1. Sustainability of Response to Knack Maneuver for Urinary Incontinence
Janis M. Miller, Lee Park, Meg Tolbert, Ruta Misiunas, John JO DeLancey
University of Michigan
NIH (ORWH & NICHD): P50 HD and UM Pelvic Floor Research Group

2. Knack Maneuver*
The trick or skill of using the pelvic floor muscles at the moment of expected urinary leakage
Date: 14th century (per Merriam Webster)
a : a clever trick or stratagem
b : a clever way of doing something
c : a special ready capacity that is hard to analyze or teach
*Miller, 1998

3. Other terms for the Knack
squeeze when you sneeze,
Kegel when you cough,
quick Kegel,
perineal blockage for stress (Bocier, 1990)
perineal lock (Cammu, 1991)
bracing,
pelvic clutch,
muscle clenching
motor learning program (Hay-Smith, 2007)

4. Knack vs Kegel Exercise
Knack: one contraction selectively timed with an event that would otherwise elicit leakage
Kegel exercise: repetitive contractions as exercise for strengthening
PFMT usually incorporates both, though may use only the Knack or only strengthening exercises (Kegels)

5. What muscles are employed?
PFM include…
Levator ani (pubococcygeal portion)
Urethral striated muscle
Both are activated on volitional effort

7. *DeLancy anatomical fig
Why would we expect Knack to work with fecal incontinence?
Closure of the anal sphincter
Why would we expect Knack to work with urinary incontinence?
Stabilization of support structures =‘s improved pressure transmission
Urethral closure
Anal sphincter closure
Anal sphincter manometer measures commonly used to demonstrate increased closure pressure on PFM contraction
Mechanism demonstrable, but does it work? Can’t measure closure and amount of incontinence at same time
Intuitive: “squeeze to hold back gas”
*DeLancy anatomical fig

8. Kegel improves urethral pressure
Levators might contribute, pressure from underneath? Separate muscles but complementary

9. *DeLancy anatomical fig
Why would we expect Knack to work with fecal incontinence?
Closure of the anal sphincter
Why would we expect Knack to work with urinary incontinence?
Stabilization of support structures =‘s improved pressure transmission
Urethral closure
Anal sphincter closure
Anal sphincter manometer measures commonly used to demonstrate increased closure pressure on PFM contraction
Mechanism demonstrable, but does it work? Can’t measure closure and amount of incontinence at same time
Intuitive: “squeeze to hold back gas”
*DeLancy anatomical fig

10. KEGEL MRI

11. *DeLancy anatomical fig
Why would we expect Knack to work with fecal incontinence?
Closure of the anal sphincter
Why would we expect Knack to work with urinary incontinence?
Stabilization of support structures =‘s improved pressure transmission
Urethral closure
Anal sphincter closure
Anal sphincter manometer measures commonly used to demonstrate increased closure pressure on PFM contraction
Mechanism demonstrable, but does it work? Can’t measure closure and amount of incontinence at same time
Intuitive: “squeeze to hold back gas”
*DeLancy anatomical fig

12. Mechanism vs Outcome Showing closure or stabilization of structures
……is different from showing that “Knack” performed at the moment of expected urinary leakage, actually prevents that leakage.

13. Theoretical mechanism demonstrable, but so what?
Does it work?
Problems:
Can’t measure urethral closure pressure and quantify urinary leakage simultaneously
Can’t measure pelvic muscle stabilization quantify urinary leakage simultaneously

14. Knack & Urinary Incontinence
You can ask a woman to cough, do the Knack, and catch any leakage on a paper towel, all at the same time

15. PTT & Knack goal No Knack cough
Knack cough (area reduction not good enough)
Knack cough
(area reduction with clinical relevance)

16. Knack & UI Evidence Base*
*Miller 1998

17. Age > 59, not childbearing years

18. Across the age spectrum, but not pregnant

19. Pregnant (about 32-35 wks gestation)

20. *Miller 2008

21. Knack works for many in controlled conditions with no distractions
Even under these very controlled conditions, not all women are helped
Can the effect be sustained in the real world environment?
…. And over time?
Is it a substantial enough effect to make a difference to women?

22. Knack in Everyday Life “Substantial Improvement” criteria
At least 50% improvement on minimally 2 of three outcome measures
PTT ≥ 50% reduction in leakage volume
Diary ≥ 50% reduction in leakage episodes
Self-report ≥ 50%
“What percent of improvement are you experiencing?”

23. Substantial Improvement:
≥50% improvement on at least 2 of 3 measures
Strict a priori criteria were used to determine response Positive response required 50% improvement on at least 2 of 3 measures: 1) incontinence episodes on diary, 2) leakage volume on quantified standing stress test, and 3) self-reported improvement using a scale of 0 – 100%.

24. Knack in Everyday Life Short-term
Phase I: 10-minute Video teaching
RCT
N=133
F/U to 1 mo with cross-over to 3 mo
Results: 53% of the women were substantially improved

25. Knack in Everyday Life Short-term
Phase II: Nurse face-to-face teaching during exam and f/u educ handout
Pre- and post-test design
N = 111
F/U to 3-mo
Results: 53% of the women were substantially improved

26. Knack in Everyday Life: Long-Term (1 year)
Phase III
Recruitment Pool: all participants from Phase I & II who had substantial improvement at the short-term evaluation.
N = 57 found/agreed to additional evaluation
Results: 79% retained substantial improvement to 1 year

28. Conclusion
Teaching the Knack may help many, per 10 minute video or in person instruction, even without dedicated exercise

29. Conclusion
We can let women know that about ½ are helped, and about ½ are not
Retention of effect long term looks promising (probably needs more data)
Early LACK OF RESPONSE should be followed up, with reevaluation no later than 1-mo to 3-mo, and alternative therapy offered