Effectiveness of Antenatal Motor Relearning Approach of Diaphragm, Deep Abdominal and Pelvic Floor Muscles Versus Kegels Exercises on Postpartum Pelvic Floor Muscle Strength

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Indian Journal of Physiotherapy & Occupational Therapy. January-March 2014, Vol. 8, No. 1 193

Effectiveness of Antenatal Motor Relearning Approach ofDiaphragm, Deep Abdominal and Pelvic Floor Muscles

Versus Kegels Exercises on Postpartum Pelvic FloorMuscle Strength

Siva Priya R1 , Kokila V2 , K Kanchana Malai3 , Suresh Kumar S4

1 Assistant Lecturer, College of Allied Health Sciences, Gulf Medical University, Ajman, UAE, 2 Associate Professor,

PSG College of Physiotherapy, 3Professor, Department of Obstetrics and Gynecology, PSG Hospitals, Coimbatore,

Tamil Nadu, India, 4Lecturer, Dr.M.V.Shetty College of Physiotherapy, Mangalore, Karnataka, India

ABSTRACT

Objective: To compare the effect of antenatal motor relearning approach of diaphragm, deep

abdominal and pelvic floor exercises versus kegels exercises on postpartum pelvic floor muscle

strength.

Design: Quasi experimental, Post test only design with a comparison group

Setting: Department of Obstetrics and Gynecology, PSG Hospitals.

Participants: 78 antenatal women randomly selected. Among the 78 women, 39 each were assigned

to Group A (interventional group) and to Group B (control group). Finally 21 women in each group

continued the treatment program.

• Group A- antenatal motor relearning approach of diaphragmatic, deep abdominal and pelvic

floor muscles

• Group B - kegels exercises

Outcome Measure: The pelvic floor muscle strength was measured using Perineometer on the third

postnatal day.

Results: Data from 42 women were analyzed. Independent 't' test was used as statistical tool. It has

been found that there is significant difference in the postpartum pelvic floor muscle strength between

the interventional and control group. The mean difference between the interventional and control

group were 1.762mm hg. The calculated 't' value using independent 't' test was 3.584 which was

greater than tabulated test statistic value of the 1.960 at (p<0.05).

Conclusion: The pelvic floor muscle strength was comparatively greater among the women who

performed antenatal motor relearning approach than kegels exercise group. Hence antenatal Motor

Relearning approach of diaphragmatic, deep abdominal and pelvic floor exercises can be implemented

during a normal pregnancy unless precluded by additional risk factors.

Keywords: Antenatal Motor Relearning Programme, Perineometer, Kegels exercises

INTRODUCTION

The muscles of the pelvic floor are extremely

important for the internal organs as well as the bladder

and bowel function.1 The pelvic floor muscles are the

Corresponding author:Siva Priya RAssistant LecturerCollege of Allied Health Sciences, Gulf MedicalUniversity, AjmanEmail: UAE. [email protected]

DOI Number: 10.5958/j.0973-5674.8.1.037



194 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2014, Vol. 8, No. 1

only transversely placed muscles in the body. 1

Pregnancy and birth trauma are the major risk factors

for pelvic floor muscle injury.7 Like any other muscles

pelvic floor muscles need a regular work out to stay

strong, especially during pregnancy.3

An audit of NICE (National Institute of Clinical

Excellence) has revealed that pregnancy causes 19.9-

70% of pelvic floor muscle weakness.19During

pregnancy, there are systemic signs that the body is

changing and expressed but changes that occurring to

Pelvic floor muscles, nerves and soft tissues are less

obvious.11It is important to have good pelvic floor

muscle strength before, during and after delivery.

During pregnancy weight of the uterus on the pelvic

floor causes these muscles to stretch and weakened

leading to pelvic floor dysfunction. Pelvic floor

muscles need particular attention during pregnancy

and post birth.16

Motor relearning programme incorporates

functional training for key motor tasks such as sitting,

standing, standing up, or walking. In this study the

key motor tasks such as contraction of pelvic floor,

normal breathing during contraction and deep

abdominal contraction during pelvic floor contraction

is analyzed.9 Each task is analyzed and the component

of the task which cannot be performed is noted. Motor

relearning programme trains the patient in those

missing or poorly performed components of the taskand ensures functional training for key motor tasks

such as contraction of pelvic floor, normal breathing

during contraction and deep abdominal contraction.

Different techniques are used to strengthen the

pelvic floor muscles like Kegels exercises, vaginal

cones and biofeedback apparatus. In this study the

pelvic floor muscles are strengthened using the 2

different approaches in the antenatal period and their

strength is assessed in the post natal period. The first

approach is Motor relearning approach of

diaphragmatic, deep abdominal and pelvic floormuscles and the second approach is kegels exercises.

NEED FOR THE STUDY

There are studies stating about the pelvic floor

muscle weakness in pregnant women who underwent

an exercise protocol and pregnant sedentary women.

None of the studies have compared the effect of

antenatal Kegels exercises and antenatal Motor

relearning approach of diaphragmatic, deep

abdominal and pelvic floor muscles on pelvic floor

muscle strength. This forms the basis of need for the

present study.

MATERIALS

• Perineometer

• Sterile Gloves

• Condoms

• Gel

• Cotton

Study Design: Two groups, between subjects,

Quasi experimental posttest only design was taken

where the posttest values were compared between two

groups and values were taken on the third post-partum

day.

Study Setting: The study was conducted among

antenatal women who visited for their check up in the

Department of Obstetrics and Gynecology at PSG

Hospitals

Criteria for Sample Selection

Inclusion Criteria

• Age between 20-35years

• Primigravida• Second trimester (16-22 weeks) of pregnancy

Exclusion Criteria

• BMI>30

• High risk pregnancies

• Mentally retarded patients

• Previous history of urinary incontinence

• Any pelvic floor injury during delivery other thanepisiotomy.

POPULATION AND SAMPLING

Seventy eight pregnant women participated in this

study, inform consent was taken from each participant.

The subjects were randomly assigned into two groups

(interventional and control group). Thirty nine subjects

in interventional group (Group A) received Motor

relearning approach exercises, and thirty nine subjects

in control group (Group B) received Kegels exercises.




Review was done once in every month till their

delivery. All participants maintained an exercise diary

and they were asked to tick the day when they

performed exercises. Subjects were asked to continue

exercises till 38 week (9 months). The diary was

checked during every follow up. In the post-partum

period, the pelvic floor muscle strength of 21 patientsof each group was taken for analysis.

Ethical Clearence: Obtained

Instrumentation

Perineometer was used to measure pelvic floor

muscle strength, which has a high intra rater reliability

[ICC (3, 1) =0.85].13 A standardize measuring procedure

using Perineometer was followed.

Technique of Data Collection

The subjects were positioned in crook lying on the

bed without the pillow under the head and their knees

were flexed 90 degrees. Under aseptic precautions the

vaginal probe is inserted into the vaginal introitus. The

resting pressure was set at 0 mmHg. The patient is

instructed to contract their pelvic floor muscles. The

reading is monitored and recorded. Data obtained

from the subjects, were analyzed using Independent

‘t’ test. It was used to find out significant changes

between two groups.

Table 1. Demographic Table: Age and Body MassIndex of the Subjects

Mean

Group Age BMI

A [ Motor relearning approach Group] 27.2 24.7

B [kegels exercise group] 26.5 24.2

GRAPH 1

Mean Value of Pelvic Floor Muscle Strength Between

Group A and Group B

Group A- Motor relearning approach group

Group B- Kegels exercise group

Table 2. Post Test Statistics For Pelvic Floor Muscle Strength

Groups Mean Mean difference Standard ‘t’ value P value[in mmHg] [in mmHg] deviation

A [ Motor relearning approach Group] 5.28 1.762 1.874 3.584 <0.05

B [kegels exercise group] 3.52 1.249

The independent ‘t’ test was performed to analyze

the significance of pelvic floor muscle strength between

group A (motor relearning approach of diaphragmatic,

deep abdominal and pelvic floor muscles) and group

B (kegels exercise). In group A and group B the meanpelvic floor strength of the participants were 5.28

mmHg and 3.52 mmHg respectively. The mean

difference between group A and group B was 1.762

mmHg. The calculated ‘t’ value was 3.584 at p<0.05

which was greater than the table value of 1.960.

[Table-2]

RESULTS AND DISCUSSION

The aim of the study was to evaluate the effect of

antenatal motor relearning approach of diaphragmatic,

deep abdominal and pelvic floor exercises on postnatal

mothers. It was hypothesized that there is significant

effect of Antenatal Motor relearning approach of

diaphragmatic, deep abdominal and pelvic floor

exercises than the Kegels exercises among the postnatal

mothers. Initially 78 participants were taken for thestudy and were randomly assigned into two groups.

Group A (Interventional) received antenatal motor


abdominal and pelvic floor muscles and Group B

(control) received Kegels exercises. The Mean age

group of participants in group A is 27.2 and group B is

26.5 and the Mean body mass index of participants in

group A and group B was 24.7 and 24.2 respectively.

[Table-1]

Each Group consists of 39 participants, initial

assessment was taken for all these participants and



196 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2014, Vol. 8, No. 1

the missing components were trained and an

immediate review was done. All participants from

group A and group B attended the first review and

second review. In third review, 3 participants from

group A and 5 participants from group B withdrawn

from the study. In fourth review 5 participants from

group A and 1 participant from group B withdrawnfrom the study. For last review (i.e. fourth) 31

participants in group A and 33 participants from group

B were present. In Group A from 31 participants, 3 had

Perineal tear, 5 went for Cesarean section and 2 did

not come for delivery. In Group B from 33 participants,

4 had Perineal tear, 4 went for cesarean section and 4

did not come for delivery. Finally post-partum pelvic

floor muscle strength was assessed for 21 participants

in each group.

It has been found that there is significant difference

in the post-partum pelvic floor muscle strength inGroup A and Group B. The mean difference between

the interventional and control group were 1.762mmHg.

The calculated ‘t’ value using independent ‘t’ test was

3.584 which was greater than tabulated test statistic

value of 1.960 at (p<0.05).Table-2

Statistical analysis between two groups showed

that there was greater improvement in postpartum

pelvic floor muscle strength in antenatal Motor


abdominal and pelvic floor exercises than kegelsexercises.

CONCLUSION

During Pregnancy Pelvic floor muscle strength is

influenced by hormones, biomechanical and structural

changes mainly of the weight of the uterus and intra-

abdominal pressure rise during pregnancy.

Pelvic floor muscle strength is essential to maintain

throughout to prevent the long term risk of pelvic floor

dysfunction. The postpartum pelvic floor muscle mayregain over months and years. Since the pelvic floor

muscle is crucial to be exercised, the exercise regimen

can be started in the antenatal period. When pelvic

floor exercises are incorporated with the co-contraction

of deep abdominal and proper breathing pattern the

effects would be long lasting and can be easily

incorporated into functional activities in daily living.

The statistical analysis done from the posttest

values from the measurements of Perineometer

showed that antenatal motor relearning approach of

diaphragm, deep abdominal and pelvic floor muscles

has significant effect on improving the pelvic floor

muscle strength among postnatal mothers than Kegels

exercises. So it is impulsive that physiotherapist must

include antenatal Motor relearning approach of

diaphragm, deep abdominal and pelvic floor

strengthening exercises as a part of routine antenatal

exercise program.

“There is greater improvement in postpartum

pelvic floor muscle strength in antenatal motor

relearning approach of diaphragm, deep abdominal

and pelvic floor strengthening than kegels exercises.”

ACKNOWLEDGEMENT

The authors are thankful to Principal, Prof. R

.Mahesh., MPT. PSG college of Physiotherapy, Dr.

Seetha Panicker., Professor and Head, Department of

Obstetrics and Gynecology, PSG Hospitals,Coimbatore, Tamilnadu for kindly providing facilities

to carry out this work.

Conflicts of Interest

The pelvic floor muscle strength in this study is

assessed in the immediate postnatal period, which in

the late postnatal period may have natural resolution

of gaining strength. The results might show

improvement in the pelvic floor muscle strength when

the assessment is taken in the long term period

REFERENCES

1. Linda J.O’ Connor, PT Rebecca J. Gourley.

Obstetric and Gynecologic Care in Physical

therapy.2nd ed. USA: Slack Incorporated; 1999.P

252-253.

2. Sundar Rao PSS, Richard. Introduction to

Biostatistics and Research methods. 4th ed. New

Delhi: Prentice Hall of India (P) Ltd; 2006.

3. Beatte carriere. Pelvic floor treatment of

incontinence and other urinary dysfunction in

men and women. In Umpherd DA. Editor.

Neurological Rehabilitation.4th ed. St. Louis:

Mosby; P.1061-1089.

4. Carolyn Kisner, Lynn Allen Colby. Therapeutic

exercise- Foundation and Techniques. 5th ed.

Philadelphia: F A Davies & Company; 2002.

P 681-705.

5. Carrie. M. Hall, Lori Thein Brody. Therapeutic

exercises: Moving towards Function. 2nd ed.

Philadelphia: Lippincott & Williams; 2005.

P 213-232.

6. Dutta. D.C. Text Book of Gynecology. 4thed.




Calcutta, India: New Central Book Agency

Limited; 1998. P105-113.

7. Eilen Brayshaw. Exercise for pregnancy and

childbirth Musculoskeletal problems in

pregnancy and postpartum, Elsevier Sciences

Limited 2003. Page no.33.

8. Hollis Herman, Elaine Wilder. Obstetrics andGynecologic Physical therapy. New York:

Churchill Livingstone; 1998. P108.

9. Hsiu- Chuan Hung et al . An alternative

intervention for urinary incontinence: Retraining

diaphragmatic, deep abdominal and pelvic floor

muscle coordinated function. Manual Therapy.

2010; 15(3): 273-279.

10. Jill Mantle, Jeanette Haslam, Sue Barton.

Physiotherapy in Obstetrics and Gynaecology. 2nd

ed. Elsevier: 2004. P: 93-140.

11. Julia herbert et al. Pregnancy and child birth -theeffects on pelvic floor muscles. Nursing times

.2009; 105: (7), 38–41.

12. Margaret Polden, Jill Mantle. Physiotherapy in

obstetrics and Gynaecology. Jaypee brothers:

1990. P 85-132.

13. Nahid Rahmani and Mohammad A. Mohseni-

Bandpei. Application of perineometer in the

assessment of pelvic floor muscle strength and

endurance: A reliability study. Journal of

bodywork and movement therapies.2011;

15(2):209-14.

14. Oliveria c de et al. Effects of pelvic floor muscle

training during pregnancy. Clinics.2001; 62:

439-446.

15. Sacomori C et al. Pelvic floor muscle strength and

body self-perception among Brazilian pregnant

women. Physiotherapy; 2010: 96 (4); 337–343.

16. Po-chun ko et al, A randomized controlled trial

of antenatal pelvic floor exercises to prevent and

treat urinary incontinence, International

urogynaecology journal. 2011; 22(1): 17-2217. Seung-chul chon et al. Effect of the abdominal

draw in maneuver in strengthening the

transverse abdominal muscles in healthy young

adults. A preliminary, randomized, controlled

study. Physiotherapy. 2010; Vol 96: pp.130-136.

18. Sharif I.M.F Ismail. An audit of NICE guidelines

on antenatal pelvic floor exercises. International

urogynaecology journal. 2009; Vol 20 :

pp.1417-1422.

19. Sharon Kilbreath et al. Strength and Endurance

of the pelvic floor muscles in continent women:An observational study. Physiotherapy.2010; Vol

96: pp.311-316.

20. Sir Morkved et al. Pelvic floor muscle training

during pregnancy and after delivery. Current

women health reviews 2007.

21. Stacy Hosp, “A new approach to the child bearing

year: physical therapy and fitness for pregnancy

and the early postpartum period.” Combined

section meeting, 2003.

22. Ursula M. Peschers, John . L. DeLancey, Levator

ani function before and after childbirth, British

Journal of Obstetrics and Gynaecology.

September 1997: Vol. 104; pp. 1004-1008



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Effectiveness of Antenatal Motor Relearning Approach of Diaphragm, Deep Abdominal and Pelvic Floor Muscles Versus Kegels Exercises on Postpartum Pelvic Floor Muscle Strength