|Year : 2021 | Volume
| Issue : 5 | Page : 501-506
Contraction techniques adopted for pelvic floor muscle exercise education by Nigeria-based physiotherapists: A preliminary study
Chidiebele Petronilla Ojukwu1, Precious Chidiebere Orji1, Stephen Sunday Ede2, Anne Ezeigwe3, Chigozie Ikenna Uchenwoke1, Emelie Anekwu4, Sylvester Emeka Igwe1
1 Department of Medical Rehabilitation, College of Medicine, University of Nigeria, Nsukka, Enugu, Nigeria
2 Department of Medical Rehabilitation, College of Medicine, University of Nigeria, Nsukka, Enugu, Nigeria; Department of Gerontology, Faculty of Social Sciences, University of Southampton, Southampton, UK
3 Department of Gerontology, Faculty of Social Sciences, University of Southampton, Southampton, UK
4 Department of Physiotherapy, Federal Teaching Hospital, Abakaliki, Ebonyi, Nigeria
|Date of Submission||18-May-2021|
|Date of Decision||22-Jun-2021|
|Date of Acceptance||22-Jun-2021|
|Date of Web Publication||11-Oct-2021|
Dr. Sylvester Emeka Igwe
Department of Medical Rehabilitation, College of Medicine, University of Nigeria, Nsukka, Enugu
Source of Support: None, Conflict of Interest: None
Objective: The objective of the study is to investigate contraction techniques adopted for pelvic floor muscle (PFM) exercise education and their perceived efficacies among physiotherapists in Nigeria. Materials and Methods: Two hundred and eight conveniently selected physiotherapists in various clinical specialties, working in different hospitals across Nigeria, responded to a structured questionnaire that investigated contraction techniques adopted for PFM exercise education and their perceived efficacies. The data was analyzed with the SPSS software version 20.0 at P = 0.5. Results: 111 male and 97 female physiotherapists (mean age of 34.2 ± 10.3 years) participated in this study. “Imagination of urinating and suddenly interrupting urine flow” (85.9%) and “gripping of therapist's fingers or vaginal electrodes with the vagina” (44.6%) were the commonly utilized contraction techniques. “Imagination of urinating and suddenly interrupting urine flow” (28.8%) and “imagination of gripping the penis with the vagina” (26.4%) were perceived as the most effective methods by the physiotherapists while “imagination of releasing flatus while attempting to obscure its sound” (0.96%) emerged as the least effective methods. Conclusion: “Imagination of urinating and suddenly interrupting urine flow” is the most common contraction technique utilized for PFM education by Nigerian physiotherapists as well as the perceived most effective method, as compared to others.
Keywords: Nigeria, pelvic floor muscle exercise, perceived efficacy, physiotherapists, teaching method
|How to cite this article:|
Ojukwu CP, Orji PC, Ede SS, Ezeigwe A, Uchenwoke CI, Anekwu E, Igwe SE. Contraction techniques adopted for pelvic floor muscle exercise education by Nigeria-based physiotherapists: A preliminary study. Niger J Med 2021;30:501-6
|How to cite this URL:|
Ojukwu CP, Orji PC, Ede SS, Ezeigwe A, Uchenwoke CI, Anekwu E, Igwe SE. Contraction techniques adopted for pelvic floor muscle exercise education by Nigeria-based physiotherapists: A preliminary study. Niger J Med [serial online] 2021 [cited 2022 Aug 12];30:501-6. Available from: http://www.njmonline.org/text.asp?2021/30/5/501/327967
| Introduction|| |
The superficial and deep layers of the pelvic floor muscles (PFMs) support the abdomen and pelvic viscera, maintain fecal and urine continence, allow voiding and defecation, promote sexual activity and delivery, and preserve pelvispinal stability. PFM anatomy and function are critical components of physiotherapy practice, notably in the prevention and treatment of pelvic floor diseases. Pelvic diseases may arise as a result of a combination of neuropathic alterations, muscle, fascia, or connective tissue injury linked with the pelvic floor.,,, Pelvic floor disorders encompass a wide range of diseases, including incontinence, pelvic organ prolapse, sexual dysfunctions, and pelvic discomfort. Facilitation of voluntary PFM contractions is a key component of PFM training exercise regimens in the context of pelvic floor diseases. PFM strengthening exercises are the most prevalent and one of the most efficient techniques for treating such illnesses. These exercises' efficacy has been shown in numerous trials, and they are frequently suggested as first-line therapy for pelvic floor problems.,,,
Physiotherapists, among others, play critical roles in the prescription, instruction, monitoring, and assessment of PFM exercises and their effects. Adoption of PFM exercises as therapy regimens necessitate thorough education programs to educate the client on the location and function of the PFMs, as well as to assist isolation and correct activation of these muscles., In contrast to other exercises involving most muscle groups, which generally entail the therapist physically demonstrating the movements to supplement verbal instructions for a better comprehension, PFM exercises cannot be taught in this manner. It is tough to teach PFM exercises. The anatomical placement of these muscles is the most difficult problem in PFM exercise teaching. Because these muscles are situated inside and the visibility of their contraction is not easily noticed, physiotherapists find it challenging to educate clients about the functions of the PFMs as well as proper strengthening procedures. This difficulty, on the other hand, extends to the client's comprehension and enjoyment of the PFM and their exercise plans. These difficulties are not only limited to the instruction of PFM exercises but also to their implementation by the client and the physiotherapist's appraisal of development. Incorrect execution of these exercises renders them useless and may possibly exacerbate the client's symptoms of pelvic floor problems., Adoption of PFM exercises necessitate four steps in a continuous process: education, comprehension, implementation, and assessment. Any shortcoming at any step, particularly the first three, results in the inadequacy of the entire process. A recent study found that teaching women to execute “the Knack” maneuver of the PFMs increased women's awareness of the pelvic floor but had no effect on voluntary contraction of the PFMs and their functions. These emphasize the need for adequacy in all stages of the PFM exercise process.
To achieve the best outcome, physiotherapists and associated professionals have used several contraction techniques of instructing PFM exercises to enable clients' better comprehension and application. Contextually, the contraction technique refers to the expressions used to urge clients to isolate and contract their PFMs. Some strategies were described, such as asking the client to envision stopping the flow of urine midstream, preventing the passage of wind, or a combination of the two. In a recent systematic review, Mateus-Vasconcelos et al. outlined other techniques, including instruction regarding the anatomy and function of the PFM, vaginal palpation, palpation on the central perineal tendon, interruption of urine flow, biofeedback using a perineometer, proprioceptive technique with a vaginal cone, hypopressive exercise, PFM contraction associated with diaphragmatic breathing and visualization using a mirror, and coactivation of the anterolateral abdominal muscles.
Asides from these, anecdotal observations show that other techniques are being conceptualized and utilized by physiotherapists and related personnel in Nigeria but lack empirical documentation. It has also been observed that utilization of these techniques is dependent on the physiotherapist's perception of proper client understanding and application as well as positive treatment outcomes. Investigating available techniques for facilitating contraction of the PFMs and their perceived efficacies are extremely necessary as this will offer valued information to physiotherapists as well as guide their clinical decision-making processes. Therefore, this survey aimed to investigate contraction techniques adopted by Nigerian physiotherapists for PFM exercise education as well as the perceived efficacies of the reported techniques.
| Materials and Methods|| |
This cross-sectional descriptive survey constitutes the first phase of an ongoing project (Evaluating Contraction Techniques Adopted for Pelvic Floor Muscle Exercise Education), designed to review and evaluate the efficacies of instructions utilized for educating clients on the location and contraction of the PFMs. This first preliminary phase sought to investigate the instruction-based contraction techniques adopted by physiotherapists for Kegel exercise education and their perceived efficacies. This information will influence the design and contents of the follow-up observational and experimental phases of this study.
This study was approved by the University of Nigeria Research Ethics Committee with the approval number: NHREC/05/01/2008B-FWA00002458-1RB00002323.
A minimum sample size of 171 respondents was calculated according to Yamane with an estimated population size of 300 physiotherapists, who attended two major physiotherapy conferences hosted by the only two Nigerian professional Associations for physiotherapists in October and November 2018. Therefore, 300 questionnaires were distributed to the conference participants and 208 eligible participants filled and returned theirs, yielding a response rate of 69.3%. The study inclusion criteria included physiotherapy training and practice in Nigeria as well as clinical experience in the management of patients that required PFM training. Physiotherapists with less than or equal to six months of working experience and no clinical experience in the management of conditions requiring prescription of PFM strengthening exercises were excluded from this study.
The conference attendees were not the most appropriate but best fit representative of Nigerian-based physiotherapists as the conferences had delegates from across the entire states of Nigeria.
A structured self-administered questionnaire was utilized for this study. This questionnaire was face and content validated by four experts. Its reliability was assessed in a pilot study by a test-retest method among 10 physiotherapists, before the conferences. Seven days were observed between the test and retest activities. The correlation coefficient of the test-retest reliability was r = 0.967 (P = 0.001).
This seven-item questionnaire has three sections (A, B, and C). Section A contained questions on the demographic and occupational characteristics of the respondents. Section B investigated the contraction techniques utilized by physiotherapists for educating clients on PFM exercises while Section C sought information on respondents' perceptions of the utilized contraction techniques in improving patient outcomes.
One hundred and eighty copies of the questionnaire were printed and distributed to the respondents by the end of the first day of each conference. At the end of the last day of each conference, the filled copies of the questionnaires were collected for data collation and analysis. Respondents who could not submit theirs by the end of the conference had them mailed to the researchers.
Data was analyzed with the SPSS software version 20.0 for data analysis (SPSS Inc., Chicago, IL, USA). Descriptive statistics of mean, standard deviation, frequencies, and percentages were used to summarize physiotherapists' responses.
| Results|| |
One hundred and eleven male and 97 female physiotherapists (mean age of 34.2 ± 10.3 years) participated in this study [Table 1]. The majority of the respondents specialized in orthopedics (29.3%) and women's health (21.6%) [Table 1]. Most (64.9%) of the respondents had greater than five years of clinical experience as physiotherapists.
|Table 1: Demographic and occupational characteristics of the respondents (n=208)|
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In descending order, the five commonly utilized contraction techniques adopted for educating PFM exercises are “imagination of urinating and suddenly interrupting urine flow” (85.9%), “gripping of therapist's fingers or vaginal electrodes with the vagina” (44.6%), “imagination of releasing flatus while attempting to obscure its sound” (43.5%), “tightening of the abdomen with hip adduction” (37.0%), “imagination of gripping the penis with the vagina during sexual intercourse” (37.0%) [Table 2].
|Table 2: Contraction techniques utilized by physiotherapists for educating Kegel's exercises (descending order)|
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The majority of the respondents perceived “imagination of urinating and suddenly interrupting urine flow” (28.8%) and “imagination of gripping the penis with the vagina during sexual intercourse” (26.4%) as the most effective methods while “imagination of releasing flatus while attempting to obscure its sound” (0.96%) was rated the least effective methods [Table 3].
|Table 3: Physiotherapists' perceived efficacy of the contraction techniques (Descending order)|
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| Discussion|| |
This novel study reported the contraction techniques utilized by physiotherapists for PFM education. The effectiveness of PFM exercises is partly dependent on the instructions provided. Verbal instruction is a key element in PFM contraction education., This study showed that Nigerian physiotherapists predominantly utilized “imagination of urinating and suddenly interrupting urine flow” and “gripping of therapist's fingers or vaginal electrodes with the vagina” for PFM education. Simulating an attempt to pause urine flow has been considered as one of the verbal instructions for educating PFM contractions in previous studies.,,, Although we could not ascertain reasons guiding physiotherapists' preferences of the reported contraction techniques, the utilization of “imagination of urinating and suddenly interrupting urine flow” in other geographical areas,,, suggests that it is a widely accepted technique.
Physiotherapists in the present study perceived “imagination of urinating and suddenly interrupting urine flow” as the most effective method for educating PFM exercises. The fact that it was the preferred method of PFM education in previous studies,,, further suggests its perceived efficacy by other authors. However, these inferences are not absolute as there is a paucity of data on the comparative effects of available contraction techniques on PFM activation. The reported efficacy in our study is largely subjective but can serve as an interim guide to related clinicians, pending the conclusion of other phases of this study. In subsequent phases, these reported contraction techniques would be evaluated to delineate more objective guidelines supported with empirical evidence.
Nevertheless, other contraction techniques were also reported in our study. The second most utilized method is the “gripping of therapist's fingers or vaginal electrodes with the vagina” technique. Logically, this approach looks to be fairly objective, as the client should be able to focus the activity on the PFMs by gripping a physical instrument (therapist's finger, vaginal electrode, or penis). These “gripping” techniques are typically used as improvised biofeedback procedures to enhance the PFMs. Such approaches allow for the provision of oral or tactile input to the client, providing rapid feedback on the strength of the contraction created. Biofeedback is a powerful tool for increasing muscle activation and training strength in the PFMs.,, Although these studies,, reported additional positive outcomes of PFM training with the inclusion of biofeedback regimens, others have shown contradicting findings.,
”Tightening the abdominal muscles with hip adduction” was also reported as a contraction technique by physiotherapists in the present study. The synergistic activation of the PFMs and each of the abdominal,, and hip adductor, muscles is generally the foundation of this approach. Because of their anatomical arrangement, the PFMs can be activated with abdominal or hip adduction movements and vice versa. As such, the adoption of abdominal and hip exercises for PFM rehabilitation has been recommended and utilized in previous studies.,,,,,
Comparing the outcomes of this study with previous studies showed some distinctions among contraction techniques used to facilitate PFM contractions in Nigeria and other climes. According to Elaine et al., common techniques used in other climes include PFM anatomy and function instruction, vaginal palpation, palpation on the central perineal tendon, interruption of urine flow, biofeedback with a perineometer, proprioceptive technique with a vaginal cone, hypopressive exercise, PFM contraction associated with diaphragmatic breathing, and visual stimulation. Asides from the interruption of urine flow and proprioceptive technique with a vaginal cone, the other techniques were not reported as contraction techniques utilized by physiotherapists in this study. Although it is known that the other techniques are utilized for evaluation and treatment purposes in most Nigerian clinical settings, it is obvious that they are not adopted for the facilitation of PFM contractions. All the studies reviewed by Elaine et al. utilized vaginal palpation to facilitate PFM contractions. The efficacy of this technique in facilitating PFM contraction in women who had difficulties isolating the PFMs was shown in several studies.,,
This study had some limitations including the use of a small sample size and the absence of information on the contraction techniques taught to the respondents during their academic and clinical training. This would have informed us of the options available to them through physiotherapy training. It is common for clinicians to adopt only clinical practices that were passed on to them during training, irrespective of the known efficacies of such practices.
Implications for practice and policy
Physiotherapists in Nigeria utilized various methods for educating PFM exercises and their perceived efficacy of each method varied based on their clinical experiences. This provides a wide spectrum of options available for physiotherapists during the education and prescription of PFM exercises. Especially, the three most used approaches to educating the PFMs including holding urine or stool along with putting a finger in the vagina or rectum to contract muscle over it are the most commonly cited in the literature.,,, However, the efficacy of these methods in achieving the aims of PFM rehabilitation needs to be further investigated objectively, preferably in an experimental approach.
| Conclusion|| |
Eight contraction techniques were reported by physiotherapists in this study. “Imagination of urinating and suddenly interrupting urine flow” and “gripping of therapist's fingers or vaginal electrodes with the vagina” were the most frequently utilized techniques. The former was scaled as the perceived most effective method, as compared to others.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]