Evidence-Based Practice

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The physical therapy profession recognizes the use of evidence-based practice (EBP) as central to providing high-quality care and decreasing unwarranted variation in practice. Midwest Physical Therapy Services includes the integration of best available research and clinical expertise to provide the best possible care for our patients. As we review dozens of articles each month, we want to provide our community with some of the findings. Below, you will find summaries of some of the latest research in addition to the reference to obtain the full article if desired. New posts will be added throughout the year. Click on the ‘-‘ in the right corner to minimize a summary.
Manual Lymph Drainage With Progressive Arm Exercises for Axillary Web Syndrome After Breast Cancer Surgery: A Randomized Controlled Trial

Reference: Torres-Lacomba M, Prieto-Gómez V, Arranz-Martín B, et al. Manual Lymph Drainage With Progressive Arm Exercises for Axillary Web Syndrome After Breast Cancer Surgery: A Randomized Controlled Trial. Phys Ther. 2022;102(3):pzab314. doi:10.1093/ptj/pzab314

Summary/Key Points:
Axillary web syndrome (AWS) is a common postop complication in breast
cancer surgery. It is characterized by visible or palpable cording and axillary pain that can extend from axilla to forearm and limit shoulder mobility. A physical therapy program including manual lymph drainage (MLD) has proven to be effective for postop breast cancer patients. Participants were randomly assigned to the control or intervention groups. Both groups received 9 visits of supervised physical therapy with standard arm exercises. The intervention group also received MLD and shoulder stretches focusing on the taut cords. Significant positive effect in the  intervention group was found immediately and at follow-up for pain control, enhancing mobility, and improving quality of life. Therefore, this article emphasized postop physical therapy with both skilled MLD and exercises for AWS with breast cancer.

Benefit of Pelvic Floor Physical Therapy in Pediatric Patients with Dyssynergic Defecation Constipation

Reference: Zar-Kessler C, Kuo B, Cole E, Benedix A, Belkind-Gerson J. Benefit of Pelvic Floor Physical Therapy in Pediatric Patients with Dyssynergic Defecation Constipation. Dig Dis. 2019;37(6):478-485. doi:10.1159/000500121

Summary/Key Points:
Pelvic floor physical therapy (PFPT) is an effective and comprehensive
treatment for outlet dysfunction constipation in the pediatric population by improving toileting posture and motor retraining of the musculoskeletal system with defecation. PFPT focuses on relaxation of appropriate pelvic muscle groups, strengthening the abdominal muscles, and coordination of the diverse muscular groups to enhance expulsion of stool. It does not involve internal intervention, which is more acceptable by children and parents who are anxious or stressed about defecation. The interventions are able to be performed at home to increase independent management of condition after discharge.
In this retrospective study, patients were split into a control group using laxative treatment only and an intervention group receiving PFPT training with laxative treatment. Statistical differences were found in constipation symptoms, hospitalization rates for bowel cleanout and colon surgery rates favoring children who received PFPT. It is remarkable that children with anxiety or low muscle tone benefited the most from PFPT with a 100% success rate compared to the control group. Therefore, this study recommends the utilization of PFPT for a pediatric patient with outlet dysfunction, particularly for those with psychiatric comorbidities or weak abdominal muscle tone.

Evaluation of a birth preparation program on lumbopelvic pain, urinary incontinence, anxiety and exercise: a randomized controlled trial

Reference: Miquelutti MA, Cecatti JG, Makuch MY. Evaluation of a birth preparation program on lumbopelvic pain, urinary incontinence, anxiety and exercise: a randomized controlled trial. BMC Pregnancy Childbirth. 2013;13:154. Published 2013 Jul 29. doi:10.1186/1471-2393-13-154

Summary/Key Points:
In prenatal and postpartum women, urinary incontinence is a common symptom. This might be caused by pelvic floor muscle weakness, overactivity, or a combination of the two. Pelvic floor muscle training has been shown as a successful treatment for postpartum urinary incontinence and is highly recommended. In this study, 197 low-risk nulliparous women were included in a randomized controlled trial. They were divided into a control group and a treatment group. A low intensity home exercise program and educational activities were given to the experimental group. The exercise program consisted of stretching, venous return, abdominal exercise, pelvic floor muscle training and relaxation. The control group received routine prenatal care, including breastfeeding and laboring education. The experimental group showed better outcomes in terms of
preventing and controlling urinary incontinence; no significant differences regarding pain or anxiety. This is likely due to lack of monitoring of exercise program and questionable compliance by the participants with exercise program. Overall, physical therapy is shown positive results in preventing urinary incontinence in the prenatal population.

Resistance Exercise and Breast Cancer-Related Lymphedema

Reference: Hasenoehrl T, Palma S, Ramazanova D, et al. Resistance exercise and breast cancer-related lymphedema-a systematic review update and meta-analysis. Support Care Cancer.  2020;28(8):3593-3603.   doi:10.1007/s00520-020-05521-x

Summary/Key Points:
This systematic review compiled several articles regarding resistance exercise (RE) with breast cancer survivors (BCS) and its implications on breast cancer-related lymphedema (BCRL). All studies reviewed had to analyze lymphedema, breast cancer, and resistance, weight, or strengthening exercises. BCS subjects could be post-surgical, in chemotherapy, physically inactive, interlimb differences due to lymphedema, or over-weight.

The different resistance exercises included: no resistance to progressively increased repetition maximums (RM) for major muscle groups of the upper extremity (UE), lower extremity (LE), and core. Specific exercises included: Chest press, latissimus pulldowns, triceps extension, bicep curls, leg press, abdominal crunches, lower back and knee extension, shoulder flexion,
abduction, and external and internal rotation, protraction and retraction of shoulder blades, wrist flexion and extension, ball pressing and moving, dumbbell fly, one-arm bent over row, squats on a chair, step-ups, kickbacks, split-leg lunges, and side lunges. They also utilized walking, dancing, ballgames, massage, and relaxation for treatment.

This systematic review reported positive beneficial effects on BCRL in BCS utilizing the same LE (lymphedema) outcome parameters following resistance exercising. They also completed a meta-analysis on 6 studies that utilized bioimpedance spectroscopy (BIS) and they reported significant reduction of BCRL in BCS along with significant increased strength for upper and lower extremities.

Treatment of a Child with Daytime Urinary Incontinence

Reference: Reilly M, Homsy Y. Treatment of a Child with Daytime Urinary Incontinence. Pediatric Phys Ther. 2008 Summer;20(2):185-93. doi: 10.1097/PEP.0b013e318171fb8d. PMID: 18480719.

Summary/Key Points:
This case study outlines the treatment of an 8 year old with secondary urinary frequency and urgency. A thorough history was obtained, the family was instructed to keep a bladder log and pelvic floor tone was objectively measured using EMG biofeedback. A pelvic exam was deferred. Interventions used to successfully reduce the patient’s urgency and frequency included strengthening to her pelvic floor, obturator internus, hip adductors and hip abductors through the “roll for control” program versus teaching a Kegel. EMG biofeedback was used at each treatment session in conjunction to the strengthening. Lifestyle modifications were made regarding water intake, fiber intake and posture. In this case study, the patient voided at a normal frequency by the 3rd visit and was consistently continent by the 11th visit demonstrating successful treatment of the condition through physical therapy.

Exercise Interventions to Improve Pelvic Floor Muscle Functioning in Older Women with Urinary Incontinence

Reference: Fricke, Anja MSc1; Lark, Sally D. PhD1; Fink, Philip W. PhD2; Mundel, Toby PhD2; Shultz, Sarah P. PhD1,3 Exercise Interventions to Improve Pelvic Floor Muscle Functioning in Older Women With Urinary Incontinence: A Systematic Review, Journal of Women’s Health Physical Therapy: July/September 2021 – Volume 45 – Issue 3 – p 115-125

doi: 10.1097/JWH.0000000000000202

Summary/Key Points:
A systematic review was conducted utilizing data from 8 randomized controlled trials on healthy women 50 years and older that were participating in specific pelvic floor muscle strengthening to diminish incontinence. Strengthening interventions included: bladder training, Kegels, pelvic floor strengthening, biofeedback, and digital vaginal palpation.

For urinary incontinence and frequency, the studies demonstrated significant improvements in symptoms along with decreased pad weight. Frequency symptoms improved equally following a home-based or a supervised program. Pelvic floor muscle strength was dramatically improved in the groups that utilized biofeedback (87% improvement) compared to no biofeedback devices (33% improvement). There were also significant strength improvements for those who had supervised exercise sessions (78% improvement) compared to those who had a home program (32% improvement).

Feedback and supervision with exercises demonstrated more significant and faster improvements compared to those without. They also saw a higher self-reported improvement if the participants had supervised sessions. Frequency and duration of interventions varied in all studies, but they all demonstrated a positive impact on urinary incontinence symptoms. Physical therapy regarding urinary incontinence can make a lasting impact through education, supervised feedback, and appropriate exercise selection.

Pelvic floor rehabilitation in the treatment of women with dyspareunia: a randomized controlled clinical trial

Reference:   Ghaderi F, Bastani P, Hajebrahimi S, Jafarabadi MA, Berghmans B. Pelvic floor rehabilitation in the treatment of women with dyspareunia: a randomized controlled clinical trial. Int Urogynecol J. 2019;30(11):1849-1855. doi:10.1007/s00192-019-04019-3

Summary:   Dyspareunia (pain with intercourse) is a common dysfunction of females in the reproductive age. Most dyspareunia patients have overactive pelvic floor muscles (PFM) resulting in a higher resting tone. These high tone muscles are likely weak requiring both lengthening and strengthening to effectively treat. A randomized control trial was conducted consisting of 64 women that were diagnosed with dyspareunia with pain greater than 8/10. They were separated into two groups. The experimental group participated in progressive pelvic floor exercises, intravaginal manual therapy, digital biofeedback and electrotherapy once a week for 3 months. The control group received no treatment. Results concluded that pelvic floor rehabilitation plays a vital role with statistically significant differences in pelvic pain, sexual function, PFM strength, and endurance in women with symptomatic dyspareunia. Three months later, the experimental group demonstrated superiority over the control group regarding a reduction in pain levels according to the VAS scale.

Different physical treatment modalities for lymphedema developing after axillary lymph node dissection for breast cancer: A review

Reference:   Devoogdt, Van Kampen, Geraerts, et.al. Different physical treatment modalities for lymphedema developing after axillary lymph node dissection for breast cancer: A review. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2010;149:3-9. doi:10.1016/j.ejogrb.2009.11.016

Summary:   This review article gives an overview of the effectiveness of physical therapy treatment, including manual lymph drainage (MLD), multilayer bandaging, compression sleeves, intermittent pneumatic compression, exercise, and arm elevation in the management of lymphedema after axillary dissection for breast cancer. In one particular study, there were three groups receiving treatment for 4 weeks. The group receiving manual lymph drainage, a vibrator massage, exercises, and wearing a compression sleeve during the day and night demonstrated a reduction of edema by 30%. It is important to note that the patients with the MLD showed improvements in emotional functioning, sleep, and arm symptoms such as pain, fullness, and heaviness. Based on the 15 articles reviewed, physical therapy is an effective treatment for arm lymphedema post axillary dissection

Fall Risk Reduction in the Elderly through PT Management of Incontinence

Reference: Fisher, Stanich, Hong, et al. Fall Risk Reduction in the Elderly through the Physical Therapy Management of Incontinence. J Womens Health PT, APTA. 2019; 43(1): 1-9.

This case study was conducted with twenty women ages 50 years and older who suffer from urinary incontinence with a high fall risk. Participants underwent pelvic floor physical therapy in an 8 week span. Physical therapy consisted of progressive PF strengthening, bladder behavioral training for stress and urgency incontinence, core strengthening, and functional activities that incorporated pelvic floor activation throughout their normal daily routine. Participants demonstrated improvement with both their urinary incontinence and gained more confidence during social and physical activities with the decrease in fear of falling.

Upper-Limb Morbidity in Patients Undergoing a Rehabilitation Program After Breast Cancer Surgery: A 10-Year Follow-up Study

Reference: Carlos-Iriarte, Mosquera-Gonzalez, Alonso-Garcia, et al. Upper Limb Morbidity in Patients Undergoing a Rehabilitation Program After Breast Cancer Surgery: A 10-Year Follow-up Study. J Rehab Oncology, APTA. 2018; 37(2): 70-76.

The purpose of this study was to follow up with 659 female patients who participated in physical therapy 10 years after their breast cancer surgery. The early rehabilitation focused on decreasing pain, gaining UE mobility, and improve limitations with their ADLs. If lymphedema was present at the time of rehab, kinesiology, MLD, and compression sleeves were also applied to their treatment. The results demonstrated 64% exhibited improvement with their symptoms with the help of their rehabilitative program.

Synergistic Action of Deep Abdominals and Pelvic Floor Muscles: Implication for Incontinence Management in Women

Reference: Singh, N., Arya, K. N., & Pervin, A. (2017). Synergistic Action of Deep Abdominals and Pelvic Floor Muscles: Implication for Incontinence Management in Women. Indian Journal of Physiotherapy and Occupational Therapy – An International Journal, 11(3), 66.

Through the Department of Rehabilitation Sciences a published article looked at a different approach of how to cure incontinence in women. It looked outside of only isolating the pelvic floor muscles, by performing a Kegel contraction. In a 52 subject study the ideal treatment program suggested global postural education, lower abdominal and PFM contraction. Which the women saw faster results with their symptoms and demonstrated an improvement of 96.7% than women who only focused on PF contraction. With women who do not suffer with incontinence symptoms, the transverse abdominals, diaphragm, and PFM contract synergistically.

Effects of Resistance Exercises on Secondary Lymphedema due to Treatment of Breast Cancer: A Review of Current Literature

Reference: Romesberg, M., Tucker, A., Kuzminski, K., & Tremback-Ball, A. (2017). The Effects of Resistance Exercises on Secondary Lymphedema Due to Treatment of Breast Cancer. Journal of Womenʼs Health Physical Therapy, 41(2), 91-99.

Current literature suggests examining the effects of resistance exercise on lymphedema with an active muscle pump to encourage lymphatic flow without exacerbating their symptoms. 3 study groups were conducted by the research comparing high to low frequency number of reps throughout the exercise program and days of completion during the week. All 3 groups did not see an increase in lymphedema, but the high frequency group saw the greatest benefit of increase in quality of life, improvement in cardiovascular health, a reduction risk of osteoporosis, and decrease in muscle atrophy.

Pelvic Floor PT Improves Pelvic Pain

Reference: Hilton L, Pelvic Floor PT Improves Pelvic Pain, Voiding Symptoms. http://www.urologytimes.com/modern-medicine-feature-articles/pelvic-floor-pt-improves-pelvic-pain-voiding-symptoms

Patients with long standing pelvic floor issues can eventually lead to pain, bowel and bladder issues, and sexual dysfunction after time. These can be masked with medications, however the issues can only be cured with proper physical therapy to retrain the effected muscles for these functional tasks. Dr. Natalie Gaines, an MD of Beaumont Hospital in Royal Oak, MI conducted a retrospective chart review on 95 women that reported either pain and/or symptoms as mentioned previously. Studies had shown a drastic decline in their pain levels, on their worst days, from an 8 to a 4.8 on the visual analog scale from pre physical therapy to post physical therapy with a focus on pelvic floor dysfunction.

Effectiveness of a Multidimensional Physical Therapy Program on Pain

Reference: Hilton L, Pelvic Floor PT Improves Pelvic Pain, Voiding Symptoms. http://www.urologytimes.com/modern-medicine-feature-articles/pelvic-floor-pt-improves-pelvic-pain-voiding-symptoms

This article examined a multidimensional physical therapy program that included strengthening exercises and massage as major components. It monitored the effects on shoulder pain and pressure hyperalgesia. With breast cancer symptoms, central sensitization is present independently with the breast cancer surgery received along with the prevalence of active muscle trigger points which also increase pressure/pain sensitivity. These changes in the nervous system may enhance the experience of pain for breast cancer survivors. Results of the study concluded that an 8-week multidimensional physical therapy program including strengthening and endurance exercises, relaxation and massage, induced changes in nociceptive processing in breast cancer survivors with a noted reduction in neck, shoulder, and axillary pain, presence of trigger points. It also exhibited a decrease in pressure pain hypersensitivity as compared with usual breast cancer care.

Physiotherapy Management of Axillary Web Syndrome following Breast Cancer Treatment

Reference: Fourie, W.j., and K.a. Robb. “Physiotherapy Management of Axillary Web Syndrome following Breast Cancer Treatment: Discussing the Use of Soft Tissue Techniques.” Physiotherapy 95.4 (2009): 314-20. Web.

Following breast cancer surgery and treatment multiple women develop edema, pain, decreased shoulder mobility, and both sensory and motor dysfunction and axillary webbing. Patient usually present with limited and painful shoulder flexion and abduction. With the help of manual soft tissue techniques the axillary cords will be released therefor increasing range of motion and decreasing the patient’s edema and pain.

A Preliminary Study on Balance Performance and Fall Status in Older Women

Reference: Nelson PR, Irish KR, Cleary KK. A Preliminary Study on Balance Performance and Fall Status in Older Women With Urinary Incontinence. Journal of Womenʼs Health Physical Therapy. 2015;39(3):102-108. doi:10.1097/jwh.0000000000000036.

Urinary incontinence (UI) is often cited as a reason for falls in the older population, but there is limited evidence using typical fall assessments for this. This study used the Tinetti Gait and Balance, Berg Balance Scale and Four Square Step Test to correlate balance scores, number of falls and patients who report UI. Those with UI scored significantly worse on all three tests and reported a higher number of falls than those without UI. This condition causes measurable impacts and distress on patients who have it. Screening for fall risk due to UI in older women is important, and physical therapists are equipped to both improve the impact of UI and also improve functional balance and mobility; making our patients safer in the community and in their homes.

The cancer rehabilitation journey

Reference: Blaney, J, A Lowe-Strong, et al. “The cancer rehabilitation journey: barriers to and facilitators of exercise among patients with cancer-related fatigue.” Physical Therapy. 90.8 (2010): 1135/1147. Print.

Researchers have begun exploring reasons for the decline in physical activity and progression toward sedentary living during, immediately after, and even years after cancer treatment. Cancer Related Fatigue (CRF) has always been expected but exercise has not been integrated as part of cancer care as a solution. Studies show that exercise is the best tool used to manage CRF and counteract the side effects induced by surgery and anti-cancer treatments. Most patients who complained about barriers to exercise also claimed later that an exercise program would have been beneficial. Most participants emphasized that an exercise program should be supervised and administered by a trained healthcare professional. The program should also be tailored specifically to the individual. Physical therapists are ideal and are trained to design and deliver exercise programs to help patients manage their fatigue and thus improve their functional status and quality of life.

A Preliminary Study on Balance Performance and Fall Status in Older Women

Reference: Nelson, Patricia R., Kathryn R. Irish, and Kimberly K. Cleary. “A Preliminary Study on Balance Performance and Fall Status in Older Women With Urinary Incontinence.” Journal of Womenʼs Health Physical Therapy 39.3 (2015): 102-08. Web.

Urinary Incontinence is prevalent in 29% of women older than 65 years old. These women that have been diagnosed with UI also have an increased risk for falls. This is due to when a person is rushing to get to the bathroom or getting up often during the night to urinate. It is also due to patient’s with more particular stress UT, the PF and trunk muscles are activate to maintain the continence and not for their balance control. In this study, women were questioned on specific questionnaires for incontinence and had to perform balance tests, which came to the conclusion that women of 65 years and older and diagnosed with UI have an increased risk for falls.

Effects of Mastectomy on Shoulder and Spinal Kinematics

Reference: Crosbie, Jack, Sharon Kilbreath, Elizabeth Dylke, et al. “Effects of Mastectomy on Shoulder and Spinal Kinematics During Bilateral Upper-Limb Movement.” Physical Therapy. 90.5 (2010): 679-692. Print.

Poor kinematics is just one byproduct of a mastectomy having been performed. While other symptoms such as lymphedema may be unavoidable increased ability of movement and patient’s range of motion is something which Physical Therapists should be able to treat. Treatment of post-surgical effects could increase functionality and quality of life as well as deter some effects which cause pain and aching.

Effect of pelvic floor muscle training compared with watchful waiting

Reference: Wiegersma M, Panman CMCR, Kollen BJ, Berger MY, Leeuwen YL-V, Dekker JH. Effect of pelvic floor muscle training compared with watchful waiting in older women with symptomatic mild pelvic organ prolapse: randomised controlled trial in primary care. Bmj. 2014;349(dec22 1).

This was a randomized controlled trial of women 55 years and older who had symptomatic mild pelvic organ prolapse. Those in the intervention group were given pelvic floor muscle training versus watchful waiting in the control group. 57% of the women in the intervention group found an improvement of overall symptoms. Physical therapy can train women with pelvic organ prolapse to strengthen their pelvic floor, improve their symptoms and therefore improve their overall quality of life.

Shoulder Impairment Before Breast Cancer Surgery

Reference: Flores, Ann Marie, and Kathleen Dwyer. “Shoulder Impairment Before Breast Cancer Surgery.” Journal of Womenʼs Health Physical Therapy 38.3 (2014): 118-24. Print.

There is little information regarding the quality of life of patients with breast cancer (BCA) after they have been diagnosed but before they receive curative treatment, and regarding the quality of life of patients with BCA coming from a minority population. Impaired joint range of motion (ROM), fatigue, pain, and needing to alter activities of daily living are some of the most common findings. While both Caucasian and African American (AA) patients had decreased shoulder AROM following biopsy but prior to surgery, AA were shown to have a greater difference. This finding, in addition to other studies cited by the authors, suggests that rehabilitation including resistance training for BCA survivors can be beneficial for improving strength, cardiac endurance, pain, and fatigue, as well as contribute to successful lymphedema management secondary to cancer treatment.

Managing a Patient's Constipation With Physical Therapy

Reference: Harrington, K., & Haskvitz, E. (2006). Managing a Patient’s Constipation With Physical Therapy. Physical Therapy, 1511-1519.

Patients suffering from constipation have been shown to respond well to physical therapy intervention, decreasing the frequency in use of laxatives and risk of colon cancer. Biofeedback training has seen an 80% improvement in the restoration of normal bowel function when used as a physical therapy intervention for patients with constipation resulting from pelvic-floor or anal sphincter dysfunction. For patients with both slow-transit and normal-transit constipation, physical therapy intervention includes focusing on moderate aerobic exercise which has been found to have an effect on increasing gut transit without affecting defecation frequency, as well as a strength training program of force-generating capacity which has been shown to accelerate whole-bowel transit time. Finally, abdominal massage for 10 – 15 minutes daily has been shown to decrease abdominal spasticity allowing the bowels to spontaneously open.

Effect of Pelvic-Floor Muscle Strengthening on Bladder Neck Mobility

Reference: Hung, H.-C., S.-M. Hsiao, S.-Y. Chih, H.-H. Lin, and J.-Y. Tsauo. “Effect of Pelvic-Floor Muscle Strengthening on Bladder Neck Mobility: A Clinical Trial.” Physical Therapy 91.7 (2011): 1030-038. Print.

A counterbracing technique called “knack” involving contracting the pelvic floor muscle (PFM) right before an increase in intra-abdominal pressure has been shown to significantly reduce urinary leakage after 1 week of training. Pelvic floor muscle (PFM) rehabilitation has also been shown to have the ability to significantly elevate the neck of the bladder at rest and increase bladder neck stiffness during the Valsalva maneuver. The authors of this study found that a 4-month daily PFM strengthening program could improve the ability of the pelvic floor to elevate the neck of the bladder, improve urinary continence, and enhance PFM strength, but not reduce the caudal displacement of the bladder neck during a cough of the Valsalva maneuver.

Characteristics of Patients Seeking Outpatient Rehabilitation for Pelvic-Floor Dysfunction

Reference: Wang, Ying-Chih, Dennis Hart, and Jerome Mioduski. “Characteristics of Patients Seeking Outpatient Rehabilitation for Pelvic-Floor Dysfunction.” Physical Therapy. 92.9 (2012): 1160-1174. Print.

The purposes of this study were to describe the characteristics of individuals with disorders associated with PFD who were seeking outpatient physical therapy. As the patients progressed from initial evaluation to discharge, they completed several self-report surveys specific to PFD. Overall, PFD disorders were more common in female patients than in male patients. It was also found that the majority of the patients were 65 years or older. The most common disorder was urinary disorder, with 67% of patients. It was found that combinations of urinary, bowel, or pelvic-floor pain disorders were not uncommon.

Effect of Pelvic-Floor Muscle Strengthening on Bladder Neck Mobility

Reference: Effect of Pelvic-Floor Muscle Strengthening on Bladder Neck Mobility: A Clinical Trail Hung HC1, Hsiao SM, Chih SY, Lin HH, Tsauo JY.

This study was directed to examine the effect of pelvic floor muscle strengthening on women population with stress or mixed urinary incontinence problems. Tasks were completed over a 4 month trial that included interventions and methods to score the results before and after treatments. Position of the bladder neck during strengthening interventions altered the position to be elevated displaying great improvement. During other stressful simulations such as the Valsalva maneuver, the bladder neck position and mobility showed no change yielding no theoretical results. Studies and results conclude that pelvic floor strengthening may in fact elevate the bladder neck, but lead to no enhancements of the stiffness during any intra- abdominal pressure.