Journal of Rawalpindi Medical College (JRMC); 2013;17(2):243-246

Original Article Impact of Kegel Exercise on Brink Scale and Activities of Daily Life(ADLs) in Patients of

Taqdees Naqaish*, Farwa Rizvi**,Javaid Iqbal Khattak*** * Department of Gynecology and Obstetrics , Shifa College of Medicine, Islamabad;** Department of Community Medicine , Islamabad Medical and Dental College, Islamabad:*** Department of Medicine),PNS Shifa, Karachi

Abstract individual's place of residence, in outdoor environments, or both.1 Basic ADLs (Basic activities of To study the impact of Kegel Background : daily living) consist of self-care tasks, including exercise on Brink scale and ADLs (Activities of daily bathing and showering (washing the body), bowel and life scale) in patients of Cystocele bladder management (recognizing the need to relieve Methods: In this randomized control trial 50 oneself), dressing, eating (including chewing and patients of cystocoele (25 each) were divided into swallowing), feeding (setting up food and bringing it two groups. Kegel’s and postural correction exercises to the mouth), functional mobility (moving from one were introduced to the experimental group and back place to another while performing activities), personal strengthening and postural correction exercises to device care, grooming (including washing hair), sexual the control group. In Kegel’s exercise alternate activity, toilet hygiene (completing the act of relieving contraction and relaxation of and oneself).2 perineal muscles were performed for the treatment Cystocele is a prolapse of the anterior vaginal wall of urinary and to strengthen the with herniation of the bladder. This means that the pelvic floor muscles. Back strengthening exercises bladder is shifted out of its normal position and its were performed by doing 5 repetitions x 2 sets and fallen base through the anterior vaginal wall has been gradually 10 x 2-3 sets each day, at least for 4 months. relaxed and elongated in both an anteroposterior and a Patients were asked to lie flat on back. lateral direction. This can result from the central or Results: In the Brink scale, 30% had 3-6 PFM lateral weakness of a pubocervical fascia between the (Pelvic floor muscle) power,48% had power between bladder and the .3 7-9, while 22% had 10-12 power. Twenty seven (54%) Brink scale measures pelvic-floor muscle (PFM) subjects had no pelvic heaviness after performing strength (force-generating capacity), which is related Kegel’s exercises, 34% subjects had slight pelvic to patient characteristics, lower urinary tract heaviness, while only 12% subjects had moderate symptoms, and symptoms.4 Brink pelvic heaviness. Nine (18%) subjects out of 50 scale considers 3 dimensions, to assess pelvic floor (100%) found difficulty in ADLs (Activities of daily muscle contraction, the compression pressure to feel life scale) and had limited activities, while 28% the fingers of the auditor, duration and the vertical females had little limitation in ADLs, while 54% displacement of the fingers of the auditor. Each females were not limited at all in ADLs, after dimension is sub-regional or separately, in a 4-point performing Kegel exercises. The results showed that scale rated categorically, and then the ratings are for a Kegel exercises proved effective on improvement of whole score 3-12.4 brink scale (p=0.000), pelvic heaviness (p=0.001), and Pelvic floor muscle training is the most commonly ADLs (p=0.007). recommended physical therapy treatment for women Conclusion: Kegel exercises are significantly with stress . It is also sometimes effective in improving brink scale, pelvic heaviness, recommended for mixed and, less commonly, urge and ADLs (Activities of daily life scale). urinary incontinence.5,6 Kegel exercises are used to Key Words: Exercise, Cystocele, Activities of daily help women in strengthening pelvic floor. These living exercises can be accomplished by muscle contractions. The effectiveness of pelvic floor muscle training in Introduction reversing or treating POP (cystocele) has been Activities of daily living (ADLs) is a term used in considered many times as pelvic floor muscle training healthcare to refer to daily self-care activities within an (PFMT) has been shown to improve symptoms

243 Journal of Rawalpindi Medical College (JRMC); 2013;17(2):243-246 associated with stress, urge, and mixed urinary relaxation of pelvic floor and perineal muscles. These incontinence.7 Kegel’s exercises should be offered to exercises were advised to be performed by doing 5 the targeted patients so that the risk of development of repetitions x 2 sets and gradually 10 x 2-3 sets each complications can be decreased. It also improves day, at least for 4 months, along with the postural quality of life of a woman and her relationship with correction exercises (core strengthening exercises like her husband. sets of basic crunches, back extensions, standing chest stretch ). In second group (Control Group) Back Patients and Methods Strengthening exercises were performed by doing 5 This randomized control trial was performed in the repetitions x 2 sets and gradually 10 x 2-3 sets each Department of Rehabilitation Shifa International day, at least for 4 months. Patients were asked to lie Hospital Islamabad, from May 2012 to November flat on back; bend knees at 90-degree angle, feet flat on 2012. Fifty patients were selected by consecutive floor. Then tighten abdomen and raise buttocks off sampling. Informed written consent was taken from floor, keeping abdominal muscles tight. Then patients the sample population and every aspect of the study were advised to tighten buttocks, Shoulder to knees was explained to them before they were enrolled for being in straight line and position to be held for a the survey. After selection by consecutive sampling count of five. Then they were asked to slowly lower (non probability), patients were randomly allocated by buttocks to floor and the whole exercise to be repeated lottery method to either group A (Experimental) or five to fifteen times. group B (Control). Inclusion criteria included patients Student t test was applied for improvement in Brink of age groups (20 years up to 40 years) with either scale scores, ADLS, and Pelvic heaviness. p value was grade I or grade II. Close ended questionnaire was found to be significant for brink scale (P=0.000), pelvic used as data instrument for the survey. Data regarding heaviness (P=0.001), and ADLS (P=0.007). patients age, number of children, and cystocoele grade was taken. Only those women were included who had Results: Cystocele prolapse; other forms of prolapses like Age profile revealed 28% were in age group 25-30 and urethrocele were excluded. years and 38% were in age group 31-35 years (Table In measurement of Brink Scale, pelvic floor muscles 1).By comparing mode of delivery with grade of were examined with women in the supine position cystocele we found out of 34 patients, 20 women were with their hips flexed and abducted and knees slightly in grade II and 14 women were in grade I, and their flexed position performed. An examiner's gloved and mode of delivery was spontaneous vaginal. While out lubricated index and middle fingers, vertically of 16 subjects, 4 subjects were in grade II and 12 oriented, were inserted along the posterior vagina to subjects were found in grade I and their mode of the level of the proximal finger joints auditor. Women delivery was multiple. This shows that higher grade were asked to contract their pelvic floor muscles.4 was found in spontaneous Vaginal deliveries (SV). When a patient, caused incorrect contraction using Fifteen subjects (30%) had 3-6 PFM power, 24 their hip muscles instead of their pelvic floor muscles, subjects (48%) had power between 7-9, while 11 the examiner did not record a Brink score for this subjects (22%) had 10-12 power at Brink scale. contraction. Only when they contracted their muscles Maximum subjects were between powers of 7-9 (Table correctly, the examiner noted the pressure and vertical 2). Statistically significant results on application of t- displacement measurements by Brink scale criteria, test that Kegel exercises have proven effective on Brink muscle contraction duration was evaluated. The scale (p=0.000), pelvic heaviness (p=0.001), and ADLS examiner noted the contraction time with a (p=0.007) (Table 3).Nine (18%) subjects out of 50 stopwatch.4,5 The stopwatch was stopped when the (100%) found difficulty in ADLS and had limited weakened contraction stopped, or when the subject activities, while 14 (28%) females having limited little maintained the contraction of about 8 seconds. The in ADLS, while 27(54%) females ADL’S were not subjects were asked not to "bear down" or to perform a limited at all, after performing exercises (Table 4). Valsalva maneuver during any pelvic floor muscle Table 1: Age profile contractions. A brief rest period (20-30 seconds) was Age (years) No(%) given between contractions.5-6 20-24 7(14) In first group (Experimental Group) patients were 25-30 14(28) advised to perform Kegel exercises and postural 31-35 19(38) exercises as well. These were alternate contraction and 36-40 10(20)

244 Journal of Rawalpindi Medical College (JRMC); 2013;17(2):243-246

Table 2: Brink Scale Systematic contraction of the muscles of the pelvic Brink score* No(%) floor can improve pelvic function. These exercises, 3-6 15 (30) commonly known as Kegel exercises, can be 7-9 24(48) accomplished by muscles contractions to strengthen 10-12 11922) pelvic floor. The effectiveness of pelvic floor muscle Total 50(100) training in reversing or treating POP (cystocele) has *Brink scale considers 3 dimensions, to assess pelvic floor muscle been shown to improve symptoms associated with contraction: the ratings are for a composite score 3-12 added, has a stress, urge, and mixed urinary incontinence.8 Women higher score for better muscle function.4 with advancement of pelvic floor exercises had better Table 3: Brink scale, pelvic heaviness, ADLS Brink scale scores. It is possible that pelvic-floor Standard Standard muscle dysfunction could both contribute to the N Mean Error of deviation development of prolapse and represent a consequence mean of disorders of urinary incontinence, LBP and sexual Brink Scale 25 1.92 .76 .15 Exp. a dysfunctions. Brink Scale 25 2.71 .70 .14 Pelvic muscle training, sometimes referred to as controla Kegel exercises as a noninvasive training has been Pelvic 25 1.21 .75 .15 shown to benefit women with urinary and/or fecal Heaviness Exp.b symptoms. It is commonly prescribed for women with Pelvic 25 1.68 .65 .13 prolapse organs or those who have other pelvic floor Heaviness symptoms, or cystocele. Correction of prolapse must b control aim to restore vaginal function and any concomitant ADL Exp. c 25 2.02 .85 .17 urinary incontinence.12,13 Karib conducted a study ADLS controlc 25 2.40 .71 .14 which showed positive results regarding the *p valuea (0.000), p valueb (0.001), p valuec (0.007) effectiveness of pelvic floor muscle training (PFMT) to Table 4: Frequency of patients showing prevent and treat POP, and how PFMT could prevent 14 Activities of daily life scale (ADLS) or reverse prolapse. A number of studies provide support for the widespread recommendation that ADLS(Activities of daily life scale) No(%) PFMT be included in first-line conservative Limited a lot 9(18.0) management programmes for women with stress, Limited Little 14 (28.0) urge, or mixed, urinary incontinence. Statistical Not Limited 27 (54.0) heterogeneity reflecting variation in incontinence type, Total 50(100) training, and outcome measurement made interpretation difficult. The treatment effect seemed to Discussion be greater in women with stress urinary incontinence Better pelvic-floor muscle function was associated alone, who participated in a supervised PFMT with less severe prolapse and urinary symptoms.8,9 programme for at least three months, but these and 15,16 Muscles education and resistive exercises of the other uncertainties require testing in further trials. pubococcygeus has proved that, these exercises when Studies reveal that conservative management applied to weak muscles of the pelvic musculature, in approaches including pelvic floor (Kegel) exercises for many women increases their quality of life and mild to moderate prolapse and use of vaginal improves ADLS.8-10 In present study Kegel exercises pessaries to mechanically support prolapsed tissues 17 were effective in improving ADLS in patients after 4 and lifestyle changes is required.

months (p=0.007).Women with prolapse can experience a variety of pelvic floor symptoms. Conclusion Treatments include mechanical devices and 1.Kegel exercises are effective to treat cystocele conservative management , such as lifestyle advice patients (grade I and grade II) for improving Brink and PFMT which are often used in cases of mild to scale, and Activities of daily life scale. moderate prolapse. The study showed that pelvic floor 2. Women having grade I and grade II cystocele can muscle exercises improved the strength of pelvic benefit from these exercises programme to improve muscle and alleviated prolapse symptoms in mild to their symptoms and enhance their daily activities moderate cystocele.11 capacity, thus improving their quality of life.

245 Journal of Rawalpindi Medical College (JRMC); 2013;17(2):243-246

10. Kegel AH. Stress Incontinence and Genital Relaxation References Naissance Holding L.C; Available from:

1. Stay WB and Lieberman D. Systematic evidence-based http://www.gyneflex.com/kegel_article.html. literature review. Am J Occup Ther. 2008; 62(2):127-29. 11. Hagen S and Stark D. Conservative prevention and 2. Roley SS, DeLany JV, Barrows CJ. Occupational therapy management of in women. Cochrane practice framework: domain & practice, 2nd edition . Am J Database Syst Rev. 2011 Dec 7; (12):CD003882. doi: Occup Ther 2008; 62 (6): 625–83. 10.1002/14651858.CD003882.pub4. 3. Comiter CV, Vasavada SP, Raz S. Transvaginal 12. Marinkovic SP, Stanton SL. Incontinence and voiding culdosuspension: technique and results. Urology 1999; difficulties associated with prolapse. J Urol 2004; 54:819–22. 171(3):1021-28. 13. Karib T T and Vinsnes A. Effect of pelvic floor muscle 4. Fitzgerald MP. Pelvic floor strength in women with training on quality of life and sexual problems in stress incontinence as assessed by the Brink Scale. Physical Therapy incontinent women. Acta Obstetricia et Gynecologica 2007; 87 (10 ):1316-24. Scandinavica 2000; 79(7):598-603. 5. Burrows LJ. Contemporary management of pelvic organ 14. Bo K. Can pelvic floor muscle training prevent and treat menopause management 2008:24-30. pelvic organ prolapse. Acta Obstetricia et Gynecologica 6. Hay-Smith EJ, Herderschee R, Dumoulin C. Comparisons of Scandinavica 2006; 85(3):263-68. approaches to pelvic floor muscle training for urinary 15. Dumoulin C and Hay-Smith J. Pelvic floor muscle training incontinence in women.Cochrane Database Syst Rev versus no treatment, or inactive control treatments, for 2011;7;(12):CD009508. doi: urinary incontinence in women. Cochrane Database Syst 7. National Academy of Sports Medicine (NASM). 2004. Rev. 2010 Jan 20; (1):CD005654. doi: 10.1002/14651858. Optimum Performance Training for the Health and Fitness 16. Hay-Smith EJ, Bø K, Berghmans LC, Hendriks HJ, de Bie RA. Professional. NASM: Calabasas, CA. Pelvic floor muscle training for urinary incontinence in 8. Kuncharapu I. Pelvic Organ Prolapse. American Family women. Cochrane Database Syst Rev. 2007 Jul 18; Physican 2010;81(9):1111-17. (1):CD001407. 9. Hagen S. Pelvic floor muscle training for stages I and II 17. Davila G W. Vaginal prolapse: management with pelvic organ prolapse. International Urogynecology Journal nonsurgical techniques. Postgrad Med 1996;99(4):171-76. and Pelvic Floor Dysfunction. 2009; 20(10):45-51.

246