Starting pelvic floor muscle training with the use of a manometer device when these muscles are very weak is controversial.
It is common practice to make use of electrical stimulation in women whose pelvic floor muscle strength is graded at the level of 1 according to the Oxford Scale. They proceed with training without electrical stimulation only when they reach grade 2 on the Oxford Scale.
During a PFM contraction, the groin moves — and so does the probe [Bump et al., 1996]. But it does not happen when the contraction is really weak as a result of poor muscle strength. Therefore, it is debatable whether patients with weak PFM should use a manometer device when exercising.
Maximum voluntary contraction (MVC) is analyzed and determined on the basis of muscle strength tests. There are many women exercising with PelviFly so it’s natural to see both those with stronger muscles and those whose muscles are very weak among them. An MVC level below 10mmHg is a red flag – such strength is comparable to grade 1 on the Oxford Scale. In such a situation, in order to make sure that training is safe, we always recommend making an in-person appointment with the physiotherapist in the treatment room.
It happens that patients are advised to suspend their training for a month or two, until the strength of their pelvic floor muscles increases thanks to electrical stimulation. There are also cases when specialists recommend starting training right away with the aid of biofeedback and vibration training with the use of our solution.
One of such patients started their training 2 months ago under the supervision of Wioleta Ostiak-Tomaszewska, PhD., a physiotherapist and osteopathist from Poznań (Poland) with many years of experience in pelvic floor physiotherapy and osteopathy in gynecology and obstetrics.
Diagnostics and training qualification
A 32-year-old patient consulted a physiotherapist at the beginning of April, when she was 2 months after natural delivery with episiotomy. Because of the pandemic, the first consultation took place online. The main objective was to assess the diastasis of the rectus abdominis muscle. The patient reported a stretch of 1.5 finger along the entire length.
The consultation included a briefing on how to manage one’s instrumental activities of daily living and learning proper breathing techniques. It also involved exercising the patient’s pelvic floor muscles and a set of exercises aimed at the reported DRAM. After the first series of exercises, the patient reported stress urinary incontinence (SUI).
At the beginning of June, she had another appointment – in person. During lifting and carrying objects, she still experienced SUI (stress urinary incontinence). A per vaginum examination revealed muscle weakness and fatigue. Yet, the patient was able to activate her muscles when used together with the transverse abdominal muscle. The DRAM remained only at the umbilicus level, measuring 1 finger only. The physiotherapist recommended exercising with PelviFly. The patient took advantage also of an episiotomy wound treatment after she reported the wound was painful.
Starting exercising with PelviFly
In mid-June, the patient started exercising with PelviFly under the supervision of Wioleta Ostiak-Tomaszewska, PhD. The earliest muscle tests with the use of the PelviFly device and application were performed by the patient at home. Her results were quite alarming. The MVC level was below 1mmHg. The situation needed to be verified so she was asked to come to the treatment room in person.
During the appointment, she performed another test and managed to reach an MVC of 3.46mmHg. The result was much better than before, but the MVC was still at grade 1 on the Oxford Scale. She had some serious problems with muscle endurance and contraction control as well. During the test there appeared a problem with excessive tension in adductor muscles and in the rectus abdominis muscle. The recommendation was to focus on relaxing pelvic floor muscles.
The ability to activate pelvic floor muscles and the transverse abdominal muscle was re-examined by palpation:
- transabdominal examination – clear proper activation of the transverse abdominal muscle
- pelvic floor muscle examination through the perineal body – slight but noticeable activation of pelvic floor muscles, but accompanied by a tension in the buttocks and the levator ani
- per vaginum examination – no sense of muscle contraction.
We asked the patient about her impressions of her first training sessions:
“My earliest experience with the device was quite a mystery to me. It was difficult to activate muscles you had never used consciously before. The visit to the physiotherapist was certainly helpful. I got many tips and suggestions on how to locate certain muscles and how to exercise with the device. I find visualizations, which help activate the right muscles, really important. That’s why the app and the “games” featured in it work like a charm. And here’s an excerpt from a message I sent to my coach: I wanted to tell you last time that my experience with this exercise set has taught me to be gentle to myself, to accept that the effects don’t come overnight, that even if you give it everything you’ve got and if you do it the right way (hope so!), you still need to wait some time for the effects, and that’s perfectly fine :)”
The therapy plan
Wioleta Ostiak-Tomaszewska, PhD. planned a hybrid therapy – supervised home exercise with PelviFly combined with regular check-up appointments in the treatment room. The training plan in the initial period of therapy was based on warm-ups during which muscles are activated to the level of 50% of their maximum strength. Other PelviFly exercises would have been too much of a challenge.
Vibrotherapy was incorporated in the plan as well. At first, biofeedback vibration (0-100Hz) was applied, with its intensity increasing with the increase in the contraction force – which made it easier to perform contractions. However, given the low contraction force, the vibration was not felt sufficiently. This was the reason to apply fixed vibration at the level of 20Hz and 50Hz. Initially, vibration was a distracting factor, but eventually the training plan incorporated 50Hz vibration, which worked best for the patient.
To make it possible to monitor all changes on an ongoing basis, muscle tests were performed every week.
The patient was exercising regularly.
“A big plus is the possibility to exercise at any time of day. Having access to a coach is something I find very helpful. I feel that without this element I would find it hard to activate my muscles the right way. The ongoing biofeedback is also highly valuable. I know what to improve and what I’ve managed to learn to some extent.”
Changes after a month of exercise
A significant improvement could be seen already after the first month of exercise – what improved was not only the contraction and muscle relaxation control but also the muscle endurance. The muscle strength increased two times compared to the first test performed in the treatment room, amounting to 6.46mmHg.
The next appointment in the treatment room showed that the patient’s pelvic floor muscles were still very weak, but their activation at 20% and the 100% of MVC was clearly noticeable and felt. The patient managed to grasp the idea of co-activation of the transverse abdominal muscle really well. She reported that the appearance of her stomach changed much for the better – it got leaner. During the appointment, the patient was subject to further treatment of her episiotomy wound, which appeared to be much less painful.
“Exercising with PelviFly produces noticeable effects really quickly. They are even more noticeable if we incorporate exercise sets recommended by a physiotherapist into the PelviFly-based training.”
Muscle test performed after 2 months
We saw another improvement in the muscle test after 2 months of exercise. The maximum contraction force increased up to 10.26mmHg, and the patient managed to arrive at grade 2 on the Oxford Scale.
Muscle endurance, which we assess at stage 4 of the test, improved as well. One of the tasks the patient was given in order to let us assess the endurance of her muscles was to maintain a contraction at 20% of MVC for 20 seconds. She failed to maintain the contraction at the set level in the initial muscle tests. But after the first month, her result was 4.50/20 seconds. After the second month, she managed to maintain the contraction correctly for 14.88/20 seconds.
The control of short 1-second contractions also improved. This could be seen in particular at stage 2 of the test, where the task was to perform three contractions on the first perceptible level and at stage, when the patient performed contractions as fast as possible with the maximum force for 20 seconds.
The patient summarized the changes which appeared to be achievable in the course of the therapy:
“During the examination it appeared that my muscles were very weak, but the problem with urinary incontinence was not that frequent – when it appeared, it was usually during exercising or lifting and carrying objects. I can tell that incontinence has been much less frequent since I started the physiotherapy. And I can see progress in the area of sexual satisfaction too. (…) I feel a significant difference in this aspect. The pain in the lumbar region doesn’t bother me anymore.”
Looking at the muscle tests from the last 2 months, we can see a considerable improvement. The patient and the physiotherapist have still a lot of work ahead of them, but it seems that the adopted direction of therapy is right.
When they manage to work out the right level of muscle control and endurance, it will be possible to extend the training plan and include new exercise sets – speed training improving muscle strength and contraction control. The further stages of exercise progression can involve changing the exercising position to the knee and elbow position, and then exercising in the functional – standing – position.
If you’d also like to take advantage of our solution, you’re welcome to join our online course during which we’ll get you ready to use PelviFly both in the treatment room and when monitoring your patients’ training remotely.