Risks and Considerations Exercising with Pelvic Floor Dysfunction

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1 Risks and Considerations Exercising with Pelvic Floor Dysfunction Maeve Whelan MSc SMISCP Specialist Chartered Physiotherapist Milltown Physiotherapy

2 Acknowledgement Taryn Hallam PT

3 THE PROBLEM 1 in 7 women experience UI during physical activity Women with severe UI are 2.64X more likely to be insufficiently active Women with UI see it as a barrier to exercise (Nygaard et al. 2005) POP substantially interferes with exercise in 27% women Women with greater symptom distress show greater impact on exercise (POPDI) Nygaard et al. 2007

4 WHAT WOMEN WANT TO KNOW When can I start? How much can I do? Can I damage myself?

5 WHAT WOMEN NEED TO KNOW Whether they are at risk for THEIR pelvic floor Pelvic floor dysfunction Whether the exercise they do is a high risk exercise What is the evidence for IAP/IVP with certain exercises? Can they damage their pelvic floor What is the evidence for now or long term?

6 Matrix for risk who CAN T do what? High Risk Exercise Moderate Risk Exercise Low Risk Exercise Low Risk Women Moderate Risk Women High Risk Women Yes No No Yes Yes No Yes Yes Yes

7 High Risk - Prolapse Hiatal area normal if <25cm 2 on valsalva Ballooning if hiatal area >25cm 2 on valsalva Mild to mod ballooning cm 2 Marked to severe ballooning 35->40cm 2 All women with marked to severe ballooning have prolapse later in life Dietz and Steensma 2008 Sydney.eu.au

8 Relationship between GH + PB and Hiatal Area on Ultrasound Khunda, Shek and Dietz 2012 GH +PB US Area (cm 2 ) POP 2+ Normal <7cm < % Mild Ballooning % Moderate Ballooning % Marked Ballooning % Severe Ballooning >10cm >40 91%

9 Matrix for risk including the KNACK cm 2 MOS 0 / 1 MOS 2 MOS 3 MOS 4 MOS 5 >10 V high V High V High High High 9-10 V High V High High High Med 8-9 V High High High Med Low 7-8 High High Med Low V Low <7 High Med Low V Low Neglig. (MOS Modified Oxford Score)

10 HIGH RISK EXERCISE / LOW RISK GROUP Cross-fit exercise resulted in a significant reduction in vaginal resting pressure immediately after exercise in nulliparous women (18-35 years) No difference in max or average squeeze pressure in either group over 2 years 4 times per week Significant difference in bone loading units between groups Middlekauf et al (2016) Am J Obstet Gynecol Sept

11 High Risk - SUI / UI 43% athletes UI during sport (N=291) 42% same athletes UI during daily life (Thyssen et al. 2002) More frequently towards end of a session (Caylet et al. 2006) Urethral hypermobility Urgency (Simeone et al. 2010) N = % urgency Thyssen et al. (2007) N = 291 Gymnasts 56% Ballet 43 Aerobics 40 Badminton 31 Volleyball 30 Athletics 25 Handball 21 Basketball 17

12 Pelvic Floor Strength in Athletes No difference in pelvic floor muscle strength in sports group population between those with and without UI (Bo et al 1994) 80% of trampolinists had UI perineometry showed strong pelvic floor (Eliasson et al. 2002) Athletes reported greater UI but no significant difference in PFM activity between groups (EMG) (Casper et al. 2008)

13 Pelvic Floor Risk in Athletes Former athletes who leaked while competing were 8.57 x more likely to have UI later in life than those who did not leak while competing (Bo & Sundgot-Borgen 2008 Scan J Med Sci Sport vol 20 no 1 ) 76% of trampolinists who had UI during trampolining had UI 5 years later / 0% who didn t had UI 5 years later (Eliasson et al. 2008) **women who trampolined for 5 years after menarche by comparison to 5 years before had greater chance of incontinence

14 ACTIVITY COMPARISON

15 Lift 3-4 kg Above head ACTIVITY COMPARISON WEIR ET AL. 2006, OBSTET & GYNEC VOL 107, NO. 2 intra abd cmh 2 0 CRUNCH Sit Up CLIMBING STAIRS WALK TREADMILL 4-5km/hr 54 (28-102) 68 (19-174) 70 (34-116) 76 (48-110) STAND UP Hands on thighs JOGGING JUMPING JACK LIFT 16kg From Floor 78.7 (24-258) 100 (estimate) 126 (59-189) 149 (65-335)

16 Lift 3-4 kg Above head ACTIVITY COMPARISON WEIR ET AL. 2006, GOSTETR & GYNAEC VOL 107, NO. 2 CRUNCH Sit Up CLIMBING STAIRS WALK TREADMILL 4-5km/hr 54 (28-102) 68 (19-174) 70 (34-116) 76 (48-110) ALL ARE LESS THAN SIMPLY STANDING FROM A CHAIR! STAND UP Hands on thighs 78.7 (24-258)

17 Do small increases in weight actually make a difference?? Intra ABDOMINAL PRESSURE Weir et al 2006, Obst and Gyn vol 107, no. 2 Weight From floor 5kg 10kg 15Kg Intra VAGINAL PRESSURE O Dell et al 2007, Int Urogyn J Weight From floor 7kg 14kg 20Kg Intra VAGINAL PRESSURE Shaw et al. J Sports Sci June ; 32(12): Weight From floor 13.6Kg 18.2Kg

18 Comparison to ADL O Dell et al Intra Vaginal cmh 2 0 Wei et al Intra Abd cmh20 Crunches in supine with breathing 12.4 Crunches in supine holding breath 23.8 Standing at rest 24 Supine Low Bicycle 31.4 Hydraulic Quads/Hamstrings 34.3 Lifting 6kg whilst sitting 47.5 Jogging 54 Laughing 85.5 Sharp Cough 98 Crunches in supine with breathing 68 Stand from chair hands on thighs 79 Walk on treadmill 3.3mph 79 Medium cough sitting 92 Rise from supine on the floor 100 Jumping Jacks 127 Forceful cough standing 136

19 Standing Walking 1.9X Running 2.2X Jumping 2.5X Weir et al. 2006

20 Shaw et al Walking IAP 5.6 KMPH 7% gradient Max range cmh 2 O Running IAP KMPH 0% gradient Max range cmh 2 0

21 PILATES Coleman et al IUJ Intraabd pressure during Pilates (cm H2O) ADL Pilates Mat Plates Reformer Supine 6.6 Bridging 12 Bridging 11.1 Prone 9.2 Chest lift 23 Hundred 32.6 Roll up 51.1 Roll up 49.6 Plank 38.4 Intraabd pressure during Pilates unlikely to cause pelvic floor harm N=20 healthy women with no symptomatic bulge Standing 28.9 Standing leg raise 40.1

22 IS THE ADVICE WE GIVE CORRECT

23 Pelvic Floor Muscle Training PFMT gold standard (Dumoulin et al 2014) Up to 50% don t contract correctly (Bump 1991) Teach knack (Miller et al 1998) THE STRONG ONES??

24 LOADING

25 Assessment & Treatment

26 PFMT Gold standard PFMT When balanced then strengthen

27 Support and Stop Gaps

28 Conclusion Make sure advice is correct and based on assessment / specific exercise Assess and monitor Educate Continue exercising when at all possible