Impact of Pelvic Floor Muscle Training Isolated and Associated with Game Therapy on Mixed Urinary Incontinence: A Randomized Controlled Trial

Abstract

Objective:

To verify whether pelvic floor muscle training (PFMT) associated with game therapy (GT) can potentiate improvements in PFM pressure, urinary loss, and perception of improvement in women with mixed urinary incontinence (MUI).

Materials and Methods:

A randomized and blinded trial was conducted with 32 women aged between 45 to 70 years presenting diagnosis of MUI. They were randomly divided into two groups: PFMT group and PFMT+GT group. Interventions occurred twice a week during 8 weeks. Primary outcome was PFM pressure, assessed by manometry, and secondary outcomes were 1-hour pad-test, International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), and patients global impression of improvement for incontinence (PGI-I). Two-way analysis of variance and post hoc Tukey analysis were performed.

Results:

Initially, no significant difference between groups was found in variables of age, body mass index, educational level, marital status, gynecological and obstetric variables, life habits, and sexual activity. Besides, at baseline clinical variables also showed similar results between groups for PFM pressure, 1-hour pad-test, and ICIQ-SF. Time–group interaction did not present statistically significant differences for PFM pressure (P = 0.56), 1-hour pad-test (P = 0.75), and ICIQ-SF (P = 0.30) in intergroup analysis. All women reported being “much better or better,” considering the comparison of urinary complaints in the beginning and end of treatment.

Conclusion:

There were no statistically significant differences between groups for PFM pressure, 1-hour pad-test, and ICIQ-SF. However, both treatments proved to be effective for MUI symptoms. Perception of improvement was highly improved, according to women's report.

Introduction

Mixed urinary incontinence (MUI) has presented higher rates in middle aged and elderly individuals.¹ The physiological mechanism has been associated with intra-abdominal pressure increase and inadequate urethral closure, causing a high vesical pressure and consequently favoring urinary losses.² Besides, another condition that has caused urinary dysfunction is urgency incontinence, consequence of involuntary contractions of the detrusor muscle.^1,2

According to the International Continence Society, pelvic floor muscle training (PFMT) presents evidence level 1 and grade A for treatment of mixed and stress Urinary incontinence (UI).³ This intervention aims to strength fast and slow fibers to provide a greater support of pelvic organs and encourage urethral closure.³

UI symptoms improvement has been reported in pregnant women,⁴ female stroke patients,⁵ and women with loss of urine⁶ by using PFMT.⁷ This treatment improves muscle power, function, and quality of life.⁷ It is important to mention that strengthening of pelvic floor muscle (PFM) favors a conscious and effective contraction in moments of increased intra-abdominal pressure by improving tone and transmission of urethral pressure, thus avoiding urinary losses.⁸

Game therapy (GT) has been suggested as a new conservative modality for UI treatments.^9,10 This intervention is a form of virtual reality used to create an interface between people and machine that allows the users to interact with the elements within this simulated scenario.^11,12 GT approach has shown several advantages, such as activation of different muscle groups, boosting participation and motivation.¹³

There are still few studies that have investigated PFMT associated with GT^9,10 and only one study that associates virtual reality with PFM contraction, simultaneously.⁹ It is important to note that pelvic floor dysfunctions, such as UI, are conditions that do not threat life, but cause significant comorbidities. The presence of urinary symptoms can strongly affect patients' quality of life and promote physical, social, occupational, and sexual limitations.^7,14 Therefore, new approaches are necessary that encourage, motivate, and be part of movement routine to help improvements of UI. We hypothesized that PFMT associated with GT can promote better PFM pressure and decrease urinary loss than PFMT isolated. According to these assumptions, this study aims to verify whether PFMT associated with GT can potentiate improvements in PFM pressure, urinary loss, and perception of improvement in women with MUI.

Methods

Trial design

A randomized double blinded trial was conducted from July 2016 to July 2017, according to the Consolidated Standards of Reporting Trials (CONSORT) recommendations.¹⁵ The study was performed at the Laboratório Multiprofissional de Pesquisas Clínica e Epidemiológica from Onofre Lopes University Hospital, Natal. It was submitted to the Research Ethics Committee of the Federal University of Rio Grande do Norte, approved under the protocol number 1.438.219 and registered on virtual platform Brazilian Clinical Trials Registry (ReBEC) under the protocol RBR-6y7m8z. All participants signed the informed consent and the study was conducted in accordance with the principles of the Declaration of Helsinki.

Participants

The sample consisted of 32 women who were selected to participate in the study according to the following criteria: age between 45 and 70 years, do not have intact hymen, do not perform exercises for PFM, do not use hormone replacement therapy for at least 3 months, to present MUI, do not present loss of 1 g or less in the 1-hour pad-test, do not present null value in the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF),¹⁶ do not present level III or IV prolapse, according to the graduation system halfway (Baden-Walker),¹⁷ to be able to understand simple verbal commands, not fail to contract PFM isolated without contraction of abdominal hip adductors and glutes muscles, do not report unbearable pain during gynecological evaluation, do not present diagnosis of diabetes, neurological diseases, or history of epilepsy. Those who presented vaginal or urinary infection, got pregnant, or started taking medicines, which could influence in muscle performance, were excluded. It is important to mention that initially all women were taught about the correct way to perform muscle contractions during the evaluation. Up to three attempts were made, and if the volunteer did not adequately perform them, she would be excluded.

Interventions

Two sessions per week were performed during 8 consecutive weeks in both groups, each session lasted 40 minutes (PFM warmup during 5 minutes and exercise strengthening during 35 minutes). All the protocol is in accordance with studies that treated and assessed UI dysfunctions.¹⁸ Interventions were performed individually and the patients received educational guidance once a week about location and function of pelvic floor, bladder, and bowel physiological functioning, types of UI and general information about risk factors for pelvic floor, and onset of UI.

Treatment of the PFMT group was composed of three modalities: breathing, abdominal, and pelvic mobility exercises. All exercises were associated with PFM contraction and progressions were performed throughout training. Each exercise modality presented two sets of eight replicates in the first 4 weeks, and three sets of eight replicates in the last 4 weeks. The rest time between each exercise was 1 minute (Table 1).

Table 1.

Pelvic Floor Muscle Training Protocol

Week	Warmup	PFMT+breathing exercises	PFMT+abdominal exercises	PFMT+pelvic mobility exercises
1–2	PFM contractions (5 fast contractions and 5 slow contractions sustained for 3 seconds) 3 coughs+PFM contractions 8 standing plantar flexions+PFM contractions	Position: supine Action: diaphragmatic pattern	Position: supine Actions: transverse muscle contraction+PFM contraction; and bipodal support bridge+PFM contraction	Position: sitting on the Swiss ball Action: pelvic mobility
3–4	PFM contractions (5 fast contractions and 5 slow contractions sustained for 3 seconds) 3 coughs+PFM contractions 8 standing plantar flexions+PFM contractions	Position: seated Action: diaphragmatic pattern	Position: plank Action: plank posture maintenance+PFM contractions 5th session: 5 seconds +1 contraction 6th session: 10 seconds +2 contractions Position: supine Action: unipodal support bridge+PFM contractions 7th session: 15 seconds +3 contractions 8th session: 20 seconds +4 contractions	Position: standing Action: pelvic mobility
5–6	PFM contractions (5 fast contractions and 5 slow contractions sustained for 3 seconds) 5 coughs+PFM contractions 12 standing plantar flexions+PFM contractions	Position: standing Action: diaphragmatic pattern	Position: plank Action: plank posture maintenance+PFM contractions 9th session: 25 seconds +5 contractions 10th session: 30 seconds +6 contractions Position: supine Action: bridge bipodal support on Swiss ball+PFM contraction 11th session: 35 seconds +7 contractions 12th session: 40 seconds +8 contractions	Position: standing and four support Action: pelvic mobility
7–8	PFM contractions (5 fast contractions and 5 slow contractions sustained for 3 seconds) 5 coughs+PFM contractions 12 standing plantar flexions+PFM contractions	Position: sitting with Swiss ball support Action: diaphragmatic pattern	Position: plank Action: plank posture maintenance+PFM contractions 13th session: 45 seconds +9 PFM contractions 14th session: 50 seconds +10 PFM contractions Position: supine Action: bridge bipodal support in Swiss ball+PFM contraction 15th session: 55 seconds +11 PFM contractions 16th session: 60 seconds +12 PFM contractions	Position: four support Action: pelvic mobility

+, associated with; PFMs, pelvic floor muscles; PFMT, pelvic floor muscle training.

Interventions using GT+PFMT were performed by using the Wii Balance Board^®. Initially, the scale captured information about weight and mass center, and along with other information previously provided, such as height and age, associations were made to recreate the patient in a virtual environment. For this study, we used balance segments of the Wii Fit Plus^® games: Lotus Focus and Penguin Slide; and aerobic segments: Basic Step and Hula Hoop. All the performances were associated with PFM contractions and pelvic mobilizations (Table 2).

Table 2.

Game Therapy Associated with Pelvic Floor Muscle Training Group Protocol

Week	Warmup	PFMT+lotus focus	PFMT+penguin slide	PFMT+step basic	PFMT+Hula Hoop
1–4	PMF contractions (5 fast contractions and 5 slow contractions sustained for 3 seconds) 3 coughs associated with PMF contraction 8 standing plantar flexions associated with PFM	Position: seated Action: PMF contractions, controlling torso stability	Position: sitting on the scale Action: PFM contractions associated with pelvic mobility	Position: standing on the scale Action: PFM contractions associated with step up and down	Position: standing on the scale Action: PFM contractions associated with pelvic mobility
5–8	PFM contractions (5 fast contractions and 5 slow contractions sustained for 3 seconds) 5 coughs+PMF contractions 12 standing plantar flexions+PFM contractions	Position: seated Action: PMF contractions+controlling torso stability	Position: seated Action: PFM contractions+pelvic mobility	Position: standing on the scale Action: PFM contractions+step up and down	Position: standing on the scale Action: PFM contractions+pelvic mobility

Outcomes

Data collections were performed before interventions (initial evaluation) and after last intervention (final evaluation). During initial evaluation, information about sociodemographic data, pre-existing diseases, use of medication in the last 3 months, life habits, urogynecology, obstetric, and sexual history was collected. The height and weight were measured on physical examination. Besides, manometry of PFM, 1-hour pad-test, and ICIQ-SF were applied. In final evaluation, manometry of PFM, ICIQ-SF, 1-hour pad-test, and patients global impression of improvement for incontinence (PGI-I) were performed.

Primary outcome was PFM pressure that was assessed by the manometry, Peritron^™ model 9300AV. To perform it, the patients were, initially, instructed to empty their bladder, then lithotomy position was adopted. A conical sensor (probe) was introduced into the vaginal canal 9 to 10 centimeters to measure pressure generated by the PFM, in cmH₂O. After, they were instructed to perform three maximum contractions of the PFM, with a 30-second interval between them, without contraction of the abdominal, hip adductors, and gluteal muscles. The maximum value between the three trials was registered.¹⁹

Secondary outcomes were 1-hour pad-test, ICIQ-SF, and PGI-I. The 1-hour pad-test was performed to quantify urinary losses through a pad (previously weight). After placing it, close to the external urethral meatus, individuals ingested 500 mL of water at rest. After 15 minutes, volunteers performed some actions simulating activities of daily living (walk for 30 minutes, go up and down stairs [14 steps], sit and get up 10 times, cough 10 times, pick up objects on the floor five times, run in the same place for 1 minute, and wash the hands in running water for 1 minute).²⁰ Finally, the pad was removed and reweighed on a precision scale. Urinary loss was evaluated and classified according to the following criteria: 1 g or less, insignificant; between 1 and 10 g, mild loss; between 11 and 50 g, moderate loss; and >50 g, severe loss.²⁰

ICIQ-SF is a simple, brief, and self-administered questionnaire that classifies urinary loss. It was translated and validated into the Portuguese language by Tamanini et al.²¹ It consists of three questions that evaluate the frequency, severity, and impact of UI over quality of life.²¹

PGI-I is a global index that assesses a condition after intervention and is considered a simple scale that presents clinical applicability about intervention perception. This instrument was composed of a single question about the current urinary condition compared with the period before treatment, ranging from 1 (much better) to 7 (very much worse).²²

Sample size

Sample size was the result of a probabilistic sampling procedure performed by Miot²³ formula, using an α error of 1.96 (5%), β error of 0.84 (20%), and the minimum difference between the means was given through a pilot study developed in the urology clinic of University Hospital, which used manometry of the PFM as primary outcome, generating an amount of 13 patients per group.

Randomization and blinding

Women who followed eligibility criteria were randomized equally (1:1) into two groups: PFMT or PFMT+GT (pelvic floor muscle training associated with GT), by platform randomization.org. All assessments and interventions were performed by a blind researcher who was trained to accomplish it.

Statistical analysis

Sample data were analyzed through Statistical Package for the Social Science (SPSS 20.0) software. Komolgorov–Smirnov's test was used, to test normality of the data, and Levene's test to analyze the homogeneity of the variances. Descriptive statistics were used to characterize sociodemographic, clinical, anthropometric, gynecological, obstetric, and PGI-I variables. In addition, independent t-test evaluated the difference between the groups at initial evaluation.

The mixed variance (two-way analysis of variance) and post hoc Tukey analysis were performed to evaluate time–group interaction, and inter/intragroup differences for manometry, pad-test, and ICIQ-SF. The independent fixed variables were time (baseline and after intervention), group of stimulation (PFMT and PFMT+GT), and the interaction term. Sphericity was tested using Mauchly test and Greenhouse–Geisser correction was used when necessary. Statistical significance was set at P ≤ 0.05. Cohen f² effect size was calculated to identify the clinical practice impact on subgroup analyses when there was statistical significance. The effect of the clinical practice was rated as a small effect (f = 0.1), medium effect (f = 0.25), and large effect (d = 0.4). Statistical significance was set at P ≤ 0.05.

Results

Two hundred fourteen women were assessed; however, 182 did not meet inclusion criteria. Thirty-two people participated in the study and were included for analysis. Study process is represented in Figure 1.

FIG. 1.

Study flow diagram according to CONSORT 10. CONSORT, Consolidated Standards of Reporting Trials; GT, game therapy; PFMT, pelvic floor muscle training.

Sociodemographic profile, gynecological and obstetric characteristics, and life habits results are presented in Table 3. There were no statistical differences between groups before intervention. Most women did not present a regular menstrual cycle, were considered overweight, sedentary, and reported to be sexually active (Table 3).

Table 3.

Sociodemographic, Gynecological, Obstetric, and Lifestyle Characteristics of the Sample

Variables	PFMT (n = 16)	PFMT+GT (n = 16)	P
Sociodemographic
Age	50.12 ± 8.62	54.43 ± 9.96	0.20
BMI	28.72 ± 3.79	26.43 ± 3.61	0.96
Education
Incomplete elementary school	31.2%	31.2%
Completed elementary school	18.8%	18.8%
Completed high school	25.0%	43.7%
Bachelor degree	25.0%	6.3%
Marital status
Single without stable union	6.3%	12.5%
Single with stable union	18.7%	12.5%
Married	68.7%	31.3%
Widow	0%	6.3%
Divorced	6.3%	37.4%
Religion
Catholic	60.0%	93.7%
Evangelical	40.0%	6.3%
Gynecological and obstetric variables
Number of pregnancies	3.18 ± 1.68	3.06 ± 0.99	0.80
Type of birth
Normal	81.3%	50.0%
Cesarean section	0%	18.7%
Normal and cesarean section	18.7%	31.3%
Regular menstrual cycle
Yes	43.7%	31.3%
No	56.3%	68.7%
Life habits variables
Sedentary
Yes	62.2%	43.7%
Sexually active
Yes	68.7%	56.3%
No	31.3%	43.7%

PFMT+GT, PFMT associated with game therapy group.

There was no statistically significant difference between groups in the initial evaluation for manometry of PFM (P = 0.56), ICIQ-SF (P = 0.30), and 1-hour pad-test (P = 0.75). In addition, it was observed that there was no time–group interaction or even statistically significant intergroup differences after interventions for PFM manometry, 1-hour pad-test, and ICIQ-SF analysis (P > 0.05). Regarding intragroup analysis (both groups), statistical difference was observed in the PFM manometry (F_1.30 = 19.874; P = 0.000; f = 0.80; Power = 0.99), in 1-hour pad-test (F_1.30 = 45.531; P = 0.000; f = 1.29; Power = 1.00), and ICIQ-SF (F_1.30 = 25.285; P = 0.000; f = 0.93; Power = 0.99). When compared before and after treatment, 93.8% of patients in PFMT group reported being “much better or better,” whereas 81.3% of patients in the PFMT+GT group reported being “much better or better” (Table 4).

Table 4.

Pelvic Floor Muscle Pressure and Urinary Loss Before and After Interventions

Variables	PFMT (n = 16)		PFMT+GT (n = 16)		Effects
Variables	Before	After	Before	After	Effects
Manometry (cmH₂O)	23.45 ± 12.20	32.91 ± 12.13	26.23 ± 14.62	31.50 ± 12.08	Interaction (F_1.30 = 1.607; P = 0.215; f² = 0.23; power = 0.23)Intergroup (F_1.30 = 0.027; P = 0.871; f² = 0.03; power = 0.05)
1-hour pad-test (g)	2.69 ± 1.94	0.41 ± 0.20	2.32 ± 1.18	0.51 ± 0.31	Interaction (F_1.27 = 0.477; P = 0.496; f² = 0.13; power = 0.10)Intergroup (F_1.27 = 0.112; P = 0.740; f² = 0.06; power = 0.06)
ICIQ-SF	12.00 ± 3.98	6.33 ± 5.00	15.62 ± 3.34	8.12 ± 7.47	Interaction (F_1.29 = 0.489; P = 0.489; f² = 0.13; power = 0.10)Intergroup (F_1.29 = 4.070; P = 0.053; f² = 0.37; power = 0.49)

ICIQ-SF, International Consultation on Incontinence Questionnaire-Short Form.

Discussion

This study aimed to compare the efficacy of PFMT isolated and associated with GT in the treatment of MUI. The results showed that both interventions improved PFM pressure, intervention perception, and decrease urinary loss. However, no statistically significant differences were found in the variables between groups. Although there were no significant intergroup differences, a significant improvement in intragroup analysis (both groups) for PFM manometry was found. The PFMT group showed an increase in muscle pressure of 28.75% and PFMT+GT increased 16.74% after interventions.

The authors presented for the first time a classification scale with standard values of manometry of PFM by Peritron equipment.²⁴ According to the proposed scale, values of pressure in cmH₂O between 7.5 and 14.5 correspond to very weak; 14.6 to 26.5 correspond to weak; 26.6 to 41.5 correspond to moderate; 41.6 to 60.5 correspond to good; and >60.6 correspond to strong pressure.²⁴ In this study, we observed that interventions performed by both groups changed from weak to moderate PFM pressure.

Urinary losses also decreased in intragroup evaluation. Women from both groups obtained a final mean of <1 g, which according to the ICS is considered as continent.²⁵ Thus, it is suggested that both protocols can be used to treat and improve MUI. Oliveira et al.²⁶ showed in the systematic review that training programs from 8 to 12 weeks seem to reduce the amount of urine leakage, and/or to increase PFM strength. Some authors suggest that PFM strengthening is an effective treatment strategy for women with UI to promote the reduction of urogynecology symptoms due to increase of urethral closure pressure and pelvic organ support.^27–29 It is emphasized that both interventions proposed in this study aimed to strengthen PFM by training fast and slow fibers. Training both types of fibers is important for the maintenance of urinary continence and should be present in PFM rehabilitation programs.³⁰ The histological composition of PFM is composed of 70% of type I fibers with the function of maintaining the pelvic organs and 30% of type II fibers that are responsible for urethral closure during activities that trigger intra-abdominal pressure increase.³¹

The ICIQ-SF showed that urinary losses decreased 89.97% and 92.36% in PFMT and PFMT associated with GT, respectively. This information showed that both groups reduced from 5 to 7 points in the ICIQ-SF final score. Nystrom et al.³² evaluated 214 women with stress UI, before and after PFMT, and found 2.5 as a minimum clinically relevant difference in the total ICIQ-SF score.

Our data showed that PFMT isolated and associated with GT presented similar results. The effects of PFMT are known in the literature¹⁸; however, information about GT is somewhat new in PFM rehabilitation. Botelho et al.²⁹ found that isolated GT (without PFMT) was able to increase PFM contractility and decrease urinary symptoms in 27 postmenopausal women with MUI. Moreover, Elliott et al.⁹ associated virtual reality with PFMT and home exercises in 24 elderly women and the results showed a reduction of urinary loss. According to Dumoulin et al.,¹⁸ women treated with any type of strengthening approach for PFM are more likely to report cure, to have better quality of life or symptoms improvements, fewer episodes of urinary loss per day, and less urine loss based on 1-hour pad-test. This information corroborates the findings of this study, which showed improvements in pressure, urinary loss, and acceptance in both groups.

It is important to note that both interventions in this study requested PFM contractions associated with active contraction of transverse abdominal muscle. Junginger et al.³³ reported that attempts to coordinate actions between abdominal muscles and PFM in rehabilitation processes should be encouraged to increase awareness and perception of PFM. This study further demonstrated that exercises with a focus on the abdominal and pelvic cavity can promote strengthening of PFM by improving its functionality. Kamel et al.³⁴ also found a significant improvement in vaginal pressure, justifying that abdominal muscles can generate secondary activations of PFM, keeping their organization, sustenance, endurance, and muscular strength.³⁵ It is also added that recruitment of the transverse abdominal and internal oblique muscles leads to an activation of PFM, acting as part of an integrated abdominal pelvic unit.³⁶

This article has some limitations that deserve to be known. It was not a urodynamic study, instead diagnosis of MUI was performed by a urologist based on clinical signs and symptoms. Another point is a lack of bladder diary that could infer additional data about loss of urine. We believe that the educational level of the participants made it difficult.

Conclusion

PFMT associated with GT did not show better improvements than PFMT isolated in PFM pressure and urinary loss. Both interventions proved to be effective for the treatment of women with MUI. Treatments proposed in this study showed good acceptance, no withdrawal, and easy applicability, and demonstrated to be effective.

Footnotes

Authors' Contributions

L.O.B., M.C.E.O., H.K.V.S., and G.F.M.O. had full access to all of the data in the study and took responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design were carried out by L.O.B., M.C.E.O., and M.T.A.B.C.M. Acquisition of data was by L.O.B., M.C.E.O., H.K.V.S., and G.F.M.O. Analysis and interpretation of data were done by L.O.B., E.M.S.F., R.P., and M.T.A.B.C.M. Drafting of the article was performed by L.O.B., E.M.S.F., and M.T.A.B.C.M. Critical revision of the article for important intellectual content was carried out by A.K.S.G. and R.P. Study was supervised by M.T.A.B.C.M.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001.

References

Gajewski

, Schurch

, Hamid

, et al. An International Continence Society (ICS) report on the terminology for adult neurogenic lower urinary tract dysfunction (ANLUTD). Neurourol Urodyn, 2018; 37:1152–1161.

Pomian

, Lisik

, Kosieradzki

, Barcz

. Obesity and pelvic floor disorders: A review of the literature. Med Sci Monit, 2016; 22:1880–1886.

Abrams

, Cardozo

, Wagg

, Wein

. Incontinence, 2017. 6th International Consultation on Incontinence. Tokyo. 2016; 22:87–88.

Kahyaoglu Sut

, Balkanli Kaplan

. Effect of pelvic floor muscle exercise on pelvic floor muscle activity and voiding functions during pregnancy and the postpartum period. Neurourol Urodyn, 2016; 35:417–422.

Shin

, Shin

, Lee

, et al. Pelvic floor muscle training for urinary incontinence in female stroke patients: A randomized, controlled and blinded trial. Clin Rehabil, 2016; 30:259–267.

Kaya

, Akbayrak

, Gursen

, Beksac

. Short-term effect of adding pelvic floor muscle training to bladder training for female urinary incontinence: A randomized controlled trial. Int Urogynecol J, 2015; 26:285–293.

Radzimińska

, Strączyńska

, Weber-Rajek

, et al. The impact of pelvic floor muscle training on the quality of life of women with urinary incontinence: A systematic literature review. Clin Interv Aging, 2018; 13:957–965.

Hay-Smith

, Bø Berghmans LC, Hendriks HJ, et al. Pelvic floor muscle training for urinary incontinence in women. Cochrane Database Syst Rev, 2001; 1:CD001407.

Elliott

, de Bruin

, Dumoulin

. Virtual reality rehabilitation as a treatment approach for older women with mixed urinary incontinence: A feasibility study. Neurourol Urodyn, 2015; 34:236–243.

10.

Martinho

, Silva

, Marques

, et al. The effects of training by virtual reality or gym ball on pelvic floor muscle strength in postmenopausal women: A randomized controlled trial. Braz J Phys Ther, 2016; 20:248–257.

11.

Grealy

, Johnson

, Rushton

. Improving cognitive function after brain injury: The use of exercise and virtual reality. Arch Phys Med Rehabil, 1999; 80:661–667.

12.

Yavuzer

, Senel

, Atay

, Stam

. “Playstation eyetoy games” improve upper extremity-related motor functioning in subacute stroke: A randomized controlled clinical trial. Eur J Phys Rehabil Med, 2008; 44:237–244.

13.

Maggio

, Russo

, Cuzzola

, et al. Virtual reality in multiple sclerosis rehabilitation: A review on cognitive and motor outcomes. J Clin Neurosci, 2019; 65:106–111.

14.

Bø K, Talseth T, Vinsnes A. Randomized controlled trial on the effect of pelvic floor muscle training on quality of life and sexual problems in genuine stress incontinent women. Acta Obstet Gynecol Scand, 2000; 79:598–603.

15.

Moher

, Hopewell

, Schulz

, et al. CONSORT 2010 Explanation and Elaboration: Updated guidelines for reporting parallel group randomised trial. J Clin Epidemiol, 2010; 340:c869.

16.

Avery

, Donovan

, Peters

, et al. ICIQ: A brief and robust measure for evaluating the symptoms and impact of urinary incontinence. Neurourol Urodyn, 2004; 23:322–330.

17.

Persu

, Chapple

, Cauni

, et al. Pelvic Organ Prolapse Quantification System (POP–Q)—A new era in pelvic prolapse staging. J Med Life, 2011; 4:75–81.

18.

Dumoulin

, Cacciari

, Hay-Smith

EJC

. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev, 2018; 10:CD005654.

19.

Da Roza

, Mascarenhas

, Araujo

, et al. Oxford Grading Scale vs manometer for assessment of pelvic floor strength in nulliparous sports students. Physiotherapy, 2013; 99:207–211.

20.

Krhut

, Zachoval

, Smith

, et al. Pad weight testing in the evaluation of urinary incontinence. Neurourol Urodyn, 2014; 33:507–510.

21.

Tamanini

JTN

, Dambros

, D'Acona

CAL

, et al. Validation of the “International Consultation on Incontinence Questionaire-Short Form (ICIQ-SF)” for portuguese. Rev Saúde Pública, 2004; 38:438–444.

22.

Yalcin

, Bump

. Validation of two global impression questionnaires for incontinence. Am J Obstet Gynecol, 2003; 189:98–101.

23.

Miot

. Tamanho da amostra em estudos clínicos e experimentais. J Vasc Bras, 2011; 10:275–278.

24.

Angelo

, Varella

LRD

, de Oliveira

MCE

, et al. A manometry classification to assess pelvic floor muscle function in women. PLoS One, 2017; 12:e0187045.

25.

Abrams

, Cardozo

, Wagg

, Wein

. Incontinence 6th Edition (2017). Bristol UK: ICI-ICS. International Consultation on Incontinence-International Continence Society;, 2013; 978-0956960733.

26.

Oliveira

, Ferreira

, Azevedo

, et al. Pelvic floor muscle training protocol for stress urinary incontinence in women: A systematic review. Rev Assoc Med Bras, 2017; 63:642–650.

27.

Herderschee

, Hay-Smith

, Herbison

, et al. Feedback or biofeedback to augment pelvic floor muscle training for urinary incontinence in women. Cochrane Database Syst Rev, 2011; 6(7):CD009252.

28.

Sherburn

, Bird

, Carey

, et al. Incontinence improves in older women after intensive pelvic floor muscle training: An assessor-blinded randomized controlled trial. Neurourol Urody, 2011; 30:317–324.

29.

Botelho

, Martinho

, Silva

, et al. Virtual reality: a proposal for pelvic floor muscle training. Int Urogynecol J, 2015; 26(11):1709–12.

30.

Marques

, Stothers

, Macnab

. The status of pelvic floor muscle training for women. Can Urol Assoc, 2010; 4:419–424.

31.

Micussi

, Freitas

, Angelo

, et al. Evaluation of the relationship between the pelvic floor muscles and insulin resistance. Diabetes Metab Syndr Obes, 2015; 8:409–413.

32.

Nystrom

, Sjostrom

, Stenlund

, Samuelsson

. ICIQ symptom and quality of life instruments measure clinically relevant improvements in women with stress urinary incontinence. Neurourol Urodyn, 2015; 34:747–751.

33.

Junginger

, Baessler

, Sapsford

, Hodges

. Effect of abdominal and pelvic floor tasks on muscle activity, abdominal pressure and bladder neck. Int Urogynecol J, 2010; 21:69–77.

34.

Kamel

, Thabeth

, Tantawy

, Radwan

. Effect of abdominal versus pelvic floor muscle exercises in obese Egyptian women with mild stress urinary incontinence: A randomised controlled trial. Hong Kong Physiother J, 2013; 31:12–18.

35.

Sapsford

, Hodges

. Contraction of the pelvic floor muscles during abdominal maneuvers. Arch Phys Med Rehabil, 2001; 82:1081–1088.

36.

Madill

, McLean

. Relationship between abdominal and pelvic floor muscle activation and intravaginal pressure during pelvic floor muscle contractions in healthy continent women. Neurourol Urodyn, 2006; 25:722–730.