Research Project [EBP-W000]

Training older adults: bringing the pelvic floor to the fore

By: Ariana-Rose Begg

Background

The main demographic attending my classes in regional NSW are women 45-65yrs. Many
experience pelvic floor muscle dysfunction, have symptomatic prolapses and continence
issues. The majority are peri or post-menopausal, and many are overweight or obese.

Having undertaken CPD on Pelvic Floor health, my understanding is this demographic of

women represent a high risk category, and may require referral to Allied health or GPs, and
may need specific training and/or modifications. I aim to ensure the care provided in class is
guideline-based and within my scope of practice.

My primary question is:

“Should specific targeted pelvic floor exercises be included as a subset of exercises in a

group class format when training women over 45 to ensure a full body workout?”

My secondary question is:

“Should exercises be modified to prevent exacerbating pelvic floor symptoms?”

I am researching with a preference for peer reviewed random controlled clinical trials, meta-
analysis, systematic analysis or clinical guidelines undertaken in the last 5-10 years. Noting
who performed the studies, strengths and limitations in sample size, randomisation, analysis
of intention to treat and bias, how sample groups where chosen, what interventions were
performed and what controls were used. The ideal are studies that assess the efficacy of
pelvic floor exercises performed in a group context in my target group, without the use of
digital or biofeedback.

Research Project 10771NAT Diploma of Clinical Pilates Breathe Education 2019

Research Project [EBP-W000]

Introduction

Pelvic floor muscle dysfunction (PFMD): mechanism of injury, aggravating and predisposing
factors
PFMD includes damaged, weak and/or tight pelvic floor muscles, and may result from trauma
sustained during childbirth, or other risk factors and pelvic pathologies, including1,2,3:

- Hysterectomy: surgical removal of the uterus and sometimes the cervix, performed
through abdominal, vaginal or laparoscopic surgery.
- Caesarian: abdominal surgery
- Uterine prolapse: decent of uterus and cervix down the vaginal canal due to weak or
damaged pelvic support structures
- Cystocele: weakened tissues between the bladder and vagina allowing a portion of the
bladder to descend and press into the vaginal wall
- Rectocele: weakening of the wall between the vagina and the rectum allowing the
rectum to descend and press into the vaginal wall
- Perimenopause: fluctuating hormonal levels preceding the cessation of menstruation,
decreasing oestrogen levels which may result in weakened pelvic floor muscles
- Menopause: the cessation of menstruation which may coincide with weakening of the
pelvic support structures.

Common symptoms
The main indicators of PFMD are:

- Symptomatic prolapse (bulge/heaviness/lower back pain, altered sexual function),

and in a stage III-IV prolapse the internal organs may protrude out of the vagina.
- Urinary incontinence (UI) including:
- Stress urinary incontinence (SUI): involuntary leakage of urine with physical
activity/cough/sneeze
- Urge incontinence: a sudden strong need to urinate
-mixed incontinence: both stress and urge UI

Some women may also experience painful intercourse and UI as a result of hypertonic pelvic
floor muscles.
Research Project 10771NAT Diploma of Clinical Pilates Breathe Education 2019
Research Project [EBP-W000]

At risk groups
According to a study of 27 000 post-menopausal women 40% have some form of prolapse4.
Current figures suggest that 45.5% of Australian women over the age of 45 experience some
form of urinary incontinence, and increased age correlates with increased prevalence5. Risk of
UI and prolapse increases with multiple pregnancies, menopause and increased BMI.6 There
is also some evidence to suggest that there is an increased prevalence of SUI in women who
attend gyms, perform high impact exercise, and exercise at an elite level7. Pelvic floor
dysfunction is correlated with an increased risk of depression, decreased quality of life,
reduced social interactions, increased inactivity and an estimated annual national cost of AUD
$1.268 billion nationally5.

Search Strategy

I searched using advanced search on the CINHAL Allied Health Database through Ebscohost.
I performed an advanced search with the terms “Pelvic floor” AND “Exercise”, with limited
search period of 2009-2020. I performed 3 searches, one for RCTs, one for systematic
reviews and one for meta-analyses. I also read some of the references in the studies I clicked
on and narrowed the studies discussed to prevent repetition.

Synthesise Key Research Findings

In healthy, continent women, pelvic floor muscles activate automatically during physical
exertion3 , however a high percentage of women experience stress incontinence during
physical exertion and many avoid physical activity3. In this group the PFM do not activate
automatically with exertion, and a targeted program of repeated voluntary pelvic muscle
contractions, supervised by a health care professional and addressing strength, rapidity and
endurance of contractions for a period of greater than 3 months may decrease leakage and
improved quality of life. PFMT may be performed with the assistance of digital feedback or
biofeedback to ensure correct execution.

There is support for a widespread recommendation for pelvic floor muscle training (PFMT) as
part of a conservative management plan3. Data from a systematic review looking at PFMT

Research Project 10771NAT Diploma of Clinical Pilates Breathe Education 2019

Research Project [EBP-W000]

taught without digital or biofeedback showed a low risk of adverse events, with some pain
reported but no significant adverse events.

PFMT decreased symptoms of UI and increased quality of life in older adults when compared
to a placebo5, and delivering PFMT in an intense manner with extra weekly sessions in a
group format increased the cure rate6. PFMT delivered with or without biofeedback is more
effective than no intervention. More research is required to determine the ideal dose and
duration, but research to date suggests that PFMT may require long-term adherence to
produce continued benefit6.

In an RCT with an intervention that included a modified Pilates class with PFMT as a distinct
exercise, it was indicated that PFMT leads to a reduction in prolapse symptoms and severity
and may reduce the need for surgery, and the recommendation is for women to undertake
pelvic floor muscle training before they have symptoms as it is a safe and easily performed
intervention that may prevent prolapse from worsening6

It was noted that women with prolapse should avoid heavy lifting and high impact activites 6
and activities that increase intraabdominal pressure, but more research is required to
adequately determine if specific exercises exacerbate prolapse or symptoms of UI.

For this population:

- Promote PFMT of 8-12 reps 3 x daily in supine, kneeling, standing and seated with 5
second hold at a near maximal contraction and 10 second rest progressing to 10
second hold and 20 second rest with an awareness of the importance of release
between contractions to prevent hypertonicity
- Exercises are ideally supervised by a trained professional and are done at a high
intensity for a period >3 months
- Potentially avoid heavy lifting and high impact activities.

Research Project 10771NAT Diploma of Clinical Pilates Breathe Education 2019

Research Project [EBP-W000]

Application to Pilates

In the studio when teaching women over 45:

- is essential to take a thorough pre-exercise screening to determine if symptoms of

prolapse or UI are present
- recognise the high prevalence of PFMD in the demographic of women doing Pilates in
regional areas.
- if symptomatic then instructors can support health outcomes by referring clients to
Allied Health/GP/Continence nurse for follow up
- be aware that in women with UI or symptomatic prolapse, pelvic floor muscles do not
contract automatically on exertion and may need modifications for exercises that
increase intra-abdominal pressure
- if the therapist is adequately trained with additional CPD modules in how to cue pelvic
floor exercises to promote strength, rapidity and endurance of contractions, PFMT
taught in a group setting can assist in reducing symptoms of prolapse and UI, promote
exercise adherence at the required intensity and may prevent the need for surgical
intervention
- discussing pelvic floor dysfunction may reduce embarrassment around the problem and
encourage clients to seek help which can assist with reducing risks of depression and
increasing quality of life

In a studio context there is no indication to cue pelvic floor activation in healthy populations,
however there is a strong indication for upskilling to be confident in providing a program of
repeated voluntary pelvic floor muscle contractions as a distinct exercise subset for at risk and
symptomatic women. Considering the statistically high rates of UI and prolapse in my
demographic the research has inspired me to continue to learn more so that I can provide my
clients with a full body workout that addresses all the key muscle groups not just the ones we
can see moving.

Research Project 10771NAT Diploma of Clinical Pilates Breathe Education 2019

Research Project [EBP-W000]

References

1
Continence foundation of Australia. (2019) The Facts. Retrieved from
https://www.continence.org.au/

2
Women’s Health QLD Wide Inc. (2019). Genital prolapse fact sheet. Retrieved from:
http://womhealth.org.au/conditions-and-treatments/genital-prolapse-fact-sheet

3
Dumoulin, C., & Hay‐Smith, J. (2010). Pelvic floor muscle training versus no treatment, or inactive
control treatments, for urinary incontinence in women. Cochrane Database of Systematic
Reviews(1). doi:10.1002/14651858.CD005654.pub2

4
Hagen S, Glazener C, McClurg D, et al. Pelvic floor muscle training for secondary prevention of
pelvic organ prolapse (PREVPROL): a multicentre randomised controlled trial. Lancet. 2017;389
North American Edition(10067):393-402. doi:10.1016/S0140-6736(16)32109-2.

5
Davidson, J. E., & Moore, K. H. (2013). Pelvic floor muscle training for urinary incontinence in
older adults: A systematic review. Australian & New Zealand Continence Journal, 19(1), 18–26

6
Imamura M, Abrams P, Bain C, Buckley B, Cardozo L, Cody J, Cook J, Eustice S, Glazener C,
Grant A, Hay-Smith J, Hislop J, Jenkinson D, Kilonzo M, Nabi G, N’dow J, Pickard R, Ternent L,
Wallace S, & Wardle J. (2010). Systematic review and economic modelling of the effectiveness
and cost-effectiveness of non-surgical treatments for women with stress urinary incontinence.
Health Technology Assessment, 14(55), 1–506.
https://doi-org.ezproxy.csu.edu.au/10.3310/hta14400

7
Fozzatti, C., Riccetto, C., Herrmann, V., Brancalion, M., Raimondi, M., Nascif, C., . . . Palma, P.
(2012). Prevalence study of stress urinary incontinence in women who perform high-impact
exercises. International Urogynecology Journal, 23(12), 1687-1691. doi:10.1007/s00192-012-
1786-z

Research Project 10771NAT Diploma of Clinical Pilates Breathe Education 2019