Are Perineal Massage and Instrument-Assisted Perineal Stretching With Short Protocol Effective for Increasing Pelvic Floor Muscle Extensibility? A Randomized Controlled Trial.

OBJECTIVE: The purpose of this study was to compare (1) the effects of the instrument-assisted perineal stretching technique with different application protocols in combination with perineal massage and (2) the effects of the isolated techniques on the extensibility and strength of the pelvic floor muscles (PFMs). METHODS: A randomized controlled clinical trial with parallel randomization, assessor blinding, and concealed allocation was conducted in the Campus Physical Education at the Federal University of Uberlândia in Brazil. Ninety-six pregnant women (18-40 years of age) were allocated into 4 groups: perineal massage (PnM) group (PnM protocol for 10 minutes); instrument-assisted perineal stretching with a long static protocol for 15 minutes [IStrLS group]); PnM + IStrLS group (both techniques applied in the 2 previous groups); and PnM + IStrSR group (the same techniques as used in the PnM + IStrLS group but with a short repeated protocol; 4 sets lasting 30 seconds each). Eight interventions were performed in all 4 groups twice weekly (beginning at the 34th gestational week). The primary outcome was PFM extensibility, assessed using vaginal dilator circumference, and the secondary outcome was PFM strength, assessed using vaginal manometry. RESULTS: For the PFM extensibility variable, a significant main effect of time (F2,88 = 87.951) and group (F3,88 = 7.193) was found. Tukey post hoc test results showed that the PnM + IStrSR group presented greater extensibility than the PnM and IStrLS groups. The PnM group showed increased PFM strength after 8 sessions compared with the other groups. CONCLUSIONS: Women who were pregnant and received the combination of perineal massage and instrument-assisted perineal stretching with short repeated application had a greater increase in PFM extensibility than perineal massage and instrument-assisted perineal stretching alone. IMPACT: The combination of perineal massage and instrument-assisted perineal stretching techniques with a short, repeated protocol led to better PFM extensibility results than the application of the techniques alone in women who were pregnant. LAY SUMMARY: Pregnant women can benefit from intervention using the combination of perineal massage and instrument-assisted perineal stretching techniques with a short, repeated protocol.

Effects of the addition of transcutaneous electrical stimulation to non-pharmacological measures in labor pain: study protocol for a randomized controlled trial.

BACKGROUND: Labor, although natural and physiological, is a period that can be marked by stress, pain, anxiety, suffering, fear, and anguish for a woman. Thus, non-pharmacological methods that reduce pain during labor are important to allow a better experience without the use of medications. Therefore, the aim of this study is to evaluate the effects of non-pharmacological pain relief methods, added or not to the application of transcutaneous electrical stimulation (TENS), on pain, satisfaction with the childbirth, duration of labor, and newborn conditions. METHODS: This is a randomized controlled clinical trial, with a non-probabilistic convenience sample, composed of women in the first active stage of labor, admitted to a public institution. The parturients will be divided into 3 groups: group 1 (n = 36) composed of parturients who will have continuous support and will be encouraged to walk, adopting different positions with the use of the Swiss ball and receiving back massage for 30 min; group 2 (n = 36) composed of parturients who will also have continuous support and will be encouraged to walk, adopt different positions using the Swiss ball, and will receive the application of TENS for 30 min; and group 3 (n = 36) composed of parturients who will have continuous support and will be encouraged to walk, adopting different positions with the use of the Swiss ball, and will receive placebo TENS application for 30 min. The outcomes evaluated in the study will be pain intensity assessed by the visual analog scale of pain applied before, immediately after, and 30 min and 1 h after the interventions; Experience and Satisfaction with Childbirth Questionnaire (QESP) applied 12 to 24 h after delivery; and data regarding delivery (type of delivery, total duration of labor, and possible obstetric complications) and neonate (weight, height, possible complications, Apgar score in the first and fifth minutes). DISCUSSION: With this research, it is expected to understand the effects of the intervention through TENS electrostimulation added to other non-pharmacological methods for pain management during labor. TRIAL REGISTRATION: Brazilian Registry of Clinical Trials (REBEC) RBR-68kh6j . Registered on March 17, 2020.

Impacto da drenagem linfática manual nos sintomas relacionados ao edema de membros inferiores de gestantes / Impacto del drenaje linfático manual sobre los síntomas relacionados con el edema de miembros inferiores en mujeres embarazadas / Impact of the manual lymphatic drainage on symptoms related to lower-extremity edema in pregnant women

RESUMO O objetivo deste artigo é analisar os efeitos da drenagem linfática manual sobre os sintomas de sensação de peso, dor, edema e formigamento nos membros inferiores de gestantes, assim como na redução da perimetria. A amostra foi composta por 23 voluntárias, e foram realizados 35 atendimentos. Foram incluídas gestantes com idade gestacional acima de 26 semanas, que apresentavam sensação de peso, dor, edema e formigamento nos membros inferiores, com autorização escrita do médico obstetra para que fossem submetidas a drenagem linfática manual utilizando o método Leduc. Foram excluídas gestantes que apresentaram pressão arterial superior a 140/100mmHg no momento da realização da drenagem linfática manual, lesão de continuidade da epiderme, doenças dermatológicas, linfáticas e cardíacas, infecções e varizes volumosas e/ou sintomáticas. As avaliações foram realizadas imediatamente após a aplicação da drenagem linfática manual e duas horas depois, por meio de questionário estruturado pelas pesquisadoras. Diferenças estatisticamente significativas foram encontradas antes, imediatamente após e após duas horas da intervenção no que se refere à melhora da dor (p=0,001*), do formigamento (p=0,01*), da sensação de peso (p=0,000*) e do inchaço (p=0,000*). Em relação à perimetria antes e após o tratamento, houve diminuição na maioria das mensurações realizadas. A técnica de drenagem linfática manual tem papel fundamental na melhora da qualidade de vida da gestante devido ao relaxamento e bem-estar proporcionado, componentes considerados essenciais para redução da ansiedade e com benefícios que podem perdurar até o parto.

RESUMEN El objetivo de este estudio es analizar los efectos del drenaje linfático manual sobre los síntomas de pesadez, dolor, edema y hormigueo en miembros inferiores de mujeres embarazadas, así como sobre la reducción de la perimetría. La muestra estuvo conformada por 23 voluntarias, y se realizaron 35 consultas. Se incluyeron a mujeres embarazadas con edad gestacional superior a 26 semanas, que presentaban sensación de pesadez, dolor, edema y hormigueo en miembros inferiores, y que habían sido autorizadas por el obstetra para someterse al drenaje linfático manual con el método Leduc. Se excluyeron a mujeres embarazadas con presión arterial superior a 140/100mmHg en el momento del drenaje linfático manual, lesión de continuidad de la epidermis, enfermedades dermatológicas, linfáticas y cardíacas, infecciones y varices grandes y/o sintomáticas. Las evaluaciones se realizaron tras aplicar el drenaje linfático manual y dos horas después, por medio de un cuestionario estructurado por las investigadoras. Se encontraron diferencias estadísticamente significativas antes, inmediatamente después y después de dos horas de la intervención en relación a la mejoría del dolor (p=0,001*), hormigueo (p=0,01*), sensación de pesadez (p=0,000*) e hinchazón (p=0,000*). La perimetría antes y después del tratamiento disminuyó en la mayoría de las mediciones realizadas. La técnica de drenaje linfático manual juega un papel fundamental en la mejora de la calidad de vida de mujeres embarazadas por provocar relajación y bienestar, componentes claves para reducir la ansiedad, con beneficios que pueden durar hasta el parto.

ABSTRACT This article aims to analyze the effects of manual lymphatic drainage on symptoms related to gestational edema in the lower limbs, such a sensation of heaviness, pain, swelling, and tingling, as well as on perimetry. The sample consisted of 23 pregnant women with gestational age above 26 weeks, who were submitted to 35 sessions of drainage based on Leduc's method upon the authorization of their physicians. Participants with blood pressure above 140/100 mmHg at the time of drainage and presenting with skin continuity wound, heart disease, dermatological disease, lymphatic disease, infections, and voluminous or symptomatic varicose veins were excluded from the study. Symptoms were evaluated immediately and two hours after drainage by means of questionnaires. Improvements in pain (p=0.001*), tingling (p=0.01*), sensation of heaviness (p=0.000*), and swelling (p=0.000*) showed statistically significant differences before, immediately after, and two hours after intervention. Most perimetry measurements also presented a decrease after treatment. The technique of manual lymphatic drainage is very important to provide well-being and a better quality of life in pregnant women. The benefits arising from such a method are essential to decrease anxiety, enduring up until childbirth.

Effects of tibial and parasacral nerve electrostimulation techniques on women with poststroke overactive bladder: study protocol for a randomized controlled trial.

BACKGROUND: Neurogenic bladder (NB) can affect people after stroke episodes. NB features changes in the normal voiding pattern at the bladder filling and emptying phases. Overactive NB is characterized by urgency symptoms, with or without urinary incontinence, caused by NB. This disorder affects many domains of life (physical, social, psychological, domestic, sexual) that limit personal autonomy and degrade the quality of life. Among the several treatments available, the conservative physical therapy intervention through tibial nerve electrostimulation (TNES) and parasacral electrostimulation (PSES) can help improve patient conditions with a smaller number of collateral effects than those of interventions based on medication. The aim of the present study is to compare the effects of TNES and PSES techniques in women with overactive NB after stroke episodes to assess the impact of urinary incontinence in these women, on their number of incontinence episodes, daytime and nocturnal urinary frequency, and quality of life. METHODS: This is a prospective clinical study to compare two randomized groups based on parallel and blind conditions. Forty-four women who have had a stroke episode at least 30 days before the trial and who have developed overactive NB will be recruited for the trial. All patients will be subjected to initial evaluation and randomly divided into two groups, TNES and PSES. Subsequently, the two groups will be subjected to a 12-session intervention protocol, twice a week. A new evaluation will be performed after the intervention. DISCUSSION: The results of this study will contribute to the physiotherapeutic treatment of women with NB after a stroke episode since such results will add information about the benefits of this treatment, urinary control, and the improvements in the quality of life of these women. TRIAL REGISTRATION: Brazilian Registry of Clinical Trials (REBEC) RBR-2bn2z4 . Registered on December 11, 2018.

The relationship between running kinematics and the pelvic floor muscle function of female runners.

INTRODUCTION AND HYPOTHESIS: To date, no study has investigated the correlation between pelvic floor muscle function and urinary incontinence in female runners. The aim of the study was to investigate the relationship between pelvic floor muscle function and to correlate urinary leakage as measured by the modified pad test with kinematic variables of running. METHODS: The sample consisted of 11 incontinent and 17 continent runners. On day 1, they performed a maximum velocity test on a treadmill using an incremental protocol. Their pelvic floor muscles were evaluated using vaginal palpation and manometry, and the adapted pad test was used to evaluate the severity of urinary incontinence. Then, running kinematics were evaluated on a treadmill using a circuit camera to capture vertical displacement, knee flexion during the load response phase, and the initial contact of the foot with the ground for subsequent analysis. The pad test was performed during the kinematic evaluation. RESULTS: The vaginal squeeze pressure of the continent group (mean = 43.40 mmHg, SD = 21.75) was higher in descriptive terms than that of the incontinent group (mean = 38.94 mmHg, SD = 31.08), but the difference was not statistically significant (p = 0.66). There was an association between the weekly training load and urinary leakage. No associations were found between pelvic floor muscle function or urinary leakage and the kinematic variables. CONCLUSIONS: Despite the correlation between the weekly training load and the severity of urinary leakage, no relationships were found between pelvic floor muscle functioning and the kinematics of running.

Effects of perineal preparation techniques on tissue extensibility and muscle strength: a pilot study.

INTRODUCTION AND HYPOTHESIS: Perineal preparation techniques for childbirth have been used with the aim of reducing perineal tears during the expulsive phase of labor. However, no studies were found to investigate the effects of instrument-assisted stretching versus perineal massage on pelvic floor muscle (PFM) variables. Therefore, the aim of this study was to evaluate the effect of instrument-assisted stretching versus perineal massage on the extensibility and strength of the PFMs. METHODS: Primiparous women were randomized to the instrument-assisted stretching (IStr) group (n = 13) and perineal massage (PnM) group (n = 14). The groups participated in eight sessions, twice weekly, beginning at the 34th gestational week. The IStr group underwent the intervention for 15 min using EPI-NO®. The PnM group underwent a perineal massage protocol for 10 min. Each woman was evaluated by a blinded physiotherapist before, after four and after eight sessions for primary (PFM extensibility using the EPI-NO® circumference) and secondary (PFM strength using a manometer) outcomes. Covariate analysis (ANCOVA) was used to compare the groups using the baseline values as a covariate. RESULTS: Both groups showed an increase in PFM extensibility compared with the evaluations before and after four and eight sessions (PnM group from 17.6 ± 1.8 to 20.2 ± 1.9 cm; IStr group from 19.9 ± 1.6 to 22.9 ± 1.6 cm;p < 0.001). There was no difference between groups. Regarding muscle strength, no statistical differences were observed between evaluations or between groups. CONCLUSIONS: Instrument-assisted stretching and perineal massage increase extensibility and do not alter the strength of PFMs in pregnant women.

Evaluation of pelvic floor muscle strength and its correlation with sexual function in primigravid and non-pregnant women: A cross-sectional study.

AIMS: We aimed to compare pelvic floor muscle (PFM) strength and sexual function in primigravid and non-pregnant women and compare PFM strength between those who exhibited and did not exhibit sexual dysfunction. METHODS: A cross-sectional observational study was conducted. The sample consisted of 154 women, including 76 primigravid and 78 non-pregnant women. The inclusion criteria were as follows: non-pregnant nulliparous women or primigravid women who were pregnant with a single foetus at least 14 weeks of gestational age and reported having sexual intercourse at least once during the last 4 weeks. The exclusion criteria were as follows: inability to contract the PFMs and prior urogynaecologic surgery. PFM strength was assessed via vaginal palpation (using the Modified Oxford Scale) and vaginal squeeze pressure (using the Peritron™ manometer). Sexual function was assessedusing the Female Sexual Function Index (FSFI) questionnaire. Sexual dysfunction was identified based on low FSFI scores.The data were analyzed using the Mann-Whiney and Spearman correlation tests. RESULTS: To discussion, primigravid women had lower FSFI scores and lower PFM strength than non-pregnant women. Women with sexual dysfunction had lower PFM strength than women without sexual dysfunction, as indicated by vaginal palpation (scores of 2 out of 5 and 4 out of 5, respectively; P < 0.001) and vaginal squeeze pressure (17.5 and 36.8 cm H2 O, P < 0.001, respectively)regardless of whether they were non-pregnant nulliparous women and primigravid. CONCLUSIONS: Primigravid women exhibited worse sexual function and lower PFM strength than non-pregnant women. Women who had higher FSFI scores demonstrated greater PFM strength.

A dimensão da diástase abdominal tem influência sobre a dor lombar durante a gestação? / Does abdominal diastasis influence lumbar pain during gestation?

RESUMO JUSTIFICATIVA E OBJETIVOS: Avaliar e comparar a ocorrência e dimensão da diástase dos músculos retos abdominais nos segundo e terceiro trimestres gestacionais e correlacioná-las com presença e intensidade da dor lombar. MÉTODOS: Estudo observacional do tipo transversal com 128 gestantes, divididas em dois grupos: 53 gestantes no segundo trimestre gestacional e 75 gestantes no terceiro trimestre gestacional. Utilizou-se para avaliar a dor lombar o questionário Roland Morris e a escala analógica visual da dor. A mensuração da diástase dos músculos retos abdominais foi realizada com auxílio de um paquímetro. Os dados foram analisados segundo a correlação de Spearman e teste U de Mann-Whitney. RESULTADOS: A comparação dos grupos demonstrou que as gestantes do terceiro trimestre apresentavam maior diástase abdominal, mais relatos de dor lombar intensa por meio da escala analógica visual p=0,0017 e maior impacto nas atividades da vida diária (p=0,0012). A correlação foi positiva entre a dimensão da diástase dos músculos retos abdominais e os escores obtidos no questionário Roland Morris e na escala analógica visual. CONCLUSÃO: A dimensão da diástase dos músculos retos abdominais, a intensidade da dor e a incapacidade determinadas pela lombalgia foram maiores nas gestantes do terceiro trimestre gestacional.

ABSTRACT BACKGROUND AND OBJECTIVES: To evaluate and compare the presence and size of recti abdominis diastasis in the second and third gestational trimester and to correlate them to lumbar pain incidence and intensity. METHODS: This is a cross-sectional observational study with 128 pregnant women divided in two groups: 53 pregnant women in the second gestational trimester and 75 pregnant women in the third gestational trimester. Lumbar pain was evaluated with Roland Morris questionnaire and Pain Visual Analog Scale. Recti abdominis diastasis was measured with a caliper rule. Data were analyzed according to Spearman correlation and Mann-Whitney U test. RESULTS: Comparison between groups has shown that pregnant women in the third gestational trimester had more recti abdominis diastasis, more reports of severe lumbar pain by the visual analog scale (p=0.0017) and further impact on daily life activities (p=0.0012). There has been positive correlation between recti abdominis diastasis size and scores obtained by Roland Morris questionnaire and visual analog scale. CONCLUSION: Recti abdominis diastasis size, pain intensity and incapacity determined by low back pain were more severe in pregnant women in the third gestational trimester.

Can Abdominal Hypopressive Technique Change Levator Hiatus Area?: A 3-Dimensional Ultrasound Study.

This study aimed to evaluate the levator hiatus area (LHA) at rest and during the performance of maximal pelvic floor muscle (PFM) contractions, during the abdominal hypopressive technique (AHT), and during the combination of PFM contractions (PFMCs) and the AHT. The study included 17 healthy nulliparous women who had no history of pelvic floor disorders. The LHA was evaluated with the patients in the lithotomy position. After a physiotherapist instructed the patients on the proper performance of the PFM and AHT exercises, 1 gynecologist performed the 3-dimensional translabial ultrasound examinations. The LHA was measured with the patients at rest. The PFMC alone, the AHT alone or the AHT in combination with a PFMC with 30 seconds of rest between the evaluations were performed. Each measurement was performed 2 times, and the mean value was used for statistical analysis. The Wilcoxon test was used to test the differences between the 2 maneuvers. Similar values were observed when comparing the LHA of the PFM at rest (12.2 ± 2.4) cm and during the AHT (11.7 ± 2.6) cm (P = 0.227). The AHT+ PFMC (10.2 ± 1.9) cm demonstrated lower values compared with AHT alone (11.7 ± 2.6) cm (P = 0.002). When comparing the PFMC (10.4 ± 2.1) cm with the AHT + PFMC (10.2 ± 1.9) cm, no significant difference (P = 0.551) was observed. During PFMC, the constriction was 1.8 cm; during the AHT, the constriction was 0.5 cm; and during the AHT + PFMC, it was 2 cm. The LHA assessed by 3-dimensional ultrasound did not significantly change with AHT. These results support the theory that AHT does not strengthen PFM.

Distensibility and strength of the pelvic floor muscles of women in the third trimester of pregnancy.

OBJECTIVE: The objective of this study was to compare the role of the pelvic floor muscles between nulliparous and multiparous women in the third trimester of pregnancy, by analyzing the relationship between electrical activity (surface electromyography-EMG), vaginal palpation (modified Oxford scale), and perineal distensibility (Epi-no). METHODS: This was an observational cross-sectional study on a sample of 60 healthy pregnant women with no cervical dilation, single fetus, gestational age between 35 and 40 weeks, and maternal age ranging from 15 to 40 years. The methods used were bidigital palpation (modified Oxford scale, graded 0-5), surface EMG (electrical activity during maximal voluntary contraction), and perineal distensibility (Epi-no device). The Pearson correlation coefficient (r) was used to analyze the Epi-no values and the surface EMG findings. The Kruskal-Wallis test was used to compare the median values from surface EMG and Epi-no, using the modified Oxford scale scores. RESULTS: Among the 60 patients included in this study, 30 were nulliparous and 30 multiparous. The average maternal age and gestational age were 26.06 (± 5.58) and 36.56 (± 1.23), respectively. It was observed that nulliparous women had both higher perineal muscle strength (2.53 ± 0.57 versus 2.06 ± 0.64; P = 0.005) and higher electrical activity (45.35 ± 12.24 µV versus 35.79 ± 11.66 µV; P = 0.003), while among the multiparous women, distensibility was higher (19.39 ± 1.92 versus 18.05 ± 2.14; P = 0.013). We observed that there was no correlation between perineal distensibility and electrical activity during maximal voluntary contraction (r = - 0.193; P = 0.140). However, we found a positive relationship between vaginal palpation and surface electromyography (P = 0.008), but none between Epi-no values (P = 0.785). CONCLUSION: The electrical activity and muscle strength of the pelvic floor muscles of the multiparous women were damaged, in relation to the nulliparous women, while the perineal distensibility was lower in the latter group. There was a positive relationship between surface EMG and the modified Oxford scale.

Cervical cancer mortality trends in Brazil: 1980-2009.

The objective was to describe time trends in cervical cancer mortality rates in Brazil as a whole and in the country's major geographic regions and States from 1980 to 2009. This was an ecological time series study using data recorded in the Mortality Information System (SIM) and census data collected by the Brazilian Institute of Geography and Statistics (IBGE). Analysis of mortality trends was performed using Poisson regression. Cervical cancer mortality rates in Brazil tended to stabilize. In the geographic regions, a downward trend was observed in the South (-4.1%), Southeast (-3.3%), and Central-West (-1%) and an upward trend in the Northeast (3.5%) and North (2.7%). The largest decreases were observed in the States of São Paulo (-5.1%), Rio Grande do Sul, Espírito Santo, and Paraná (-4.0%). The largest increases in mortality trends occurred in Paraíba (12.4%), Maranhão (9.8%), and Tocantins (8.9%). Cervical cancer mortality rates stabilized in the country as a whole, but there was a downward trend in three geographic regions and 10 States, while two geographic regions and another 10 States showed increasing rates.

Cervical cancer mortality trends in Brazil: 1980-2009 / Tendência da mortalidade por câncer do colo do útero no Brasil: 1980 a 2009 / Tendencia de la mortalidad por cáncer del cuello de útero en Brasil: 1980 a 2009

The objective was to describe time trends in cervical cancer mortality rates in Brazil as a whole and in the country's major geographic regions and States from 1980 to 2009. This was an ecological time series study using data recorded in the Mortality Information System (SIM) and census data collected by the Brazilian Institute of Geography and Statistics (IBGE). Analysis of mortality trends was performed using Poisson regression. Cervical cancer mortality rates in Brazil tended to stabilize. In the geographic regions, a downward trend was observed in the South (-4.1%), Southeast (-3.3%), and Central-West (-1%) and an upward trend in the Northeast (3.5%) and North (2.7%). The largest decreases were observed in the States of São Paulo (­5.1%), Rio Grande do Sul, Espírito Santo, and Paraná (-4.0%). The largest increases in mortality trends occurred in Paraíba (12.4%), Maranhão (9.8%), and Tocantins (8.9%). Cervical cancer mortality rates stabilized in the country as a whole, but there was a downward trend in three geographic regions and 10 States, while two geographic regions and another 10 States showed increasing rates.

O objetivo deste estudo foi fornecer um quadro quanto à tendência da mortalidade por câncer do colo de útero no Brasil, em suas regiões e estados, entre 1980 e 2009. Estudo ecológico de série temporal, com uso de informações sobre óbitos (Sistema de Informações sobre Mortalidade - SIM) e base demográfica (Instituto Brasileiro de Geografia e Estatística - IBGE). Foram realizadas análises das tendências da mortalidade por meio da regressão de Poisson. Houve estabilização nas taxas de mortalidade no Brasil. Nas regiões, houve queda no Sul (-4,1%), Sudeste (-3,3%) e Centro-Oeste (-1%); aumento no Nordeste (3,5%) e Norte (2,7%). As maiores reduções foram observadas em São Paulo (-5,1%), Rio Grande do Sul, Espírito Santo e Paraná (-4,0%). Os maiores aumentos foram observados na Paraíba (12,4%), Maranhão (9,8%) e Tocantins (8,9%). No Brasil, houve estabilização na mortalidade por câncer do colo do útero. No entanto, houve redução em 3 regiões e em 10 estados, enquanto, em 2 regiões e em outros 10 estados, a mortalidade segue aumentando. Uma das razões para essa disparidade pode ser o menor acesso ao tratamento para as pacientes de áreas menos desenvolvidas.

El objetivo fue analizar la mortalidad por cáncer de cuello de útero en Brasil, en sus macrorregiones y estados en el período de 1980 a 2009. Se trata de un estudio ecológico de serie temporal, con uso de información sobre óbitos del Sistema de Información sobre Mortalidad (SIM), y base demográfica del Instituto Brasileño de Geografía y Estadística (IBGE). Se realizaron análisis de las tendencias de la mortalidad, mediante la regresión de Poisson. En Brasil se observó la estabilización en las tasas de mortalidad. En las macrorregiones, hubo caída en el Sur (-4,1%), Sudeste (-3,3%) y Centro-Oeste (-1%); aumento en el Nordeste (3,5%) y Norte (2,7%). En los estados, las principales caídas fueron observadas en São Paulo (-5,1%), Rio Grande do Sul, Espírito Santo y Paraná (-4%). Los mayores aumentos se observaron en Paraíba (12,4%), Maranhão (9,8%) y Tocantins (8,9%). Conclusión: Brasil presenta estabilización en las tasas de mortalidad. No obstante, hubo una reducción en 3 macrorregiones y en 10 estados, mientras que en 2 macrorregiones y en 10 estados la mortalidad sigue aumentando. Una de las razones para esa disparidad puede ser el menor acceso al tratamiento para las pacientes de áreas menos desarrolladas.

Efeito da adição do biofeedback ao treinamento dos músculos do assoalho pélvico para tratamento da incontinência urinária de esforço / Effect the adding of biofeedback to the training of the pelvic floor muscles to treatment of stress urinary incontinence

OBJETIVO: Verificar o efeito da adição do biofeedback (BF) ao treinamento dos músculos do assoalho pélvico (TMAP) para o tratamento da incontinência urinária de esforço (IUE). MÉTODOS: Estudo piloto prospectivo, randomizado e controlado, com mulheres com IUE sem deficiência esfincteriana detectada ao estudo urodinâmico e que realizavam a correta contração dos MAP. Foram excluídas mulheres com doenças neuromusculares e com prolapso genital graus III e IV. Foram randomizadas 40 mulheres em Grupo Controle e Grupo BF. O protocolo de TMAP com equipamento de BF foi constituído de três séries de dez contrações lentas (tônicas), com tempo de manutenção de seis a oito segundos em cada contração, seguido de um período de repouso de mesmo valor. Após cada contração sustentada, eram realizadas de três a quatro contrações rápidas (fásicas) em decúbito dorsal e ortostatismo, duas vezes na semana, totalizando 12 sessões. Avaliou-se o efeito da adição do BF ao TMAP na qualidade de vida pelo King's Health Questionnaire (KHQ), nos sintomas urinários pelo diário miccional e na função dos músculos do assoalho pélvico (MAP) pela palpação digital. A avaliação foi realizada inicialmente e após as 12 sessões de tratamento. O resultado foi descrito em médias e desvios padrão. Para análise de homogeneidade e verificação das diferenças entre os grupos utilizou-se o teste de Mann-Whitney, e para diferenças entre os momentos de observação, o teste de Wilcoxon, com nível de significância de 0,05. RESULTADOS: Diminuição significativa nos escores dos domínios avaliados pelo KHQ na comparação entre os grupos, exceto para o domínio saúde geral (Grupo BF 32,8±26,9 versus Grupo Controle 48,4±29,5; p<0,13). Em concordância, observou-se melhora da função dos MAP após o tratamento no grupo BF, na power (4,3±0,8; p=0,001), endurance (6,0±2,2; p<0,001) e fast (9,3±1,9; p=0,001). Quando comparados os grupos, o Grupo BF destacou-se positivamente em relação ao power (Grupo BF 4,3±0,8 versus Grupo Controle 2,5±0,9; p<0,001), endurance (Grupo BF 6,0±2,2 versus Grupo Controle 2,7±1,9; p<0,001) e fast (Grupo BF 9,3±1,9 versus Grupo Controle 4,6±3,2; p<0,001). Redução da frequência urinária noturna (1,2±1,2 versus 0,7±0,9; p=0,02) e da perda de urina nos esforços (1,5±1,4 versus 0,6±0,8; p=0,001) foi observada no Grupo BF. CONCLUSÃO: A adição do BF ao TMAP para o tratamento da IUE, aplicado de acordo com o protocolo descrito, contribui para melhora da função dos MAP, redução dos sintomas urinários e melhora da qualidade de vida.

PURPOSE: To investigate the effect of adding biofeedback (BF) to the training of pelvic floor muscles (PFMT) for the treatment of stress urinary incontinence (SUI). METHODS: A prospective pilot study, randomized and controlled with women with SUI without sphincter deficiency, detected by urodynamic study and who performed the correct PFM contraction. Women with neuromuscular disorders and grade III and IV genital prolapse were excluded. Forty women were randomized into a Control Group and BF Group. The PFMT protocol with BF equipment consisted of three sets of ten slow contractions (tonic), with a holding time of six to eight seconds at each contraction followed by a rest period of equal duration. After each sustained contraction, they performed three to four fast contractions (phasic) in the supine and standing position twice a week, for a total of 12 sessions. We evaluated the effect of adding BF to PFMT on quality of life using King's Health Questionnaire (KHQ) regarding urinary symptoms based on a voiding diary and regarding the function of pelvic floor muscles by digital palpation. The evaluation was performed initially and after 12 treatment sessions. Data are reported as mean and standard deviation. The Mann-Whitney test was used for the analysis of homogeneity and to determine differences between groups, and the Wilcoxon test was used to determine possible differences between the times of observation, with the level of significance set at 0.05. RESULTS: A significant decrease in the scores of the domains assessed by the KHQ was observed in the comparison between groups, except for the general health domain (BF Group: 32.8±26.9 versus Control Group: 48.4±29.5, p<0.13). Accordingly, there was improvement in PFM function after treatment in the BF Group, regarding power (4.3±0.8, p= 0.001), endurance (6.0±2.2, p<0.001) and fast (9.3±1.9, p=0.001). When comparing the groups, the BF Group showed a positive result regarding power (BF Group 4.3±0.8 versus Control Group 2.5±0.9, p<0.001), endurance (6.0±2.2 BF Group versus Control Group 2.7±1.9, p<0.001) and fast (BF Group 9.3±1.9 versus Control Group 4.6 ± 3.2, p<0.001). Reduction of nocturnal urinary frequency (1.2±1.2 versus 0.7±0.9, p=0.02) and of effort urine loss (1.5±1.4 versus 0.6±0.8, p=0.001) was observed in the BF Group. CONCLUSION: The addition of BF to the PFMT for the treatment of SUI, applied according to the protocol described, improved PFM function, reduced urinary symptoms, and improved of the quality of life.

Impact of pelvic floor muscle training on the quality of life in women with urinary incontinence.

OBJECTIVE: To evaluate the impact of pelvic floor muscle (PFM) training on the quality of life (QOL) in women with stress urinary incontinence (SUI). METHODS: Prospective clinical trial with 36 women with a diagnosis of SUI confirmed by urodynamic study. Women with neuromuscular diseases, using hormone replacement therapy, and with prolapse stage III and IV were not included. The exercise protocol for the PFM consisted of slow contractions (tonic fibers), followed by rapid contractions (phasic fibers) practiced in the supine, sitting, and standing positions, three times a week for a period of three months. We evaluated the impact of PFM on QOL using the King's Health Questionnaire (KHQ), a voiding diary, and digital palpation to assess the function of the PFMs during the initial evaluation and after three months of treatment. The result was described as means and standard deviations. We used the Wilcoxon test for comparison of the KHQ scores for paired samples, and the significance level was set at 0.05. RESULTS: There was a significant decrease in the mean scores of the domains assessed by the KHQ regarding the perception of health, impact of the incontinence, limitations of daily activities, physical limitations, social limitations, personal relationships, emotions, sleep/disposition, and measures of severity. In agreement with these results, significant decrease in nocturnal urinary frequency and urinary incontinence, as well as significant increase in muscle strength and endurance were observed. CONCLUSION: PFM training resulted in significant improvement in the QOL of women with SUI.

Impacto do treinamento dos músculos do assoalho pélvico na qualidade de vida em mulheres com incontinência urinária / Impact of pelvic floor muscle training on the quality of life in women with urinary incontinence

OBJETIVO: Avaliar o impacto do treinamento dos músculos do assoalho pélvico (TMAP) na qualidade de vida (QV) em mulheres com incontinência urinária de esforço (IUE). MÉTODOS: Ensaio clínico prospectivo com 36 mulheres com diagnóstico médico de IUE conrmado no estudo urodinâmico. Não foram incluídas mulheres com doenças neuromusculares, com uso de reposição hormonal e com prolapso grau III e IV. O protocolo de exercícios para os músculos do assoalho pélvico foi constituído de contrações lentas (bras tônicas), seguidas de contrações rápidas (bras fásicas), realizadas nas posições de decúbito dorsal, sentada e ortostática, três vezes na semana, por um período de três meses. Avaliou-se o impacto do TMAP na QV por meio do King's Health Questionnaire (KHQ), diário miccional e palpação digital para avaliar a função dos músculos do assoalho pélvico, durante a avaliação inicial e após os três meses de tratamento. O resultado foi descrito em médias e desvios-padrões. Utilizou-se o teste de Wilcoxon para comparação dos escores referentes ao KHQ para amostras pareadas, e adotou-se como nível de signicância o valor de 0,05. RESULTADOS: Observou-se diminuição signicativa das médias dos escores dos domínios avaliados pelos KHQ. Esses domínios consistem na percepção da saúde, impacto da incontinência, limitações das atividades diárias, limitações físicas, limitações sociais, relações pessoais, emoções, sono/disposição e também medidas de gravidade. Em concordância com esses resultados, foram observados diminuição signicativa na frequência urinária noturna e na perda urinária, bem como aumento signicativo na força e endurance muscular. CONCLUSÃO: O treinamento muscular do assoalho pélvico proporcionou melhora signicativa na QV de mulheres com IUE.

OBJECTIVE: To evaluate the impact of pelvic floor muscle (PFM) training on the quality of life (QOL) in women with stress urinary incontinence (SUI). METHODS: Prospective clinical trial with 36 women with a diagnosis of SUI confirmed by urodynamic study. Women with neuromuscular diseases, using hormone replacement therapy, and with prolapse stage III and IV were not included. The exercise protocol for the PFM consisted of slow contractions (tonic fibers), followed by rapid contractions (phasic fibers) practiced in the supine, sitting, and standing positions, three times a week for a period of three months. We evaluated the impact of PFM on QOL using the King's Health Questionnaire (KHQ), a voiding diary, and digital palpation to assess the function of the PFMs during the initial evaluation and after three months of treatment. The result was described as means and standard deviations. We used the Wilcoxon test for comparison of the KHQ scores for paired samples, and the significance level was set at 0.05. RESULTS: There was a significant decrease in the mean scores of the domains assessed by the KHQ regarding the perception of health, impact of the incontinence, limitations of daily activities, physical limitations, social limitations, personal relationships, emotions, sleep/disposition, and measures of severity. In agreement with these results, significant decrease in nocturnal urinary frequency and urinary incontinence, as well as significant increase in muscle strength and endurance were observed. CONCLUSION: PFM training resulted in significant improvement in the QOL of women with SUI.

Biofeedback for the treatment of female pelvic floor muscle dysfunction: a systematic review and meta-analysis.

Biofeedback (BF) has been widely used in the treatment of pelvic floor dysfunctions, mainly by promoting patient learning about muscle contraction with no side effects. However, its effectiveness remains poorly understood with some studies suggesting that BF offers no advantage over the isolated pelvic floor muscle training (PFMT). The main objective of this study was to systematically review available randomized controlled trials assessing the effectiveness of BF in female pelvic floor dysfunction treatment. Trials were electronically searched and rated for quality by use of the PEDro scale (values of 0-10). Randomized controlled trials assessing the training of pelvic floor muscle (PFM) using BF in women with PFM dysfunction were selected. Outcomes were converted to a scale ranging from 0 to 100. Trials were pooled with software used to prepare and update Cochrane reviews. Results are presented as weighted mean differences with 95 % confidence intervals (CI). Twenty-two trials with 1,469 patients that analyzed BF in the treatment of urinary, anorectal, and/or sexual dysfunctions were included. PFMT alone led to a superior but not significant difference in the function of PFM when compared to PFMT with BF, by using vaginal measurement in the short and intermediate term: 9.89 (95 % CI -5.05 to 24.83) and 15.03 (95 % CI -9.71 to 39.78), respectively. We found a few and nonhomogeneous studies addressing anorectal and sexual function, which do not provide the cure rate calculations. Limitations of this review are the low quality and heterogeneity of the studies, involving the usage of distinct protocols of interventions, and various and different outcome measures. The results of this systematic review suggest that PFMT with BF is not more effective than other conservative treatments for female PFM dysfunction.

Electromyographic evaluation of pelvic floor muscles in pregnant and nonpregnant women.

INTRODUCTION AND HYPOTHESIS: We compared the maximal voluntary contraction (MVC) and strength of pelvic floor muscles (PFM) of pregnant and nonpregnant women using surface electromyography (SEMG). METHODS: Fifteen pregnant primiparous women and 15 nulliparous nonpregnant women were evaluated. The healthy pregnant women were in the third trimester of pregnancy with a single fetus and did not have any neuromuscular alterations. The nonpregnant women did not present with PF dysfunctions and, as with the pregnant women, did not have any previous gynecological surgeries or degenerative neuromuscular alterations. The evaluation methods used were digital palpation (Oxford Grading Scale, which ranges from 0 to 5) and SEMG. In the EMG exam, MVC activity was evaluated, and the better of two contractions was chosen. Before the evaluation, all women received information about PFM localization and function and how to correctly contract PFM. RESULTS: In the EMG evaluation, MVC was significantly greater in the nonpregnant group (90.7 µv) than in the pregnant group (30 µv), with p < 0.001. The same results were observed after vaginal palpation, measured by the Oxford scale, which presented an average of 2.1 in the pregnant group and 4.5 in the nonpregnant group (p = 0.005). CONCLUSION: In comparison to nulliparous women, pregnant women demonstrated worse PFM function with decreased strength and electrical activity.

Efficacy of pelvic floor muscle training and hypopressive exercises for treating pelvic organ prolapse in women: randomized controlled trial.

CONTEXT AND OBJECTIVE: Previous studies have shown that women with pelvic floor dysfunctions present decreased cross-sectional area (CSA) of the levator ani muscle. One way to assess the effects of training programs is to measure the CSA of the muscle, using ultrasonography. The aim here was to evaluate the efficacy of pelvic floor muscle training and hypopressive exercises for increasing the CSA of the levator ani muscle in women with pelvic organ prolapse. DESIGN AND SETTING: Prospective randomized controlled trial at the Urogynecology outpatient clinic of Universidade Federal de São Paulo. METHODS: Fifty-eight women with stage II pelvic organ prolapse were divided into three groups for physiotherapy: a pelvic floor muscle training group (GI); a hypopressive exercise group (GII); and a control group (GIII). The patients underwent transperineal ultrasonographic evaluation using a transducer of frequency 4-9 MHz. The (CSA) of the levator ani muscle was measured before physiotherapy and after 12 weeks of treatment. RESULTS: The groups were homogeneous regarding age, number of pregnancies, number of vaginal deliveries, body mass index and hormonal status. Statistically significant differences in CSA were found in GI and GII from before to after the treatment (P < 0.001), but not in relation to GIII (P = 0.816). CONCLUSIONS: The CSA of the levator ani muscle increased significantly with physiotherapy among the women with pelvic organ prolapse. Pelvic floor muscle training and hypopressive exercises produced similar improvements in the CSA of the levator ani muscle.

Can hypopressive exercises provide additional benefits to pelvic floor muscle training in women with pelvic organ prolapse?

AIMS: The aim of the study was to compare the effect of hypopressive exercises including pelvic floor muscle contraction, pelvic floor muscle training (PFMT) alone and control on pelvic floor muscle function in women with pelvic organ prolapse (POP). METHODS: Fifty-eight women with a mean age of 55.4 (± 9.8) years old with stage II POP were randomly assigned to participate in the PFMT group, the hypopressive exercises associated with PFMT (HE + PFMT) group or the control group. Each treatment group underwent a 3-month course of treatment. The three groups received lifestyle advice regarding weight loss, constipation, coughing, and the avoidance of heavy lifting. Participants were evaluated before and after the treatment. Maximal voluntary contraction (MVC) and endurance were assessed using the Modified Oxford grading system. To evaluate muscle activation, surface electromyography (SEMG) was used. RESULTS: The two treatment group significantly increase pelvic floor muscle function as measured by MVC (P < 0.001) using the Modified Oxford grading system, as well as muscle activation (P < 0.001), measured by SEMG. The PFMT group was superior regarding endurance (P = 0.007). Both groups were superior to the control group regarding MVC, endurance and muscle activation. CONCLUSION: Adding hypopressive exercises to PFMT does not improve PFM function. Both treatment groups performed better than the control group.

[Effect the adding of biofeedback to the training of the pelvic floor muscles to treatment of stress urinary incontinence]. / Efeito da adição do biofeedback ao treinamento dos músculos do assoalho pélvico para tratamento da incontinência urinária de esforço.

PURPOSE: To investigate the effect of adding biofeedback (BF) to the training of pelvic floor muscles (PFMT) for the treatment of stress urinary incontinence (SUI). METHODS: A prospective pilot study, randomized and controlled with women with SUI without sphincter deficiency, detected by urodynamic study and who performed the correct PFM contraction. Women with neuromuscular disorders and grade III and IV genital prolapse were excluded. Forty women were randomized into a CONTROL GROUP and BF Group. The PFMT protocol with BF equipment consisted of three sets of ten slow contractions (tonic), with a holding time of six to eight seconds at each contraction followed by a rest period of equal duration. After each sustained contraction, they performed three to four fast contractions (phasic) in the supine and standing position twice a week, for a total of 12 sessions. We evaluated the effect of adding BF to PFMT on quality of life using King's Health Questionnaire (KHQ) regarding urinary symptoms based on a voiding diary and regarding the function of pelvic floor muscles by digital palpation. The evaluation was performed initially and after 12 treatment sessions. Data are reported as mean and standard deviation. The Mann-Whitney test was used for the analysis of homogeneity and to determine differences between groups, and the Wilcoxon test was used to determine possible differences between the times of observation, with the level of significance set at 0.05. RESULTS: A significant decrease in the scores of the domains assessed by the KHQ was observed in the comparison between groups, except for the general health domain (BF Group: 32.8 ± 26.9 versus CONTROL GROUP: 48.4 ± 29.5, p<0.13). Accordingly, there was improvement in PFM function after treatment in the BF Group, regarding power (4.3 ± 0.8, p= 0.001), endurance (6.0 ± 2.2, p<0.001) and fast (9.3 ± 1.9, p=0.001). When comparing the groups, the BF Group showed a positive result regarding power (BF Group 4.3 ± 0.8 versus CONTROL GROUP 2.5 ± 0.9, p<0.001), endurance (6.0 ± 2.2 BF Group versus CONTROL GROUP 2.7 ± 1.9, p<0.001) and fast (BF Group 9.3 ± 1.9 versus CONTROL GROUP 4.6 ± 3.2, p<0.001). Reduction of nocturnal urinary frequency (1.2 ± 1.2 versus 0.7 ± 0.9, p=0.02) and of effort urine loss (1.5 ± 1.4 versus 0.6 ± 0.8, p=0.001) was observed in the BF Group. CONCLUSION: The addition of BF to the PFMT for the treatment of SUI, applied according to the protocol described, improved PFM function, reduced urinary symptoms, and improved of the quality of life.