Pelvic Floor Muscle Training in Gymnasts With Stress Urinary Incontinence

April 2, 2022 updated by: Kari Bø, Norwegian School of Sport Sciences

Effect of Pelvic Floor Muscles Training on Symptoms, Bother and Amount of Stress Urinary Incontinence in Female Gymnasts, Team Gymnasts and Cheerleaders. An Assessor Blinded Randomized Controlled Trial

There is a high prevalence of urinary incontinence (UI) among female athletes participating in high impact sports, such as artistic gymnastics, trampoline jumping and ball games. UI is defined as "the complaint of involuntary loss of urine". Stress urinary incontinence (SUI) is the most common type of UI and is defined as "the complaint of involuntary loss of urine on effort or physical exertion (e.g. sporting activities), or or sneezing or coughing". Urinary leakage during sport activities may affect the athletes' performance, cause bother, frustration and embarrassment and furthermore lead to avoidance and cessation of sport activities. Pelvic floor muscle (PFM) training is highly effective in treating SUI in the general female population. However, evidence of the effect of PFM training in elite athletes in high impact sports is sparse.

The purpose of this assessor-blinded randomized controlled trial (RCT) is to assess the effect of PFM training on symptoms, bother and amount of SUI in female artistic gymnasts, team gymnasts and cheerleaders.

Study Overview

Status

Terminated

Intervention / Treatment

Detailed Description

BACKGROUND:

Physical activity and exercise have well-known beneficial effects on several physical and psychological health outcomes. However, it has been proposed that regular participation in physical activity and exercise may lead to greater risk of developing pelvic floor dysfunctions (PFD) in women. The pelvic floor consists of muscles, fascia and ligaments and forms a hammock-like support at the base of the abdomino-pelvic cavity. The function of the pelvic floor is to provide support to the pelvic organs (the bladder, urethra, vagina, uterus and rectum) and to counteract all increases in intra-abdominal pressure and ground reactions forces during daily activities. Additionally, the pelvic floor facilitates intercourse, vaginal birth, storage of stool and urine and voluntary defecation and urination. A dysfunctional pelvic floor can lead to urinary and anal incontinence, pelvic organ prolapse, sexual problems and chronic pain syndromes. UI is the most common PFD, defined as "the complaint of involuntary loss of urine". SUI, urgency urinary incontinence (UUI) and mixed urinary incontinence (MUI) are common subtypes of UI. In women, SUI accounts for approximately half of all incontinence types and is defined as "the complaint of involuntary loss of urine on effort or physical exertion (e.g. sporting activities), or on sneezing or coughing". UUI is defined as the "complaint of involuntary loss of urine associated with urgency" and MUI as "complaints of both stress and urgency urinary incontinence".

High prevalence rates of UI among both parous and nulliparous female athletes and exercisers have been reported in several cross-sectional studies. The prevalence rates varies between 0-80% with the highest prevalence found in high impact sports such as trampoline jumping, gymnastics and ball games. Leakage during sport activities may affect the athletes' performance and cause bother, frustration and embarrassment. Some athletes have reported that UI issues have also led to avoidance or cessation of sport or exercise.

To date, there is level 1 evidence and grade A recommendation for PFM training alone to be first line treatment for SUI, MUI and pelvic organ prolapse in the general female population. In addition, PFM training is highly effective as primary prevention; pregnant continent women who exercise the PFM are at 62% less risk of UI in late pregnancy and 29% less risk of UI 3-6 months postpartum. Evidence of the effect of PFM training in athletes or strenuous exercisers is sparse.

In one study on female soldiers and two small case series in female athletes and exercisers, PFM training led to reduced symptoms of UI. However, none of these studies included a non-treated control group and the internal validity is therefore low. To our knowledge, only one RCT has assessed effects of PFM training on SUI in athletes. Female volleyball players (n=16) who followed a PFM training program had significant improvements of SUI compared to a control group (n=16).

Based on today's knowledge we do not know whether PFM training is effective in elite athletes exposed to excessive impact in sports including elements of acrobatics and jumping. Given the high impact on the pelvic floor in these athletes, it is presumed that they need much better pelvic floor muscle function than non-exercisers. On the other hand, elite athletes are highly motivated for regular training. Strength training of the PFM, if proven effective, may be easily incorporated in their basic training regimens both as prevention and treatment strategies of SUI.

AIMS:

The aim of this RCT is to assess the effect of PFM training on symptoms, bother and amount of SUI among female artistic gymnasts, team gymnasts and cheerleaders.

STUDY DESIGN AND METHODS:

A cross-sectional study will be conducted to assess prevalence of SUI among female artistic gymnasts, team gymnasts and cheerleaders from 12 years of age competing on high national levels in Norway. Athletes reporting symptoms of SUI will be asked to participate in the RCT.

The study is an assessor-blinded RCT evaluating the effect of PFM training on SUI in elite female gymnasts, team gymnasts and cheerleaders. At baseline, all athletes will perform a pad weight-test, measuring the amount of leakage during gymnastic and acrobatic activities. In addition, the athletes will respond to a standardized questionnaire, measuring self-reported symptoms of UI and bother. The athletes will be randomly assigned to either a PFM training group (EG) or a control group (CG) with no intervention. The intervention consists of a daily home-based PFM training program with weekly follow-up by a physiotherapist. After a three-months intervention period, all athletes will perform a post-test including the same previous mentioned outcome measures.

Study Type

Interventional

Enrollment (Actual)

4

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

      • Oslo, Norway, 0863
        • Norwegian School of Sport Sciences, Department of Sport Medicine

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

10 years and older (Child, Adult, Older Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

Female

Description

Inclusion Criteria:

  • female artistic gymnasts, team gymnasts and cheerleaders
  • eligible to compete in the Norwegian National Championship or competitions of higher levels
  • > 12 years of age
  • total score on ICIQ-UI-SF of >3
  • positive pad weight-test: >1 gram of leakage
  • self-reported SUI with ICIQ-UI-SF (urinary leakage during physical activity, exercise, sneezing or coughing)

Exclusion Criteria:

  • history of pregnancy, pelvic surgery, pelvic trauma, inflammatory bowel diseases or respiratory diseases/symptoms
  • male gymnasts
  • < 12 years of age
  • not eligible to competed in the Norwegian National Championship or competitions of higher levels
  • athletes who are unable to correctly contract the PFM, examined by suprapubic transabdominal 2D ultrasound

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: Single

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
No Intervention: Control Group
No intervention
Experimental: Intervention Group
Three months home-based PFM training program with weekly follow-up by a physiotherapist
The intervention will consist of a home-based PFM training program with weekly follow-up by phone by a physiotherapist. Before commencing PFM training, the gymnasts in the intervention group will have an individual session with a physiotherapist including thorough teaching on how to perform a correct PFM contraction (inward lift of the pelvic floor assessed with suprapubic 2D ultrasound) and instructions on how to perform the training program. The athletes will be offered at least one individual follow-up session with the same physiotherapist during the intervention period. The program will consist of 3 sets of 8-12 maximum contractions per day. An electronic app (Athlete monitoring) will be used to assess adherence to the program. The athletes will be asked to register their training sessions in a personal account. A reminder to adhere to the program will be sent by phone. The training period will be 3 months and the exercises will take approximately 10 minutes per day to perform.
Other Names:
  • Pelvic Floor Muscle Training in Elite Gymnasts

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Pad-weight Stress Test for Stress Urinary Incontinence
Time Frame: Change from baseline pad-test at three months
The test will be modified from the descriptions by Mørkved & Bø, Eliasson, Larsson & Mattson and Ferreira et al. The athletes will be requested to void 30 minutes before the test, to drink 0.5 liter of water and thereafter not empty their bladder. A pre-weighted pad will be applied, and the athletes will perform a 10 minutes intensive warm-up followed by 5 minutes of high impact gymnast- or cheerleading routines.
Change from baseline pad-test at three months

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
The International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI-SF)
Time Frame: Change in total score from baseline at three months
A reliable and valid questionnaire assessing self-reported prevalence, amount of leakage, bother and type of UI. A change in ICIQ-UI-SF score of 1.58 points will be considered as between-treatment minimum important difference.
Change in total score from baseline at three months
Patient Global Impression of Improvement (PGI-I) Scale
Time Frame: Post-test after a 3-months intervention period
The gymnasts will be asked to rate their perceived change of the condition. A validated 7-point scale with response choices ranging from "very much better" to "very much worse" will be used.
Post-test after a 3-months intervention period
Self-Efficacy Scale for Practicing Pelvic Floor Exercises (SESPPFE)
Time Frame: At baseline in both groups. Athletes in the intervention group will also be asked to answer the questionnaire again within the first month of the intervention period.
The gymnasts will be asked to rate their self-efficacy (from 0-100) on 16 different items regarding PFM training. The scale have been tested to have good internal consistency (α = 0.92) and acceptable reliability (rho = 0.89).
At baseline in both groups. Athletes in the intervention group will also be asked to answer the questionnaire again within the first month of the intervention period.

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Investigators

  • Study Chair: Kari Bø, PhD, Norwegian School of School of Sport Sciences

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

January 20, 2020

Primary Completion (Actual)

August 19, 2020

Study Completion (Actual)

August 19, 2020

Study Registration Dates

First Submitted

October 4, 2019

First Submitted That Met QC Criteria

October 9, 2019

First Posted (Actual)

October 10, 2019

Study Record Updates

Last Update Posted (Actual)

April 5, 2022

Last Update Submitted That Met QC Criteria

April 2, 2022

Last Verified

April 1, 2022

More Information

Terms related to this study

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

No

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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