Who s in Charge of your Exercise? You or Your Pelvic Floor?

Transcription

1 Who s in Charge of your Exercise? You or Your Pelvic Floor? Ingrid Nygaard, MD, MS Professor University of Utah Department of Obstetrics and Gynecology

2 Exercise is good for you.

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5 Factors Considered At Least A Moderate Barrier to Exercise Lack of Time Out of Shape Lack of Interest Pain Overweight Money Health Facilities Fear of Injury UI Heart Problems

6 Why does a urogynecologist care about exercise?

7 Pelvic floor disorders are common

8 Surgery for PFDs is common! Lifetime risk of surgery for POP and UI: 1 in 9 Americans (Olsen, 1997) POP: 1 in 5 Australians (Smith F, 2010) POP: 1 in 5 Danes (Løwenstein E, 2014)

9 More women are obese

10 Number of surgeries will increase Wu, AJOG, 2013

11 To prevent PFDs, American Urogynecologic Society recommends Avoiding increased pressure inside the abdomen and on the pelvic floor is wise. Avoid heavy lifting. Avoid repetitive strenuous activities.

12 Is this good advice? What s the evidence behind it? And who s in charge of your exercise?

13 What was she thinking about?

14 Pelvic floor has to put up with a lot Pelvic floor must withstand force generated by 25 pounds of viscera Plus forces generated by exercise Even if fatigued And must react quickly

15 Taking the pelvic floor for granted. PELVIC FLOOR

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17 Now running doesn t look so good..

18 Why might activity impact the pelvic floor (and thus UI/POP)? Direct effect: damage or strengthening of muscles, ligaments, connective tissue Indirect effect: by activity s effect on something else that in turn impacts UI/POP (like obesity) By accentuating hidden symptom of leakage or bulge

19 Predispose Gender Racial Neurologic Anatomic Collagen Muscular Cultural Environmental Intervene Behavioral Pharmacologic Physiotherapy Devices Electrical stim. Surgery Incite Childbirth Nerve damage Muscle damage Radiation Surgery PFD No PFD Promote Obesity Constipation Smoking Recreation Lung Disease Medications Menopause Surgery Fluid Intake Infection Toilet Habits Diet Occupation Decompensate Aging Dementia Debility Disease Environment Medications

20 Unmeasured confounding Suppose a study showed that 100% of contortionists have POP. Do you conclude that the activity of contortionism causes POP?

21 Unmeasured confounding Collagen abnormalities? Contortionism POP

22 Exercise incontinence is common Recreational athletes (U.S.) 30% Recreational athletes (Italy) 30% PE Students (Norway) 26% College varsity athletes (U.S.) 28% Sports clubs (Denmark) 52% Trampolinists (Sweden) 80% Yoga/pilates instructors (Norway) 26% Population-based (U.S.) 16%

23 Why is exercise UI common? Continence threshold is exceeded Influenced by Congenital/hereditary factors Muscle mass Connective tissue strength Acquired factors Childbirth Trauma

24 Exercise incontinence The fact that many women leak drops of urine during exercise does not mean that exercise or other physical activity causes real urinary incontinence.

25 Current physical activity and PFDs Many studies on UI Most assess exercise only, questionnaires Fewer studies on POP Assess work/exercise in basic categories Almost no studies on FI

26 Physical activity and UI in community-dwelling women Cross-sectional studies: Recreational exercise does not increase risk of UI after adjusting for age, BMI, parity, coughing and wheezing (EPICONT study) Cohort study: Recreational exercise (especially walking) decreases risk of new onset UI (Nurses Health Study) No data on strenuous exercise

27 Physical Activity and Pelvic Organ Prolapse Exercise: No association in 4 studies Heavy work classification: odds of POP surgery (2 studies) odds of POP on exam (2 studies) No association with bulge symptom (2 studies)

28 Acute physical activity and pelvic floor support Between habitual nulliparous CrossFit exercisers and controls: No difference in vaginal support before exercise Slight worsening of support after acute exercise bout in women group doing CrossFit and in controls doing walking Middlekauf et al, 2016

29 What about REALLY strenuous activity? 9 nulliparous infantry trainees developed SUI and pelvic floor defects after airborne training, which included parachute jumping No difference in UI prevalence between female paratroopers and soldiers that completed regular summer training but paratroopers had more stage II prolapse on examination (OR 2.7)

30 The Physical Activity and Pelvic Floor Disorders Study (PhActS) Explore associations between lifetime physical activity and SUI and POP in 2 separate case-control studies Overcomes some limitation of prior research Primary care based population not seeking care Adequately powered Measures all types of physical activity Uses lifetime activity questionnaire developed for women

31 Physical Activity and Pelvic Floor Disorders study Cases and age-matched controls identified from 1538 women ages 39 to cases with POP below the hymen; 191 controls with support above hymen; no SUI 213 cases with SUI; 213 controls; no POP

32 Odds of POP/SUI by activity measure POP: No associations between odds of POP and overall lifetime physical activity lifetime leisure activity lifetime strenuous activity SUI: lifetime leisure activity: overall lifetime physical activity: slight OR 1.32 [1.02, 1.71] per 70 MET hrs/wk lifetime strenuous activity: no association

33 Odds of POP by teen strenuous Marginally significant association (p=0.046) Cubic polynomial relationship with increased odds after 21 hours/week activity

34 Odds of SUI by teen strenuous activity

35 PHACTS conclusions Overall lifetime and lifetime strenuous activity have no clinically relevant effect on SUI or on POP. Lifetime leisure protects against SUI. Strenuous activity during teenage years appears to increase the risk of both, but only above a threshold Never draw conclusions from one epidemiologic study!

36 What about effect of general fitness/strength on pelvic floor parameters?

37 Fit women may have larger pelvic floor muscles Levator ani muscle cross-sectional area on MRI 20% greater for athletes than nulliparous controls Levator ani muscle diameter greater on ultrasound in high-impact, frequent intense trained athletes compared to age & BMImatched controls Kruger J 2005; Kruger J, 2007

38 But fit women don t seem to have stronger pelvic floor muscles (PFM) More bladder descent and no difference in PFM strength (Kruger 2007) Lower PFM strength in volleyball and basketball players than non-athletes (Borin 2013) No difference in PFM strength between CrossFit exercisers and non-athletes (Middlekauf 2016) No difference in PFM strength between Pilates devotees and controls (Ferla 2016)

39 And, PFM fatigue In young nulliparas with symptoms of mild SUI, PFM strength decreased 20% after 90-minute interval training program but not after 90 minute rest period Ree, 2007

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41 Clinical questions (we wish we knew the answer to) How much physical activity/intraabdominal pressure (IAP) is too much? Where is the sweet spot between benefit and harm? What should women do after surgery? After childbirth? Can limiting increases in IAP help prevent POP/UI or progression of early PFD?.

42 Big variation in post-op activity recommendations Survey of Danish GYNs Lifting restriction ranged from < 15 kg for 2 weeks to < 2 kg for 12 weeks. (Moller C, 2001)

43 Measuring activity relevant to the pelvic floor is challenging Oxygen consumption tests or pedometer counts likely not relevant. For PFDs, want to understand Effect of abdominal loading Counter-balancing effect of strength

44 Measuring IAP using urodynamics catheter Rising out of a chair (76.3 cm H 2 O peak) = Climbing stairs Performing abdominal crunches Walking on a treadmill at mean speeds of 2.2, 2.7, and 3.3 mph Weir, Nygaard 2006

45 Rising out of a chair > Lifting 8 lbs from counter, low table, and overhead Lifting 13 lbs from counter and floor Lifting 20 lbs from counter

46 Patient tethered to computer Artificial settingurodynamics lab Transducer not at physiologic source Rectal balloon catheter

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49 Running

50 Net maximal IAP, based on WRAPS study Lifting Tasks N IAP Range Median (IQR) Lift 13.6 kg, floor to counter & back ( ) Lift 18.2 kg, floor to counter & back ( ) Seated shoulder press, 3.6 kg ( ) Seated shoulder press, 4.5 kg ( ) Seated shoulder press, 5.5 kg ( ) Seated shoulder press, 6.8 kg ( ) Seated shoulder press, 9.1 kg ( )

51 Speed increases IAP Mean IAP 42.5 Mean IAP 50.7 Mean IAP 62.2

52 Grade increases IAP

53 Method of lifting impacts IAP * Reference 77.3* * P< N=46

54 Method of exercise matters Pilates Reformer roll-up Pilates Mat roll-up

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56 Do these data mean: You should walk slowly on a flat surface to protect your pelvic floor? Unlikely Fitness/strength likely compensate for PF loading---and the relative increase in IAP is low.

57 Putting IAP in perspective IAP during vaginal delivery is extreme 42 women with spontaneous occiput anterior vaginal deliveries Average peak pressure on the fetal head and pelvic floor during bearing down efforts: ± 82.4 mm Hg Rempen A, Kraus M

58 Bottom line One standard safe cut-point for IAP can not be created Too much inter-subject variation In IAP In strength In PFM function In connective tissue structure

59 Bottom line We now have tools to measure IAP in real world setting Should help illuminate real clinical questions For now, reasonable not to restrict activities that don t raise IAP more than getting out of a chair Reassure women that PA in general should not be avoided to prevent PFDs Effect of high-volume teen strenuous activity on POP/ SUI bears further study.

60 Conclusion The balance of activity to optimally support and maintain pelvic floor function in healthy populations and after surgical interventions and childbirth has yet to be elucidated. Motherhood And Pelvic health (MAP) study: studies the influences of intraabdominal pressure, physical activity and strength on pelvic floor support after vagainal childbirth

61 Who s in charge of your exercise?

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