Floor Muscle Training and Neurogenic Overactive Bladder in Stroke and Multiple Sclerosis

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© Springer Nature Switzerland AG 2020
G. Lamberti et al. (eds.)Suprapontine Lesions and Neurogenic Pelvic DysfunctionsUrodynamics, Neurourology and Pelvic Floor Dysfunctionsdoi.org/10.1007/978-3-030-29775-6_9

9. Pelvic Floor Muscle Training and Neurogenic Overactive Bladder in Stroke and Multiple Sclerosis

Kari Bø1, 2  

Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway

Department of Obstetrics and Gynecology, Akershus University Hospital, Akershus, Norway



Kari Bø


ExerciseMultiple sclerosisPelvic floor musclesStrokeStrengthStress urinary incontinenceTrainingUrgency urinary incontinence

9.1 Introduction

Pelvic floor muscle training (PFMT) has Level 1 evidence and A recommendation for treatment of urinary incontinence (UI) in the female population [13]. The Cochrane review [1] on 31 randomized controlled trials (RCTs)/quasi RCTs in 1817 women from 14 countries compared PFMT with no treated control groups in trials of women with stress urinary incontinence (SUI), urgency urinary incontinence (UUI), and mixed urinary incontinence (MUI). Women with SUI who did PFMT were eight times more likely to report cure (56% vs. 6%; risk ratio (RR) 8.38, 95% confidence interval (CI) 3.68–19.07). They had statistically significant better improvement in quality of life (QoL), fewer UI episodes, and less UI on pad test compared to controls. The effect was higher in women with SUI only and with supervised training. Based on this evidence and that PFMT has no adverse effects, PFMT is recommended as first-line treatment for UI in women [13]. RCTs of PFMT on UI in men have so far focused on post-prostatectomy incontinence [1, 2]. However, the results differ and are not as convincing as for women, although single RCTs with high methodological and interventional quality have found statistically significant and clinically relevant results [4].

The rationale for PFMT to treat and prevent SUI is that strength training of the muscles will improve structural support of the bladder and urethra by lifting the pelvic floor higher into the pelvis, narrow the levator hiatus area, prevent descent during rise in intra-abdominal pressure, and increase maximum urethral closure pressure [5]. Such morphological changes have been shown in an assessor-blinded RCT [6]. The rationale for PFMT to prevent and treat OAB symptoms is based on a theory that contraction of the PFM will inhibit urgency to void and detrusor contraction [7]. Shafic and Shafic [8] found a significant decrease in detrusor pressure and increase in urethral pressure and no leakage in patients with OAB symptoms during a single PFM contraction during urgency. However, to date there is no strong evidence from RCTs that PFMT alone is effective in treatment of overactive bladder (OAB) symptoms (nocturia, frequency, urgency, and (UUI) [7].

UI is prevalent in the general population and causes distress and reduced quality of life [9]. In patients with neurological diseases this adds to the total burden of an illness with reduced mobility. UI may be caused by neurological diseases and be the first symptom of such conditions, but many of these patients may also have different forms of UI caused by other factors before they present with neurological diseases such as stroke, multiple sclerosis (MS), or Parkinson’s disease.

The aim of this chapter is to review the scientific literature of RCTs on PFMT after stroke and in patients with MS and Parkinson’s disease. Furthermore it aims to give some recommendations to guide clinical practice and future clinical research.

9.2 Methods

This is a narrative review on PFMT for UI in patients after stroke and patients with MS and Parkinson’s disease. Search on Cochrane library of systematic reviews, NICE guidelines, and the chapter of Van Kampen and Geraerts in Evidence based physical therapy for teh pelvic floor. Bridging science and clinical prcatice [10]—were used to find relevant studies of PFMT for UI in patients with stroke, MS, and Parkinson’s disease. In addition, search for new studies on PubMed of May 2019 using the terms stroke AND pelvic floor muscle training or multiple sclerosis or AND pelvic floor muscle training was performed. Only randomized controlled trials written in English language were included. The interventions could include PFMT alone or a combination of other conservative interventions such as bladder training, electrical stimulation, or transcutaneous tibial nerve stimulation. Studies including pharmacotherapy were excluded.

9.3 Results

No randomized controlled trials were found of PFMT on UI in patients with Parkinson’s disease. This was supported by a recent systematic review on management of neurogenic bladder in Parkinson’s disease that only found two pilot studies, one on PFMT and one on bladder training. Their conclusion was that well-designed RCTs are needed [11]. One Cochrane review from 2008 was found on treatment of UI after stroke [12]. Results of the RCTs of PFMT for UI in patients with stroke or MS are shown in Tables 9.1 and 9.2.

Table 9.1

Randomized controlled trials (RCTs) of pelvic floor muscle training (PFMT) for urinary incontinence (UI) in stroke patients. Chronological order




Diagnosis of UI

Training protocol



Results on PFM function

Results on UI

Tibaek-04, 05 [13, 14]

Assessor-blinded two-arm RCT:

1. PFMT n = 14

2. Control n = 12

No treatment for UI, standard rehabilitation program

26 women. Mean age 60 years (range 56–74) after ischemic stroke

UI assessed by IIQ-7 (urgency, stress, and mixed incontinence)

12 weeks of PFMT

6-, 3-, and 30-s contractions. Every contraction 4–8 times in different positions. Conducted in groups + individual assessment with vaginal palpation and home exercise 1–2 times/day

2 dropouts (8%)


Statistically significant increase in PFM endurance compared with control

Statistically significant improvement in PFMT in frequency of daytime voiding from 7 to 6 (p = 0.018), 24-h pad test from 8 to 2 g (p = 0.013)

No effect in SF-36 or IIQ-7



6-month follow-up of assessor-blinded RCT

1. PFMT n = 12

2. Control n = 12

24 women with postischemic stroke

UI assessed by IIQ-7

Same as Tibaek (2005)



Telephone interview: Trend, but not statistically significant difference between groups in Short form SF-36 or IIQ-7

Shin-16 [16]

Assessor-blinded two-arm RCT:

1. PFMT (n = 16) general rehabilitation + PFMT

2. Control (n = 15) general rehabilitation

31 female patients >3 months post-stroke

SUI assessed by B-FLUTS

6 weeks of PFMT

3 dropouts


After intervention:

Manometry (mmHg):

1. 18.35 (5.24)

2. 8.46 (3.50)

sEMG ((μV):

1. 12.09 (2.24)

2. 9.33 (3.40)

B-FLUTS Change of scores:


1. −15.00 (6.25)

2. −0.17 (1.59)

Score of symptoms:

1. −4.17 (4.00)

2. −0.25 (1.29) p < 0.05


Tibaek-17 [17, 18]

Assessor-blinded two-arm RCT

1. Control: General rehabilitation, n = 15

2. General rehabilitation + PFMT, n = 15

31 post-stroke men, median age 68


3 months of 12-weekly 60-min sessions of group PFMT with physical therapist including anal assessment + home exercise

1 dropout

Median PFMT adherence 11/12 (92%)

Anal palpation

Statistically significant better improvement (p > 0.03) in PFM function in PFMT than control in short term, but not long term


No sign difference in change between groups

SF-36 and nocturia QoL questionnaire: No statistically significant difference between groups

B-FUTS Bristol Female Lower Urinary Tract Symptom Questionnaire, DAN-PSS-1 Danish Prostate Symptom Score, IIQ-7 Incontinence Impact Questionnaire, PFM pelvic floor muscles, PFMT pelvic floor muscle training, QoL quality of life

Table 9.2

Randomized controlled trials (RCTs) of pelvic floor muscle training (PFMT) on urinary incontinence (UI) in patients with multiple sclerosis (MS. Chronological order)




Diagnosis of UI

Training protocol



Results PFM function

Results outcome

Vahtera-97 [19]

Not blinded two-arm RCT:

1. PFMT + interferential ES, n = 40

2. No treatment for LUTD, n = 40

50 women and 30 men with MS, age range 25–68

LUTS by self-administered questionnaire

6 months of 10 times 3-s contractions, 5 times 5-s contractions, 5 times 15-s contraction in different positions.

ES: interferential, carrier frequency: 2000 Hz, frequency, 5–19 Hz, 10–50 Hz, and 50 Hz (10 min of each). Six sessions during 21 days outpatient. Home exercise: 20 contractions 3–5 days/week in sitting and standing position

2/40 in treatment group

No information about controls



Sign improvement over control, p < 0.01

Significant improvement in intervention over control group in UI, nocturia, and urgency p < 0.001, QoL (traveling, social shame, and need for pads)

McClurg-06 [20]

Not blinded three-arm RCT:

1. PFMT + advice n = 10

2. PFMT + advice + EMG biofeedback n = 10

3. PFMT + advice + sEMG biofeedback + ES n = 10

30 women with MS, age range 33–67

Leakage on voiding diary, 24-h pad test, uroflowmetry

9-week treatment period, assessment at weeks 0, 9, 16, 24

ES: biphasic constant current, 5–30 min daily, two parameter settings: 40 Hz, 5-s on, 10-s off

10 Hz, 10-s on, 3-s off



Vaginal palpation

Number of leaks (p = 0.014) and pad test (p = 0.001) significantly better in group 3 compared to group 1 and between groups 2 and 1 for pad test (p = 0.001)

McClurg-08 [21]

Assessor and subject-blinded two-arm RCT:

1. Control: PFMT, biofeedback + placebo ES, n = 37

2. ES: PFMT, biofeedback + ES, n = 37

74 women with MS, age range 27–72

Leakage on voiding diary, 24-h pad test, uroflowmetry

9-week treatment, assessment at weeks 0, 9, 16, 24

ES: biphasic constant current, 5–30 min daily, two parameter settings: 40 Hz, 5-s on, 10-s off

10 Hz, 10-s on, 3-s off



Vaginal palpation, sEMG

Sign difference in favor of ES for leakage, 24-h pad test



Not blinded two-arm RCT:

1. Bladder rehab, n = 40

2. Control: usual care, n = 34

74 women with MS, age range 29–65


Inpatient program: 3 h/day over 6 weeks

Outpatient program: 30 min 2–3 times/week

Therapy: individual, assessment of bladder type, diary with strict fluid, PFMT, timed voiding



Significant difference in favor of intervention in UDI-16, NSD, AUA, IIQ-7 (p < 0.01). Improvement in bladder function, overactivity and QoL

Lucio-10, -11 [23, 24]

Assessor-blinded two-arm RCT

1. PFMT with vaginal manometry, n = 18

2. Sham PFMT: Insertion of vaginal instrument with no contraction, n = 17

35 women with MS, age range 20–49

Lower urinary tract dysfunction assessed with urodynamics

30 min 2 times/week for 12 weeks (outpatient)

PFMT with vaginal manometer: 30 slow contractions, 3 min of fast contractions, supine position. Home exercise: 3 × 30 slow contractions, 3 min with fast contractions



Vaginal manometry. Statistically significant improvement in muscle strength, endurance, resistance, number of fast contractions, p < 0.001

Between-group differences in favor of PFMT:

Pad test: 87.5–6.03 vs. 69.46–75.88, p < 0.001

Number of pads: 3.61–2.15 vs. 3.42–3.28, p = <0.01

Nocturia events: 2.38–0.46 vs. 2.55–2.47, p > 0.001, ICIQ, OAB questionnaire, medical outcome study, QoL: Qualiveen questionnaire.

No sign difference in urodynamics

Gaspard-14 [25]

Assessor-blinded RCT:

1. PFMT + biofeedback n = 16

2. Transcutaneous posterior tibia nerve stimulation n = 15

31 participants

EDSS score <7 and lower urinary tract symptoms

9 session of 30 weekly sessions

1. Muscle endurance and relaxation

2. Rectangular alternative biphasic current with low frequency


No information. Article in French. Abstract in English.

Statistically significant improvement in QoL, frequency of urgency episodes, but no difference between groups

Ferreira-15 [26]

Assessor-blinded RCT:

1. PFMT + ES

2. Home PFMT

24 women, mean age 43.2 years (10.68)

Moderate stage of MS, 3.0–5.0 EDSS

48 sessions 2 times /week over 6 months with physical therapist

Electrostimulation, 2 Hz, 1 ms pulse duration, tolerable intensity on S4 dermatome- perineum + 3 sets of 10 PFM contractions per day

Control group; 10 sets of home PFM contractions per day


Vaginal palpation. Group 1 had statistically significant improvement over the control group in al sub-scores, p < 0.001

QoL: Only statistical significant difference in “Restrictions,” p = 0.0031, OAB: statistically significant difference in change in favor of Group 1, p = 0.039.

Hospital anxiety and depression: no statistically significant difference between groups

Lucio-16 [27]

Assessor-blinded RCT

1. PFMT with sEMG biofeedback + sham ES, n = 10

2. PFMT with sEMG biofeedback + ES, n = 10

3. PFMT with sEMG + transcutaneous tibial nerve stimulation, n = 10

30 women with MS, 42–52 years old

MS with EDSS score <6.5

LUTS: score ≥ 9 on


Urodynamic assessment


12-week intervention with physical therapist 50 min twice a week

5 dropouts


Ability to contract PFM: vaginal palpation.

Statistically significant improvement in Group 2 in PFM tone, flexibility, ability to relax PFM

24-h pad test: no difference between groups

OAB-V8: Group 2 significant improvement over other groups, p < 0.01

AUA American Urology Association, EDSS Expanded Disability Status Scale in Multiple Sclerosis, ES electrical stimulation intravaginal), ICIQ-UI-SF International Consultation of Incontinence Questionnaire-urinary incontinence-short form, LUTS lower urinary tract symptoms, NMES neuromuscular electrical stimulation, NSD Neurological Disability Scale, OAB-V8 Overactive Bladder Questionnaire, version 8, PFM pelvic floor muscle, QoL quality of life, sEMG surface electromyography, UDI-16 Urogenital Distress Inventory

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Mar 23, 2021 | Posted by in ABDOMINAL MEDICINE | Comments Off on Floor Muscle Training and Neurogenic Overactive Bladder in Stroke and Multiple Sclerosis
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