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Introdução: Após a menopausa mulheres tem maior risco de desenvolver doenças cardiovasculares. A prática de exercício físico é um dos tratamentos para e redução da incidência dessas doenças, e o método Pilates consiste em um programa completo de condicionamento físico. Objetivos: Verificar as respostas da Monitorização Ambulatorial da Pressão Arterial (MAPA) e da Variabilidade da Pressão Arterial após uma única sessão de Mat Pilates em mulheres após a menopausa não obesas. Métodos: Este é um estudo cruzado randomizado com 15 mulheres pós-menopáusicas normotensas, que participaram de uma única sessão de Mat Pilates e de uma sessão de controle. A sessão de Pilates durou 50 minutos, com 5 minutos de aquecimento. Em cada exercício, houve 1 série de 10 repetições com 45 segundos de descanso entre as séries. A sessão controle teve a mesma duração, mas as voluntárias permaneciam sentadas. A MAPA foi avaliada durante 24 horas após a intervenção. Estatística: Utilizou-se ANOVA de dois fatores com post hoc de Newman-Keuls para análise das variáveis da MAPA e teste t de Student para análise da variabilidade de pressão arterial. Resultados: Não houve diferença significativa (p

Aims To compare the effects of manual visceral therapy (MVT) associated with pelvic floor muscle training (PFMT) on urinary incontinence (UI) symptoms, vaginal resting pressure, and maximum voluntary contraction of the pelvic floor muscles (PFM). Methods A double-blinded randomized controlled trial of 5 weeks duration with two active intervention arms: PFMT + MVT and PFMT + manual sham therapy (MST). Participants were women over 18 years of age with complaint or diagnosis of UI symptoms. The primary outcome was the severity of UI symptoms, assessed by the International Consultation on Incontinence Questionnaire - Short Form. The secondary outcomes measures included the vaginal resting pressure and the maximum voluntary contraction of PFM assessed by digital manometry. Results Fifty-two incontinent women participated in the study. There was no significant difference between groups in UI symptoms (F (1.74, 86.9) = 0.406; p = 0.638), vaginal resting pressure (mean difference -1.5 cmH₂0 [95% confidence interval [CI] -4.5 to 1.5; p = 0.33]), and maximum voluntary contraction of PFM (median 0.0 cmH₂0 [25%-75% interquartile range 0.0-5.6; p = 0.12]) after the intervention period. Conclusions Combining MVT with PFMT was not more effective than PFMT alone in reducing UI symptoms, in change vaginal resting pressure and maximum voluntary contraction of PFM. Due to the limitations of the study, further investigations are still needed to confirm these findings.

To date, no study has investigated the correlation between pelvic floor muscle function and urinary incontinence in female runners. The aim of the study was to investigate the relationship between pelvic floor muscle function and to correlate urinary leakage as measured by the modified pad test with kinematic variables of running. The sample consisted of 11 incontinent and 17 continent runners. On day 1, they performed a maximum velocity test on a treadmill using an incremental protocol. Their pelvic floor muscles were evaluated using vaginal palpation and manometry, and the adapted pad test was used to evaluate the severity of urinary incontinence. Then, running kinematics were evaluated on a treadmill using a circuit camera to capture vertical displacement, knee flexion during the load response phase, and the initial contact of the foot with the ground for subsequent analysis. The pad test was performed during the kinematic evaluation. The vaginal squeeze pressure of the continent group (mean = 43.40 mmHg, SD = 21.75) was higher in descriptive terms than that of the incontinent group (mean = 38.94 mmHg, SD = 31.08), but the difference was not statistically significant (p = 0.66). There was an association between the weekly training load and urinary leakage. No associations were found between pelvic floor muscle function or urinary leakage and the kinematic variables. Despite the correlation between the weekly training load and the severity of urinary leakage, no relationships were found between pelvic floor muscle functioning and the kinematics of running.

Objective The purpose of this study was to compare (1) the effects of the instrument-assisted perineal stretching technique with different application protocols in combination with perineal massage and (2) the effects of the isolated techniques on the extensibility and strength of the pelvic floor muscles (PFMs). Methods A randomized controlled clinical trial with parallel randomization, assessor blinding, and concealed allocation was conducted in the Campus Physical Education at the Federal University of Uberlândia in Brazil. Ninety-six pregnant women (18–40 years of age) were allocated into 4 groups: perineal massage (PnM) group (PnM protocol for 10 minutes); instrument-assisted perineal stretching with a long static protocol for 15 minutes [IStrLS group]); PnM + IStrLS group (both techniques applied in the 2 previous groups); and PnM + IStrSR group (the same techniques as used in the PnM + IStrLS group but with a short repeated protocol; 4 sets lasting 30 seconds each). Eight interventions were performed in all 4 groups twice weekly (beginning at the 34th gestational week). The primary outcome was PFM extensibility, assessed using vaginal dilator circumference, and the secondary outcome was PFM strength, assessed using vaginal manometry. Results For the PFM extensibility variable, a significant main effect of time (F2,88 = 87.951) and group (F3,88 = 7.193) was found. Tukey post hoc test results showed that the PnM + IStrSR group presented greater extensibility than the PnM and IStrLS groups. The PnM group showed increased PFM strength after 8 sessions compared with the other groups. Conclusions Women who were pregnant and received the combination of perineal massage and instrument-assisted perineal stretching with short repeated application had a greater increase in PFM extensibility than perineal massage and instrument-assisted perineal stretching alone. Impact The combination of perineal massage and instrument-assisted perineal stretching techniques with a short, repeated protocol led to better PFM extensibility results than the application of the techniques alone in women who were pregnant. Lay summary Pregnant women can benefit from intervention using the combination of perineal massage and instrument-assisted perineal stretching techniques with a short, repeated protocol.

Aim To verify which one improves better stress urinary incontinence (SUI) symptoms: abdominal hypopressive technique (AHT) or pelvic floor muscle training (PFMT). Methods Randomized controlled trial. Women with SUI who had not participated of physiotherapy program before were invited. The outcome measures were 7-day bladder diary, International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) and pelvic floor muscles (PFM) function measured by Modified Oxford grading System with vaginal palpation and manometry with Peritron. Intervention consisted by 12 weeks of exercises program including PFMT or AHT program, in groups of maximum three women, twice a week, with physiotherapist supervision. Results AHT and PFMT groups reduced urinary leakage episodes in 7 days, -0.64 and -1.91, respectively, but PFMT was superior, whit mean difference -1.27 (95% confidence interval [CI]: -1.92 to -0,62) and effect size was 0.94 in favor to PFMT. Regarding to total score of ICIQ-SF, both groups improved, with mean difference between groups -4.7 (95% CI: -6.90 to -2.50) and effect size was 1.04 in favor to PFMT. Manometry also presented improvement after treatment for both groups with mean difference between them of 11 (95% CI: 6.33-15.67) and effect size was 1.15 also in favor to PFMT. Conclusion Regarding to SUI symptoms, quality of life impact and PFM function both groups presented improvement, however, PFMT was superior to AHT among all of them.

Aims To verify if hypopressive exercises (HEs) can improve pelvic organ prolapse (POP) symptoms equally or better than pelvic floor muscle training (PFMT). Methods Randomized controlled trial. Symptomatic women with untreated stage II POP according to the Pelvic Organ Prolapse Quantification System (POP-Q) having the ability to contract their pelvic floor muscles were invited. The outcome measures were POP symptoms as measured by specific questions and Prolapse Quality of Life (P-QoL); POP severity as measured by POP-Q; and PFM function. Intervention consisted by 12 weeks of PFMT or an HE home exercise program with bimonthly sessions with a physiotherapist. The protocol consisted of three initial sessions to learn how to perform the exercises correctly, followed by 3 months of exercise with monthly progression. Volunteers filled out exercise diaries to record their compliance. Results PFMT presented better results in terms of the following symptoms: a bulge/lump from or in the vagina, heaviness or dragging on the lower abdomen, and stress incontinence. PFMT also presented better results regarding the Prolapse impact and role, social and personal limitations of P-QoL. Regarding the total number of symptoms at the end, the PFMT group presented a mean of 1.7 (±1.2), and the HE group presented a mean of 2.8 (±1,1); the effect size was 1.01 in favor of the PFMT group (95%CI = 1.002-1.021). Conclusion Both groups exhibited improvements in POP symptoms, quality of life, prolapse severity, and PFM function. PFMT was superior to HE for all outcomes.

Background: Exercise and supplementation with isoflavones are therapies used to prevent and treat climacteric symptoms. Aim: To verify the effects of 10 weeks of combined aerobic and resistance training and isoflavone supplementation on climacteric symptoms in postmenopausal women. Methods: A randomised, double-blind, controlled clinical trial was performed. A total of 32 postmenopausal women, aged 54.4 ± 5.4 years, with a body mass index of 26.6 ± 3.0 kg/m2 and 5.6 ± 4.6 years after menopause, were randomly assigned to groups: placebo and exercise (PLA + EXE, n = 15) or 100 mg of isoflavone and exercise (ISO + EXE, n = 17). At the beginning and after 10 weeks of aerobic + resistance (20 min each, moderate intensity) training, climacteric symptoms were evaluated using the Blatt–Kupperman Menopausal Index, Cervantes Scale and Menopause Rating Scale. ANCOVA was used for analysis between groups and at different times, with the covariate adjusted by the pre-value. The level of significance considered was p < 0.05. Results: A reduction in climacteric symptoms was observed in both groups, without differences between the interventions. The reductions were 45% and 50% for the Blatt–Kupperman Menopausal Index, 41% and 52% for the MRS and 39% and 39% for the Cervantes Scale in the ISO + EXE and PLA + EXE groups, respectively. In the descriptive analysis of the Blatt–Kupperman Menopausal Index values, there was an increase in the absence of symptoms from 48−77% in the ISO + EXE group and 24−58% in the PLA + EXE group. Conclusions: A period of 10 weeks of combined training was effective in improving climacteric symptoms in post-menopausal women. However, isoflavone supplementation did not promote additional effects in improving symptoms.

Aims We aimed to compare pelvic floor muscle (PFM) strength and sexual function in primigravid and non-pregnant women and compare PFM strength between those who exhibited and did not exhibit sexual dysfunction. Methods A cross-sectional observational study was conducted. The sample consisted of 154 women, including 76 primigravid and 78 non-pregnant women. The inclusion criteria were as follows: non-pregnant nulliparous women or primigravid women who were pregnant with a single foetus at least 14 weeks of gestational age and reported having sexual intercourse at least once during the last 4 weeks. The exclusion criteria were as follows: inability to contract the PFMs and prior urogynaecologic surgery. PFM strength was assessed via vaginal palpation (using the Modified Oxford Scale) and vaginal squeeze pressure (using the Peritron™ manometer). Sexual function was assessedusing the Female Sexual Function Index (FSFI) questionnaire. Sexual dysfunction was identified based on low FSFI scores.The data were analyzed using the Mann-Whiney and Spearman correlation tests. Results To discussion, primigravid women had lower FSFI scores and lower PFM strength than non-pregnant women. Women with sexual dysfunction had lower PFM strength than women without sexual dysfunction, as indicated by vaginal palpation (scores of 2 out of 5 and 4 out of 5, respectively; P

Aims The aim of this study was to evaluate the effectiveness of a Pilates exercise program with pelvic floor muscle (PFM) contraction compared to a conventional intervention in pregnant women. Methods Fifty primiparous women, without gestational alterations, were randomized to the Pilates group (n = 25) and control group (n = 25). Interventions for both groups consisted of twice-weekly sessions of 1 h each during the period between the 14-16th and 32-34th gestational weeks. The Pilates group performed a Pilates exercises program with the addition of voluntary PFM contraction. Mat-based Pilates exercises were performed involving movement of the upper limbs, lower limbs and trunk in all sessions. The Control group walked for 10 min and performed strengthening exercises of the lower limbs, upper limbs, and trunk with resistance from an elastic band and body weight. Each woman was evaluated by an unblinded physiotherapist before and after intervention for primary (PFM strength using a manometer) and secondary (PFM strength using Oxford Scale, endurance and repeatability) outcomes. Covariance analysis (ANCOVA) was used to compare the groups using the baseline values as a covariate. Results Thirty-six women were included in the analysis. There were no differences between the groups for manometry. An increase in the PFM strength, endurance, and repeatability was only observed in the Pilates group. In addition, the Pilates group showed greater adherence to the intervention. Conclusion Pilates exercise program with PFM contraction is not able to change the PFM strength assessed by manometer in pregnant women, but it improved adherence to the intervention.

Apesar de a cinesioterapia para o assoalho pélvico fazer parte do padrão áureo para o tratamento das disfunções do assoalho pélvico, um terço das mulheres apresenta dificuldade de identificação daquela musculatura o que tolhe o iní­cio do tratamento. A ginástica hipopressiva é técnica recente que promete contração reflexa da musculatura do assoalho pélvico, mas é parca a evidência a este respeito. Métodos: Organização da evidência, especialmente por exames de imagem e eletromiografia, publicada até o momento. Resultados: A ginástica hipopressiva provoca momento cranial das ví­sceras, o que pode ser observado por ultrassonografia, ressonância magnética e observação direta via espéculo. A eletromiografia durante a manobra sugere ativação reflexa da musculatura do assoalho pélvico. Conclusão: A ginástica hipopressiva age no assoalho pélvico, e pode ser utilizada como técnica adjuvante para o despertar proprioceptivo da musculatura local.Palavras-chave: ginástica hipopressiva, cinesioterapia, assoalho pélvico, propriocepção, fisioterapia.

Introdução: Prolapso genital é definido como deslocamento das ví­sceras pélvicas em sentido caudal. Trata-se de afecção comum, especialmente em mulheres menopausadas e, não obstante, pode estar associado í incontinência urinária de esforço (IUE). Estudos mostram que mulheres com prolapso genital possuem função muscular do assoalho pélvico diminuí­da. Objetivo: Verificar se há diferença entre a função dos músculos do assoalho pélvico (MAP) de mulheres incontinentes com ou sem prolapso genital. Métodos: Participaram dessa pesquisa 24 voluntárias divididas em dois grupos, a saber: Grupo I composto por 12 mulheres com IUE associada ao prolapso genital; e Grupo II, composto por 12 mulheres com IUE e sem prolapso genital associado. Avaliou-se a função dos MAP por meio de palpação bidigital, utilizando-se as escalas de Avaliação Funcional do Assoalho Pélvico (AFA) e Oxford, teste de tempo máximo de contração (endurance) e exame com perineômetro. Para a análise estatí­stica, utilizou-se o test t de Student, para comparar as médias obtidas e o ní­vel de significância. Resultados: As mulheres com prolapso genital associado apresentaram menor AFA (p = 0,043), Oxford (p = 0,043) e tempo de sustentação da contração mensurado pelo perineômetro (p = 0,044). Conclusão: Mulheres incontinentes com prolapso genital apresentam menor função muscular e menor tempo de sustentação da contração.Palavras-chave: prolapso genital, avaliação, músculos do assoalho pélvico, incontinência urinária de esforço.

Objetivo: O presente estudo tem como objetivo mensurar o arco plantar de mulheres corredoras e correlacionar com a função dos músculos do assoalho pélvico. Métodos: Trata-se de um estudo transversal, descritivo e observacional, aprovado pelo Comitê de Ética em Pesquisa na Universidade Federal de Uberlândia (No. 1451984/2016). Foram incluídas 26 atletas corredoras no estudo. O protocolo de pesquisa foi dividido em duas etapas. Inicialmente foi realizada a avaliação dos músculos do assoalho pélvico por palpação vaginal (graduada pela Escala de Oxford) e posteriormente pela manometria de pressão, utilizando um perineômetro. Em seguida, foi realizada a fotopodoscopia, com os pés descalços, apoio bipodal e postura ortostática com braços ao longo do corpo, sendo a imagem da impressão plantar refletida no espelho foi capturada por uma câmera. Resultados: Não foram encontradas correlações entre o tamanho do arco plantar e a função dos músculos do assoalho pélvico. As atletas apresentaram baixa força muscular de assoalho pélvico mensurada pela manometria de pressão (pico de contração: 46,10(29,34) cmH2O). Ainda, foi encontrada alta prevalência de incontinência urinária entre as atletas (9 mulheres relataram perda involuntária de urina durante a prática da corrida, o que representa 34,6% da amostra). Conclusão: Não foi encontrada correlação entre o arco plantar e a função dos músculos do assolho pélvico de atletas corredoras.

Objetivos: a) Identificar a prevalência da incontinência urinária em atletas e praticantes de atividade física; b) Verificar o impacto da atividade física nos músculos do assoalho pélvico de atletas; e c) Averiguar as evidências científicas sobre o tratamento fisioterapêutico da incontinência urinária em atletas e praticantes de atividade física. Métodos: Foi realizada uma revisão crítica da literatura com buscas nas bases de dados Pubmed e Lilacs, nos últimos dez anos. Foram incluídos estudos experimentais que avaliaram a prevalência de incontinência urinária durante a prática esportiva, estudos sobre o impacto da atividade física nos músculos do assoalho pélvico e estudos de intervenção nas disfunções dos músculos do assoalho pélvico em atletas. Resultados: Foram incluídos 17 estudos. A prevalência da incontinência urinária variou entre 5% e 88,9%, a depender do tipo de atividade física. A idade média das mulheres foi de 24,9 anos sendo a maioria nuligesta. No que se refere ao impacto da atividade física nos músculos do assoalho pélvico, os principais métodos de avaliação muscular utilizados foram a palpação vaginal, eletromiografia e ultrassonografia tridimensional. Por fim, em relação ao tratamento, foram encontrados três estudos de intervenção, tipo antes e depois, onde diferentes tipos de protocolos foram utilizados com objetivo de reabilitação dos músculos do assoalho pélvico em mulheres atletas com queixa de incontinência urinária, mostrando efetividade. Conclusões: A reabilitação muscular pareceu ser eficaz para a melhora da incontinência urinária, são necessários mais estudos randomizados para melhor comprovação da sua prática.

This study aimed to evaluate the levator hiatus area (LHA) at rest and during the performance of maximal pelvic floor muscle (PFM) contractions, during the abdominal hypopressive technique (AHT), and during the combination of PFM contractions (PFMCs) and the AHT. The study included 17 healthy nulliparous women who had no history of pelvic floor disorders. The LHA was evaluated with the patients in the lithotomy position. After a physiotherapist instructed the patients on the proper performance of the PFM and AHT exercises, 1 gynecologist performed the 3-dimensional translabial ultrasound examinations. The LHA was measured with the patients at rest. The PFMC alone, the AHT alone or the AHT in combination with a PFMC with 30 seconds of rest between the evaluations were performed. Each measurement was performed 2 times, and the mean value was used for statistical analysis. The Wilcoxon test was used to test the differences between the 2 maneuvers. Similar values were observed when comparing the LHA of the PFM at rest (12.2 ± 2.4) cm and during the AHT (11.7 ± 2.6) cm (P = 0.227). The AHT+ PFMC (10.2 ± 1.9) cm demonstrated lower values compared with AHT alone (11.7 ± 2.6) cm (P = 0.002). When comparing the PFMC (10.4 ± 2.1) cm with the AHT + PFMC (10.2 ± 1.9) cm, no significant difference (P = 0.551) was observed. During PFMC, the constriction was 1.8 cm; during the AHT, the constriction was 0.5 cm; and during the AHT + PFMC, it was 2 cm. The LHA assessed by 3-dimensional ultrasound did not significantly change with AHT. These results support the theory that AHT does not strengthen PFM.

Perineal preparation techniques for childbirth have been used with the aim of reducing perineal tears during the expulsive phase of labor. However, no studies were found to investigate the effects of instrument-assisted stretching versus perineal massage on pelvic floor muscle (PFM) variables. Therefore, the aim of this study was to evaluate the effect of instrument-assisted stretching versus perineal massage on the extensibility and strength of the PFMs. Primiparous women were randomized to the instrument-assisted stretching (IStr) group (n = 13) and perineal massage (PnM) group (n = 14). The groups participated in eight sessions, twice weekly, beginning at the 34th gestational week. The IStr group underwent the intervention for 15 min using EPI-NO®. The PnM group underwent a perineal massage protocol for 10 min. Each woman was evaluated by a blinded physiotherapist before, after four and after eight sessions for primary (PFM extensibility using the EPI-NO® circumference) and secondary (PFM strength using a manometer) outcomes. Covariate analysis (ANCOVA) was used to compare the groups using the baseline values as a covariate. Both groups showed an increase in PFM extensibility compared with the evaluations before and after four and eight sessions (PnM group from 17.6 ± 1.8 to 20.2 ± 1.9 cm; IStr group from 19.9 ± 1.6 to 22.9 ± 1.6 cm;p

The objective was to evaluate the pelvic floor muscles (PFM) in primigravidae and compare them with those in nonpregnant nulliparous women. The sample consisted of 141 women with a mean age of 22.8 years, divided into four groups: 36 nonpregnant nulliparous (C), 31 primigravidae in the first trimester (1T), 42 primigravida in the second trimester (2T), and 32 primigravidae in the third trimester (3T). The participants were examined by digital palpation for pelvic floor muscle contraction using the Modified Oxford Scale, by measuring maximal vaginal squeeze pressure with a vaginal perineometer, and by measuring PFM maximal strength using a vaginal dynamometer. The best value of three maximal strengths was considered for analysis, the Kruskal–Wallis and Mann–Whitney U tests were used and differences were considered significant at p ≤ 0.05. The mean values for group C were 3.2 (digital palpation), 45.6 cmH2O (perineometry), and 11.7 N (dynamometry); for group 1T the corresponding values were 2.5, 21.1 cmH2O, and 8.8 N; for group 2T: 2.8, 22.9 cmH2O, and 7.8 N; and for group 3T: 2.1, 17.3 cmH2O, and 6.8 N. Groups were compared in pairs for digital palpation, perineometry, and dynamometry. There were significant differences between group C and group 1T, and between group C and group 3T. There was a significant difference between group C and group 2T with regard to perineometry and dynamometry, but not digital palpation. Dynamometry demonstrated a difference between groups 1T and 3T, digital palpation between groups 2T and 3T. Pelvic floor muscles in primigravidae are not as strong as those in nonpregnant nulliparous women.

OBJETIVO: Avaliar o impacto do treinamento dos músculos do assoalho pélvico (TMAP) na qualidade de vida (QV) em mulheres com incontinência urinária de esforço (IUE). MÉTODOS: Ensaio clínico prospectivo com 36 mulheres com diagnóstico médico de IUE conrmado no estudo urodinâmico. Não foram incluídas mulheres com doenças neuromusculares, com uso de reposição hormonal e com prolapso grau III e IV. O protocolo de exercícios para os músculos do assoalho pélvico foi constituído de contrações lentas (bras tônicas), seguidas de contrações rápidas (bras fásicas), realizadas nas posições de decúbito dorsal, sentada e ortostática, três vezes na semana, por um período de três meses. Avaliou-se o impacto do TMAP na QV por meio do King's Health Questionnaire (KHQ), diário miccional e palpação digital para avaliar a função dos músculos do assoalho pélvico, durante a avaliação inicial e após os três meses de tratamento. O resultado foi descrito em médias e desvios-padrões. Utilizou-se o teste de Wilcoxon para comparação dos escores referentes ao KHQ para amostras pareadas, e adotou-se como nível de signicância o valor de 0,05. RESULTADOS: Observou-se diminuição signicativa das médias dos escores dos domínios avaliados pelos KHQ. Esses domínios consistem na percepção da saúde, impacto da incontinência, limitações das atividades diárias, limitações físicas, limitações sociais, relações pessoais, emoções, sono/disposição e também medidas de gravidade. Em concordância com esses resultados, foram observados diminuição signicativa na frequência urinária noturna e na perda urinária, bem como aumento signicativo na força e endurance muscular. CONCLUSÃO: O treinamento muscular do assoalho pélvico proporcionou melhora signicativa na QV de mulheres com IUE.OBJECTIVE: To evaluate the impact of pelvic floor muscle (PFM) training on the quality of life (QOL) in women with stress urinary incontinence (SUI). METHODS: Prospective clinical trial with 36 women with a diagnosis of SUI confirmed by urodynamic study. Women with neuromuscular diseases, using hormone replacement therapy, and with prolapse stage III and IV were not included. The exercise protocol for the PFM consisted of slow contractions (tonic fibers), followed by rapid contractions (phasic fibers) practiced in the supine, sitting, and standing positions, three times a week for a period of three months. We evaluated the impact of PFM on QOL using the King's Health Questionnaire (KHQ), a voiding diary, and digital palpation to assess the function of the PFMs during the initial evaluation and after three months of treatment. The result was described as means and standard deviations. We used the Wilcoxon test for comparison of the KHQ scores for paired samples, and the significance level was set at 0.05. RESULTS: There was a significant decrease in the mean scores of the domains assessed by the KHQ regarding the perception of health, impact of the incontinence, limitations of daily activities, physical limitations, social limitations, personal relationships, emotions, sleep/disposition, and measures of severity. In agreement with these results, significant decrease in nocturnal urinary frequency and urinary incontinence, as well as significant increase in muscle strength and endurance were observed. CONCLUSION: PFM training resulted in significant improvement in the QOL of women with SUI.

Biofeedback (BF) has been widely used in the treatment of pelvic floor dysfunctions, mainly by promoting patient learning about muscle contraction with no side effects. However, its effectiveness remains poorly understood with some studies suggesting that BF offers no advantage over the isolated pelvic floor muscle training (PFMT). The main objective of this study was to systematically review available randomized controlled trials assessing the effectiveness of BF in female pelvic floor dysfunction treatment. Trials were electronically searched and rated for quality by use of the PEDro scale (values of 0-10). Randomized controlled trials assessing the training of pelvic floor muscle (PFM) using BF in women with PFM dysfunction were selected. Outcomes were converted to a scale ranging from 0 to 100. Trials were pooled with software used to prepare and update Cochrane reviews. Results are presented as weighted mean differences with 95 % confidence intervals (CI). Twenty-two trials with 1,469 patients that analyzed BF in the treatment of urinary, anorectal, and/or sexual dysfunctions were included. PFMT alone led to a superior but not significant difference in the function of PFM when compared to PFMT with BF, by using vaginal measurement in the short and intermediate term: 9.89 (95 % CI -5.05 to 24.83) and 15.03 (95 % CI -9.71 to 39.78), respectively. We found a few and nonhomogeneous studies addressing anorectal and sexual function, which do not provide the cure rate calculations. Limitations of this review are the low quality and heterogeneity of the studies, involving the usage of distinct protocols of interventions, and various and different outcome measures. The results of this systematic review suggest that PFMT with BF is not more effective than other conservative treatments for female PFM dysfunction.

Summary Objective To evaluate the impact of pelvic floor muscle (PFM) training on the quality of life (QOL) in women with stress urinary incontinence (SUI). Methods Prospective clinical trial with 36 women with a diagnosis of SUI confirmed by urodynamic study. Women with neuromuscular diseases, using hormone replacement therapy, and with prolapse stage III and IV were not included. The exercise protocol for the PFM consisted of slow contractions (tonic fibers), followed by rapid contractions (phasic fibers) practiced in the supine, sitting, and standing positions, three times a week for a period of three months. We evaluated the impact of PFM on QOL using the King's Health Questionnaire (KHQ), a voiding diary, and digital palpation to assess the function of the PFMs during the initial evaluation and after three months of treatment. The result was described as means and standard deviations. We used the Wilcoxon test for comparison of the KHQ scores for paired samples, and the significance level was set at 0.05. Results There was a significant decrease in the mean scores of the domains assessed by the KHQ regarding the perception of health, impact of the incontinence, limitations of daily activities, physical limitations, social limitations, personal relationships, emotions, sleep/disposition, and measures of severity. In agreement with these results, significant decrease in nocturnal urinary frequency and urinary incontinence, as well as significant increase in muscle strength and endurance were observed. Conclusion PFM training resulted in significant improvement in the QOL of women with SUI.

Aims The aim of the study was to compare the effect of hypopressive exercises including pelvic floor muscle contraction, pelvic floor muscle training (PFMT) alone and control on pelvic floor muscle function in women with pelvic organ prolapse (POP). Methods Fifty-eight women with a mean age of 55.4 (±9.8) years old with stage II POP were randomly assigned to participate in the PFMT group, the hypopressive exercises associated with PFMT (HE + PFMT) group or the control group. Each treatment group underwent a 3-month course of treatment. The three groups received lifestyle advice regarding weight loss, constipation, coughing, and the avoidance of heavy lifting. Participants were evaluated before and after the treatment. Maximal voluntary contraction (MVC) and endurance were assessed using the Modified Oxford grading system. To evaluate muscle activation, surface electromyography (SEMG) was used. Results The two treatment group significantly increase pelvic floor muscle function as measured by MVC (P

A eletromiografia de superfície tem grande importância clínica e de pesquisa para o fisioterapeuta. Apesar de captar a atividade elétrica promovida pelo recrutamento das unidades motoras, há boa correlação entre o número de unidades ativadas e a força muscular. É um dos métodos de maior especificidade na avaliação do assoalho pélvico, embora não haja consenso em relação à sua aplicação. Essa revisão de literatura foi desenvolvida com o objetivo de agrupar as informações sobre o uso da eletromiografia de superfície na avaliação do assoalho pélvico. Foram pesquisados artigos nas bases de dados Medline, PubMed, Lilacs, SciELO e Biblioteca Cochrane, e selecionados os que avaliassem o assoalho pélvico feminino por meio de eletromiografia de superfície. Apesar de sua metodologia ainda carecer de padronização, é um instrumento que deve ser considerado nas pesquisas científicas em nosso meio, pois parece apresentar boa reprodutibilidade e confiabilidade. Pacientes com disfunções do assoalho pélvico possuem alterações no tempo de ativação dos músculos do assoalho pélvico (MAP) e músculos abdominais. Quanto à gestação e puerpério, ainda faltam evidências sobre possíveis alterações da ativação elétrica dos MAP nesses períodos.Surface electromyography has clinical and research importance for the physiotherapist. Although capturing electrical activity promoted by recruitment of motor units, there is a good correlation between the number of activated units and muscle strength. This is one of the methods of higher specificity in pelvic floor evaluation, although the lack of consensus regarding its application. The aim of this literature review was to cluster information regarding to the use of surface electromyography in the evaluation of pelvic floor. Papers were searched in Medline, Pubmed Lilacs, SciELO and Cochrane Library. Were selected papers which methods used surface electromyography to evaluate the pelvic floor. Although its methodology still lacks standardization, is an instrument that should be considered in scientific research in our country because it seems to have good reproducibility and reliability. Women with pelvic floor disorders have changes in the activation time of the pelvic floor muscles (PFM) and abdominal muscles. With respect to pregnancy and postpartum, there is a lack of evidence on possible changes in electrical activation of PFM in these periods.

A eletromiografia de superfície tem grande importância clínica e de pesquisa para o fisioterapeuta. Apesar de captar a atividade elétrica promovida pelo recrutamento das unidades motoras, há boa correlação entre o número de unidades ativadas e a força muscular. É um dos métodos de maior especificidade na avaliação do assoalho pélvico, embora não haja consenso em relação à sua aplicação. Essa revisão de literatura foi desenvolvida com o objetivo de agrupar as informações sobre o uso da eletromiografia de superfície na avaliação do assoalho pélvico. Foram pesquisados artigos nas bases de dados Medline, PubMed, Lilacs, SciELO e Biblioteca Cochrane, e selecionados os que avaliassem o assoalho pélvico feminino por meio de eletromiografia de superfície. Apesar de sua metodologia ainda carecer de padronização, é um instrumento que deve ser considerado nas pesquisas científicas em nosso meio, pois parece apresentar boa reprodutibilidade e confiabilidade. Pacientes com disfunções do assoalho pélvico possuem alterações no tempo de ativação dos músculos do assoalho pélvico (MAP) e músculos abdominais. Quanto à gestação e puerpério, ainda faltam evidências sobre possíveis alterações da ativação elétrica dos MAP nesses períodos. Surface electromyography has clinical and research importance for the physiotherapist. Although capturing electrical activity promoted by recruitment of motor units, there is a good correlation between the number of activated units and muscle strength. This is one of the methods of higher specificity in pelvic floor evaluation, although the lack of consensus regarding its application. The aim of this literature review was to cluster information regarding to the use of surface electromyography in the evaluation of pelvic floor. Papers were searched in Medline, Pubmed Lilacs, SciELO and Cochrane Library. Were selected papers which methods used surface electromyography to evaluate the pelvic floor. Although its methodology still lacks standardization, is an instrument that should be considered in scientific research in our country because it seems to have good reproducibility and reliability. Women with pelvic floor disorders have changes in the activation time of the pelvic floor muscles (PFM) and abdominal muscles. With respect to pregnancy and postpartum, there is a lack of evidence on possible changes in electrical activation of PFM in these periods.

Aims: The abdominal hypopressive technique (AHT) is performed mainly via transversus abdominis (TrA) activation and has been indicated for pelvic floor muscle (PFM) disorders. In some European countries, this technique has become widely used. This study aimed to investigate PFM and TrA activation during the AHT through surface electromyography. Methods: Thirty-four nulliparous physical therapists in good general health were asked to participate in the trial. To ascertain a correct PFM contraction, each of the participants was assessed by inspection and digital palpation. Ability to contract the TrA was assessed by surface electromyography and AHT training was given before analysis. TrA and PFM activity was recorded using surface electromyography. Results: The mean age of the volunteers was 28.1 (� 6.0) years and the mean body mass index was 23.7 (� 3.3) kg/m 2 . More than half of the volunteers were physically active (61.3%) and regularly performed PFM training (52.9%) but not TrA exercises (58.8%). Although the AHT activates the PFM when compared to resting tone (P < 0.001), this method is significantly less effective than PFM alone (P < 0.001). Additionally, the combination of the two techniques (AHT þ PFM) was similarly effective as isolated PFM contraction (P ¼ 0.586). Although the AHT activated the TrA significantly more than did PFM alone (P ¼ 0.002), the addition of PFM contraction to the AHT significantly increased the amount of TrA activation (P < 0.001). Conclusions: Based on our results, the AHT is less effective than PFM contraction alone, and adding PFM contraction to AHT also improves the TrA contraction. Neurourol. Urodynam. 2011 Wiley-Liss, Inc.

To determine if Paula method of circular muscles contraction e.g., those surrounding the eyes, mouth and fingers, could increase pelvic floor muscle (PFM) activity.Thirty-four healthy, nulliparous volunteers were included, with an average age of 28 (± 5.9) years and body mass index of 23.8 (± 3.3) kg/m(2). They were assigned to randomly perform the sequence: a PFM maximal voluntary contraction, a contraction of circular muscles, followed by a simultaneous combination of PFM and circular muscle contraction. The PFM were evaluated using surface electromyography.PFM activity at baseline was 22.6 (± 10.9) μv. It was unchanged with Paula method contraction (p=0.322). There were also no differences between values of PFM maximal voluntary contraction alone, 99.8 (± 44.3) μv and in combination with the Paula method, 91.8 (± 35.3) μv (p=0.093).The Paula method seems not to increase PFM activity in nulliparous women.

BACKGROUND AND OBJECTIVES: To evaluate and compare the presence and size of recti abdominis diastasis in the second and third gestational trimester and to correlate them to lumbar pain incidence and intensity. METHODS: This is a cross-sectional observational study with 128 pregnant women divided in two groups: 53 pregnant women in the second gestational trimester and 75 pregnant women in the third gestational trimester. Lumbar pain was evaluated with Roland Morris questionnaire and Pain Visual Analog Scale. Recti abdominis diastasis was measured with a caliper rule. Data were analyzed according to Spearman correlation and Mann-Whitney U test. RESULTS: Comparison between groups has shown that pregnant women in the third gestational trimester had more recti abdominis diastasis, more reports of severe lumbar pain by the visual analog scale (p=0.0017) and further impact on daily life activities (p=0.0012). There has been positive correlation between recti abdominis diastasis size and scores obtained by Roland Morris questionnaire and visual analog scale. CONCLUSION: Recti abdominis diastasis size, pain intensity and incapacity determined by low back pain were more severe in pregnant women in the third gestational trimester.

Objective.The objective of this study was to compare the role of the pelvic floor muscles between nulliparous and multiparous women in the third trimester of pregnancy, by analyzing the relationship between electrical activity (surface electromyography—EMG), vaginal palpation (modified Oxford scale), and perineal distensibility (Epi-no).Methods.This was an observational cross-sectional study on a sample of 60 healthy pregnant women with no cervical dilation, single fetus, gestational age between 35 and 40 weeks, and maternal age ranging from 15 to 40 years. The methods used were bidigital palpation (modified Oxford scale, graded 0–5), surface EMG (electrical activity during maximal voluntary contraction), and perineal distensibility (Epi-no device). The Pearson correlation coefficient (r) was used to analyze the Epi-no values and the surface EMG findings. The Kruskal-Wallis test was used to compare the median values from surface EMG and Epi-no, using the modified Oxford scale scores.Results.Among the 60 patients included in this study, 30 were nulliparous and 30 multiparous. The average maternal age and gestational age were 26.06 (±5.58) and 36.56 (±1.23), respectively. It was observed that nulliparous women had both higher perineal muscle strength (2.53 ± 0.57versus2.06 ± 0.64;P = 0.005) and higher electrical activity (45.35 ± 12.24 μV versus35.79 ± 11.66 μV;P = 0.003), while among the multiparous women, distensibility was higher (19.39 ± 1.92versus18.05 ± 2.14;P = 0.013). We observed that there was no correlation between perineal distensibility and electrical activity during maximal voluntary contraction (r = -0.193;P = 0.140). However, we found a positive relationship between vaginal palpation and surface electromyography (P = 0.008), but none between Epi-no values (P = 0.785).Conclusion.The electrical activity and muscle strength of the pelvic floor muscles of the multiparous women were damaged, in relation to the nulliparous women, while the perineal distensibility was lower in the latter group. There was a positive relationship between surface EMG and the modified Oxford scale.

OBJETIVO: Verificar o efeito da adição do biofeedback (BF) ao treinamento dos músculos do assoalho pélvico (TMAP) para o tratamento da incontinência urinária de esforço (IUE). MÉTODOS: Estudo piloto prospectivo, randomizado e controlado, com mulheres com IUE sem deficiência esfincteriana detectada ao estudo urodinâmico e que realizavam a correta contração dos MAP. Foram excluídas mulheres com doenças neuromusculares e com prolapso genital graus III e IV. Foram randomizadas 40 mulheres em Grupo Controle e Grupo BF. O protocolo de TMAP com equipamento de BF foi constituído de três séries de dez contrações lentas (tônicas), com tempo de manutenção de seis a oito segundos em cada contração, seguido de um período de repouso de mesmo valor. Após cada contração sustentada, eram realizadas de três a quatro contrações rápidas (fásicas) em decúbito dorsal e ortostatismo, duas vezes na semana, totalizando 12 sessões. Avaliou-se o efeito da adição do BF ao TMAP na qualidade de vida pelo King's Health Questionnaire (KHQ), nos sintomas urinários pelo diário miccional e na função dos músculos do assoalho pélvico (MAP) pela palpação digital. A avaliação foi realizada inicialmente e após as 12 sessões de tratamento. O resultado foi descrito em médias e desvios padrão. Para análise de homogeneidade e verificação das diferenças entre os grupos utilizou-se o teste de Mann-Whitney, e para diferenças entre os momentos de observação, o teste de Wilcoxon, com nível de significância de 0,05. RESULTADOS: Diminuição significativa nos escores dos domínios avaliados pelo KHQ na comparação entre os grupos, exceto para o domínio saúde geral (Grupo BF 32,8±26,9 versus Grupo Controle 48,4±29,5; p

To investigate the effect of adding biofeedback (BF) to the training of pelvic floor muscles (PFMT) for the treatment of stress urinary incontinence (SUI).A prospective pilot study, randomized and controlled with women with SUI without sphincter deficiency, detected by urodynamic study and who performed the correct PFM contraction. Women with neuromuscular disorders and grade III and IV genital prolapse were excluded. Forty women were randomized into a CONTROL GROUP and BF Group. The PFMT protocol with BF equipment consisted of three sets of ten slow contractions (tonic), with a holding time of six to eight seconds at each contraction followed by a rest period of equal duration. After each sustained contraction, they performed three to four fast contractions (phasic) in the supine and standing position twice a week, for a total of 12 sessions. We evaluated the effect of adding BF to PFMT on quality of life using King's Health Questionnaire (KHQ) regarding urinary symptoms based on a voiding diary and regarding the function of pelvic floor muscles by digital palpation. The evaluation was performed initially and after 12 treatment sessions. Data are reported as mean and standard deviation. The Mann-Whitney test was used for the analysis of homogeneity and to determine differences between groups, and the Wilcoxon test was used to determine possible differences between the times of observation, with the level of significance set at 0.05.A significant decrease in the scores of the domains assessed by the KHQ was observed in the comparison between groups, except for the general health domain (BF Group: 32.8 ± 26.9 versus48.4 ± 29.5, p0.13). Accordingly, there was improvement in PFM function after treatment in the BF Group, regarding power (4.3 ± 0.8, p= 0.001), endurance (6.0 ± 2.2, p0.001) and fast (9.3 ± 1.9, p=0.001). When comparing the groups, the BF Group showed a positive result regarding power (BF Group 4.3 ± 0.8 versus CONTROL GROUP 2.5 ± 0.9, p0.001), endurance (6.0 ± 2.2 BF Group versus CONTROL GROUP 2.7 ± 1.9, p0.001) and fast (BF Group 9.3 ± 1.9 versus CONTROL GROUP 4.6 ± 3.2, p0.001). Reduction of nocturnal urinary frequency (1.2 ± 1.2 versus 0.7 ± 0.9, p=0.02) and of effort urine loss (1.5 ± 1.4 versus 0.6 ± 0.8, p=0.001) was observed in the BF Group.The addition of BF to the PFMT for the treatment of SUI, applied according to the protocol described, improved PFM function, reduced urinary symptoms, and improved of the quality of life.

OBJETIVO: Avaliar o impacto do treinamento dos músculos do assoalho pélvico (TMAP) na qualidade de vida (QV) em mulheres com incontinência urinária de esforço (IUE). MÉTODOS: Ensaio clínico prospectivo com 36 mulheres com diagnóstico médico de IUE conrmado no estudo urodinâmico. Não foram incluídas mulheres com doenças neuromusculares, com uso de reposição hormonal e com prolapso grau III e IV. O protocolo de exercícios para os músculos do assoalho pélvico foi constituído de contrações lentas (bras tônicas), seguidas de contrações rápidas (bras fásicas), realizadas nas posições de decúbito dorsal, sentada e ortostática, três vezes na semana, por um período de três meses. Avaliou-se o impacto do TMAP na QV por meio do King's Health Questionnaire (KHQ), diário miccional e palpação digital para avaliar a função dos músculos do assoalho pélvico, durante a avaliação inicial e após os três meses de tratamento. O resultado foi descrito em médias e desvios-padrões. Utilizou-se o teste de Wilcoxon para comparação dos escores referentes ao KHQ para amostras pareadas, e adotou-se como nível de signicância o valor de 0,05. RESULTADOS: Observou-se diminuição signicativa das médias dos escores dos domínios avaliados pelos KHQ. Esses domínios consistem na percepção da saúde, impacto da incontinência, limitações das atividades diárias, limitações físicas, limitações sociais, relações pessoais, emoções, sono/disposição e também medidas de gravidade. Em concordância com esses resultados, foram observados diminuição signicativa na frequência urinária noturna e na perda urinária, bem como aumento signicativo na força e endurance muscular. CONCLUSÃO: O treinamento muscular do assoalho pélvico proporcionou melhora signicativa na QV de mulheres com IUE. OBJECTIVE: To evaluate the impact of pelvic floor muscle (PFM) training on the quality of life (QOL) in women with stress urinary incontinence (SUI). METHODS: Prospective clinical trial with 36 women with a diagnosis of SUI confirmed by urodynamic study. Women with neuromuscular diseases, using hormone replacement therapy, and with prolapse stage III and IV were not included. The exercise protocol for the PFM consisted of slow contractions (tonic fibers), followed by rapid contractions (phasic fibers) practiced in the supine, sitting, and standing positions, three times a week for a period of three months. We evaluated the impact of PFM on QOL using the King's Health Questionnaire (KHQ), a voiding diary, and digital palpation to assess the function of the PFMs during the initial evaluation and after three months of treatment. The result was described as means and standard deviations. We used the Wilcoxon test for comparison of the KHQ scores for paired samples, and the significance level was set at 0.05. RESULTS: There was a significant decrease in the mean scores of the domains assessed by the KHQ regarding the perception of health, impact of the incontinence, limitations of daily activities, physical limitations, social limitations, personal relationships, emotions, sleep/disposition, and measures of severity. In agreement with these results, significant decrease in nocturnal urinary frequency and urinary incontinence, as well as significant increase in muscle strength and endurance were observed. CONCLUSION: PFM training resulted in significant improvement in the QOL of women with SUI. Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departamento de Ginecologia UNIFESP, EPM, Depto. de Ginecologia SciELO

We compared the maximal voluntary contraction (MVC) and strength of pelvic floor muscles (PFM) of pregnant and nonpregnant women using surface electromyography (SEMG).Fifteen pregnant primiparous women and 15 nulliparous nonpregnant women were evaluated. The healthy pregnant women were in the third trimester of pregnancy with a single fetus and did not have any neuromuscular alterations. The nonpregnant women did not present with PF dysfunctions and, as with the pregnant women, did not have any previous gynecological surgeries or degenerative neuromuscular alterations. The evaluation methods used were digital palpation (Oxford Grading Scale, which ranges from 0 to 5) and SEMG. In the EMG exam, MVC activity was evaluated, and the better of two contractions was chosen. Before the evaluation, all women received information about PFM localization and function and how to correctly contract PFM.In the EMG evaluation, MVC was significantly greater in the nonpregnant group (90.7 μv) than in the pregnant group (30 μv), with p0.001. The same results were observed after vaginal palpation, measured by the Oxford scale, which presented an average of 2.1 in the pregnant group and 4.5 in the nonpregnant group (p = 0.005).In comparison to nulliparous women, pregnant women demonstrated worse PFM function with decreased strength and electrical activity.

The abdominal hypopressive technique (AHT) is performed mainly via transversus abdominis (TrA) activation and has been indicated for pelvic floor muscle (PFM) disorders. In some European countries, this technique has become widely used. This study aimed to investigate PFM and TrA activation during the AHT through surface electromyography.Thirty-four nulliparous physical therapists in good general health were asked to participate in the trial. To ascertain a correct PFM contraction, each of the participants was assessed by inspection and digital palpation. Ability to contract the TrA was assessed by surface electromyography and AHT training was given before analysis. TrA and PFM activity was recorded using surface electromyography.The mean age of the volunteers was 28.1 (±6.0) years and the mean body mass index was 23.7 (±3.3) kg/m(2) . More than half of the volunteers were physically active (61.3%) and regularly performed PFM training (52.9%) but not TrA exercises (58.8%). Although the AHT activates the PFM when compared to resting tone (P 0.001), this method is significantly less effective than PFM alone (P 0.001). Additionally, the combination of the two techniques (AHT + PFM) was similarly effective as isolated PFM contraction (P = 0.586). Although the AHT activated the TrA significantly more than did PFM alone (P = 0.002), the addition of PFM contraction to the AHT significantly increased the amount of TrA activation (P 0.001).Based on our results, the AHT is less effective than PFM contraction alone, and adding PFM contraction to AHT also improves the TrA contraction.

The aim of the study was to compare the effect of hypopressive exercises including pelvic floor muscle contraction, pelvic floor muscle training (PFMT) alone and control on pelvic floor muscle function in women with pelvic organ prolapse (POP).Fifty-eight women with a mean age of 55.4 (± 9.8) years old with stage II POP were randomly assigned to participate in the PFMT group, the hypopressive exercises associated with PFMT (HE + PFMT) group or the control group. Each treatment group underwent a 3-month course of treatment. The three groups received lifestyle advice regarding weight loss, constipation, coughing, and the avoidance of heavy lifting. Participants were evaluated before and after the treatment. Maximal voluntary contraction (MVC) and endurance were assessed using the Modified Oxford grading system. To evaluate muscle activation, surface electromyography (SEMG) was used.The two treatment group significantly increase pelvic floor muscle function as measured by MVC (P0.001) using the Modified Oxford grading system, as well as muscle activation (P0.001), measured by SEMG. The PFMT group was superior regarding endurance (P = 0.007). Both groups were superior to the control group regarding MVC, endurance and muscle activation.Adding hypopressive exercises to PFMT does not improve PFM function. Both treatment groups performed better than the control group.

Introduction and hypothesis This pilot study aimed to investigate the effectiveness of pelvic floor muscle training (PFMT) for the treatment of pelvic organ prolapse. Methods Thirty-seven women with stage II prolapse were randomized to either the intervention group (n=21) or the control group (n=16). The evaluation included assessments of pelvic floor muscle function and surface electromyography at baseline and post 14 weeks of treatment. The severity of prolapse was quantified by the POP-Q method and symptoms by P-QoL questionnaire. Results The intervention group showed significantly greater anatomic improvements in the anterior and posterior vaginal wall prolapses than did the control group (P

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) CONTEXTO E OBJETIVO: Estudos anteriores mostraram que mulheres com disfunção do assoalho pélvico possuem diminuição da área de secção transversal (AST) do músculo levantador do ânus. Uma forma de avaliar os efeitos de um programa de treinamento é mensurar a AST do músculo por ultrassonografia. O objetivo foi avaliar a eficácia do treinamento da musculatura do assoalho pélvico e de exercícios hipopressivos no aumento da AST do músculo levantador do ânus em mulheres com prolapso de órgãos pélvicos. TIPO DE ESTUDO E LOCAL: Estudo prospectivo, randomizado e controlado realizado no Ambulatório de Uroginecologia da Universidade Federal de São Paulo (UNIFESP). MÉTODOS: Cinquenta e oito mulheres com prolapso de órgãos pélvicos estádio II foram divididas em três grupos para tratamento fisioterapêutico: (GI) grupo de treinamento dos músculos do assoalho pélvico, (GII) grupo de exercícios hipopressivos e (GIII) grupo controle. As pacientes se submeteram a avaliação ultrassonográfica transperineal com transdutor de frequência 4-9 MHz. Foi mensurada a AST do músculo levantador do ânus antes e após 12 semanas de tratamento fisioterapêutico. RESULTADOS: Os grupos foram homogêneos no que se refere a idade, número de gestações, número de partos vaginais, índice de massa corpórea e estado hormonal. Diferença significante foi observada na AST de GI e GII antes e após o tratamento (P < 0,001) e isso não ocorreu com o GIII (P = 0,816). CONCLUSÕES: A AST do músculo levantador do ânus aumentou significativamente com tratamento fisioterapêutico em mulheres com prolapso de órgãos pélvicos. Treinamento dos músculos do assoalho pélvico e exercícios hipopressivos são semelhantes no que se refere ao aumento da AST do músculo levantador do ânus. CONTEXT AND OBJECTIVE: Previous studies have shown that women with pelvic floor dysfunctions present decreased cross-sectional area (CSA) of the levator ani muscle. One way to assess the effects of training programs is to measure the CSA of the muscle, using ultrasonography. The aim here was to evaluate the efficacy of pelvic floor muscle training and hypopressive exercises for increasing the CSA of the levator ani muscle in women with pelvic organ prolapse. DESIGN AND SETTING: Prospective randomized controlled trial at the Urogynecology outpatient clinic of Universidade Federal de São Paulo (UNIFESP). METHODS: Fifty-eight women with stage II pelvic organ prolapse were divided into three groups for physiotherapy: a pelvic floor muscle training group (GI); a hypopressive exercise group (GII); and a control group (GIII). The patients underwent transperineal ultrasonographic evaluation using a transducer of frequency 4-9 MHz. The (CSA) of the levator ani muscle was measured before physiotherapy and after 12 weeks of treatment. RESULTS: The groups were homogeneous regarding age, number of pregnancies, number of vaginal deliveries, body mass index and hormonal status. Statistically significant differences in CSA were found in GI and GII from before to after the treatment (P < 0.001), but not in relation to GIII (P = 0.816). CONCLUSIONS: The CSA of the levator ani muscle increased significantly with physiotherapy among the women with pelvic organ prolapse. Pelvic floor muscle training and hypopressive exercises produced similar improvements in the CSA of the levator ani muscle. Universidade Federal de São Paulo (UNIFESP) Department of Gynecology Universidade Federal de Uberlândia Department of Gynecology and Obstetrics UNIFESP, Department of Gynecology FAPESP: 2007/08246-8 SciELO

Dear Editor, We are pleased to read that Liebergall-Wischnitzer agrees that pelvic floor muscle training (PFMT) is effective and should be recommended as level A evidence for pelvic floor dysfunction [1]. Although in a previous paper, he and colleagues claim that the Paula method is superior in terms of cure rate (p. 377) [2]. We used surface electromyography to evaluate the pelvic floor muscle (PFM) activation during the contraction of circular muscles (Paula method). In nulliparous women, these exercises did not increase PFM activation. In two previous papers by Liebergall-Wischnitzer et al. [2, 3], patients included in the Paula group practiced, besides contraction of circular muscles, PFM voluntary contraction in a weekly individual 45-minute sessions for 12 weeks and were encouraged to practice daily for 45 min at home (p.378) [2]. Patients included in the PFMT group did structured exercise program in groups of 1–10 people for 30 min once weekly for 4 weeks, followed by two more lessons 4 weeks apart each (overall six lessons) (p.378) [2]. How can one compare so distinct training programs? Actually, the patients in both groups practiced PFMT in different proportions. What is the benefit of adding circular muscle contractions? It is well established that supervised training significantly improves the results of PFMT [4, 5]. The only way to investigate if circular contractions are more effective than the PFMT alone is to do a head-to-head assessor blinded RCT with the same training dosage and therapist contact in both arms, or add the new concept to current practice in one arm. According to Liebergall-Wischnitzer’s letter [1], PFM strength is not a desirable outcome of Paula exercises, but according to Liebergall-Wischnitzer et al. in 2005, exercising the ring muscles in a certain area of the body will result in strengthening the circular muscles in other areas (p. 345) [3]. With this phrase, we understood that strengthening was the main goal of Paula exercises. At first, how can you be sure that any circular muscle contraction leads to contraction of the others? What are the evidences for that? If this is proven, could external sphincter ani contract alone? Or PFM will be recruited too? How could the external sphincter ani be strengthened and not the PFM? Liebergall’s letter also said that when contracting the eyes/mouth and the PFM, co-contraction is not a reflex, but training is required. After a training period, the trainee begins to feel that these muscles can work together and naturally integrate with PFMT. However, in the article they say “The theory that lies behind the Paula method is that all sphincters in the human body work simultaneously, mutually affecting one another possibly mediated by oscillation of the spinal cord” (p. 345) [3]. If they naturally affect one another because of spinal cord oscillation, how could the spinal cord be trained? If it could be trained, how long this training is necessary to these muscles work together? Moreover, if a patient is taught to contract PFM during some exercises such as Pilates and yoga, with some A. P. M. Resende (*) :C. D. Petricelli : S. M. Alexandre : M. U. Nakamura :M. R. D. Zanetti Obstetrics Department, Federal University of Sao Paulo, Rua Napoleao de Barros, 875, Sao Paulo 04024–002, Brazil e-mail: anapaulamrb@gmail.com

CNPq - Conselho Nacional de Desenvolvimento Científico e Tecnológico Objetivo: Verificar o impacto de 24 sessões de Pilates na força dos músculos do assoalho pélvico (MAP) de mulheres continentes e incontinentes. Método: Estudo clínico, com dois grupos de mulheres: incontinentes (GI) e continentes (GC). O desfecho primário foi a força dos músculos do assoalho pélvico mensurada pela palpação vaginal (Escala modificada de Oxford) e manometria utilizando o Peritron. A frequência de perda urinária foi avaliada utilizando o diário miccional por 7 dias e a qualidade de vida foi avaliada utilizando o questionário de consulta internacional de incontinência – versão curta (ICIQ‐SF), o questionário de impacto do assoalho pélvico (PFIQ-7) e o questionário de desconforto do assoalho pélvico (PFDI-20). O protocolo de intervenção incluiu 24 sessões de Pilates solo realizadas em grupo, três vezes na semana durante 8 semanas. A contração voluntária dos MAP não foi pedida durante os exercícios. Resultado: Não houve diferença na força dos MAP intra-grupo mensurada pela escala de Oxford ou pela manometria para o GI ou GC. A comparação entre os grupos para escala de Oxford não demonstrou diferença, com diferença media de 0,31 (95% intervalo de confiança [IC]: -0,76 para 0,14) e tamanho de efeito de 0,42. Resultado similar foi encontrado para a avaliação com manometria com diferença media entre os grupos de -2,56 (95% IC -7,86 para 2,74) e tamanho do efeito de 0,16. Em relação a frequência de perda urinária no grupo GI, nenhuma diferença foi encontrada antes 1,0 (0 – 2,4) e depois 0,4 (0 – 2,0) da intervenção (p= 0.162, tamanho do efeito: 0,11), contudo, a pontuação final do ICIQ-SF mostrou melhora pré (13,0 [9,0 – 15,0]) e pós (9,0 [6,0 – 14,0]) intervenção (p= 0.006, tamanho do efeito: 0,43), a pontuação final do PFIQ-7 mostrou melhora pré (42,4 [18,9 – 94,8]) e pós (23,6 [0 – 56,6]) intervenção (p= 0.001, tamanho do efeito: 0,59), e a pontuação final do PFDI-20 mostrou melhora pré (95,7 [42,5 – 135,5]) e pós (58,2 [28,1 – 116,5]) intervenção (p= 0.003, tamanho do efeito: 0,47).Conclusão: O programa de Pilates sem a solicitação da contração voluntária dos MAP não aumenta a força dos MAP de mulheres continentes e incontinentes, não reduz a frequência de perda urinária de mulheres incontinentes, contudo é capaz de melhorar a qualidade de vida percebida pela mulher incontinente. Aim: To verify the impact of 24-session Pilates program in pelvic floor muscles (PFM) strength in continent and incontinent women. Methods: Clinical trial, with two groups of female: incontinent (IG) and continent (CG). Primary outcome measure was pelvic floor muscle strength measured by digital palpation (Modified Oxford grading system) and manometry by means of Peritron. The frequency of urinary loss was assessed using the voiding diary for 7 days and quality of life was assessed using the international incontinence consultation questionnaire - short form (ICIQ-SF), the pelvic floor impact questionnaire (PFIQ-7) and the pelvic floor distress questionnaire (PFDI-20). The intervention protocol included 24 Pilates solo sessions performed in groups, three times a week for 8 weeks. Voluntary contraction of MAP was not requested during the exercises Results: There was no difference in the strength of the intra-group MAP measured by the Oxford scale or by the manometry for the IG or CG. The comparison between groups for the Oxford scale showed no difference, with an average difference of 0.31 (95% confidence interval [CI]: -0.76 to 0.14) and effect size of 0.42. A similar result was found for the evaluation with manometry with an average difference between the groups of -2.56 (95% CI -7.86 to 2.74) and effect size of 0.16. Regarding the frequency of urinary loss in the GI group, no difference was found before 1.0 (0 - 2.4) and after 0.4 (0 - 2.0) of the intervention (p = 0.162, effect size: 0.11), however, the final score of ICIQ-SF showed improvement before (13.0 [9.0 - 15.0]) and after (9.0 [6.0 - 14.0]) intervention (p = 0.006, effect size: 0.43), the final PFIQ-7 score showed improvement before (42.4 [ 18.9 - 94.8]) and post (23.6 [0 - 56.6]) intervention (p = 0.001, effect size: 0.59), and the final PFDI-20 score showed improvement before (95.7 [42.5 - 135.5]) and after ( 58.2 [28.1 - 116.5]) intervention (p = 0.003, effect size: 0.47). Conclusion: The Pilates program without the request for voluntary contraction of the MAP does not increase the strength of the MAP of continent and incontinent women, does not reduce the frequency urinary loss of incontinent women, however it is able to improve the quality of life perceived by incontinent women. Dissertação (Mestrado)

Observa-se na literatura a presença de escalas e métodos de avaliação com o objetivo de classificar a função dos MAP. Entretanto, suas categorias são variáveis e algumas vezes não apresentam claramente a definição de uma contração adequada, além de apresentar reprodutibilidade intraexaminador variável. Sabe-se que a palpação vaginal é o método mais comumente usado para a avaliação dos MAP e sua reprodutibilidade intraexaminador varia de moderada a boa (Laycock e Jerwood, 2001; Frawley et al., 2006; Sartori et al., 2015). Já o uso do dinamômetro não se encontra amplamente disponível, havendo a necessidade de confirmação quanto à sua reprodutibilidade intraexaminador de cada equipamento específico. Este estudo teve como objetivo primário verificar a reprodutibilidade intraexaminador da palpação vaginal, manometria e da dinamometria na aferição da função muscular em mulheres com e sem disfunções dos MAP; e como objetivos secundários, correlacionar os resultados da palpação vaginal, manometria e dinamometria na diferenciação da capacidade de contração dos MAP, utilizando a palpação vaginal como referência, além de comparar o nível de desconforto gerado pelos três métodos de avaliação. Trata-se de um estudo clínico de teste reteste. As participantes foram avaliadas por meio de palpação vaginal, manometria e dinamometria, em ordem aleatorizada, sendo solicitadas três CVM dos MAP para cada método de avaliação, onde foi considerada a média dos valores de pico para cada método. As análises dos dados foram realizadas por meio do software SPSS Statistics e Software Stata. Inicialmente foi realizada uma análise descritiva. Para avaliação da concordância nas diferentes avaliações foi feito o cálculo da reprodutibilidade intraexaminador para a contração voluntária máxima, considerando a média dos picos das três contrações voluntárias máximas para cada um dos métodos de avaliação. A reprodutibilidade foi analisada usando Kappa ponderado, Coeficiente de Correlação Intraclasse (CCI) e Bland Altman, com intervalos de confiança (CI) de 95%, sendo considerado estaticamente significativo p

The pelvic floor muscles (PFM) are responsible for supporting the pelvic viscera and for promote urinary and fecal continence. Several studies observed the consequences of the perineal trauma during childbirth on the PFM, but there is lack of research in order to evaluate these muscles during pregnancy, so, although the physiological changes of pregnancy is known, there is not enough data on how these changes influence the PFM function. Therefore, this study aims to evaluate the functions of PFM during pregnancy and compare with nulliparous pelvic floor (PF) function. It is a cross-sectional study, observational, comparative, conducted between April and July 2015.The study population consisted of 141 women: 36 nulliparous (C group), 31 primiparous on first trimester pregnancy (1T group), 42 on second trimester (2T group) and 32 on third (3T group). The PF was evaluate by measuring the size of the genital hiatus (HG) and the perineal body (CP) and measuring the strength of the muscles through the bi-digital palpation (Pb), perineometry (Pe) and dynamometry (Din). The Levene test was used to check homogeneity of the samples regarding age, the Kruskal-Wallis test (ANOVA non-parametric) was applied on the variables to assess significant differences in the groups (C, 1T, 2T and 3T) and U test of Mann-Whitney for paired comparison. For correlation of the variables, we calculated the correlation coefficient by Spearman\'s Rank. The level of significance was establish at 0.05. Regarding the HG and CP variables, when comparing the groups, the lowest values were observed in C group (HG = 1.75cm and CP = 2.5cm) and increased in 3T group (HG = 2.25 cm and CP = 3, 5cm). Concerning the strength variables (Pb, Pe and Din) the initial study hypothesis was confirmed, with the group of nulliparous higher (Pb = 3.2; Pe = 45.6 cmH2O and Din = 1.2 kgf) of strength compared to the third trimester primiparous group (Pb = 2.1; Pe = 17.3 cmH2O and Din = 0.7 kgf). The correlation between the HG, CP and the strength measurements, demonstrated that the variable HG was not found and the CP was negatively correlated with Pe and Din (r = - 0.219 and r = - 0.228). Already comparing Pb variables, Pe and Din, it was possible to establish a positive correlation (Pb x Pe (r = 0.757); Pe x Din (r = 0.755) and Pb x Din (r = 0.564). For variables HG and CP, the highest numbers in 3T group were expected due to changes during pregnancy. The highest values for Pb, Pe and Din found in C group can also be explained when compared to lower values in 3T group, also for sustained changes by pregnant women. The positive correlation between the strength of assessment methods (Pb, Pe and Din) proven by this study, strengthened our results and concluded that there is a significant difference in PFM strength between primiparous on third trimester of pregnancy and nulliparous, suggesting pregnancy as a risk factor for reduction of the PFM strength. A musculatura do assoalho pélvico (MAP) é responsável por suportar as vísceras pélvicas e por promover a continência urinária e fecal. Inúmeros estudos publicados tem como enfoque as consequências do trauma perineal durante o parto sobre a MAP, mas há escassez de pesquisas que visem a avaliação dessa musculatura durante o período gestacional, ou seja, apesar de conhecidas as alterações fisiológicas da gravidez, faltam dados objetivos sobre como essas alterações influenciam a função da MAP. Para isso, esse estudo visa avaliar as funções da MAP durante a gestação e comparar com o assoalho pélvico (AP) de nuligestas. Tratou-se de um estudo transversal, observacional e comparativo, realizado entre abril e julho de 2015. A população do estudo foi composta por 141 mulheres:36 nuligestas (Grupo C), 31 primigestas de primeiro trimestre (Grupo 1T), 42 de segundo (Grupo 2T) e 32 de terceiro (Grupo 3T). O AP foi avaliado mensurando os tamanhos do hiato genital(HG) e do corpo perineal(CP) e medindo a força da musculatura através da palpação bidigital(Pb), da perineometria(Pe) e da dinamometria(Din). O teste Levene foi aplicado para verificar homogeneidade das amostras em relação a idade, o teste de Kruskal-Wallis (ANOVA não-paramétrica) foi aplicado nas variáveis para avaliar diferença significativa em relação aos grupos (C,1T, 2T e 3T) e o teste U de Mann-Whitney, para comparação em pares. Para correlação das variáveis foi calculado o Coeficiente de Correlação por Postos de Spearman. O nível de significância foi estabelecido em 0,05. Em relação as variáveis HG e CP, quando comparados os grupos, os menores valores foram observados no Grupo C (HG=1,75 cm e CP=2,5 cm) e maiores no Grupo 3T (HG=2,25 cm e CP=3,5 cm). Já em relação as variáveis de força (Pb, Pe e Din) a hipótese inicial do estudo foi confirmada, apresentando o grupo de nuligestas valores mais elevados (Pb=3,2; Pe=45,6 cmH2O e Din=1,2 kgf) de força em comparação ao grupo de primigestas de terceiro trimestre (Pb=2,1; Pe=17,3 cmH2O e Din=0,7 kgf). Na correlação entre as variáveis HG e CP, com as medidas de força, a variável HG não foi encontrada e o CP apresentou correlação negativa com Pe e Din (r = - 0,219 e r = - 0,228). Já comparando as variáveis Pb, Pe e Din, foi possível comprovar uma correlação positiva (Pb x Pe (r=0,757); Pe x Din (r=0,755) e Pb x Din (r=0,564). Para as variáveis HG e CP, os valores mais elevados no Grupo 3T eram esperados devido as alterações durante a gestação. A correlação positiva entre os métodos de avaliação de força (Pb, Pe e Din), comprovada por este estudo, fortaleceu os resultados encontrados e o presente trabalho pode concluir que há uma diferença significativa na força da MAP entre primigestas no terceiro trimestre de gestação e nuligestas, sugerindo a gestação como um fator de risco para redução da força do AP. Mestre em Ciências da Saúde

A corrida é um dos tipos mais populares de atividade física do mundo e as mulheres estão cada vez mais inseridas nessa modalidade esportiva. O exercício físico extenuante que aumenta a pressão intra-abdominal pode sobrecarregar e danificar cronicamente o os músculos do assoalho pélvico, os ligamentos e as fáscias, além de diminuir a força de contração dessa musculatura. Na corrida, as forças de reação vertical com o solo podem aumentar entre 1,6 e 2,5 vezes o peso corporal e a transmissão do choque entre os pés e o chão pode afetar o mecanismo de continência pela alteração da quantidade de força transmitida ao assoalho pélvico. Estudos apontaram que a prevalência de incontinência urinária em corredoras de longa distância é de 62,2%. Torna-se importante investigar se os padrões cinemáticos estão relacionados com a perda urinária, pois acredita-se que as características dos movimentos podem aumentar a carga de impacto nas extremidades inferiores resultando em sobrecarga excessiva sobre os músculos do assoalho pélvico, visto que é um esporte de alto impacto que envolve aterrisagem. Os objetivos do presente estudo foram avaliar a perda urinária em atletas corredoras e correlacionar com a carga de treino semanal e com variáveis cinemáticas da corrida. Trata-se de um estudo observacional transversal. Amostra constituída por 11 corredoras com incontinência atlética e 17 corredoras continentes. No dia 1 foi realizado o teste de velocidade máxima na esteira utilizando um protocolo incremental. Após 48 horas, foi realizada avaliação dos músculos do assoalho pélvico por meio da palpação vaginal graduada pela Escala de Oxford, perineometria e teste do absorvente adaptado durante a corrida. Em seguida, foi avaliada a cinemática da corrida na esteira por meio de um circuito de câmeras. O teste do absorvente para quantificar a perda urinária foi realizado durante a avaliação da cinemática da corrida. Para a gravação das imagens, a velocidade da esteira foi ajustada em 75% da velocidade máxima obtida. O deslocamento vertical foi mensurado em plano dorsal durante um ciclo completo da passada, a flexão de joelho durante a fase de resposta a carga, e o tipo de aterrissagem do pé com o solo, ambos no plano sagital. Após avaliação da corrida, o absorvente foi recolhido pelo pesquisador. A pressão de contração dos músculos do assoalho pélvico obtida pelo grupo de continentes (43,40(21,75)) foi maior quando comparada ao grupo de incontinentes (38,94(31,08)), porém sem diferença estatisticamente significante (p=0,66). Foi encontrada associação entre carga de treino semanal e perda de urina, sugerindo que mulheres que perdem urina percorrem maior distância por semana. Não foram encontradas correlações entre a perda de urina e as variáveis cinemáticas estudadas. Não foram encontradas correlações entre a perda urinária durante a corrida e o deslocamento vertical, flexão do joelho e o tipo de aterrissagem do pé com o solo. A carga de treino semanal parece estar associada a menor força dos músculos do assoalho pélvico. Running is one of the most popular types of physical activity in the world and women are increasingly included in this sport. Strenuous physical exercise that increases intra-abdominal pressure can chronically overwhelm and damage the pelvic floor muscles, ligaments and fascia, and decrease the contraction force of the muscles. In the running, vertical reaction forces with the ground can increase between 1.6 and 2.5 times the body weight and the transmission of the shock between the feet and the ground can affect the mechanism of continence by changing the amount of force transmitted to pelvic floor muscles. Studies have shown that the prevalence of urinary incontinence in long-distance runners is 62.2%. It is important to investigate whether kinematic patterns are related to urinary loss because it is believed that the characteristics of the movements can increase the impact load on the lower extremities resulting in excessive overload on the pelvic floor muscles since it is a sport of high impact that involves landing. The aims of this study was to evaluate if pelvic floor muscle function is related to the weekly training load and kinematic variables of the running. A cross-sectional observational study. Sample consisting of 11 runners with athletic incontinence and 15 continents runners. On day 1, the maximum velocity test on the treadmill was performed using an incremental protocol. On day 1, the maximum velocity test on the treadmill was performed using an incremental protocol. After 48 hours, evaluation of the pelvic floor muscles was performed through the vaginal palpation graded by the Oxford Scale, perineometry and adapted pad test. Then, the kinematics of the race on the treadmill through a circuit cameras. For recording the images, the speed of the treadmill was set at 75% of the maximum speed obtained. The vertical displacement was measured in a posterior view during a complete gait cycle, the knee flexion during the load response phase, and the initial contact of the foot with the ground, both in the right lateral view. The vaginal squeeze pressure obtained by the group of continents (45,10(20,74)) was higher when compared to the incontinent group (38,94(31,08)), but without statistically significant difference (p=0,55). There was an association between weekly training load and urine loss, suggesting that women who lose urine greater distance run per week. No associations were found between urine loss and kinematic variables. No relationship was found between the strength of the pelvic floor muscles and the vertical displacement, knee flexion and ground attack. The weekly training load seems to be associated with lower strength of the pelvic floor muscles. Dissertação (Mestrado)