFM contraction capa-
city, there were many methodological limitations,
including small sample size, lack of a control group
and no masking of assessors. The study by Talasz,
Kalchschmid, Kofler, and Lechleitner (2012) also con-
sidered women to have normal PFM contraction if they
scored at least three on the Modified Oxford grading
scale.
The literature suggests that knowledge and aware-
ness of the PFM are essential to effective PFM contrac-
tion, even in women who are able to contract their
pelvic floor (Devreese et al., 2004). More than one
study has shown that not only women completely
unable to perform voluntary PFM contraction, but
also women with poor PFM contraction, may require
instruction and interventions to facilitate effective PFM
contraction (Brincat, Delancey, Miller, 2011; Dietz and
Shek, 2012; Thompson, O’Sullivan, Briffa, and
Neumann, 2006). In the clinical setting, the capacity
to contract the PFM is evaluated by vaginal palpation,
and PFM strength, endurance and coordination are
often evaluated using vaginal palpation scales. The lit-
erature shows that not only women who score zero
using the Modified Oxford grading system, but also
women classified as grade 1 or 2, present inadequate
urethral closure associated with levator ani muscle con-
traction as shown by image ultrasound, meaning that
those women may still need additional interventions to
be able to follow a regular PFMT program (Brincat,
Delancey, Miller, 2011; Dietz and Shek, 2012;
Thompson, O’Sullivan, Briffa, and Neumann, 2006).
All the studies combined instruction on the contrac-
tion of the PFM with other interventions. Vaginal

palpation was the specific intervention most commonly
used. Digital vaginal palpation has been strongly
recommended to teach patients to properly contract
the PFM. During contraction attempts, it provides
immediate feedback to the patient via the therapist,
who offers tactile information regarding the region
that needs to be activated (Abrams et al., 2002; Bø
and Finckenhagen, 2001; Bø and Morkved, 2007).
According to Minschaert (2003), vaginal palpation
and self-palpation enable control and localization of
the muscles. Despite its methodological limitations,
the study by Pinheiro et al. (2012) observed a signifi-
cant improvement in PFM contraction in the group of
women unable to perform a correct PFM contraction
who received vaginal palpation, but they did not find
Downloaded by [Australian National University] at 01:08 27 December 2017
any significant difference in terms of effect between
vaginal palpation and biofeedback performed using a
perineometer.
The findings of Benvenuti et al. (1987) indicated that
a protocol including vaginal palpation, interruption of
the urinary stream, PFMT and instruction led to an
increase in the number of women capable of contract-
ing their PFM after intervention. However, one limita-
tion of this study was that it lacked a control group. In
addition, the authors did not provide further details as
to how study participants were instructed to interrupt
urinary flow (e.g. if this was performed one or more
times during urination). According to Bø and Morkved
(2007), interruption of urine flow is not recommended
in a training protocol, because it can impair the neu-
rological balance between the pressures in the bladder
and urethra during urination. There should be no
activity of the PFM just before and during urination.
Therefore, interruption of urine flow at the end of
urination is recommended to test ability to contract
the PFM, and many patients report that they learn to
recruit these muscles through this method (Bø and
Morkved, 2007). Talasz, Kalchschmid, Kofler, and
Lechleitner (2012) verified that co-activation of the
abdominal anterolateral muscles (external and internal
obliques and transverse abdominis muscles) with PFM
and instruction resulted in an increase in the number of
women with normal PFM contraction. However, the
study was limited by its design, small sample size, and
heterogeneous sample of women with functional and
non-functional PFM at baseline.
Only two studies explained the possible mechanism
of action of the method to facilitate PFM contraction
that was investigated. According to Resende et al.
(2012), hypopressive exercises are based on relaxing
the diaphragm, decreasing abdominal pressure and
activating abdominal muscles and the PFM via a reflex
action. Talasz, Kalchschmid, Kofler, and Lechleitner
PHYSIOTHERAPY THEORY AND PRACTICE 11
(2012) stated that there is coactivation of the PFM
with contraction of the anterolateral abdominal
muscles.
The databases consulted in this review showed no
systematic reviews specifically evaluating methods to
facilitate voluntary PFM contraction. Also, to date no
RCT has been found that evaluated and compared the
effects of such methods only in women completely
unable to perform voluntary PFM contraction. Thus,
the present review appears to be the first systematic
literature review of physiotherapeutic methods aimed at
facilitating voluntary contraction of the PFM. The
authors believe that this review makes a unique con-
tribution to the topic, providing a synthesis and critical
analysis of the available research in order to guide best
practice for physiotherapists. However, future studies
should be clearly defined and provide the option to
include only women completely unable to perform
voluntary contraction or women unable to correctly
contract their PFM. Outcome measures, expected effect
size, and relevant clinical improvement expected should
be defined a priori and the methods to facilitate volun-
tary contraction investigated as a primary outcome.
The current systematic review depended on the par-
ticipation of two trained reviewers to select the articles
and evaluate the methodological quality of the studies.
The decision to use the GRADE scale of evaluation was
based on the fact that this instrument provides trans-
parent classification of the quality of research evidence
in health care (Guyatt et al., 2011f). GRADE is a sys-
tematic approach to making judgements about quality
of evidence and strength of recommendations. It was
developed by the Grading of Recommendations,
Assessment, Development and Evaluations Working
Group, and it is now widely seen as the most effective
method of linking evidence-quality evaluations. The
GRADE Working Group aims to reduce confusion
arising from multiple systems for grading evidence
and recommendations. GRADE has been widely used
and is recommended by many organizations for the
evaluation and development of guidelines for health-
care technology around the world, including the World
Health Organization, the Cochrane Collaboration, the
Agency for Healthcare Research and Quality (US) and
the National Institute of Health and Care Excellence
(UK) (Meader et al., 2014).
A weakness of the current review that should be
pointed is the failure to perform a meta-analysis. The
heterogeneity of samples, interventions and protocols,
coupled with the low methodological quality of the
studies, undermined the ability to determine the best
physiotherapy method to facilitate PFM contraction. To
date, none of the many methods currently used to
 12 E. C. L. MATEUS-VASCONCELOS ET AL.
facilitate correct PFM contraction can be recommended
over the others, although it appears that various meth-
ods have a potential positive effect on facilitating cor-
rect PFM contraction.
It is worth mentioning that the available studies
revealed no side effects or complications of the inter-
ventions investigated; however, every intravaginal pro-
cedure has the potential to cause some degree of
discomfort and embarrassment to patients. The degree
of discomfort or embarrassment was not reported in
any of the studies included in this review. It would be
desirable for future studies investigating this topic to
also address this issue. Possible embarrassment or dis-
comfort caused by intravaginal procedures needs to be
discussed with patients, as well as the advantages and
Downloaded by [Australian National University] at 01:08 27 December 2017
disadvantages of each intervention. The specific poten-
tial of vaginal palpation to promote a direct proprio-
ceptive stimulus that may facilitate the PFM voluntary
contraction should be explained to patients, besides the
advantage of enabling the physiotherapist to monitor
the correct contraction of the PFM during the inter-
vention. It is essential to clarify that although there are
studies suggesting good results, the levels of scientific
evidence available are not high enough to guarantee a
better effect over non-intravaginal methods. Non-intra-
vaginal interventions should always be presented and
discussed as treatment options, making patients aware
of their disadvantage in not allowing simultaneous
monitoring of correct contraction of the PFM by the
physiotherapist.
If a patient does not agree with an intravaginal
procedure or state to be embarrassed or uncomfortable
with this, a non-intravaginal intervention should be
provided. The clinical decision-making needs to be
shared with patients and individualized considering
their preferences and the complete acceptance of the
proposed intervention.
Conclusion
The current review identified the following methods to
facilitate voluntary PFM contraction: instruction
regarding the anatomy and function of the PFM; vagi-
nal palpation; palpation on the central perineal tendon;
interruption of urinary flow; biofeedback using a peri-
neometer; vaginal cone; hypopressive exercise; PFM
contraction associated with diaphragmatic breathing
and visualization using a mirror; and coactivation of
the anterolateral abdominal muscles. All the studies
observed improvement in PFM contraction using the
various methods, but none were superior to the others.
Most of the studies had low methodological quality.
The studies revealed no adverse effects of the
interventions used. The risk/benefit relationship for
adoption of the methods identified in this review
should be carefully weighed by physiotherapists and
discussed with patients to guide the best clinical deci-
sions, given the absence of a high level of scientific
evidence supporting their use. Patient preferences
should be taken into account in clinical decision mak-
ing. More studies of high methodological quality on
this topic are urgently needed.
Declaration of interest
The authors report none.
ORCID
Aline Moreira Ribeiro, PT, MSc http://orcid.org/0000-
0001-6126-2774
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