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DOI Number: 10.5958/j.0973-5674.8.1.

037
Indian Journal of Physiotherapy & Occupational Therapy. January-March 2014, Vol. 8, No. 1 193

Effectiveness of Antenatal Motor Relearning Approach of


Diaphragm, Deep Abdominal and Pelvic Floor Muscles
Versus Kegels Exercises on Postpartum Pelvic Floor
Muscle Strength
Siva Priya R1, Kokila V2, K Kanchana Malai3, Suresh Kumar S4
Assistant Lecturer, College of Allied Health Sciences, Gulf Medical University, Ajman, UAE, 2Associate Professor,
PSG College of Physiotherapy, 3Professor, Department of Obstetrics and Gynecology, PSG Hospitals, Coimbatore,
Tamil Nadu, India, 4Lecturer, Dr.M.V.Shetty College of Physiotherapy, Mangalore, Karnataka, India

ABSTRACT
Objective: To compare the effect of antenatal motor relearning approach of diaphragm, deep
abdominal and pelvic floor exercises versus kegels exercises on postpartum pelvic floor muscle
strength.
Design: Quasi experimental, Post test only design with a comparison group
Setting: Department of Obstetrics and Gynecology, PSG Hospitals.
Participants: 78 antenatal women randomly selected. Among the 78 women, 39 each were assigned
to Group A (interventional group) and to Group B (control group). Finally 21 women in each group
continued the treatment program.

Group A- antenatal motor relearning approach of diaphragmatic, deep abdominal and pelvic
floor muscles

Group B - kegels exercises

Outcome Measure: The pelvic floor muscle strength was measured using Perineometer on the third
postnatal day.
Results: Data from 42 women were analyzed. Independent 't' test was used as statistical tool. It has
been found that there is significant difference in the postpartum pelvic floor muscle strength between
the interventional and control group. The mean difference between the interventional and control
group were 1.762mm hg. The calculated 't' value using independent 't' test was 3.584 which was
greater than tabulated test statistic value of the 1.960 at (p<0.05).
Conclusion: The pelvic floor muscle strength was comparatively greater among the women who
performed antenatal motor relearning approach than kegels exercise group. Hence antenatal Motor
Relearning approach of diaphragmatic, deep abdominal and pelvic floor exercises can be implemented
during a normal pregnancy unless precluded by additional risk factors.
Keywords: Antenatal Motor Relearning Programme, Perineometer, Kegels exercises

Corresponding author:
Siva Priya R
Assistant Lecturer
College of Allied Health Sciences, Gulf Medical
University, Ajman
Email: UAE. Siva5pt@yahoo.co.in

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INTRODUCTION
The muscles of the pelvic floor are extremely
important for the internal organs as well as the bladder
and bowel function.1 The pelvic floor muscles are the

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194 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2014, Vol. 8, No. 1

only transversely placed muscles in the body. 1


Pregnancy and birth trauma are the major risk factors
for pelvic floor muscle injury.7 Like any other muscles
pelvic floor muscles need a regular work out to stay
strong, especially during pregnancy.3
An audit of NICE (National Institute of Clinical
Excellence) has revealed that pregnancy causes 19.970% of pelvic floor muscle weakness. 19 During
pregnancy, there are systemic signs that the body is
changing and expressed but changes that occurring to
Pelvic floor muscles, nerves and soft tissues are less
obvious.11It is important to have good pelvic floor
muscle strength before, during and after delivery.
During pregnancy weight of the uterus on the pelvic
floor causes these muscles to stretch and weakened
leading to pelvic floor dysfunction. Pelvic floor
muscles need particular attention during pregnancy
and post birth.16
Motor relearning programme incorporates
functional training for key motor tasks such as sitting,
standing, standing up, or walking. In this study the
key motor tasks such as contraction of pelvic floor,
normal breathing during contraction and deep
abdominal contraction during pelvic floor contraction
is analyzed.9 Each task is analyzed and the component
of the task which cannot be performed is noted. Motor
relearning programme trains the patient in those
missing or poorly performed components of the task
and ensures functional training for key motor tasks
such as contraction of pelvic floor, normal breathing
during contraction and deep abdominal contraction.
Different techniques are used to strengthen the
pelvic floor muscles like Kegels exercises, vaginal
cones and biofeedback apparatus. In this study the
pelvic floor muscles are strengthened using the 2
different approaches in the antenatal period and their
strength is assessed in the post natal period. The first
approach is Motor relearning approach of
diaphragmatic, deep abdominal and pelvic floor
muscles and the second approach is kegels exercises.

muscle strength. This forms the basis of need for the


present study.
MATERIALS

Perineometer

Sterile Gloves

Condoms

Gel

Cotton

Study Design: Two groups, between subjects,


Quasi experimental posttest only design was taken
where the posttest values were compared between two
groups and values were taken on the third post-partum
day.
Study Setting: The study was conducted among
antenatal women who visited for their check up in the
Department of Obstetrics and Gynecology at PSG
Hospitals
Criteria for Sample Selection
Inclusion Criteria

Age between 20-35years

Primigravida

Second trimester (16-22 weeks) of pregnancy

Exclusion Criteria

BMI>30

High risk pregnancies

Mentally retarded patients

Previous history of urinary incontinence

Any pelvic floor injury during delivery other than


episiotomy.

NEED FOR THE STUDY

POPULATION AND SAMPLING

There are studies stating about the pelvic floor


muscle weakness in pregnant women who underwent
an exercise protocol and pregnant sedentary women.
None of the studies have compared the effect of
antenatal Kegels exercises and antenatal Motor
relearning approach of diaphragmatic, deep
abdominal and pelvic floor muscles on pelvic floor

Seventy eight pregnant women participated in this


study, inform consent was taken from each participant.
The subjects were randomly assigned into two groups
(interventional and control group). Thirty nine subjects
in interventional group (Group A) received Motor
relearning approach exercises, and thirty nine subjects
in control group (Group B) received Kegels exercises.

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Indian Journal of Physiotherapy & Occupational Therapy. January-March 2014, Vol. 8, No. 1 195

Review was done once in every month till their


delivery. All participants maintained an exercise diary
and they were asked to tick the day when they
performed exercises. Subjects were asked to continue
exercises till 38 week (9 months). The diary was
checked during every follow up. In the post-partum
period, the pelvic floor muscle strength of 21 patients
of each group was taken for analysis.

Table 1. Demographic Table: Age and Body Mass


Index of the Subjects
Mean
Group

Age

BMI

A [ Motor relearning approach Group]

27.2

24.7

B [kegels exercise group]

26.5

24.2

GRAPH 1
Mean Value of Pelvic Floor Muscle Strength Between
Group A and Group B

Ethical Clearence: Obtained


Instrumentation

Group A- Motor relearning approach group

Perineometer was used to measure pelvic floor


muscle strength, which has a high intra rater reliability
[ICC (3, 1) =0.85].13 A standardize measuring procedure
using Perineometer was followed.

Group B- Kegels exercise group

Technique of Data Collection


The subjects were positioned in crook lying on the
bed without the pillow under the head and their knees
were flexed 90 degrees. Under aseptic precautions the
vaginal probe is inserted into the vaginal introitus. The
resting pressure was set at 0 mmHg. The patient is
instructed to contract their pelvic floor muscles. The
reading is monitored and recorded. Data obtained
from the subjects, were analyzed using Independent
t test. It was used to find out significant changes
between two groups.
Table 2. Post Test Statistics For Pelvic Floor Muscle Strength
Groups

Mean
[in mmHg]

Mean difference
[in mmHg]

Standard
deviation

t value

P value

A [ Motor relearning approach Group]

5.28

1.762

1.874

3.584

<0.05

B [kegels exercise group]

3.52

The independent t test was performed to analyze


the significance of pelvic floor muscle strength between
group A (motor relearning approach of diaphragmatic,
deep abdominal and pelvic floor muscles) and group
B (kegels exercise). In group A and group B the mean
pelvic floor strength of the participants were 5.28
mmHg and 3.52 mmHg respectively. The mean
difference between group A and group B was 1.762
mmHg. The calculated t value was 3.584 at p<0.05
which was greater than the table value of 1.960.
[Table-2]
RESULTS AND DISCUSSION
The aim of the study was to evaluate the effect of
antenatal motor relearning approach of diaphragmatic,
deep abdominal and pelvic floor exercises on postnatal

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1.249

mothers. It was hypothesized that there is significant


effect of Antenatal Motor relearning approach of
diaphragmatic, deep abdominal and pelvic floor
exercises than the Kegels exercises among the postnatal
mothers. Initially 78 participants were taken for the
study and were randomly assigned into two groups.
Group A (Interventional) received antenatal motor
relearning approach of diaphragmatic, deep
abdominal and pelvic floor muscles and Group B
(control) received Kegels exercises. The Mean age
group of participants in group A is 27.2 and group B is
26.5 and the Mean body mass index of participants in
group A and group B was 24.7 and 24.2 respectively.
[Table-1]
Each Group consists of 39 participants, initial
assessment was taken for all these participants and

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196 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2014, Vol. 8, No. 1

the missing components were trained and an


immediate review was done. All participants from
group A and group B attended the first review and
second review. In third review, 3 participants from
group A and 5 participants from group B withdrawn
from the study. In fourth review 5 participants from
group A and 1 participant from group B withdrawn
from the study. For last review (i.e. fourth) 31
participants in group A and 33 participants from group
B were present. In Group A from 31 participants, 3 had
Perineal tear, 5 went for Cesarean section and 2 did
not come for delivery. In Group B from 33 participants,
4 had Perineal tear, 4 went for cesarean section and 4
did not come for delivery. Finally post-partum pelvic
floor muscle strength was assessed for 21 participants
in each group.
It has been found that there is significant difference
in the post-partum pelvic floor muscle strength in
Group A and Group B. The mean difference between
the interventional and control group were 1.762mmHg.
The calculated t value using independent t test was
3.584 which was greater than tabulated test statistic
value of 1.960 at (p<0.05).Table-2
Statistical analysis between two groups showed
that there was greater improvement in postpartum
pelvic floor muscle strength in antenatal Motor
relearning approach of diaphragmatic, deep
abdominal and pelvic floor exercises than kegels
exercises.
CONCLUSION
During Pregnancy Pelvic floor muscle strength is
influenced by hormones, biomechanical and structural
changes mainly of the weight of the uterus and intraabdominal pressure rise during pregnancy.
Pelvic floor muscle strength is essential to maintain
throughout to prevent the long term risk of pelvic floor
dysfunction. The postpartum pelvic floor muscle may
regain over months and years. Since the pelvic floor
muscle is crucial to be exercised, the exercise regimen
can be started in the antenatal period. When pelvic
floor exercises are incorporated with the co-contraction
of deep abdominal and proper breathing pattern the
effects would be long lasting and can be easily
incorporated into functional activities in daily living.
The statistical analysis done from the posttest
values from the measurements of Perineometer
showed that antenatal motor relearning approach of
diaphragm, deep abdominal and pelvic floor muscles

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has significant effect on improving the pelvic floor


muscle strength among postnatal mothers than Kegels
exercises. So it is impulsive that physiotherapist must
include antenatal Motor relearning approach of
diaphragm, deep abdominal and pelvic floor
strengthening exercises as a part of routine antenatal
exercise program.
There is greater improvement in postpartum
pelvic floor muscle strength in antenatal motor
relearning approach of diaphragm, deep abdominal
and pelvic floor strengthening than kegels exercises.
ACKNOWLEDGEMENT
The authors are thankful to Principal, Prof. R
.Mahesh., MPT. PSG college of Physiotherapy, Dr.
Seetha Panicker., Professor and Head, Department of
Obstetrics and Gynecology, PSG Hospitals,
Coimbatore, Tamilnadu for kindly providing facilities
to carry out this work.
Conflicts of Interest
The pelvic floor muscle strength in this study is
assessed in the immediate postnatal period, which in
the late postnatal period may have natural resolution
of gaining strength. The results might show
improvement in the pelvic floor muscle strength when
the assessment is taken in the long term period
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