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Exercise, fitness and the pelvic floor Kolding, Sept 2013 Kari Bø Professor, PhD PT, Exerc. Sci. Norwegian School of Sport Sciences Dept of Sports Med.

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Presentation on theme: "Exercise, fitness and the pelvic floor Kolding, Sept 2013 Kari Bø Professor, PhD PT, Exerc. Sci. Norwegian School of Sport Sciences Dept of Sports Med."— Presentation transcript:

1 Exercise, fitness and the pelvic floor Kolding, Sept 2013 Kari Bø Professor, PhD PT, Exerc. Sci. Norwegian School of Sport Sciences Dept of Sports Med

2 The pelvic floor muscles

3 Pelvic floor muscles (PFM) Piriformis Ischiococcygeus Iliococcygeus M. Pubooccygeus puborectalis pubovaginalis puboviseralis Standring 2005 Levator ani Coccygeus Thickness: 8,0- 9,8 mm (Dietz et al 2005, Brækken et al, -09) Levator hiatus

4 Optimal function? Forms a structural support (placement, cross sectional area, stiffness, hiatus opening) Prevent urethral descent Readiness for action Quick and strong co-contraction during/before increase in abdominal pressure Inhibition of detrusor contraction Ability to relax before and during voiding

5 Female pelvic floor dysfunction Bump & Norton 1998 Urinary incontinence (30%) Fecal incontinence (11-15%) Pelvic organ prolapse (51%) Sensory and emptying abnormalities of the lower urinary tract Defecatory dysfunction (constipation) Sexual dysfunction (30%) Chronic pain syndromes (15%)

6 What can weaken connective tissue and pelvic floor muscles? Brubaker et al 2002 INACTIVITYOverweight: 55-60% of US population over 18 years of age!!! INACTIVITY Constipation – straining with bowel motion Smoking – excessive coughing Pregnancy and childbirth (stretch/rupture of nerves, muscles, connective tissue) Pelvic surgery Inherited weak connective tissue Strenous work/ heavy lifting/sport (??)

7 General fitness activities? Physically active women report less UI (Milsom et al-08) –Selection bias

8 Hypothesis 1: Athletic women have strong PFM General PA increases PFM strength? Stretch and fatigue facilitate contraction? Co-contraction with other muscle groups and increase in intra- abdominal pressure?

9 Can general PA train the PFM? Exercise –horse back riding? (22% UI Eliasson et al- 04 ) –ballet ? (43% UI Thyssen et al -02 ) Sexuality –Orgasm? –PFM strength and mode of delivery did not affect sexual function (Baytur et al -05)

10 PFM strength in power lifters and controls Bø 2001, preliminary unpublished data 4 power lifters, mean age 23.5 years (SD 4.4) 19 controls, mean age 24.4 years (SD 2.4) power lifterscontrols 22.6 cm H 2 0 (9.1)ns19.3 cm H 2 0 (6.8)

11 PFM strength in athletes compared to controls Borin et al -13 10 volleyball:4.4 mmHg (1.4) 10 basketball: 3.7 mmHg (1.4) 10 handball:5.6 mmHg (1.4) 10 controls:6.7 mmHg (1.9) Stat sign lower strength in volleyball and baskeballplayers compared to controls Moderate neg correlation (-0.51) between SUI and nocturia AND PFM strength

12 PFM morphology in female athletes and controls Kruger et al -05 MRI in 10 athletes and 10 age-matched controls Results –No diff in size of pelvis –No diff in urogenital hiatus: 8.9 (9.5) vs 8.3 (11.4) cm 2 p=0.2 –CSA of levator ani: 20% higher in athletes Prolonged labor?

13 Pelvic floor function in elite nulliparous athletes and controls Kruger et al 2007 24 nulliparous elite athletes (at least 5 years at national or international standard and involving high impact activity sport) compared to 25 age and BMI matched controls 3D/4D translabial ultrasound Results –Larger levator hiatus area on valsalva in athletes (21.5 cm 2 (10.0) versus 14.9 cm 2 (7.2)) p= 0.01 –Higher muscle diameter in athletes (0.96 versus 0.7 cm) p< 0.01 –Greater bladder descent on valsalva in athletes (22.7 mm (7.8) versus 15.1 mm (10.2)) p=0.03 –No signficant difference on hiatal area at rest or during PFM contraction

14 High prevalence of UI in women participating in regular PA Women with SUI –2/3 of sedentary women report UI to be main reason for withdrawal Bø et al -90 Sport students: –26% Bø et al-89 33% of exercisers Nygaard et al -90 40% of mid-age women exercising; 30% avoided sporting activities Brown &Miller-01 49% of exercisers Urwin & Urwin-03 26% of group fitness instructors, same in Pilates/yoga Bø et al -11 Nulliparous women attending gyms and controls –24.6% versus 14.3% Fozzatti et al-12

15 UI in female athletes 28% varsity athletes Nygaard et al -94 41%/16% elite athletes Bø & Sundgot- Borgen -01 52% athletes and dancers Thyssen et al -02 80% /51% of trampolinists Eliasson et al -02/05:

16 Anal incontinence Vitton et al J Women’s Health -11 Questionnaire to 169 female high level sport participants (> 8 h/week) and 224 non intensive sport participants Anal incontinence: 14.8/ 4.9% –Flatus: 84% Urinary incontinence:33.1/18.3% Intensive sport and BMI were significantly linked to anal and urinary incontinence controlled for age and births

17 Conclusion hypothesis 1: Does general PA train the PFM? Physical activity does not seem to protect against UI Few studies on PFM strength No evidence that athletic women have stronger PFM

18 Hypothesis 2: PA may overload, stretch and weaken the PFM

19 Multifactorial model of athletic injury etiology Meeuwisse 1994 Predisposed athlete Susceptible athlete Injury PFM anatomy Connective tissue Previous injury Etniticity Intrinsic riskfactors Eksposure to extrinsic risk factors Inciting event Risk factors for injuryMechansim of Injury

20 ACUTE INJURIES Acute injuries occur when tissue loading is sufficient to cause sudden irreversible deformation of the tissue Bahr et al 2004

21 Can high impact activities cause SUI? Larsen & Yavorek 2007 116 nulliparous women (80.6%), mean age 20.7 (19- 24) examined with POP-Q and questionnaire before and after 6 weeks of summer military training Female paratroopers (n=37) singificantly more likely to have stage II prolapse (RR= 2.72) and worsening of their pelvic support regardless of initial prolapse stage (RR= 1.57) No association with UI and paratrooper training

22 Maximum vertical ground reaction forces during activity (times body weight, in Hay -93) Running 3-4 Jumping 5-12 Front somersault 9 Double back somersault 14 Long-jump 16 Javelin throwing 9.1 (lead food)

23 IAP mmHg Faber-Hansen & Pedersen -86, Eie -71 Lifing 305 kg:400 Sneezing:100-125 Valsalva: 83 Ski-jumping (land): 67 Double-sticking: 50 Double leg-lift: 41 Sit-up (rectus ab): 15 Sit-up (obliques): 7-12

24 Increase in IAP during PA Weir et al 2006 30 women performed 3 reps of different activities with measurement of abdominal pressure (microtip rectal catheters) Results (median, min-max) –Sit up68 cm H 2 O (19.7-174.0) –Stand up from chair70 cm H 2 O (36.0-229.0) Abd crunches, climbing stairs, walking on a treadmill, and many lifting acitivites did not increase abdominal pressure significantly more than standing up from a chair

25 IAP during exercise O’Dell et al 2008 12 healthy women, mean age 31.1 (20-51) measured by vaginal pressure in posterior fornix during cough and different exercises Results –Median cough 98.0 cm H 2 O –Lifting 45 pounds from floor70.9 cm H 2 O –Jogging54.0 cm H 2 O –All other exercise < 55 cm H 2 O –Abdominal exercise < 100 cm H 2 O, the same as laughter, cough and bearing down in sitting position –Holding breath/exhaling no influence on IAP during exercise

26 Daily activities 23 POP patients before and after surgery Vaginal pressure was 4-5 times higher during coughing/ valsalva than during lifting 2 and 5 kg Postopr care should focus more on treating chronic cough and constipation Mouritsen et al-07

27 Does one bout of strenuous general PA cause PFM fatigue? Lindland & Bø 2005 Young nulliparous women with SUI symptoms. Muscle fatigue –maximal voluntary contraction (MVC) –vaginal resting pressure –holding time

28 Intervention Lindland &Bø 2005 90 minutes interval training program Heavy strength training High impact endurance activities ActivityMinutes Running20 Jumps down from step-cases, jumping jacks, vertical jumps5 Lounges4 Jumps down from step-cases, jumping jacks, vertical jumps5 Lounges4 Jumps down from step-cases, jumping jacks, vertical jumps.5 Lounges4 Running down stairs5 Squats4 Running down stairs5 Squats4 Running down stairs5 Squats4

29 Results Lindland & Bø 2005 17% decrease in MVC No change in resting pressure or holding time

30 Overuse injuries Occur as a result of repeated overloading, each incidence of which, alone, is not enough to cause irreverisible deformation, but which when accumulated over time exceeds the tissue injury threshold Bahr et al 2004

31 Weaker PFM in female athletes? Borin et al 2013 10 volley, 10 basket, 10 handball and 10 controls Statistically sign difference between volley/basket and control Low PFM strength correlates with symptoms of UI

32 Long term effect of high impact PA 20 year follow-up of former olympians (1960-76), N= 104 (51%) Nygaard et al-97 –No difference in gymnasts / track & field or swimmers 15 year follow up of former elite athletes and controls in Norway Bø & Sundgot –Borgen -09 –Former elite athletes were not more likely to experience UI later in life compared to controls –Former high impact activities did not influence prevalence of UI later in life –UI early in life experienced during sport was strongly associated with UI later in life

33 Long term effect of high impact PA? 305 ex-tramponisits, median age 21 (18-44) 76% of women with leakage during trampolining continued to leak after ending competetive sport Prevalence of current leakage was higher in ex-trampolinists than in a reference group Eliassson et al 2005

34 Conclusion hypothesis 2: Does strenuous PA weaken the pelvic floor? ? It is possible...

35 Treatment and prevention in athletic women?

36 Does UI affect the athletes? Eliasson et al 2005 305 athletes (response rate 60%) median age 21(18-44) with licence to compete in trampoline answered questionnaire (Eliasson et al -05 ). –61% UL when trampolining –72% discussed it with someone –35% affected in daily life –53% affected psychologically –12% stopped because of leakage 157 athletes Nimes, France answered questionnaire (low response%) (Caylet et al-05) –even small quantity of urine loss reported to be embarrassing. 84% had not spoken about it

37 Effect of preventive devices Glavind -97 6 women with SUI, age 44-68 years Performed aerobic exercise for 30 minutes with and without vaginal sponge RESULTS: no leakage with sponge in situ

38 Effect of PFMT in athletes? No RCTs 3 nulliparous volleyball players. PFMT++ for 3 mo –all cured Rivalta et al-10 Case series of 7 sport students: –6 of 7 cured, sign improved PFM strength Roza -11

39 CONCLUSION (Bø, Sports Med,- 04, Milsom et al, ICI -13) Strenuous exercise is likely to unmask UI Some evidence that strenuous exercise may cause pelvic floor dysfunction, BUT…. More research is needed: –heavy exertion as etiology? –prevention and treatment? –return to sport after childbirth?

40 Women’s Health: Exercise throughout a lifespan


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