Effect of Weight Training with Pelvic Floor Muscle Training in Elderly Women with Urinary Incontinence

Research Quarterly for Exercise and Sport
ISSN: 0270-1367 (Print) 2168-3824 (Online) Journal homepage: https://www.tandfonline.com/loi/urqe20
Effect of Weight Training with Pelvic Floor
Muscle Training in Elderly Women with Urinary
Incontinence
Janeisa Franck Virtuoso, Enaiane Cristina Menezes & Giovana Zarpellon
Mazo
To cite this article: Janeisa Franck Virtuoso, Enaiane Cristina Menezes & Giovana Zarpellon Mazo
(2019): Effect of Weight Training with Pelvic Floor Muscle Training in Elderly Women with Urinary
Incontinence, Research Quarterly for Exercise and Sport, DOI: 10.1080/02701367.2019.1571674
To link to this article: https://doi.org/10.1080/02701367.2019.1571674
Published online: 04 Apr 2019.
Submit your article to this journal
View Crossmark data
Full Terms & Conditions of access and use can be found at
https://www.tandfonline.com/action/journalInformation?journalCode=urqe20
RESEARCH QUARTERLY FOR EXERCISE AND SPORT
https://doi.org/10.1080/02701367.2019.1571674
Effect of Weight Training with Pelvic Floor Muscle Training in Elderly Women
with Urinary Incontinence
Janeisa Franck Virtuosoa, Enaiane Cristina Menezesb, and Giovana Zarpellon Mazob
a
Federal University of Santa Catarina; bState University of Santa Catarina
ARTICLE HISTORY
ABSTRACT
Purpose: To determine if weight training combined with pelvic floor muscle training is more
efficient than pelvic floor muscle training alone for the treatment of urinary incontinence (UI)
symptoms in elderly women. Method: This was a two-arm, parallel, randomized controlled trial.
Twenty-six women with stress UI participated in the study. The intervention group (IG) underwent
training with moderate intensity weights combined with pelvic floor muscle training, whereas the
control group (CG) only underwent pelvic floor muscle training. Intervention occurred twice
a week over 12 weeks. The International Consultation on Incontinence Questionnaire–Short
Form was used as the main measure. Scores of zero defined the absence of symptoms. The
absence of symptoms was evaluated at 4 weeks, 12 weeks, and 1 month after the end of
treatment. Moreover, activities related to UI and the use and change of daily protection were
investigated. Results: The rate of absence of symptoms was significantly higher in IG after
4 weeks (58.3%) compared to CG (14.8%). The relative risk was 4.1 (95% confidence interval [CI]
[1.08, 16.06]). Although no intention-to-treat analysis was performed, there was no difference in
the evaluations after the interventions. Conclusion: Compared to pelvic floor muscle training
alone, the combination of weight training and pelvic floor muscle training provided earlier
improvement of UI in elderly women.
Urinary incontinence (UI) causes a series of negative
effects on the quality of life of women (Elbiss, Osman,
& Hammad, 2013). The prevalence of this dysfunction
is 36.3% (Marques, Schneider, Giehl, Antes, & D’Orsi,
2015). Randomized clinical trials have demonstrated
the efficacy of pelvic floor muscle training (PFMT) in
improving UI (Kashanian, Ali, Nazemi, & Bahasadri,
2011; Sherburn, Bird, Carey, Bø, & Galea, 2011).
A systematic review conducted by Dumoulin and HaySmith (2010) concluded that PFMT provides better
results than nontreatment or placebo treatments, especially in people with stress UI.
In clinical trials using PFMT combined with physical
exercise (thigh, abdominal, and back training), 55.4% of
elderly women reported cure of UI (Kim, Suzuki,
Yoshida, & Yoshida, 2007) after 3 months of training.
In addition, a reduction in UI episodes and improvement in walking speed were reported (Kim, Yoshida, &
Suzuki, 2011a). On the other hand, few clinical trials
have submitted elderly women with UI to weight training (WT) and they used similar interventions based on
strengthening of some muscle groups, such as the
Received 6 October 2017
Accepted 3 January 2019
KEYWORDS
Clinical trial; exercise;
rehabilitation; resistance
training
abdominal, flexor, and knee extensor muscles (Kim
et al., 2007; Kim, Yoshida, & Suzuki, 2011b; Kim
et al., 2011a). However, these studies did not provide
detailed descriptions of systematization and planning of
such interventions, such as number of sets, repetitions,
and weights used, impairing replication in clinical practice. The rationale would be that a multidimensional
WT program will lead to cocontraction of the PFM (Bø,
2004) and improve muscle volume. Moreover, for the
elderly, there is scientific evidence that WT improves
cardiovascular health and physical fitness (Gurjão et al.,
2012; Raymond, Bramley-Tzerefos, Jeffs, Winter, &
Holland, 2013). Furthermore, WT is a safe and efficient
strategy for the maintenance and development of muscle strength in women (Gurjão et al., 2012).
Therefore, considering the high prevalence of UI
in the elderly population (Elbiss et al., 2013; Marques
et al., 2015) and the importance of promoting WT
programs that improve UI, the aim of this study was
to compare the effect of WT combined with PFMT
and PFMT alone in elderly women with UI
symptoms.
CONTACT Janeisa Franck Virtuoso
janeisa.virtuoso@ufsc.br
Department of Physiotherapy, Federal University of Santa Catarina, Rua Gov. Jorge
Lacerda, 3201, Urussanguinha, Araranguá-SC CEP: 88905-355, Brazil
Trial registration: Brazilian Registry of Clinical Trials UTN: U1111-1149-2398. http://www.ensaiosclinicos.gov.br/
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/urqe.
© 2019 SHAPE America
2
J. F. VIRTUOSO ET AL.
The specific research question for this clinical trial
was, “Is WT combined with PFMT more effective than
PFMT alone for the treatment of UI symptoms in
elderly women?”
The physiotherapist who conducted the PFMT sessions with the IG and CG had 7 years of experience in
UI physiotherapy. The researcher who conducted the
WT sessions with the IG had 3 years of experience in
teaching WT for older adults.
Methods
Design, participants, and therapists
Intervention
This was a randomized clinical trial conducted in
Florianópolis, Brazil, between August 2013 and
January 2015. The trial was registered in the Brazilian
Registry of Clinical Trials (REBEC) (UTN: U1111-11492398, http://www.ensaiosclinicos.gov.br/rg/RBR-85qvn9/
). The Ethics Committee of the State University of Santa
Catarina (UDESC) approved this study under number
498.443, and written informed consent was obtained
from the participants. The study lasted 12 weeks, with
two sessions per week. The sample was divided into an
intervention group (IG; n = 14) and a control group (CG;
n = 18). The IG underwent PFMT combined with WT,
whereas the CG underwent only PFMT.
This study included women age ˃ 60 years,
recruited in the community, who experienced clinical UI symptoms during coughing, sneezing, or
other physical activities (stress incontinence) and
two or three episodes of UI per week. The muscle
and pelvic floor strength of the participants was ≥ 2
according to the Oxford scale (Laycock & Jerwood,
2001), and their cognitive function was preserved
(Brucki, Nitrin, Caramelli, Bertolucci, & Okamoto,
2003). Exclusion criteria were: physiotherapy treatment for symptoms of recent UI (< 6 months ago),
urgent UI resulting from neurological causes, presence of symptoms of urinary tract infection, participation in WT in the past 6 months, and diseases
with contraindications for WT.
To guarantee a similar number of elderly women
and randomization by stage in IG and CG, randomization was performed in groups of 10 participants. For
this purpose, an external researcher generated
a computerized sequence of random numbers and the
woman was allocated to IG or CG according to her
order of participation in the study. This randomization
was carried out after assessment of the patient, which
was a blind assessment.
The external researcher told the participants about
the importance of keeping the WT part confidential, as
the physiotherapist who conducted PFMT also assessed
the participants. It should be noted that the evaluator did
not know which participants belonged to the IG. The
study design is shown in Figure 1.
Pelvic floor muscle training in the intervention and
control groups
The PFMT protocol was based on the recommendations
proposed by Bo, Talseth, and Holme (1999) and Choi,
Palmer, and Park (2007). The sessions were conducted
twice a week for approximately 30 minutes per session.
Each group was composed of a maximum of six women.
The intervention consisted of three exercises in different positions: lying down, sitting, and standing. The exercises proposed by da Luz (2011) were used (Appendix).
Each exercise comprised eight to 12 repetitions of PFMT.
The verbal command for PFM contraction was “hold
pee,” which was performed during expiration. After
eight sessions, the “knack” maneuver was used during
sessions. The progression of PFMT over a period of
3 months (12 weeks) is shown in Figure 2.
All participants were encouraged to execute this
series of PFM contractions at home. Adherence to
home exercises was measured by asking, “How frequently did you follow the guidelines for pelvic floor
muscle contractions in your home?” (0 = not at all and
10 = followed completely). An informative banner about
correct PFM contraction, the importance of exercising
at home (at least 30 contractions), and keeping the WT
status private was placed at the training facility.
Weight training in the intervention group
Immediately after the PFMT sessions, the IG participants
were taught WT. The WT protocol was based on the
American College of Sports Medicine’s program
(American College of Sports Medicine et al., 2009). The
WT program was carried out for 12 weeks and comprised
two weekly sessions of 50 minutes per session. The training
consisted of 15 repetitions maximum (RM), with a oneminute interval between sets. The exercises were performed in an alternating order, starting with the largest
muscle groups. The WT protocol was divided into three
stages: familiarization stage, weight determination, and
training sessions. Protocol details can be found in the
Appendix.
To remind participants in the study about PFM contraction during muscle exercises, an informative banner
was placed at the facility where WT was carried out. These
RESEARCH QUARTERLY FOR EXERCISE AND SPORT
3
UI women who sought treatment (n = 99)
Exclusion criteria (n = 67)
Women referred to the study – Randomization (n = 32)
Intervention Group
(n = 14)
Day 0
Losses
Inguinal hernia
(n = 1)
Transport problem
(n = 1)
Control Group
(n = 18)
Intervention:
PFMT twice a
week plus WT
Intervention:
PFMT twice a
week
Losses
Familial problem
(n = 1)
Laziness
(n = 1)
Transport problem
(n = 1)
Desmotivation
(n = 1)
Assessment of urinary loss
4 weeks
Intervention Group
(n = 12)
Control Group
(n = 14)
Intervention:
PFMT twice a
week plus WT
Intervention:
PFMT twice a
week
Assessment of urinary loss
12 weeks
Intervention Group
(n = 12)
Control Group
(n = 14)
Assessment of urinary loss
1-month
follow-up
Intervention Group
(n = 12)
Control Group
(n = 14)
Figure 1. Design and flow of participants in the trial.
contractions were encouraged because this was the first
clinical trial using WT for the treatment of IU to avoid
adverse effects of increased intrabdominal pressure.
Outcome measures
The participants were interviewed, and information
about sociodemographic data and UI risk factors in
elderly women was recorded (Bø, 2004; Virtuoso,
Menezes, & Mazo, 2015). Body mass was determined
with a digital scale and stature was measured with
a stadiometer. The body mass index was calculated
dividing body mass (kg) by the squared height of the
participant (m2). The waist circumference (cm) was
measured at the midpoint between the lower border
of the last rib and the iliac crest using a round 1.50-m
tape measure.
4
J. F. VIRTUOSO ET AL.
Start of
treatment
After eight
weeks
• Six-second
sustained
contractions,
plus three fast
contractions.
After 16 weeks
• Eight-second
sustained
contractions,
plus four fast
contractions.
• Knack
Maneuver.
• Ten-second
sustained
contractions,
plus five fast
contractions.
• Knack
Maneuver.
Figure 2. Progression of pelvic floor muscle training.
Urinary incontinence
The International Consultation on Incontinence
Questionnaire–Short Form (ICIQ-SF) was developed
by Avery et al. (2004) and was translated, adapted,
and validated for Brazil by Tamanini, Dambros,
D’Ancona, Palma, and Rodrigues Netto (2004). Its
aim is to assess the impact of UI on quality of life
and to qualify UI. This questionnaire evaluates the
frequency of UI, the amount of incontinence, and
how much these parameters interfere with a person’s
daily life. These items yield the final quality of life
score.
and effect size was calculated using Cohen’s d. A 95%
CI was used.
A 40% difference in the absence of symptoms rate
between groups indicated a clinically important difference. The calculations assumed a two-sided effect, with
alpha of 0.05 and power of 80.0%. A total sample size of
21 women was calculated. Assuming a dropout rate of
20.0%, the desired sample size at enrollment was 26
women. No intention-to-treat analysis was performed
in this study.
Results
Severity of symptoms
To identify UI severity, an interview form including
questions about length of UI symptoms (in years), use
of daily sanitary pads, number of daytime and nocturnal changes of sanitary pads, and episodes of UI was
applied.
Data analysis
All collected variables were analyzed descriptively. The
Shapiro-Wilk test was used to assess the normality of
the data. Depending on the distribution of the data, the
paired t test or Wilcoxon test was used for intragroup
comparison and the t test for independent samples or
Mann-Whitney U test for intergroup comparison.
A level of significance of 5% was adopted.
The measures used to compare the two interventions
were the relative risk (RR) and the number needed to
treat (NNT) for the absence of symptoms (dichotomized outcome). The numerical outcome was determined as the difference between mean ICIQ-SF scores
In this study, 32 elderly women were randomized, 14 to
the IG and 18 to the CG. Some sample losses occurred
during the clinical trial. As can be seen in Figure 1, 12
women in IG (85.7%) and 14 in CG (77.8%) completed
the study. The dropout rate was 14.3% and 22.2%,
respectively.
The participants in IG had a mean age of
64.8 ± 4.7 years; most women were married (75.0%),
had 11 years of schooling (83.3%), and a household
income of more than six Brazilian minimum wages (>
R$ 4068.00; 75.0%). The participants in CG had a mean
age of 66.5 ± 5.5 years; most women were married
(57.1%), had 5 to 8 years of schooling (50.0%), and
a household income of more than six Brazilian minimum wages (> R$ 4068.00; 35.7%) or between three
and four minimum wages (R$ 2034.00–R$
2712.00; 28.6%). In addition to activity-related UI
symptoms (stress incontinence), most elderly women
of IG (66.7%) and CG (57.1%) displayed UI associated
with urinary urgency.
Table 1 shows the comparison of some risk factors
for UI development and severity measures between IG
RESEARCH QUARTERLY FOR EXERCISE AND SPORT
5
Table 1. Comparison of risk factors for urinary incontinence (UI) development and severity measurements between elderly women
of intervention group (IG; n = 12), and control group (CG; n = 14) at baseline.
Risk Factors and Severity Measurements
Menopause time years; Mean ± SD
Normal birth number; median (IQR)
Arterial hypertension presence; n (%)
Diabetes presence; n (%)
Constipation presence; n (%)
Regular physical activity presence; n (%)
Family history presence; n (%)
Body Mass Index kg/m2; Mean ± SD
Waist circumference cm; Mean ± SD
UI time years; Mean ± SD
Activities causing incontinence yes; n (%)
Sneezing
Coughing
Laughing
Jumping
Weight lifting
Running
Daily protection use number; n (%)
Always
Occasionally
Never
Daily protection changes number; median (IQR)
Nocturnal protection changes number; median
Intervention Group
Control Group
p value
14.5 ± 8.4
0.5 (3.0)
6 (50.0)
2 (16.7)
5 (41.7)
10 (83.3)
8 (66.7)
30.3 ± 4.5
93.9 ± 8.5
4.7 ± 3.5
17.9 ± 7.7
2.0 (3.0)
9 (64.3)
2 (14.3)
2 (14.3)
7 (50.0)
9 (64.3)
28.8 ± 4.7
91.1 ± 9.1
10.3 ± 11.9
0.176
0.347
0.462
0.578
0.246
0.085
0.613
0.728
0.689
0.631
12
12
9
6
5
5
14 (100.0)
14 (100.0)
12 (85.7)
9 (64.3)
6 (42.9)
8 (57.1)
1.000
1.000
0.422
0.462
0.951
0.431
7 (50.0)
5 (35.7)
2 (14.3)
1.5 (2)
0.0 (1)
0.140
(100.0)
(100.0)
(75.0)
(50.0)
(41.7)
(41.7)
2 (18.2)
5 (45.5)
4 (36.4)
0.5 (2)
0.0 (1)
(IQR)
0.118
0.527
Note: Subscript texts represent the units of the variable; when a numerical variable, it can be expressed in median and amplitude, or mean and standard
deviation, or n and % for categorical variables. IQR = interquartile range; n = absolute frequency; % = relative frequency.
and CG before the beginning of this study. The data
suggested that both groups were similar (p > .05) in
terms of risk factors and severity measures.
Figure 3 shows a reduction in the ICIQ-SF score in
both groups at the end of the intervention (p < .001).
These finding indicate a decrease in the frequency and
amount of UI and an impact on the quality of life of
elderly women. The reduction in mean ICIQ-SF score
between pre- and postintervention was greater in CG
(9.1 ± 5.0) than in IG (8.0 ± 5.6), but this difference was
not significant (t = −0.875, p = .390, d = .215).
The rate of absence of symptoms of UI was 58.3% in
IG, whereas this rate was 14.3% in CG (Figure 4).
18.0
(11.11–15.18)
16.0
14.0
* d = 2.42
* d = 2.53
13.14
(8.49–11.51)
12.0
10.0
10.0
(1.88–6.26)
8.0
(–0.41–4.41)
6.0
4.1
4.0
2.0
2.0
0.0
Intervention Group
ICIQ pretest
Control Group
ICIQ post test
Figure 3. Comparison between pre- and postvalues measured
using
International
Consultation
on
Incontinence
Questionnaire–Short time in the intervention group and control
group. *p < .001.
A significant association was observed between group
and the absence of symptoms after 4 weeks (χ2 = 5.539,
p = .025), suggesting that PFMT combined with WT
leads to earlier improvement in symptoms as observed
in IG. In addition, the RR indicated a 4.1 times greater
rate of absence of symptoms in the first 4 weeks of
intervention in the group undergoing PFMT combined
with WT compared to women undergoing only PFMT
(RR = 4.1, 95% CI [1.08, 16.06]). The NNT was two
(95% CI [1.0, 14.0]), suggesting that one in two women
with UI undergoing PFMT combined with WT achieve
complete reduction of symptoms within a month.
The absence of symptoms rate after the end of treatment was 75.0% in IG and 35.7% in CG (χ2 = 4.013, p
= .05) (Figure 4). Although this rate was higher in GI,
the RR indicated that this association was not significant (RR = 2.14, 95% CI [0.97, 4.55]).
As shown in Figure 4, the absence of symptoms rate
one month after the end of treatment was 83.3% in IG,
whereas it was 50.0% in CG (χ2 = 3.172, p = .085).
There was no association between absence of symptoms
and group (RR = 1.68, 95% CI [0.93, 3.00]) at this time
point.
Figure 5 shows a decrease in the most frequent
situations causing incontinence, such as sneezing,
coughing, and laughing, at the end of treatment in
both groups. Moreover, improvement during running
and jumping activities was observed in CG (p < .05).
Comparison of the proportions of improvement indicated no significant difference between IG and CG
(p > .05).
6
J. F. VIRTUOSO ET AL.
X² = 5.539
p = .025
100.0
80.0
41.7
85.7
60.0
40.0
(a)
58.3
20.0
14.3
0.0
Intervention Group
Absence of symptoms
100.0
Control Group
Presence of symptoms
X² = 4.013
p = .05
25.0
80.0
64.3
(b)
60.0
40.0
75.0
35.7
20.0
0.0
Intervention Group
Absence of symptoms
100
confirm that both groups adhered similarly to the proposed guidelines (p =.860).
Control Group
Presence of symptoms
X² = 3.172
p = .085
16.7
50.0
80
(c)
60
83.3
40
50.0
20
0
Intervention Group
Absence of symptoms
Control Group
Presence of symptoms
Figure 4. Association between occurrence of cure of urinary
incontinence symptoms in the intervention group and control
group after 4 weeks (a) and 12 weeks of treatment (b), and
1-month follow-up (c).
Note. χ2 = chi-square test statistics; p = significance level.
Regarding the use of daily protections (Table 2) measured only at the end of treatment, intragroup comparison
showed a higher median number of daily changes in CG
(p = .046), whereas there was a decrease in the number of
nocturnal changes in IG (p = .007). No difference in the use
of sanitary pads (paper/cloth) or daily changes was
observed between groups.
The median adherence to home exercises was 9
(3–10) in IG and 8 (4–10) in CG. These findings
Discussion
This trial compared the effects of WT combined with
PFMT and PFMT alone on improving incontinence in
elderly women with UI. The working hypothesis was
that intervention with WT combined with PMFT is
better than the use of PFMT alone. The results indicated a higher rate of absence of symptoms and earlier
recovery among IG women, as well as higher absence of
symptoms rates in the first 4 weeks of intervention,
compared to CG women.
PFMT is reported in the literature as the best conservative treatment for activity-related UI (Dumoulin &
Hay-Smith, 2010). According to Choi et al. (2007), the
effects are even better in younger women (< 60 years).
However, Davison and Moore (2013) suggested that
PFMT is also beneficial for the elderly population.
This training alleviates symptoms and increases PFM
strength. This information was confirmed in this study
in which the CG had significantly lower ICIQ-SF scores
after PFMT.
Although no significant difference in ICIQ-SF scores
was observed between groups, the rate of absence of
symptoms, defined as a score of zero using this tool, was
greater among women at the end of treatment with WT
and PFMT (75.0%) compared to those who only underwent PFMT (35.7%). As reported by Grewar and McLean
(2008), motor control, musculoskeletal, and behavioral
factors are thought to be modifiable and may influence
the function of the urinary continence system.
Consequently, reflex PFM contraction is believed to
occur (Bø, 2004) as soon as the intra-abdominal pressure
during physical exercise increases. This co-contraction
may explain the higher rate of absence of symptoms
among IG women.
Furthermore, a higher rate of absence of symptoms
was observed in IG after 4 weeks of intervention
(58.3%). This earlier recovery may be explained by the
overlap of treatments resulting in an extra stimulus for
PFM contraction, though it has been shown that conventional WT protocols do not stimulate contraction of
this musculature.
PFMT causes morphological and functional changes
in PFM, in addition to the improvement of UI symptoms (Braekken et al., 2010). The training proposed in
that study consisted of one session per week for
3 months and one session every 2 weeks for 3 months,
totaling 6 months of treatment. The sessions comprised
RESEARCH QUARTERLY FOR EXERCISE AND SPORT
7
8.3
Run
41.7
Posttest
Pretest
8.3
Lift weight
41.7
(a)
8.3
Jump
50.0
8.3 *
Laugh
75.0
16.7 *
Cough
100.0
16.7 *
Sneeze
100.0
0.0
10.0
20.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
7.7 *
Run
57.1
(b)
14.3
Lift weight
42.9
15.4 *
Jump
Laugh
30.0
64.3
0.0 *
85.7
15.4 *
Cough
100.0
30.8 *
Sneeze
100.0
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
Figure 5. Comparison between pre- and postintervention in the intervention group (a) and control group (b) regarding urinary loss
situation proportions.
Note. *p < .05.
Table 2. Comparison of use of sanitary napkins (paper/cloth)
and number of their changes between elderly women in the
intervention group (IG; n = 12) and control group (CG; n = 14).
Use of sanitary pads
Never wears protection n (%)
Pre
Post
p¥
Daily changes median (minimum-
Intervention
Group (IG)
Control
Group (CG)
5 (41.7)
8 (66.7)
0.412
2 (15.4)
6 (46.2)
0.202
0.530
0.5 (0–5)
0.0 (0–2)
0.334
1.5 (0–7)
0.5 (0–2)
0.046*
0.457
0.0 (0–2)
0.0 (0–1)
0.007*
0.0 (0–1)
0.0 (0–1)
0.180
0.705’
p§
maximum)
Pre
Post
p¥
Nocturnal changes
median
(minimum- maximum)
Pre
Post
p¥
Note: Subscript texts represent the units of the variable; when a numerical
variable, it can be expressed in median and amplitude, or mean and
standard deviation, or n and % for categorical variables. n = absolute
frequency; % = relative frequency; p ¥ = intragroup significance level; p
§
= intergroup significance level (post).
*p < .05.
three sets of eight to 12 maximum contractions of the
pelvic floor lying down, sitting, and standing. The
authors found a significant increase in pubovisceral
muscles, a decrease in the urogenital hiatus, and
a reduction in muscle length among women who
underwent PFMT.
These anatomical changes make it possible for two
urinary continence mechanisms to work: increase in
urethral closing pressure at rest and increase in urethral closing pressure during increased intraabdominal pressure (Delancey & Ashton-Miller,
2004). Thus, the anatomical changes in PFM after
PFMT may explain the improvement of activityrelated (stress) UI in both groups and the earlier
improvement observed in IG.
The American College of Sports Medicine (ACSM et
al., 2009) recommends 60% to 80% of eight to 12 RM in
older adults for strength gain and hypertrophy.
However, progressive resistance training with sets of 15
RM also provides strength gains in the elderly (Harris,
DeBeliso, Spitzer-Gibson, & Adams, 2004). Accordingly,
it is possible to build strength by increasing the weight
within a prescribed zone, as was done in this study in
which moderate intensity was used, with a 15 RM
recommended zone. This demonstrates the importance
of integral physiotherapy treatment, which provides
interventions that improve different aspects of health.
This type of physical exercise is considered a protection
8
J. F. VIRTUOSO ET AL.
factor against UI as it improves strength and general
health, increases muscle strength, and reduces body
weight, the occurrence of stress UI and pelvic organ
prolapse (Nygaard, Shaw, & Egger, 2012).
Improvement of some muscular parameters was
observed in a study involving older adults participating in
only 6 weeks of weight training (Scanlon et al., 2014). There
was improvement of 32.0% in muscle strength, 31.0% in
muscle quality, and 7.4% in vastus lateralis. Positive shortterm changes were also observed in the present study in
which the rate of absence of symptoms was higher among
women in IG. The combination of WT and PFMT resulted
in earlier improvement of symptoms within 4 weeks.
However, although the short-term efficacy of a health strategy is key in clinical practice, the response may not persist if
the intervention is ended prematurely. Further research is
necessary to clarify the innovative proposal of this study.
The follow-up period of this study was short
(1 month). However, as the rate of absence of UI
symptoms increased in both groups (IG and CG),
the effects of PFMT seem to have been constant
during that period. Long-term recurrence of UI is
common and was identified in the study by Beyar
and Groutz (2017) in which almost all women
reported UI 5 years after PFMT, though 41.7% had
adhered to the exercises during that period. A study
indicated a 40% relapse rate of UI per year after
physiotherapy treatment (Krüger, Luz, & Virtuoso,
2011) and a significant association between the
absence of UI symptoms and performing exercises
at home twice a week or more (p = .001).
In a systematic review, Bø and Hilde (2013) evaluated long-term outcomes of PFMT in female UI. As
stated by the authors, long-term adherence varies from
10% to 70%, but levels of PFMT and follow-up strategies are different across studies. Such findings reiterate
the need for maintaining PFM exercises at home after
the end of treatment. Moreover, physiotherapists
should design strategies based on theories that would
help women remember such exercises (Borello-France
et al., 2010; Sacomori, Berghmans, Mesters, de Bie, &
Cardoso, 2015).
Study limitations
This study has some limitations such as the lack of blinding
of the patients and the subjective assessment of UI.
Although urodynamic examination is the gold standard
for determining the type of UI, this bias was reduced by
using an international validated tool (ICIQ-SF) that assesses
the frequency and severity of symptoms. Additionally, in
clinical practice, the use of this tool is easier and less
expensive than urodynamic examination.
What does this article add?
The current knowledge about the relationship between
physical exercise and the management of urinary incontinence is still conflicting. The type and intensity of exercise
have a bidirectional relationship (negative and positive),
influencing the symptoms of urinary loss (Nygaard et al.,
2012). This article reports an innovative proposal for the
interdisciplinary treatment of urinary incontinence in older
adults using weight training at moderate intensity (extremely important for the elderly) and physical therapy (pelvic
floor muscle training). The constantly growing elderly
population is known to increase healthcare costs. Thus,
strategies designed to rapidly and efficiently improve symptoms are necessary, especially in the case of UI, which is
associated with worsening quality of life, social isolation
and depression. This study provides physical education,
physical therapy, and urogynecology professionals with an
interdisciplinary and global approach to the care of older
women with urinary incontinence aimed at short-term
treatment.
Acknowledgments
Government of Santa Catarina State (FUMDES scholarship)
and CNPq for grant productivity to GZM.
Funding
This research was funded by the Government of Santa
Catarina State (FUMDES scholarship), the Coordination for
the Improvement of Higher Education Personnel (CAPES
scholarship), and a National Council for Scientific and
Technological Development (CNPq) productivity grant to
Giovana Zarpellon Mazo.
References
American College of Sports Medicine, Chodzko-Zajko, W. J.,
Proctor, D. N., Fiatarone Singh, M. A., Minson, C. T.,
Nigg, C. R., & Skinner, J. S. (2009). American College of
Sports Medicine position stand. Exercise and physical
activity for older adults. Medicine and Science in Sports
and Exercise, 41(7), 1510–1530.
Avery, K., Donovan, J., Peters, T. J., Shaw, C., Gotoh, M., &
Abrams, P. (2004). ICIQ: A brief and robust measure for
evaluating the symptoms and impact of urinary
incontinence. Neurourology and Urodynamics, 23(4),
322–330. doi:10.1002/nau.20041
Beyar, N., & Groutz, A. (2017). Pelvic floor muscle training
for female stress urinary incontinence: Five years
outcomes. Neurourology and Urodynamics, 36(1),
132–135. doi:10.1002/nau.22888
Bø, K. (2004). Urinary incontinence, pelvic floor dysfunction,
exercise and sport. Sports Medicine (Auckland, N.Z.), 34
(7), 451–464. doi:10.2165/00007256-200434070-00004
RESEARCH QUARTERLY FOR EXERCISE AND SPORT
Bø, K., & Hilde, G. (2013). Does it work in the long
term?-A systematic review on pelvic floor muscle training
for female stress urinary incontinence. Neurourology and
Urodynamics, 32(3), 215–223. doi:10.1002/nau.22292
Bo, K., Talseth, T., & Holme, I. (1999). Single blind, randomised controlled trial of pelvic floor exercises, electrical
stimulation, vaginal cones, and no treatment in management of genuine stress incontinence in women. BMJ, 318
(7182), 487–493. doi:10.1136/bmj.318.7182.487
Borello-France, D., Burgio, K. L., Goode, P. S., Markland, A. D.,
Kenton, K., Balasubramanyam, A., & Stoddard, A. M. (2010).
Adherence to behavioral interventions for urge incontinence
when combined with drug therapy: Adherence rates, barriers,
and predictors. Physical Therapy, 90(10), 1493–1505.
doi:10.2522/ptj.20080387
Braekken, I. H., Hoff Braekken, I., Majida, M., Engh, M. E.,
Bø, K., & Bo, K. (2010). Morphological changes after
pelvic floor muscle training measured by 3-dimensional
ultrasonography: A randomized controlled trial. Obstetrics
and Gynecology, 115(2 Pt 1), 317–324. doi:10.1097/
AOG.0b013e3181cbd35f
Brucki, S. M. D., Nitrin, R., Caramelli, P., Bertolucci, P. H. F.,
& Okamoto, I. H. (2003). Sugestões para o uso do miniexame do estado mental no Brasil. Arquivos de NeuroPsiquiatria,
61(3B),
777–781.
doi:10.1590/S0004282X2003000500014
Choi, H., Palmer, M. H., & Park, J. (2007). Meta-analysis of
pelvic floor muscle training. Nursing Research, 56(4),
226–234. doi:10.1097/01.NNR.0000280610.93373.e1
da Luz, S. C. T. (2011). Educação Perineal Progressiva EPP em busca da continência urinária (Biblioteca). São Paulo,
Brazil: Biblioteca 24 horas.
Davison, J. E., & Moore, K. (2013). Pelvic floor muscle training for
urinary incontinence in older adults: A systematic review.
Australian and New Zealand Continence Journal, 19(1), 18–26.
Delancey, J. O. L., & Ashton-Miller, J. A. (2004). Pathophysiology
of adult urinary incontinence. Gastroenterology, 126(Suppl. 1),
S23–S32. doi:10.1053/j.gastro.2003.10.080
Dumoulin, C., & Hay-Smith, J. (2010). Pelvic floor muscle
training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane
Database of Systematic Reviews, 20(1). doi:10.1002/
14651858.CD005654.pub2
Elbiss, H. M., Osman, N., & Hammad, F. T. (2013). Social
impact and healthcare-seeking behavior among women
with urinary incontinence in the United Arab Emirates.
International Journal of Gynecology & Obstetrics, 122(2),
136–139. doi:10.1016/j.ijgo.2013.03.023
Grewar, H., & McLean, L. (2008). The integrated continence
system: A manual therapy approach to the treatment of
stress urinary incontinence. Manual Therapy, 13(5),
375–386. doi:10.1016/j.math.2008.01.003
Gurjão, A. L. D., Gobbi, L. T. B., Carneiro, N. H.,
Gonçalves, R., Ferreira de Moura, R., Cyrino, E. S., …
Gobbi, S. (2012). Effect of strength training on rate of
force development in older women. Research Quarterly
for Exercise and Sport, 83(2), 268–275. doi:10.1080/
02701367.2012.10599857
Harris, C., DeBeliso, M. A., Spitzer-Gibson, T. A., &
Adams, K. J. (2004). The effect of resistance-training intensity on strength-gain response in the older adult. The
9
Journal of Strength and Conditioning Research, 18(4), 833.
doi:10.1519/14758.1
Kashanian, M., Ali, S. S., Nazemi, M., & Bahasadri, S. (2011).
Evaluation of the effect of pelvic floor muscle training
(PFMT or Kegel exercise) and assisted pelvic floor muscle
training (APFMT) by a resistance device (Kegelmaster
device) on the urinary incontinence in women “comparison between them: A randomized tri. European Journal of
Obstetrics & Gynecology and Reproductive Biology, 159(1),
218–223. doi:10.1016/j.ejogrb.2011.06.037
Kim, H., Suzuki, T., Yoshida, Y., & Yoshida, H. (2007).
Effectiveness of multidimensional exercises for the treatment
of stress urinary incontinence in elderly community-dwelling
Japanese Women: A randomized, controlled, crossover trial.
Journal of the American Geriatrics Society, 55(12), 1932–1939.
doi:10.1111/j.1532-5415.2007.01447.x
Kim, H., Yoshida, H., & Suzuki, T. (2011a). The effects of
multidimensional exercise on functional decline, urinary
incontinence, and fear of falling in community-dwelling
elderly women with multiple symptoms of geriatric syndrome: A randomized controlled and 6-month follow-up
trial. Archives of Gerontology and Geriatrics, 52(1), 99–105.
doi:10.1016/j.archger.2010.02.008
Kim, H., Yoshida, H., & Suzuki, T. (2011b). The effects of multidimensional exercise treatment on community-dwelling
elderly Japanese women with stress, urge, and mixed urinary
incontinence: A randomized controlled trial. International
Journal of Nursing Studies, 48(10), 1165–1172. doi:10.1016/j.
ijnurstu.2011.02.016
Krüger, A. P., Luz, S. C. T., & Virtuoso, J. F. (2011).
Home exercises for pelvic floor in continent women
one year after physical therapy treatment for urinary
incontinence: An observational study. Revista Brasileira
de Fisioterapia, 15(5), 351–356. doi:10.1590/S141335552011005000006
Laycock, J., & Jerwood, D. (2001). Pelvic floor muscle assessment: The PERFECT scheme. Physiotherapy, 87(12),
631–642. doi:10.1016/S0031-9406(05)61108-X
Marques, L. P., Schneider, I. J. C., Giehl, M. W. C.,
Antes, D. L., & D’Orsi, E. (2015). Demographic, health
conditions, and lifestyle factors associated with urinary
incontinence in elderly from Florianópolis, Santa
Catarina, Brazil. Revista Brasileira de Epidemiologia,
18(3), 595–606. doi:10.1590/1980-5497201500030006
Nygaard, I., Shaw, J., & Egger, M. J. (2012). Exploring
the association between lifetime physical activity and
pelvic floor disorders: Study and design challenges.
Contemporary Clinical Trials, 33(4), 819–827.
doi:10.1016/j.cct.2012.04.001
Raymond, M. J., Bramley-Tzerefos, R. E., Jeffs, K. J., Winter, A., &
Holland, A. E. (2013). Systematic review of high-intensity
progressive resistance strength training of the lower limb compared with other intensities of strength training in older adults.
Archives of Physical Medicine and Rehabilitation, 94(8),
1458–1472. doi:10.1016/j.apmr.2013.02.022
Sacomori, C., Berghmans, B., Mesters, I., de Bie, R., &
Cardoso, F. L. (2015). Strategies to enhance self-efficacy and
adherence to home-based pelvic floor muscle exercises did not
improve adherence in women with urinary incontinence:
A randomised trial. Journal of Physiotherapy, 61(4), 190–198.
doi:10.1016/j.jphys.2015.08.005
10
J. F. VIRTUOSO ET AL.
The training sessions lasted 2 weeks. After this time,
a new weight determination was performed. During the
WT intervention period, three weight determinations
were made.
The muscle groups focused on during the weight training protocol were: Pectoral (Fly); Gluteus, Quadriceps, and
Hamstrings (Leg Press 180º); Latissimus Dorsi (Closed
Grip Seated Cable Row); Adductor (Adductor Chair);
Triceps Brachii (Pulley Machine); Biceps Brachii (Pulley
Machine); and Rectus Abdominis (Abdominal Crunch).
During the exercises, pelvic floor muscle (PFM) contraction was initiated by the command “hold pee.”
Contraction occurred during activity, between the initial
and final positions of movement, and the concentric
phase of exercise, and began after the seventh session,
when the participants were familiar with the muscle exercise routines. WT exercises were performed using bodybuilding machines (Tonus Fitness Equipament®).
Scanlon, T. C., Fragala, M. S., Stout, J. R., Emerson, N. S.,
Beyer, K. S., Oliveira, L. P., & Hoffman, J. R. (2014).
Muscle architecture and strength: Adaptations to
short-term resistance training in older adults. Muscle &
Nerve, 49(4), 584–592. doi:10.1002/mus.23969
Sherburn, M., Bird, M., Carey, M., Bø, K., & Galea, M. P.
(2011). Incontinence improves in older women after
intensive
pelvic
floor
muscle
training:
An
assessor-blinded randomized controlled trial. Neurourol
ogy and Urodynamics, 30(3), 317–324. doi:10.1002/
nau.20968
Tamanini, J. T. N., Dambros, M., D’Ancona, C. A. L.,
Palma, P. C. R., & Rodrigues Netto, N. (2004).
Validation of the “International Consultation on
Incontinence Questionnaire - Short Form” (ICIQ-SF)
for Portuguese. Revista de Saúde Pública, 38(3),
438–444. doi:10.1590/S0034-89102004000300015
Virtuoso, J. F., Menezes, E. C., & Mazo, G. Z. (2015).
Fatores de risco para incontinência urinária em mulheres idosas praticantes de exercícios físicos. Revista
Brasileira de Ginecologia e Obstetrícia, 37(2), 82–86.
doi:10.1590/SO100-720320140005040
Pelvic floor muscle training
Appendix
The pelvic floor muscle training (PFMT) protocol was
conducted by a physiotherapist, who talked about urinary
incontinence issues and clarified doubts during the beginning of the session. Then, PFMT exercises were done. The
PFMT protocol of 24 sessions is described below, detailing
the session topic, in which the physiotherapist spoke about
urinary incontinence and pelvic floor issues, training
volume, and exercises to be done.
Weight training
The weight training protocol was divided into three
stages:
Stage 1 – Familiarization: Initially, there was a 1-week familiarization period. There were two sessions for the elderly
women to adapt to the weight training room and its equipment. They were also taught proper breathing and range of
motion.
Stage 2 – Weight determination: After the familiarization stage, the first weight determination was performed. As a warm-up activity, 10 repetitions with
50% of the weight, in preparation for 15 repetitions
maximum (RM), were done, as determined by the
evaluator. After a 30-second break, the test was
started with the execution of as many repetitions as
possible for each exercise. If the participant executed
a number greater than the 15 RM, she would wait
for 10 minutes for another try, and the weight was
adjusted, adding one kilogram for every two excessive repetitions. If the participant executed a number
less than 10 RM, the weight was adjusted by trial and
error. Two attempts to determine weight were made
for each exercise per session. The evaluator had up
to three sessions to adjust the weight for the determined repetition zone (15 RM).
Stage 3 – Training sessions: Training sessions included execution of three sets of 15 RM, with a 1-minute break
between them. Each participant’s repetitions were registered and monitored during the training sessions.
Session 1 through Session 8
Training volumea:
Two sets of eight to 12 contractions (6-second contraction followed by
three quick contractions), one in each position. Six-second rest between
contractions.
a
In the first session, only two sets were carried out, since the presentation of
the proposal raised several questions by the participants, and time was
taken to address those concerns.
Session 9 through Session 16
Training volumea:
Three sets of eight to 12 contractions (8-second contraction followed
by four quick contractions), one in each position. Eight-second rest
between contractions.
a
New training volume.
Session 17 through Session 24
Training volumea:
Three sets of eight to 12 contractions (10-second contraction followed
by five quick contractions), one in each position. Ten-second rest
between contractions.
a
New training volume.