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Female Urology, Urodynamics, Incontinence,
and Pelvic Floor Reconstructive Surgery
Effects of Stabilization Exercises
Focusing on Pelvic Floor Muscles on
Low Back Pain and Urinary
Incontinence in Women
Fariba Ghaderi, Khadijeh Mohammadi, Ramin Amir Sasan, Saeed Niko Kheslat, and
Ali E. Oskouei
OBJECTIVE To investigate the effects of stabilization exercises focusing on pelvic floor muscles on both low
back pain (LBP) and urinary incontinence (UI) in women suffering from chronic nonspecific LBP.
METHODS In a randomized clinical trial, 60 women, ranging from 45 to 60 years old, with chronic nonspe-
cific LBP and stress UI were recruited. They were randomly assigned to the control group (n = 30)
that received routine physiotherapy modalities and regular exercises, or the training group (n = 30)
that received routine physiotherapy modalities and stabilization exercises focusing on pelvic floor
muscle (12 weeks). Clinical characteristics of the study subjects including UI intensity and quality
of life assessed by International Consultation on Incontinence Questionnaire-Urinary Inconti-
nence Short Form questionnaire, functional disability assessed by Oswestry disability index scores,
pain intensity, pelvic floor muscle strength and endurance, and transverses abdominis muscle strength
were measured before and after treatment.
RESULTS Functional disability and pain intensity were significantly decreased in control (P<.05) and train-
ing groups (P<.05), with no significant difference between the groups after treatment. However,
UI intensity was smaller for the training group (P<.05). Pelvic floor muscle strength and en-
durance, and transverses abdominis muscle strength were statistically increased in the training
group compared with those in the control group (P<.05).
CONCLUSION Stabilization exercises focusing on pelvic floor muscle improves stress UI as well as LBP in women
with chronic nonspecific LBP. UROLOGY 93: 50–54, 2016. © 2016 Elsevier Inc.
Low back pain (LBP) is considered as one of the most
common musculoskeletal conditions in industrial
countries, with more than 70%-80% of people who
experienced it at least once in their lives.1,2 Its preva-
lence in nurses and pregnant women in Iran has been re-
ported to be 62% and 84%, respectively.3,4 LBP has a major
influence on general health and is usually associated with
decreased health-related conditions as well as quality of life.
The economic and social costs of LBP are substantial and
need to be highly considered in the management of LBP.5
Hence, different treatment strategies for LBP have been
proposed by researchers and therapists. Therapeutic exer-
cises in mechanical LBP have been widely accepted and
documented by different studies.6
Eliasson et al investigated 200 women with LBP and
found that 78% of them suffer from stress urinary incon-
tinence (UI) as well, suggesting a hypothesis that there
might be an association between LBP and UI.7Stress UI
is defined as an involuntary leakage of urine during an effort
or exertion, or on coughing, sneezing, and laughing.8Stress
UI has a high prevalence in women, and factors such as
age, pregnancy, childbirth, and hormone-related condi-
tions have been reported to increase its prevalence. UI has
a negative and undeniable impact on health and quality
of life that affects social, psychological, occupational, physi-
cal, and sexual activities of the sufferers.9,10
The stability system of the spine is composed of the mus-
cular, structural, and neural subsystems, which normally work
in harmony and provide mechanical stability. The muscles
responsible for the spine stability, surrounding the abdomen
Financial Disclosure: The authors declare that they have no relevant financial
interests.
Funding Support: This study was supported by the Physical Medicine and Rehabilita-
tion Research Center affiliated with the Tabriz University of Medical Sciences.
From the Department of Physiotherapy, Faculty of Rehabilitation, Tabriz University
of Medical Sciences, Tabriz, Iran; the Department of Sport Physiology, Faculty of Physi-
cal Education and Sport Sciences, University of Tabriz, Tabriz, Iran; and the Physical
Medicine and Rehabilitation Research Center, Tabriz University of Medical Sciences, Tabriz,
Iran
Address correspondence to: Ali E. Oskouei, Ph.D., Department of Physiotherapy, Physi-
cal Medicine and Rehabilitation Research Center, Tabriz University of Medical Sci-
ences, Valiasr St., Tabriz, Iran. E-mail: eterafoskouei@tbzmed.ac.ir
Submitted: December 8, 2015, accepted (with revisions): March 16, 2016
50 http://dx.doi.org/10.1016/j.urology.2016.03.034
0090-4295
© 2016 Elsevier Inc.
All rights reserved.
and spine as a capsule, work as a synergy.11 They include the
diaphragm superiorly, pelvic floor muscles (PFM) inferiorly,
transverses abdominis (TrA) anteriorly, and deep lumbar ex-
tensors muscles posteriorly.12,13 Among these muscles, PFM
has an important role not only in trunk and lumbo-pelvic sta-
bility but also in maintenance of continence. The double func-
tion of PFM may describe more the occurrence of UI in women
with LBP found by Eliasson et al.7
Furthermore, coactivation of PFM and deep abdomi-
nal muscles, specifically TrA, has been reported to happen
in voluntary contraction of PFM and abdominal stabiliz-
ing exercises in such a way that it is hard, if not impos-
sible, to contract the PFM without the contraction of the
deep abdominal muscles.14 The finding on the synergetic
activation pattern of the deep abdominal muscles and the
PFM might be a good reason to consider coactivation of
the abdominal muscles and PFM in the rehabilitation
program of patients with LBP and UI.
There is some evidence showing improvement in either
LBP or UI by performing PFM exercise.15,16 To our knowl-
edge, there are no studies investigating the effect of one
type of exercise on LBP and UI simultaneously. Despite the
fact that stabilization and PFM exercises seem to improve
LBP and UI, respectively, performing only 1 type of exer-
cise to improve both conditions, that is, LBP and UI si-
multaneously, has not been established yet. Therefore, the
purpose of this study was to investigate the effects of “sta-
bilization exercises focusing on PFM” on both LBP and UI
simultaneously in women suffering from both conditions
in comparison with routine physiotherapy treatment.
We hypothesized that the stabilization exercises focus-
ing on pelvic floor muscle is associated with improve-
ment in LBP and UI simultaneously. If so, the effectiveness
of stabilization exercises focusing on PFM on UI and LBP
might be caused by coactivation of the abdominal muscles,
specifically TrA and PFM.
METHODS
In a randomized clinical trial, registered in Iranian Reg-
istry of Clinical Trials (IRCT) with the number
2014081218760N1, 60 women with chronic nonspecific
LBP and stress UI ranging from 45 to 60 years old and who
had an experience of 2 or 3 normal delivery were re-
cruited. Subjects were excluded from the study if they met
any of the following criteria: experience of the pelvic surgery
or spine, malignant condition, pelvic or spine fracture, had
twins or more, and have LBP with specific condition.17
The qualifying subjects were first informed of the study
purpose and the treatment methods. Written informed
consent was then obtained from all of the subjects, and the
protocol was approved by the Tabriz University of Medical
Sciences Ethics Committee.
Sixty subjects were randomly assigned to the control
group (n = 30 women), which received routine physio-
therapy modalities including transcutaneous electrical nerve
stimulation (TENS), hot pack, and therapeutic ultra-
sound, and regular exercises or the training group (n = 30
women), which received routine physiotherapy modali-
ties and stabilization exercises focusing on PFM.
For the control and training groups, TENS was admin-
istered to the low back area for 20 minutes each session,
3 days a week (10 sessions), at a frequency of 110 Hz, with
a pulse duration of 90 μs, and at an intensity that pro-
duced a comfortable tingling sensation. Therapeutic ul-
trasound was then administrated to the low back area for
10 minutes per session, at a frequency of 1 MHz, with an
intensity of 1 W/cm2and a duty cycle of 50%.
Following the routine physiotherapy modalities, pa-
tients in the control group performed the regular exer-
cises including the strengthening and endurance exercises
for the abdominal and paravertebral muscles 3 days a week,
3 sets a day, and 10 repetitions of each exercise. For the
last 9 weeks, the patients met the physiotherapist once a
week for monitoring of exercise progression (12 weeks in
total) without receiving physiotherapy modalities.
The training group was identical to the control group,
except that the patients performed the progressed stabili-
zation exercises for the deep abdominal and lumbar muscles
focusing on PFM at 30% of maximal voluntary contrac-
tion as shown in Figure 1.
All exercises in both groups were separated by a 2-minute
rest interval.
In both control and training groups, exercises (regular
or stabilization) were taught by a physiotherapist, and a
booklet and video CD including exercise instruction were
provided by the subjects.
UI intensity of the subjects was evaluated by the Inter-
national Consultation on Incontinence Questionnaire-
Urinary Incontinence Short Form questionnaire, which was
composed of 6 questions and responses ranged from no UI
to severe UI.
Functional disability of the subjects was evaluated by a
validated Persian version of the Oswestry disability index
questionnaire,18,19 and pain intensity was rated from 0 to
10 by using visual analog scale, which indicated no pain
and maximum pain, respectively. PFM strength was evalu-
ated by vaginal examination using Oxford grading scale from
no contraction (0 grade) to normal (5 grade).12 Length of
time the subjects were able to maintain PFM maximal vol-
untary contraction was evaluated by vaginal examina-
tion as PFM endurance.12 TrA muscle strength was assessed
using pressure biofeedback (Stabilizer TM, Chattanooga
Group) in crook lying position.20
The outcome measures were taken during the first and
last sessions (hereafter called before and after treatment,
respectively).
Statistical Analysis
The mean, standard error, and percentage improvement in
outcome measures were calculated for all patients in the
control and training groups. Statistical analysis was per-
formed using Statistical Package for Social Sciences, version
17.0 (SPSS, Chicago, IL). The data for each group were
tested for the normal distribution with the Kolmogorov-
Smirnov test.
51UROLOGY 93, 2016
Differences within and between the two groups were as-
sessed using paired ttest and independent samples ttest,
respectively. Significance was accepted for values of P<.05
in all analysis.
RESULTS
A total of 60 subjects with LBP and UI were studied. De-
scriptive statistics of the subject’s characteristics are pre-
sented in Table 1. The outcome measure showed a normal
distribution in each group. Clinical characteristics of the
subjects including UI intensity assessed by the Interna-
tional Consultation on Incontinence Questionnaire-
Urinary Incontinence Short Form questionnaire, functional
disability assessed by Oswestry disability index scores, pain
intensity, strength and endurance of the PFM, and strength
of TrA muscle are presented in Table 2. There was no sta-
tistically significant between-group differences in any clini-
cal characteristics of the study patients with LBP and UI
before treatment (Table 2,P>.05). Functional disability
and pain intensity were significantly lower in both control
(P<.05) and training groups (P<.05) after treatment, with
no significant difference between the groups. However, UI
intensity was smaller only for the training group (P<.05)
after treatment.
PFM strength, PFM endurance, and TrA strength were
statistically greater in the training group compared with
those in the control group (P<.05).
The comparison of clinical characteristics between two
groups revealed that the percentage of improvement in UI
intensity, PFM strength, PFM endurance, and TrA strength
in the training group was significantly greater than those
in the control group. However, there was no significant dif-
ference between the 2 groups with regard to functional dis-
ability and pain intensity (Table 3).
DISCUSSION
The present study revealed that the regular exercise and
stabilization exercise focusing on PFM improved func-
tional disability and pain intensity. The improvement in
these clinical characteristics may be attributable to the
routine physiotherapy modalities including TENS, hot pack,
and therapeutic ultrasound. The effectiveness of these mo-
dalities for pain relief and improvement in functional dis-
ability in patients with LBP and UI has been reported by
some studies.21 Previous studies have reported that TENS
activates the gate control mechanism, and that therapeu-
tic ultrasound decreases inflammation that may result in
improvement in pain intensity in patients with LBP.22
Here we add the result that improvement in PFM
strength and endurance, TrA strength, and UI intensity
also occurs in patients with LBP and UI who performed
stabilization exercises for the deep abdominal and lumbar
muscles focusing on PFM. TrA muscle strength, among those
improvements, plays an important role in back mechani-
cal stability23 that was significantly observed in this study
only in the training group that received stabilization ex-
ercises focusing on PFM.
Figure 1. Examples of stabilization exercises focusing on PFM. In all exercises, subjects were asked to perform coactivation
of the abdominal muscles and PFM while they maintain the corresponding positions. PFM, pelvic floor muscles.
Table 1. Descriptive statistics (mean ±SE) of the sub-
ject’s characteristics with LBP and UI in control and train-
ing groups
Characteristics Control Group Training Group
Age (y) 52.6 ±1.06 53.2 ±1.1
Height (cm) 162.2 ±0.7 162.4 ±0.7
Weight (kg) 73.6 ±1.68 75.4 ±0.9
BMI (kg/m2) 27.5 ±0.8 26.6 ±0.7
BMI, body mass index; LBP, low back pain; UI, urinary incontinence.
52 UROLOGY 93, 2016
A literature review of the effects of stabilization exer-
cises on pain and disability intensities as well as TrA muscle
strength by using ultrasonography, electromyography, or pres-
sure biofeedback revealed that stabilization exercises improve
TrA muscle function.21,23
In the present study, we used stabilization exercises fo-
cusing on PFM and observed that the improvement in PFM
strength and endurance and TrA muscle strength, mea-
sured by pressure biofeedback,20 occurred, suggesting that
the improvement in the muscle function was caused by per-
forming stabilization exercises.
In studies on patients with UI, there was significant
improvement in PFM function and stress UI symptoms
that were treated by PFM exercises or a combination of
PFM exercises and stabilization exercises.14,24,25 In another
study, pain and disability of patients with LBP were
decreased after performing PFM exercises compared with
the regular exercises, which might in turn lead to an
improvement in PFM strength and endurance.6,18 Need-
less to say, PFM exercises and stabilization exercises differ
from stabilization exercises focusing on PFM in which all
improvements including functional disability, pain inten-
sity, PFM strength and endurance, as well as TrA strength
occurred.
The possible mechanism behind the effectiveness of the
stabilization exercises focusing of PFM on UI (Table 3)
might be associated with coactivation of TrA muscle and
PFM that might lead to an improvement in UI in pa-
tients with chronic nonspecific LBP and UI.26,27 Al-
though pain intensity significantly decreased in control and
training groups after treatment (Tables 2 and 3), there was
no between-group changes with regard to improvement in
pain intensity. This may further suggest that improve-
ment in pain is attributed to routine physiotherapy
treatment.21 Unlike pain reduction and functional disabil-
ity, the TrA strength was similar in the control group before
and after routine physiotherapy, indicating that this may
increase the risk of LBP recurrency, as TrA is assumed to
function as a main back stabilizer.23
Continence is controlled by tonic and phasic muscles
of the PFM. In other words, closure pressure of urinary tract
is considered as the main factor in controlling urine during
an effort or exertion, coughing, and sneezing, which results
in an increased intra-abdominal pressure. In such func-
tional activities, PFM along with the abdominal muscles
are activated to control continence.25 In other words, PFM
need to obstruct urinary tract and anus before intra-
abdominal pressure is increased. The effectiveness of PFM
exercises in patients with LBP and UI on UI improve-
ment is confirmed by some studies in patients only with
stress UI.14,25 Furthermore, the effectiveness of PFM exer-
cise on LBP due to coactivation of TrA muscle and PFM
has been reported in some studies of patients with LBP.6,17,28
A systematic review on PFM exercises showed that stabi-
lization exercises focusing on PFM caused an improve-
ment in UI only in patients with stress UI. Taking these
Table 2. Within-group changes in clinical characteristics (mean ±SE) of the study subjects with LBP and UI in control
and training groups before and after treatment
Clinical Characteristics
Control Group Training Group
Before After PValue Before After PValue
UI intensity 11.46 ±0.24 11.03 ±0.26 .13 11.26 ±0.32 7.90 ±0.41 .00
Functional disability 42.20 ±1.04 13.06 ±0.84 .00 41.06 ±1.04 14.33 ±0.60 .00
Pain intensity 6.91 ±0.32 2.96 ±0.17 .00 6.75 ±0.33 2.17 ±0.18 .00
PFM strength 2.96 ±0.15 3.03 ±0.13 .16 3.20 ±0.13 3.93 ±0.16 .00
PFM endurance (s) 6.10 ±0.18 6.13 ±0.17 .32 6.13 ±0.17 7.70 ±0.34 .00
TrA strength (mmHg) 68.66 ±0.84 66.20 ±0.83 .09 69.03 ±3.59 63.70 ±0.43 .00
Abbreviations as in Table 1.
Bold values indicate statistically significant within-group changes.
UI intensity assessed by the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form questionnaire;
functional disability assessed by Oswestry disability index score; pain intensity assessed by visual analog scale; pelvic floor muscles
(PFM) strength and endurance assessed by vaginal examination; transverses abdominis (TrA) muscle strength assessed by pressure
biofeedback.
Table 3. Between-group changes in clinical characteristics of the study subjects with LBP and UI in control and training
groups after treatment
Clinical Characteristics
Changes in Control Group Changes in Training Group
Mean ±SE Improvement (%) Mean ±SE Improvement (%)
UI intensity 0.433 ±0.28 3.7 3.36 ±0.48 29.8*
Functional disability 29.13 ±1.40 69 26.73 ±1.07 65
Pain intensity 3.95 ±0.19 57.2 4.58 ±0.26 67.8
PFM strength 0.06 ±0.05 2.4 0.73 ±0.16 22.8*
PFM endurance (s) 0.33 ±0.03 0.5 1.56 ±0.35 25.6*
TrA strength (mmHg) 2.46 ±0.52 3.6 5.33 ±0.55 7.7*
Abbreviations as in Table 1.
Bold values indicate statistically significant between-group changes.
*P<.05.
53UROLOGY 93, 2016
into account, it appears that stabilization exercises focus-
ing on PFM can improve UI as well as LBP in patients suf-
fering from chronic nonspecific LBP, as we observed in our
study.
In conclusion, routine physiotherapy modalities includ-
ing TENS, hot pack, and therapeutic ultrasound seem to
improve functional disability and pain intensity. On the
other hand, the stabilization exercises focusing on PFM im-
proved the UI intensity, PFM strength and endurance, and
TrA muscle strength. Therefore, stabilization exercises fo-
cusing on PFM can be used as an effective treatment for
patients with chronic nonspecific LBP and UI.
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54 UROLOGY 93, 2016
