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Objectives: To evaluate the effect of ankle positions on pelvic floor muscles in women. Methods: Multiple databases were searched from inception-July 2017. Study quality was rated using the grading of recommendations, assessment, development, and evaluation system and the ‘threats to validity tool’. Results: Four studies were eligible for inclusion. Meta-analysis revealed significantly greater resting activity of pelvic floor muscles in neutral ankle position (-1.36 [95% CI -2.30, -0.42] p=0.004) and induced 15° dorsiflexion (-1.65 [-2.49, -0.81] p=0.0001) compared to induced 15° plantar flexion. Significantly greater maximal voluntary contraction of pelvic floor was found in dorsiflexion compared to plantar flexion (-2.28 [-3.96, -0.60] p=0.008). Meta-analyses revealed no significant differences between the neutral ankle position and 15° dorsiflexion for either resting activity (0.30 [-0.75, 1.35] p=0.57) or maximal voluntary contraction (0.97 [-0.77, 2.72] p=0.27). Conclusion: Pelvic floor muscle-training for women with urinary incontinence could be performed in standing with ankles in a neutral position or dorsiflexion to facilitate greater maximal pelvic floor muscle contraction. As urethral support requires resting contraction of pelvic floor muscles, decreased resting activity in plantar flexion identified in the meta-analysis indicates that high-heel wearers with urinary incontinence might potentially experience more leakage during exertion in a standing position.
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Disability and Rehabilitation
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Ankle positions potentially facilitating greater
maximal contraction of pelvic floor muscles: a
systematic review and meta-analysis
Priya Kannan, Stanley Winser, Ravindra Goonetilleke & Gladys Cheing
To cite this article: Priya Kannan, Stanley Winser, Ravindra Goonetilleke & Gladys
Cheing (2018): Ankle positions potentially facilitating greater maximal contraction of pelvic
floor muscles: a systematic review and meta-analysis, Disability and Rehabilitation, DOI:
10.1080/09638288.2018.1468934
To link to this article: https://doi.org/10.1080/09638288.2018.1468934
Published online: 07 May 2018.
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RESEARCH ARTICLE
Ankle positions potentially facilitating greater maximal contraction of pelvic floor
muscles: a systematic review and meta-analysis
Priya Kannan
a
, Stanley Winser
a
, Ravindra Goonetilleke
b
and Gladys Cheing
a
a
Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong;
b
Human Performance Laboratory,
Department of Industrial Engineering and Logistics Management, The Hong Kong University of Science and Technology, Kowloon, Hong Kong
ABSTRACT
Objectives: To evaluate the effect of ankle positions on pelvic floor muscles in women.
Methods: Multiple databases were searched from inception-July 2017. Study quality was rated using the
grading of recommendations, assessment, development, and evaluation system and the threats to validity
tool.
Results: Four studies were eligible for inclusion. Meta-analysis revealed significantly greater resting activity
of pelvic floor muscles in neutral ankle position (1.36 (95% CI 2.30, 0.42) p¼0.004) and induced 15
dorsiflexion (1.65 (95% CI 2.49, 0.81) p¼0.0001) compared to induced 15plantar flexion.
Significantly greater maximal voluntary contraction of pelvic floor was found in dorsiflexion compared to
plantar flexion (2.28 (95% CI 3.96, 0.60) p¼0.008). Meta-analyses revealed no significant differences
between the neutral ankle position and 15dorsiflexion for either resting activity (0.30 (95% CI 0.75,
1.35) p¼0.57) or maximal voluntary contraction (0.97 (95% CI 0.77, 2.72) p¼0.27).
Conclusion: Pelvic floor muscle-training for women with urinary incontinence could be performed in
standing with ankles in a neutral position or dorsiflexion to facilitate greater maximal pelvic floor muscle
contraction. As urethral support requires resting contraction of pelvic floor muscles, decreased resting
activity in plantar flexion identified in the meta-analysis indicates that high-heel wearers with urinary
incontinence might potentially experience more leakage during exertion in a standing position.
äIMPLICATIONS FOR REHABILITATION
Pooled analyses revealed that maximal voluntary contraction of pelvic floor muscle is greater in
induced ankle dorsiflexion than induced plantar flexion.
As pelvic floor muscle strengthening involves achieving a greater maximal voluntary contraction, pel-
vic floor muscle training for women with stress urinary incontinence could be performed in standing
either with ankles in a neutral position or dorsiflexion.
Decreased resting activity in plantar flexion identified in the meta-analysis indicates that high-heel
wearers with stress urinary incontinence might potentially experience more leakage during exertion in
a standing position.
Women with stress urinary incontinence should be advised to wear flat shoes instead of high-heels
and should be cautioned about body posture and ankle positions assumed during exercise and
daily activities.
ARTICLE HISTORY
Received 13 December 2017
Revised 20 April 2018
Accepted 20 April 2018
KEYWORDS
Ankle positions; pelvic floor
muscles; stress urinary
incontinence; system-
atic review
Introduction
Urinary incontinence is a common condition in women, with a
prevalence of 8.538% [1]. The majority of women with urinary
incontinence have stress urinary incontinence (SUI) [1]. SUI is
controlled by the bladder neck support and sphincteric closure
systems [1]. The levator ani muscles (key pelvic floor muscle
(PFM)) form a major component of the urethral support system
[1]. The levator ani muscles consist of Type 1 striated muscle
fibers, which maintain the constant muscle tone necessary to
keep the urogenital hiatus closed [1]. In addition, PFMs play an
important role in urethral closure at rest and when the intra-
abdominal pressure increases during exertion (e.g., sneezing or
exercise) [2]. Deconditioning or dysfunction of PFMs commonly
leads to urinary incontinence [1]. Studies have shown that PFM
activity can be influenced by different body positions (e.g., sit-
ting or standing) [3,4] and lumbopelvic posture [5]. Significantly
higher PFM resting activity is found in standing [4,5]; however,
maximal voluntary contraction (MVC) does not differ between
sitting or standing positions [4]. Capson et al. [5] found signifi-
cantly greater PFM resting activity in the hypolordotic posture
compared to hyperlordotic posture. They also found significantly
greater PFM MVC in the normal standing posture compared to
standing with hyper- or hypolordosis [5]. In addition to support-
ing the abdominal and pelvic viscera, PFMs also contribute to
the segmental stability of the lumbar spine and pelvis [69].
Thus, it has been postulated that changes in lumbopelvic pos-
ture (lumbar lordosis and pelvic tilt/inclination) might create
changes in PFM activity [5].
CONTACT Priya Kannan priya.kannan@polyu.edu.hk Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon,
Hong Kong
ß2018 Informa UK Limited, trading as Taylor & Francis Group
DISABILITY AND REHABILITATION
https://doi.org/10.1080/09638288.2018.1468934
Previous studies have found that different ankle positions
(dorsiflexion, neutral, and plantar flexion) alter PFM activity in
women, but with contradictory results [1014]. Some studies
found significantly greater PFM activity in induced ankle plantar
flexion (wedges under heels) compared to ankle neutral and
induced dorsiflexion (placing wedges under toes) [12,14].
However, other studies found greater PFM activity in ankle neutral
and induced dorsiflexion as opposed to induced plantar flexion
[10,13]. As ankle positions can influence resting and MVC PFM, it
is worth identifying the ankle position facilitating greater maximal
contraction to aid PFM training for women with SUI.
Studies of high-heeled gait kinetics report that the shoes force
the ankles into plantar flexion in standing and walking [15,16]. A
weight of biomechanical evidence suggests that high-heeled
shoes create changes in lumbopelvic posture [1723]. Given the
influence of high-heeled shoes on ankle position and the associ-
ation between ankle position and PFM activity, investigating the
effect of high-heeled shoes on PFM activity is necessary.
The objective of this systematic review is: (1) to evaluate the effect of
ankle position on resting and MVC of PFMs in women and (2) to review
the literature regarding the impact of high-heeled shoes on PFM activity
in women.
Findings of this review will inform clinicians as to which ankle
position could be used as an adjunct to PFM training for women
with SUI.
Materials and methods
Study design
This systematic review was developed and reported in accordance
with the preferred reporting items for systematic reviews and
meta-analyses (PRISMA) guidelines [24]. Our review is registered in
the PROSPERO registry (CRD42017072460).
Search strategy
An electronic search was conducted of AMED, CINAHL, EMBASE,
Ovid Medline, PubMed, Web of Science, and Google Scholar from
database inception to July 2017. Reference lists of all included
full-text articles were searched for further eligible articles. No add-
itional searches were conducted. Database specific Medical
Subject Headings (MeSH) and keywords were used to retrieve
studies. As the electronic databases have specific MeSH terms,
each was searched independently. The search strategy for Ovid
Medline is reported in Table 1. One reviewer performed searches
in the electronic databases. Included articles were combined into
one reference library and duplicated articles were removed. Two
reviewers independently performed title, abstract, and full-text
screening. Discrepancies were resolved by discussion between
reviewers. A third reviewer was contacted for unresolved
discrepancies.
Eligibility criteria
Articles were included for review if they met the following inclu-
sion criteria: women of all age ranges; evaluating the effect of
ankle position (i.e., neutral, bare feet, dorsiflexion, and plantar flex-
ion) or high-heeled shoes on PFM activity using surface electro-
myography (EMG), ultrasound, dynamometry, or digital palpation.
Conference abstracts, short communications, and PhD theses were
also included in the review. Conference abstracts and short com-
munications providing mean and standard deviation data were
included for meta-analysis but not for methodological quality
evaluation. Observational and randomized controlled trials (RCTs)
were considered eligible for inclusion in this review. No search
restriction was applied regarding the language of publication.
Authors were contacted for any incomplete data in the
included studies.
Quality assessment and data extraction
Two independent reviewers performed quality assessment of each
included study. Quality assessment of included studies was con-
ducted utilizing two tools: (1) the GRADE tool developed to evalu-
ate the quality of observational studies and RCTs and (2) threats
to validity,which is a generic tool developed to detect threats to
internal validity in observational studies [25].
GRADE profiler 3.6 software was used to rate the evidence
quality. In the GRADE system, observational studies begin as low
quality.Studies can be upgraded if the pooled analyses show a
large effect (þ1 large; þ2 very large) [26]. Study quality was down-
graded for the following reasons:
1. Risk of bias: limitations in observational studies such as failure
to apply eligibility criteria, flaws in the measurement of
exposure and outcomes, and failure to control confounding
factors [27].
2. Inconsistency: statistical heterogeneity expressed by large chi-
squared value (I
2
>50%) [28].
3. Indirectness: use of surrogate outcome measures [29].
4. Imprecision: when the confidence interval does not overlap
or is wide [30].
5. Publication bias: downgraded if studies are industry spon-
sored. If more than 10 studies were available for meta-ana-
lysis, we used a funnel plot [31].
The internal validity of a study is rated using nine items in the
threats to validitytool: selection bias (diagnostic inaccuracy, par-
ticipant representativeness, and sampling); random variation/
chance (sample size); detection bias (validity of assessment tools,
follow-up period similar for cases and controls, and blinding); attri-
tion bias (lost to follow-up); and reporting bias (investigator/fund-
ing bias) [25]. Items are scored as a tick () for no evidence of
bias, cross (X) for evidence of bias, question mark (?) for poor
reporting or uncertain risk of bias, and n/a for not applicable to
research design [25]. According to this quality assessment tool,
Table 1. Search terms and search strategy for Ovid Medline.
Subject areas (Combined with And’”) Search terms used (combined with Or)
High-heels High-heel.mp; high-heeled shoe.mp; positive heel. mp; negative heel.mp; wedge
heel.mp; platform heel.mp; stiletto.mp; positive inclination.mp; negative inclination.mp;
wedges.mp; and shoes/.
Ankle positions Ankle/; Neutral.mp; dorsiflexion.mp; plantar flexion.mp; bare feet.mp; and horizon-
tal standing.mp.
Pelvic floor muscle activity Pelvic floor/; pelvic floor muscle.mp; pelvic floor muscle activity; PFM.mp; resting contrac-
tion.mp; and maximal voluntary contraction.mp.
mp: keyword; /: medical subject heading;
: truncation.
2P. KANNAN ET AL.
the methodological quality of a study is rated as high,
moderate,or low.Studies scoring 70% were considered high,
4069% moderate, and <40% considered low quality, respectively
[25]. The percentages were obtained by dividing the total number
of tics by the total number of validity items used by the tool [25].
Two reviewers independently extracted data from each
included study utilizing a standardized data extraction form.
Discrepancies were resolved by discussion between the two
reviewers and a third reviewer was contacted for any unresolved
discrepancies. Data extracted from the studies included: author
and year, language and country of publication, study design, par-
ticipants, assessment tool, heel height in inches/ankle positions,
and PFM activity data for various ankle positions.
Data analysis
Resting and MVC PFM data were used to obtain a pooled
estimate of the difference between ankle positions using Review
Manager 5.3. A computer-based algorithm was used to
calculate mean and SD from median and interquartile ranges (IQR)
(http://vassarstats.net/median_range.html)[32]. Meta-analyses for
PFM resting activity and MVC were conducted for the following
comparisons: (1) ankle neutral position and plantar flexion, (2)
ankle neutral position and dorsiflexion, and (3) dorsiflexion and
plantar flexion. All studies included for meta-analysis used the
same outcome measure and therefore weighted mean difference
was calculated. A fixed-effect model was used for minimal hetero-
geneity (I
2
<50%) and a random effects model used for maximum
heterogeneity (I
2
>50%) [33].
Results
Flow of studies through the review
The searches identified 25 potentially relevant articles; of which
nine were screened at the abstract stage and seven were eligible
for full-text screening. Of the seven articles, four (three full-text
and one conference abstract) were eligible for inclusion. The flow
of studies through the review is summarized in Figure 1. All three
Figure 1. Flow of studies through the review.
ANKLE POSITIONS AND PELVIC FLOOR MUSCLE ACTIVITY 3
full-text articles and one conference abstract were observational
studies. No RCTs were identified in the search.
Characteristics of individual studies
A summary of the included studies is presented in Table 2.In
total, data from 230 women were included in the meta-analysis.
All included studies were published in English. Two studies were
conducted in Taiwan, one in Egypt, and one in Italy. Of the four
included studies, two [12,14] reported mean and SD, one reported
mean and IQR [11], and one study reported median and IQR [13].
The mean age of women in the included studies ranged from
2672 years. Three of the four studies used EMG with a vaginal
probe and one study used a surface electrode with EMG to evalu-
ate the bioelectrical PFM activity. No study evaluating the
effect of high-heeled shoes on PFM activity was identified in
the searches.
One included study [13] evaluated the effect of eight ankle
positions (active dorsiflexion and plantar flexion, passive ankle
dorsiflexion and plantar flexion using 2.5 cm, and 4.5 cm wooden
blocks under the toes and heels, respectively and active ankle
dorsiflexion and plantar flexion with arms held above the should-
ers) on PFM activity in women without incontinence. One study
[12] evaluated the effect of three ankle positions (neutral ankle
position, passive ankle dorsiflexion, and plantar flexion using an
adjustable platform set at 15under the toes and heels, respect-
ively) on PFM activity in women with SUI. One study [14] eval-
uated the effect of ankle position combined with pelvic tilt
(neutral ankle position with normal pelvic tilt, anterior pelvic tilt
created by ankle dorsiflexion, and posterior pelvic tilt created by
ankle plantar flexion) on PFM activity in women with SUI. One
study [11] of women with SUI evaluated the PFM activity in seven
ankle positions: horizontal standing and standing with ankles in
dorsi- and plantar flexion at 5, 10, and 15, respectively.
Quality
The summary of findings generated by the GRADE profiler soft-
ware is presented in Table 3. The GRADE quality of evidence for
comparisons ranged from lowto moderate.The methodo-
logical quality of included studies is presented in Table 4. Of the
three full-text studies, two were of moderate methodological qual-
ity, and one of low quality. The items, diagnostic inaccuracy, par-
ticipant representativeness, validity of assessment tool, and
reporting bias were reported in all three studies. No reporting
bias was identified in any of the included studies.
Effects of ankle position on PFM activity
Resting activity
The methodological quality of the three studies contributing rest-
ing PFM activity data ranged from low to moderate. The pooled
analysis showed significantly greater resting PFM activity in ankle
neutral position compared to ankle plantar flexion (1.36 (95% CI
2.30, 0.42) p¼0.004; n¼168; Figure 2); the GRADE evidence
for this comparison was low. The meta-analysis revealed signifi-
cantly greater PFM resting activity in ankle dorsiflexion compared
to ankle plantar flexion (1.65 (95% CI 2.49, 0.81) p¼0.0001;
n¼168; Figure 3). The GRADE evidence for this comparison was
also low. There was no significant difference in resting PFM activ-
ity between ankle neutral position and dorsiflexion (0.30 [95% CI
0.75, 1.35] p¼0.57; n¼168; Figure 4). The GRADE evidence was
judged to be moderate for this comparison.
MVC of PFMs
Data pooled from four studies [1114] revealed significantly
greater PFM MVC in ankle dorsiflexion compared to plantar flexion
(2.28 [95% CI 3.96, 0.60] p¼0.008; n¼230); Figure 5).
However, there was no significant MVC difference in ankle neutral
position compared to dorsiflexion (0.97 [95% CI 0.77, 2.72]
p¼0.27; n¼230; Figure 6). The GRADE evidence for both of these
comparisons was moderate and the methodological quality of
studies contributing data for these comparisons ranged from low
to moderate.
Sensitivity analysis
A sensitivity analysis was performed by removing two studies: one
study [11] that provided mean and IQR and one that provided
median and IQR [13]. The sensitivity analysis did not alter the
results obtained for any comparisons of either resting or MVC.
Resting activity: ankle neutral vs. plantar flexion (p¼0.002); dorsi-
flexion vs. plantar flexion (p¼0.003); and ankle neutral vs. dorsi-
flexion (p¼0.95). MVC: dorsiflexion vs. plantar flexion (p¼0.006)
and ankle neutral vs. dorsiflexion (p¼0.26).
Discussion
PFM training is the first line treatment for SUI in women [10].
Training PFMs facilitates an automatic and unconscious contrac-
tion of the PFMs, increasing the urethral closure pressure during
rest and exertion [34]. Identifying the optimal ankle position to
enhance MVC is crucial for training PFMs in women with SUI. As a
result of contradictory evidence, the optimal ankle position for
greater resting and maximal PFM contraction in women is not
known. To date, no systematic review has evaluated the effect of
ankle position on PFM activity in women. The effect of high-
heeled shoes (which align ankles in plantar flexion) on PFM activ-
ity has also not been evaluated. Therefore, we analyzed the effect
of ankle position on PFM activity in women.
The pooled analyses revealed a significantly greater resting
activity for PFMs in neutral ankle position and 15dorsiflexion
compared to 15plantar flexion. The PFMs and endopelvic fascia
work in unison to maintain continence and provide urethral sup-
port [1]. The activity of PFMs at rest ensures that the support
function (urethral support system) is normal [35]. The constant
PFM tone maintains the rigidity of the supportive layer under the
urethra [1]. When the rigidity of the supportive layer is reduced,
there is less resistance to deformation under increased intra-
abdominal pressure. This loss of rigidity increases the possibility of
SUI due to the inefficient closure of the urethral lumen [1]. Based
on the findings herein, we hypothesize that high-heel wearers
with SUI may experience more leakage during exertion in a stand-
ing position due to the decreased stiffness of the supportive
urethral layer. Further investigation is required to confirm this due
to the small sample size, methodological quality, and limited num-
ber of studies included for meta-analysis.
The meta-analysis revealed that 15ankle dorsiflexion facili-
tates greater MVC of PFMs than 15plantar flexion in women
with SUI. There was no significant difference in MVC between the
neutral ankle position and 15dorsiflexion. Conservative manage-
ment of SUI is primarily based on perineal reeducation, which is
used to increase the strength and endurance of the PFMs and stri-
ated urethral sphincter [2]. PFM-strengthening involves achieving
a greater MVC [36]. Based on the results of this review, we sug-
gest that PFM training in women with SUI should be performed
with ankles in a neutral position or 15dorsiflexion. Women with
4P. KANNAN ET AL.
Table 2. Characteristics of included studies.
Author and date
Language and country
of publication Study design Participants Assessment tool Heel height/ankle position
Mean (SD) resting and MVC
of PFMs
Chen et al. [12] English,
Taiwan
Observation Women with SUI
n¼39
Age: 3872 years
Parity: mean 3.2 (range 18)
EMG biofeedback using intra-
vaginal probe with surface
EMG electrodes.
Ankle neutral, standing with
ankles in DF (with platform set
at 15under the toes), and PF
(with adjustable platform set at
15under the heels).
Resting:
AN: 6.9 (3.2).
DF: 6.9 (2.7).
PF: 5.5 (2.1).
MVC:
AN: 15.1 (5.5).
DF: 16.1 (4.8)
PF: 13.9 (5.0).
Cerruto et a.l [11] English,
Italy
Observation Women with SUI
n¼15
Age: 2949 years
Parity: mean and range are not
reported.
EMG biofeedback using surface
EMG electrodes
Ankle neutral, standing with
ankles dorsiflexed, and plantar
flexed at 15.
Resting:
AN: 32 (8.8).
DF: 58 (18.5).
PF: 40 (11.8).
MVC:
AN: 278.5 (225.6).
DF: 233.5 (122.6).
PF: 316 (147.7).
Chen et al. [13] English,
Taiwan
Observation Continent women
n¼31
Age: 2660 years
Parity: mean and range are not
reported.
EMG biofeedback using intra-
vaginal probe with surface
EMG electrodes.
Ankle neutral, standing with
ankles in DF (with wooden
blocks of 2.5 cm under toes),
and PF (with wooden blocks of
2.5 cm under heels).
MVC: AN: 16.7 (7.637.5).
DF: 18.0 (7.837.6).
PF: 16.4 (5.840.9).
El-Shamy et al. [14] English,
Egypt
Observation Women with SUI
n¼30
Age: 4050 years
Parity: mean and range are not
reported.
Urodynamic device (EMG)
using intravaginal probe
with surface electrodes.
Ankle neutral with normal pelvic
tilt, standing with anterior pel-
vic tilt and ankles in DF (with
an adjustable platform set at
15under the toes), and stand-
ing with posterior pelvic tilt
and ankles in PF (with an
adjustable platform set at 15
under the heels).
Resting:
AN: 8.9 (3.8)
DF: 9.0 (3.2)
PF: 7.2 (2.0)
MVC:
AN: 19.7 (6.6).
DF: 20.9 (5.8).
PF: 18.0 (6.0).
AN: ankle neutral position; DF: dorsiflexion; EMG: electomyography; MVC: maximal voluntary contraction; PF: plantar flexion; SUI: stress urinary incontinence.
ANKLE POSITIONS AND PELVIC FLOOR MUSCLE ACTIVITY 5
SUI could be discouraged from wearing high-heeled shoes due to
the effect of ankle plantar flexion on MVC.
The proposed mechanism of how ankle positions might affect
PFM activity is related to the anterior and posterior pelvic tilts
induced by dorsiflexion and plantar flexion, respectively [5,12,14].
Anterior pelvic tilt created by dorsiflexion is postulated to increase
the pelvic outlet, move ischial tuberosities apart, and the sacrum
and coccyx in an anterior and inferior direction, resulting in the
closure of the sub-urethral vaginal wall, urethra, and bladder neck,
and elevating the urethral support [12]. In addition, dorsiflexion
induced changes at the pelvis, sacrum, and coccyx causes the
attachments of the pubococcygeus muscle move closer, resulting
in a shortening of the muscle fibers. These distortions are thought
to increase the contractility of the PFM muscles [4,14].
Various methods such as surface perineometry, digital palpa-
tion, ultrasound, magnetic resonance imaging, and EMG have
been used to record PFM activity. Of these, digital palpation and
perineometry are regarded as the gold standardsfor the assess-
ment of PFM contraction [37,38]. However, digital palpation has
the disadvantages of subjective bias and low repeatability [37,39],
while perineometry is limited by interference from intra-abdominal
pressure [37,40]. Despite limitations in detection and electrical
noise that affects the signal, surface EMG is one of the modalities
used to investigate PFM function in real time [4,41]. All of the
studies included herein used surface EMG to measure PFM activ-
ity. Three of the four included studies used surface EMG with a
vaginal probe and one study used only surface electrodes. It is
worth noting that PFM EMG via vaginal probe has high intra-rater
Table 3. Summary of findings (GRADE).
Resting PFM activity
Illustrative comparative risks(95% CI)
Corresponding risk
Outcomes
Assumed risk
Plantar flexion
Resting PFM activity:
ankle neutral
Relative effect
(95% CI)
Number of participants
(studies)
Quality of the evidence
(GRADE) Comments
Resting PFM activity:
neutral vs.
plantar flexion
The mean resting PFM activity:
neutral vs. plantar flexion in
the intervention groups was
1.51 lower
(2.460.57 lower)
138
(2 studies)
丣丣€€
low
ac
Resting PFM activity:
dorsiflexion vs.
plantar flexion
The mean resting PFM activity:
dorsiflexion vs. plantar flex-
ion in the intervention
groups was
1.55 lower
(2.40.71 lower)
138
(2 studies)
丣丣€€
low
ac
Resting PFM activity:
ankle neutral vs.
dorsiflexion
The mean resting PFM activity:
ankle neutral vs. dorsiflexion
in the intervention groups
was
0.04 higher
(1.02 lower1.09 higher)
138
(2 studies)
丣丣丣
moderate
a,b,d
a
Eligibility criteria specified; adequate follow-up (therefore not downgraded).
b
I
2
¼0% (therefore not downgraded).
c
Wide CI (therefore downgraded).
d
Narrow CI (therefore not downgraded).
Maximal voluntary contraction of PFMs
Illustrative comparative risks(95% CI)
Assumed risk Corresponding risk Relative effect No of Participants Quality of the evidence
Outcomes Plantar flexion MVC of PFMs: dorsiflexion (95% CI) (studies) (GRADE) Comments
MVC of PFMs: dorsiflex-
ion vs. plan-
tar flexion
The mean MVC of PFMs: dorsi-
flexion vs. plantar flexion in
the intervention groups was
2.28 lower
(3.90.60 lower)
230
(4 studies)
丣丣丣
moderate
ac
MVC of PFMs: ankle
neutral vs.
dorsiflexion
The mean MVC of PFMs: ankle
neutral vs. dorsiflexion in
the intervention groups was
0.97 higher
(0.77 lower 2.72 higher)
230
(4 studies)
丣丣丣
moderate
ac
The basis for the assumed risk (e.g., the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval
(CI)) is based on the assumed risk in the comparison group, and the relative effect of the intervention (and its 95% CI).
GRADE Working Group grades of evidence
High quality: further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: we are very uncertain about the estimate.
a
Eligibility criteria specified; adequate follow-up (therefore not downgraded).
b
I
2
¼0% (therefore not downgraded).
c
Wide CI (therefore downgraded).
CI: confidence interval; MVC: maximal voluntary contraction; PFM: pelvic floor muscle.
6P. KANNAN ET AL.
Figure 2. Resting activity of pelvic floor muscle: ankle neutral vs. plantar flexion.
Figure 4. Resting activity of pelvic floor muscle: ankle neutral vs. dorsiflexion.
Table 4. Methodological quality of included studies.
Threats to validity Chen et al. [12] Chen et al. [13] El-Shamy et al. [14]
Selection bias (diagnostic inaccuracy)  
Selection bias (participant representativeness)  
Selection bias (sampling) X X X
Random variation/chance (sample size) X X X
Detection bias (validity of assessment tool)  
Detection bias (follow-up) n/a n/a n/a
Detection bias (blinding) n/a n/a n/a
Attrition bias (loss to follow-up)  ?
Reporting bias (investigator or funding bias)  
Quality rating Moderate (55%) Moderate (55%) Low (44%)
: no evidence of bias; X: evidence of bias; ?: poor reporting or uncertain risk of bias; n/a: not applicable to research design.
Figure 3. Resting activity of pelvic floor muscles: dorsiflexion vs. plantar flexion.
Figure 5. Maximal voluntary contraction of pelvic floor muscle: ankle dorsiflexion vs. plantar flexion.
ANKLE POSITIONS AND PELVIC FLOOR MUSCLE ACTIVITY 7
reliability (Intraclass Correlation Coefficient (ICC) 0.780.99) for
resting and MVC of PFMs and re-test reliability (ICC 0.380.96) for
MVC of PFMs in women [42].
Strengths and limitations
This study is the first systematic review and meta-analysis evaluat-
ing the effect of ankle position on PFM activity in women.
Rigorous screening procedures were carried out to identify poten-
tially relevant articles. In addition, the gray literature (unpublished
studies such as abstract proceedings) was searched to eliminate
publication bias. Our systematic review does have some limita-
tions which should be considered when interpreting the findings.
Only four studies were included for the review and the meta-anal-
yses were conducted among 34 studies, therefore these results
need to be considered with caution. Despite the comprehensive
search strategy and rigorous procedures carried out to minimize
potential biases and ensure high methodological quality for this
review, synthesis of the evidence proved difficult. The GRADE and
methodological quality of individual studies ranged from low to
moderate and studies included in this review were of small size or
inadequately powered.
Implications for clinical practice
Integration of the SUI control system
Women with SUI are required to strengthen their PFMs and to
know when to contract them to prevent urinary leakage [1]. It has
been shown that women with SUI could eliminate urinary leakage
by simply learning to time a PFM contraction to occur during a
cough or sneeze [1,43,44]. Thus, teaching proper PFM timing is
crucial [1]. Given that the neutral ankle position could facilitate a
greater maximal PFM contraction than plantar flexion, women
with SUI should be advised to wear flat shoes instead of high-
heels. Due to the effect of gravity and pressure on the musculo-
fascial structures near the pelvic organs, it is common for urine
leaks to occur in standing [4]. Thus, women with SUI should be
cautioned about body posture [4] and ankle positions assumed
during exercise and daily activities.
There is some preliminary evidence from four studies of low-
moderate GRADE quality that PFM MVC is significantly greater in
induced ankle dorsiflexion than induced plantar flexion. The meta-
analysis showed no significant differences between the neutral
ankle position and 15dorsiflexion for either resting activity or
MVC. These findings suggest that PFM training for women with
SUI should be performed in standing either with ankles in a neu-
tral position or dorsiflexion (with wedges under the toes) to
enhance the MVC of PFMs.
Acknowledgements
We would like to thank Ms. Nga Ying Chan for her assistance with
the searches.
Disclosure statement
No potential conflict of interest was reported by the authors.
References
[1] Ashton-Miller DH, John OL, Delancey J. The functional anat-
omy of the female pelvic floor and stress continence con-
trol system. Scand J Urol Nephrol. 2001;35:17.
[2] Dompeyre P, Fritel X, Fauconnier A, et al. [Pelvic floor
muscle contraction and maximum urethral closure pres-
sure]. Prog Urol. 2015;25:200205. French.
[3] Sapsford RR, Richardson CA, Stanton WR. Sitting posture
affects pelvic floor muscle activity in parous women: an
observational study. Aust J Physiother. 2006;52:219222.
[4] Chmielewska D, Stania M, Sobota G, et al. Impact of differ-
ent body positions on bioelectrical activity of the pelvic
floor muscles in nulliparous continent women. BioMed Res
Int. 2015;2015:905897.
[5] Capson AC, Nashed J, McLean L. The role of lumbopelvic
posture in pelvic floor muscle activation in continent
women. J Electromyogr Kinesiol. 2011;21:166177.
[6] Bruno P. The use of stabilization exercisesto affect neuro-
muscular control in the lumbopelvic region: a narrative
review.J Can Chiropr Assoc. 2014;58:119.
[7] Lee M, Song C, Jo Y, et al. The effects of core muscle
release technique on lumbar spine deformation and low
back pain. J Phys Ther Sci. 2015;27:15191522.
[8] Kweon M, Hong S, Jang GU, et al. The neural control of spi-
nal stability muscles during different respiratory patterns.
J Phys Ther Sci. 2013;25:14211424.
[9] Hodges P, Sapsford R, Pengel L. Postural and respiratory
functions of the pelvic floor muscles. Neurourol Urodyn.
2007;26:362371.
[10] Cerroto M, Vedovi E, Rossi S, et al. The effect of ankle
inclination in supine and standing position on the electro-
myigraphic activity of abdominal and pelvic floor muscles
in women with and without stress urinary incontinence:
preliminary results from a pilot study. Eur Urol. 2008;7:145.
[11] Cerruto MA, Vedovi E, Dalla Riva S, et al. The effect of ankle
inclination in upright position on the electromyigraphic
activity of pelvic floor muscles in women with stress urinary
incontinence. Eur Urol. 2007;6:102.
[12] Chen CH, Huang MH, Chen TW, et al. Relationship between
ankle position and pelvic floor muscle activity in female
stress urinary incontinence. Urology. 2005;66:288292.
[13] Chen HL, Lin YC, Chien WJ, et al. The effect of ankle pos-
ition on pelvic floor muscle contraction activity in women.
J Urol. 2009;181:12171223.
[14] El-Shamy FF, Moharm AA. Effect of pelvic postural changes
on pelvic floor muscle activity in women with urinary stress
incontinence. Bulletin of Faculty of Physical Therapy.
2013;18.
Figure 6. Maximal voluntary contraction of pelvic floor muscle: ankle neutral position vs. dorsiflexion.
8P. KANNAN ET AL.
[15] Ebbeling CJ, Hamill J, Crussemeyer JA. Lower extremity
mechanics and energy cost of walking in high-heeled
shoes. J Orthop Sports Phys Ther. 1994;19:190196.
[16] Esenyel M, Walsh K, Walden JG, et al. Kinetics of high-
heeled gait. J Am Podiatr Med Assoc. 2003;93:2732.
[17] de Oliveira Pezzan PA, Jo~
ao SMA, Ribeiro AP, et al. Postural
assessment of lumbar lordosis and pelvic alignment angles
in adolescent users and nonusers of high-heeled shoes.
J Manipulative Physiol Ther. 2011;34:614621.
[18] Nasser J, Mello S,
Avila A, editors. An
alise do impulso em
calc¸ados femininos em diferentes alturas de salto. Anais do
VII Congresso Brasileiro de Biomec^
anica[Analysis of the
impulse in women's shoes at different heights. Proceedings
of the VII Brazilian Congress of Biomechanics]; 1999.
Portugese.
[19] Snow RE, Williams KR. High heeled shoes: their effect on
center of mass position, posture, three-dimensional kine-
matics, rearfoot motion, and ground reaction forces. Arch
Phys Med Rehabil. 1994;75:568576.
[20] Bendix T, SØrensen SS, Klausen K. Lumbar curve, trunk
muscles, and line of gravity with different heel heights.
Spine. 1984;9:223.
[21] Opila KA, Wagner SS, Schiowitz S, et al. Postural alignment
in barefoot and high-heeled stance. Spine. 1988;13:
542547.
[22] Opila-Correia K. Kinematics of high-heeled gait. Arch Phys
Med Rehabil. 1990;71:304309.
[23] Russell BS, Muhlenkamp KA, Hoiriis KT, et al.
Measurement of lumbar lordosis in static standing pos-
ture with and without high-heeled shoes. J Chiropr Med.
2012;11:145153.
[24] Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA state-
ment for reporting systematic reviews and meta-analyses of
studies that evaluate health care interventions: explanation
and elaboration. PLoS Med. 2009;6:e1000100.
[25] Daley DJ, Myint PK, Gray RJ, et al. Systematic review on
factors associated with medication non-adherence in
Parkinson's disease. Parkinsonism Relat Disord. 2012;18:
10531061.
[26] Guyatt G, Oxman A, Vist G, et al. GRADE: an emerging con-
sensus on rating quality of evidence and strength of rec-
ommendations. BMJ. 2008;336:924926.
[27] Guyatt GH, Oxman AD, Vist G, et al. GRADE guidelines: 4.
Rating the quality of evidence-study limitations (risk of
bias)). J Clin Epidemiol. 2011;64:407415.
[28] Guyatt GH, Oxman AD, Kunz R, et al. GRADE guidelines: 7.
Rating the quality of evidence-inconsistency. J Clin
Epidemiol. 2011;64:12941302.
[29] Guyatt GH, Oxman AD, Kunz R, et al. GRADE guidelines: 8.
Rating the quality of evidence-indirectness. J Clin
Epidemiol. 2011;64:13031310.
[30] Guyatt GH, Oxman AD, Kunz R, et al. GRADE guidelines 6.
Rating the quality of evidence-imprecision. J Clin
Epidemiol. 2011;64:12831293.
[31] Guyatt GH, Oxman AD, Montori V, et al. GRADE guidelines:
5. Rating the quality of evidence-publication bias. J Clin
Epidemiol. 2011;64:12771282.
[32] Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and
variance from the median, range, and the size of a sample.
BMC Med Res Methodol. 2005;5:13.
[33] Borenstein M, Hedges LV, Higgins J, et al. A basic introduc-
tion to fixed-effect and random-effects models for meta-
analysis. Res Synth Method. 2010;1:97111.
[34] Zubieta M, Carr RL, Drake MJ, et al. Influence of voluntary
pelvic floor muscle contraction and pelvic floor muscle
training on urethral closure pressures: a systematic litera-
ture review. Int Urogynecol J. 2016;27:687696.
[35] Messelink B, Benson T, Berghmans B, et al. Standardization
of terminology of pelvic floor muscle function and dysfunc-
tion: report from the pelvic floor clinical assessment group
of the International Continence Society. Neurourol Urodyn.
2005;24:374.
[36] Halski T, Słupska L, Dymarek R, et al. Evaluation of bioelec-
trical activity of pelvic floor muscles and synergistic muscles
depending on orientation of pelvis in menopausal women
with symptoms of stress urinary incontinence: a preliminary
observational study. BioMed Res Int. 2014;2014:274938.
[37] Yang SH, Huang WC, Yang SY, et al. Validation of new
ultrasound parameters for quantifying pelvic floor muscle
contraction. Ultrasound Obstet Gynecol. 2009;33:465471.
[38] Isherwood P, Rane A. Comparative assessment of pelvic
floor strength using a perineometer and digital examin-
ation. BJOG. 2000;107:10071011.
[39] Bø K, Finckenhagen HB. Vaginal palpation of pelvic floor
muscle strength: Inter-test reproducibility and comparison
between palpation and vaginal squeeze pressure. Acta
Obstet Gynecol Scand. 2001;80:883887.
[40] Peschers U, Gingelmaier A, Jundt K, et al. Evaluation of pel-
vic floor muscle strength using four different techniques.
Int Urogynecol J. 2001;12:2730.
[41] Bø K. Urinary incontinence, pelvic floor dysfunction, exer-
cise and sport. Sports Med. 2004;34:451464.
[42] Koenig I, Luginbuehl H, Radlinger L. Reliability of pelvic
floor muscle electromyography tested on healthy women
and women with pelvic floor muscle dysfunction. Ann Phys
Rehabil Med. 2017;60:382386.
[43] Miller JM, Ashton-Miller JA, DeLancey JO. Quantification of
cough-related urine loss using the paper towel test. Obstet
Gynecol. 1998;91:705709.
[44] Miller JM, Ashton-Miller JA, DeLancey JO. A pelvic muscle
precontraction can reduce cough-related urine loss in
selected women with mild SUI. J Am Geriatr Soc. 1998;
46:870874.
ANKLE POSITIONS AND PELVIC FLOOR MUSCLE ACTIVITY 9
... Due to the potential consequences of slips and falls, it is recommended that the best heel height for the maintenance of balance is from 3 to 5 cm (12)(13)(14), which is a comfortable height with a good impact on women's appearance. In addition, wearing high-heeled shoes is found to have an impact on the rotational motion of the ankle complex during walking (15), and different ankle positions can alter PFM activity (16). The association between wearing high heels and pelvic floor function has not been fully clarified. ...
... However, wearing high-heeled shoes with an excessive focus on design or fashion may increase the risk of falls and result in various musculoskeletal disorders and deformities (18,19). In addition, wearing high-heeled shoes influences the rotational motion of the ankle complex during walking (15), and the ankle position is found to be related to the pelvis inclination and PFM activation (16). Whether there is an association between wearing high heels and PFM activity has not been fully investigated. ...
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Background: Wearing high-heeled shoes is a common phenomenon among women. However, the association between wearing high heels and pelvic floor function is largely unknown. Our aim was to evaluate the effects of wearing different height shoes on pelvic floor function and to analyze the influencing factors. Methods: This was a population-based, cross-sectional study performed in general hospitals with a pelvic floor subspecialty in some cities of China. All participants completed a Urogenital Distress Inventory (UDI-6) questionnaire that consisted of demographic data, information about wearing shoes, and information about pelvic floor function (UDI-6). One-way ANOVA was carried out to compare the differences among 4 groups according to the heel height (<3, 3-5, 5-7, and >7 cm groups). Multivariate logistic regression was performed to identify the factors influencing the effect of wearing 3-5 cm high-heeled shoes on pelvic floor function. Results: In total, 1,263 participants finished the questionnaire and full data were collected. The 4 groups were comparable for clinical data, and participants who wore 3-5 cm high-heeled shoes had the lowest UDI-6 scores. Multivariate analysis revealed that the number of hours (≥8 h) wearing high heels per day and the thickness diameter (≥3 cm) of the heel were important factors affecting the protective effect of wearing 3-5 cm high-heeled shoes on pelvic floor function. Conclusions: Wearing heeled shoes with a 3-5 cm heel height and ≥3 cm thickness for a long period of time is good for the pelvic floor function of women.
... Also, protracted shoulder and forward head posture in patients with chronic pelvic pain have also been reported (14,16). However, there are controversial studies that did not find any significant correlation between the postural variables and PFDs (17)(18)(19). Investigation of the relationship between postural changes and PFDs can improve the assessment and treatment protocols in patients with PFDs. Although these changes may not be the primary cause of PFDs, they can lead to increasing pain and symptoms in these patients (9). ...
... There was one controversial study (2016) which reported no significant thoracic and lumbar curvature changes in patients with PFDs using spinal x-rays. But there was no time limitation and a specific position for taking X-rays so it could be the point of these controversial results (17). On the other hand, studies have shown that an increased rate of depression can be another reason for the kyphotic posture and rounded shoulder in PFD patients (26). ...
... Also, protracted shoulder and forward head posture in patients with chronic pelvic pain have also been reported (14,16). However, there are controversial studies that did not find any significant correlation between the postural variables and PFDs (17)(18)(19). Investigation of the relationship between postural changes and PFDs can improve the assessment and treatment protocols in patients with PFDs. Although these changes may not be the primary cause of PFDs, they can lead to increasing pain and symptoms in these patients (9). ...
... There was one controversial study (2016) which reported no significant thoracic and lumbar curvature changes in patients with PFDs using spinal x-rays. But there was no time limitation and a specific position for taking X-rays so it could be the point of these controversial results (17). On the other hand, studies have shown that an increased rate of depression can be another reason for the kyphotic posture and rounded shoulder in PFD patients (26). ...
... This weakens the core muscle over time, which normally induces low back pain (LBP). Researchers discovered that posterior pelvic tilt enables the coccyx to rotate backwards, which elongates the pelvic floor and activates pelvic floor muscle (PFM) [2]. Postural control muscles, such as transverse abdominis, multifidus muscle, and deep muscles of the spine, all work synchronously with PFM [3]. ...
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... As urethral support requires resting pelvic floor muscle activity, decreased resting contraction in plantar flexion indicates that women wearing high-heeled shoes with urinary incontinence might experience more leakage during exertion (e.g., sneezing or exercise) in a standing position. [5]. Pathogenetically, urinary incontinence is not a separate entity, but a symptom that occurs in the case of disorders of the lower urinary tract and the nervous system [6]. ...
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High-heeled shoes (so-called stilettos) are an important element of women’s wardrobe. Unfortunately, wearing high heels forces the ankle joint into plantar flexion. The daily positioning of the foot in plantar flexion can lead to many abnormalities in the human body. This position is unnatural for the organism from the point of biomechanics. The aim of the study was to present the effect of wearing high-heeled shoes (plantar position of the foot) on the activity of the pelvic floor muscles and the associated negative effects, such as urinary incontinence. The authors on the basis of the research showed that the activity of the pelvic floor muscles is the lowest in the dorsiflexion position of the ankle joint. A weakening of the pelvic floor can be associated with urinary incontinence and thus a deterioration of the quality of life.
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... The aim of the PFM exercises is improvement of posture in addition to strengthening, relaxing, and stretching the muscles that affect the activity of the PFM. Also, improvement of PFM control with respect to the functional goals (identification, strengthening, endurance, tone, timing, and relaxation) in addition to isolated contraction of these muscles in cooperation with synergic muscles and coordination between the PFM and breathing muscles, all are other treatment purposes of the exercises [65][66][67]. ...
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Objective: To identify the most frequently used protocols for analyzing the myoelectric activity of the pelvic floor muscles during surface electromyography in women aged 18 years or older. Introduction: Surface electromyography is normally used in assessment and treatment for research purposes when it is intended to quantitatively measure the electrophysiological behavior of the neuromuscular system. However, although there are internationally standardized, non-invasive assessment protocols for most muscle groups, there is no consensus for pelvic floor muscles, which makes it difficult to standardize in scientific research and clinical applicability. Inclusion criteria: Studies that explore registration protocols and filtering parameters of surface electromyographic signals in women aged over 18 years old with or without pelvic floor dysfunction will be considered. Studies encompassing either electromyographic biofeedback as treatment resource only or electroneuromyography (needle electrode) will be excluded. Methods: Primary studies published in the last 10 years in MEDLINE, Embase, Scopus, Web of Science, CINAHL, and Cochrane Central databases will be included. The search will encompass descriptors registered in MeSH. The identified articles will be assessed for eligibility by two independent reviewers in three stages: evaluation by title, abstract, and full text. If there is any disagreement, a third reviewer will be consulted. Data will be extracted and organized in standardized spreadsheets. The results will be assigned to categories in order to facilitate the organization of a protocol with the most used parameters for non-invasive assessment of myoelectric activity of pelvic floor muscles.
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We examined pelvic floor muscles (PFM) activity (%MVC) in twenty nulliparous women by body position during exercise as well as the activation of abdominal muscles and the gluteus maximus during voluntary contractions of the PFMs. Pelvic floor muscle activity was recorded using a vaginal probe during five experimental trials. Activation of transversus abdominis, rectus abdominis, and gluteus maximus during voluntary PFM contractions was also assessed. Significant differences in mean normalized amplitudes of baseline PFM activity were revealed between standing and lying () and lying and ball-sitting positions (). Average peak, average time before peak, and average time after peak did not differ significantly during the voluntary contractions of the PFMs. Baseline PFM activity seemed to depend on the body position and was the highest in standing. Pelvic floor muscles activity during voluntary contractions did not differ by position in continent women. Statistically significant differences between the supine lying and sitting positions were only observed during a sustained 60-second contraction of the PFMs.
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Objectives: Electromyography (EMG) is a well-established method to quantify the relative pelvic floor muscle (PFM) activity. PFM EMG has shown good reliability in healthy women. However, its reliability has not been tested in women with PFM dysfunction. The reliability of EMG analysis methods concerning EMG normalization needs to be determined to assess specific therapeutic interventions. Therefore, the aim of this study was to investigate the intra-session reliability of PFM EMG variables by using 3 different analysis methods in women with PFM dysfunction. Methods: EMG data analysis involved women who were healthy, had weak PFM and had stress urinary incontinence (SUI). We evaluated the reliability of EMG during rest and maximum voluntary contraction and compared muscle activity onset by visual determination and by calculation. All variables were checked for normality (Shapiro-Wilk). Descriptive statistics (mean, SD), systematic error within repeated measures (Wilcoxon) and reliability indexes were tested and presented descriptively (intraclass correlation coefficient [ICC], standard error of measurement [SEM], SEM%, minimal difference [MD], MD%). Results: For 20 women who were healthy, 17 with weak PFM and 50 with SUI, ICC values were high for all variables (0.780-0.994), and SEM and MD values were relatively high (SEM%: 7.5-15.7; MD%: 21.0-43.8). Conclusion: We need reliable methods to analyse clinical intervention studies. PFM EMG variables had high ICCs, but relatively high SEM and MD values modified the reliability. All EMG analysis methods were comparable in healthy women, but only the visual-onset determination was dependable in women with PFM dysfunction.
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Introduction and hypothesis: Stress urinary incontinence (SUI) is managed with pelvic floor muscle training (PFMT), but the mechanism of treatment action is unclear. Resting maximal urethral closure pressure (MUCP) is lower in women with SUI, but it is unknown whether PFMT can alter resting MUCP. This systematic review evaluated whether voluntary pelvic floor muscle (PFM) contraction increases MUCP above its resting value (augmented MUCP) and the effect of PFMT on resting and augmented MUCP. Methods: Experimental and effect studies were identified using PubMed and PEDro. The PEDro scale was used to assess internal validity of interventional studies. Results: We identified 21 studies investigating the influence of voluntary PFM contraction in women. Comparison was hindered by varying demographics, antecedent history, reporting of confirmed correct PFM contraction, and urethral pressure profilometry (UPP) techniques. Mean incremental increase in MUCP during PFM contraction in healthy women was 8-47.3 cm H2O; in women with urinary incontinence (UI), it was 6-24 cm H2O. Nine trials reporting MUCP as an outcome of PFMT were found. Wide variation in PFMT regimes affected the findings. Two studies found significant improvement in MUCP of 5-18 cm H20. Seven studies assessed augmentation of MUCP with PFM contraction; mean increase was -0.1 to 25 cm H20. Conclusions: There is no definitive evidence that PFMT increases resting MUCP as its mechanism of action in managing SUI. The degree to which a voluntary PFM contraction augments MUCP varies widely. There was evidence to suggest PFMT increases augmented MUCP. Drawing firm conclusions was hampered by study methodologies.
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