The effects of training by virtual reality or gym ball on pelvic floor muscle strength in postmenopausal women: a randomized controlled trial

Martinho, Natalia M.; Silva, Valéria R.; Marques, Joseane; Carvalho, Leonardo C.; Iunes, Denise H.; Botelho, Simone

doi:10.1590/bjpt-rbf.2014.0148

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Brazilian Journal of Physical Therapy

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Original Articles • Braz. J. Phys. Ther. 20 (3) • May-Jun 2016 • https://doi.org/10.1590/bjpt-rbf.2014.0148 copy

The effects of training by virtual reality or gym ball on pelvic floor muscle strength in postmenopausal women: a randomized controlled trial

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective

To evaluate the effectiveness of abdominopelvic training by virtual reality compared to pelvic floor muscle training (PFMT) using a gym ball (a previously tested and efficient protocol) on postmenopausal women’s pelvic floor muscle (PFM) strength.

Method

A randomized controlled trial was conducted with 60 postmenopausal women, randomly allocated into two groups: Abdominopelvic training by virtual reality – APT_VR (n=30) and PFMT using a gym ball – PFMT_GB (n=30). Both types of training were supervised by the same physical therapist, during 10 sessions each, for 30 minutes. The participants’ PFM strength was evaluated by digital palpation and vaginal dynamometry, considering three different parameters: maximum strength, average strength and endurance. An intention-to-treat approach was used to analyze the participants according to original groups.

Results

No significant between-group differences were observed in most analyzed parameters. The outcome endurance was higher in the APT_VR group (p=0.003; effect size=0.89; mean difference=1.37; 95% CI=0.46 to 2.28).

Conclusion

Both protocols have improved the overall PFM strength, suggesting that both are equally beneficial and can be used in clinical practice. Muscle endurance was higher in patients who trained using virtual reality.

Keywords:
physical therapy; menopause; muscle strength dynamometer; pelvic floor; virtual reality exposure therapy

	APT_VR (n=30)	PFMT_GB (n=30)
Age M(SD)	61.9 (8.6)	61 (8.5)
BMI M(SD)	28.1 (3.9)	28 (3.7)
Physical activity (f / %)
No	9 (30)	9 (30)
Yes (twice per week)	10 (33.3)	8 (26.7)
Yes (3-7 times per week)	11 (36.7)	13 (43.3)
Urinary incontinence (f / %)
Absence	9 (30)	7 (23.3)
SUI symptoms	3 (10)	7 (23.3)
UUI symptoms	8 (26.7)	6 (20)
MUI symptoms	10 (33.3)	10 (33.4)
Hormonal history
Years of post-menopause M(SD)	13.3 (8.1)	13 (8.5)
Hormone replacement (f / %)
Have never had	16 (53.3)	16 (53.3)
Were having^* * Hormone replacement therapy that has been stable for at least six consecutive months.	4 (13.4)	2 (6.7)
Had previously had	10 (33.3)	12 (40)
Obstetric history
Parity (f / %)
Nulliparous	5 (16.7)	3 (10)
Primiparous/Multiparous	25 (83.3)	27 (90)
Number of pregnancies M(SD)	3.5 (2.7)	3.9 (2.9)
Delivery mode (f / %)
Exclusively vaginal	21 (70)	14 (46.7)
Exclusively cesarean	3 (10)	7 (23.3)
Vaginal and cesarean	3 (10)	5 (16.7)
No delivery	3 (10)	4 (13.3)

	DIGITAL PALPATION
		Pre-training	Post-training	Time p-value ¹ 1 Wilcoxon Test.	Between –Group differences p-value ² 2 Mann-Whitney Test.
Per-protocol analysis	APT_VR (n=27) f (%)			0.0001 ^* * p≤0.05.	0.7
	0	0 (0)	0 (0)
	1	1 (4)	0 (0)
	2	17 (63)	8 (30)
	3	8 (30)	15 (56)
	4	0 (0)	3 (11)
	5	1 (4)	1 (4)
	PFMT_GB (n=20) f (%)			0.001 ^* * p≤0.05.
	0	0 (0)	0 (0)
	1	4 (20)	1 (5)
	2	6 (30)	6 (30)
	3	7 (35)	4 (20)
	4	3 (15)	8 (40)
	5	0 (0)	1 (5)
Intention-to-treat analysis	APT_VR (n=30) f (%)			0.0001 ^* * p≤0.05.	0.7
	0	0 (0)	0 (0)
	1	2 (7)	1 (3)
	2	18 (60)	9 (30)
	3	8 (27)	15 (50)
	4	1 (3)	4 (14)
	5	1 (3)	1 (3)
	PFMT_GB (n=30) f (%)			0.0005 ^* * p≤0.05.
	0	0 (0)	0 (0)
	1	5 (17)	2 (7)
	2	11 (36)	11 (37)
	3	9 (30)	6 (20)
	4	5 (17)	10 (33)
	5	0 (0)	1 (3)

		Within-group analysis
		Pre-training	Post-training	*p-value*¹ 1 Wilcoxon Test. ,² 2 Paired t Test.	*Power*	*Effect size*	Between-group mean differences	95% CI	*p-value* ³ 3 Mann-Whitney Test.	*Power*	*Effect size*
Per-protocol analysis	APT_VR (n=20)						–0.08 (MS) 0.01 (AS) 1.83 (E)	–0.25 – 0.08 (MS) –0.05 – 0.09 (AS) 0.61 – 3.05 (E)	0.1(MS) 0.6 (AS) 0.007^* * p≤0.05. (E)	0.68 (MS) 0.60 (AS) 0.93 (E)	0.32 (MS) 0.17 (AS) 1.04 (E)
	Maximum strength (Kgf) M(SD)	0.58 (0.4)	0.67 (0.6)	0.1	0.29	0.17
	Average strength (Kgf) M(SD)	0.23 (0.2)	0.28 (0.2)	0.02 ^* * p≤0.05.	0.36	0.24
	Endurance (seconds) M(SD)	3.12 (1.7)	4.03 (2.4)	0.05 ^* * p≤0.05.	0.57	0.42
	PFMT_GB (n=15)
	Maximum strength (Kgf) M(SD)	0.71 (0.3)	0.89 (0.4)	0.02 ^* * p≤0.05.	0.74	0.46
	Average strength (Kgf) M(SD)	0.32 (0.1)	0.34 (0.2)	0.5	0.52	0.11
	Endurance (seconds) M(SD)	4.27 (2.1)	3.35 (1.7)	0.04 ^* * p≤0.05.	0.75	0.48
Intention-to-treat analysis	APT_VR (n=23)						–0.03 (MS) 0.02 (AS) 1.37 (E)	–0.16 – 0.09 (MS) –0.03 – 0.07 (AS) 0.46 – 2.28 (E)	0.5 (MS) 0.3 (AS) 0.003^* * p≤0.05. (E)	0.52 (MS) 0.6 (AS) 0.9 (E)	0.14 (MS) 0.31(AS) 0.89 (E)
	Maximum strength (Kgf) M(SD)	0.57 (0.4)	0.65 (0.5)	0.1	0.56	0.16
	Average strength (Kgf) M(SD)	0.2 (0.1)	0.3 (0.2)	0.02 ^* * p≤0.05.	0.6	0.21
	Endurance (seconds) M(SD)	2.93 (1.7)	3.73 (2.4)	0.05 ^* * p≤0.05.	0.73	0.37
	PFMT_GB (n=24)
	Maximum strength (Kgf) M(SD)	0.63 (0.3)	0.74 (0.4)	0.02 ^* * p≤0.05.	0.67	0.29
	Average strength (Kgf) M(SD)	0.3 (0.1)	0.3 (0.1)	0.5	0.51	0.06
	Endurance (seconds) M(SD)	4.12 (2.1)	3.54 (1.9)	0.04 ^* * p≤0.05.	0.67	0.28

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[1] *Correspondence Simone Botelho Universidade Federal de Alfenas Escola de Enfermagem Curso de Fisioterapia Avenida Jovino Fernandes Sales, 2600, Santa Clara Edifício C, Sala101-K CEP 37130-000, Alfenas, MG, Brazil e-mail: simone.botelho@unifal-mg.edu.br