Submitted by Nadir Basilio (nadirsb@uninove.br) on 2018-07-20T20:10:21Z No. of bitstreams: 1 Erica Feio Carneiro Nunes.pdf: 1021018 bytes, checksum: 040c57768f7aed071b8aa73bd056ade6 (MD5) / Made available in DSpace on 2018-07-20T20:10:21Z (GMT). No. of bitstreams: 1 Erica Feio Carneiro Nunes.pdf: 1021018 bytes, checksum: 040c57768f7aed071b8aa73bd056ade6 (MD5) Previous issue date: 2018-03-06 / Contextualization: Weakening of pelvic floor muscles (PMFs) has been considered a major cause of stress urinary incontinence (SUI). In this way, the physiotherapeutic treatment, classically, turned to the strengthening of these muscles. In this study it was hypothesized that, in addition to PMFs weakness, this dysfunction may also be related to a change in the pattern of reflex response of these muscles. Objective: The study objectives were to compare the contraction response time and strength of cough-induced PMFs among continents and SUI women, and to conduct a literature review on the use of biofeedback for pelvic floor muscle training in women with this dysfunction. Methods: Study II: A systematic review was conducted with a search of the databases Science Direct, Embase, MEDLINE, Pedro, SciELO, CINAHL and LILACS for randomized clinical trials that had biofeedback (BF) as a therapeutic tool for SUI. Study II: This was a cross-sectional study that evaluated the cough PMFs of 20 healthy women and 20 women with SUI. The clinical evaluation consisted of the application of questionnaires that assessed the severity of urinary incontinence and quality of life. Signal capture was performed with a 4-channel acquisition system (EMG System do Brasil Ltda®) to capture the signals obtained through vaginal dynamometry, electromyography (EMG) of the right external obliquus muscle and accelerometry. Statistical analysis was performed using the Shapiro-Wilk, independent t test or Mann-Whitney test according to the data distribution and the covariance analysis (ANCOVA) with post hoc Bonferrone test. The statistical significance considered for all tests was p <0.05. Results: Study I: the training of the PMFs with BF was not better than the control group (without training and orientation, vaginal electrical stimulation). However, these contradictory results and poor quality of the studies are probably not clinically significant. Study II: the contraction response of the PMFs was significantly different between the groups for the activation time of the PMFs (F = 19.51, P <0.0001, p2= 0.61), external oblique muscle activation time (F = 11.41, P <0.002, p2= 0.23) and time of the cough pulse (F = 4.21, P <0.04, p2= 0.10). Conclusion: The systematic review provides evidence that the training of BF-PMFs does not offer superior therapeutic benefits to other types of interventions in the treatment of female SUI. The cross-sectional study showed that women with SUI have delayed cough-induced contraction of PMFs. / Contextualização: O enfraquecimento dos músculos do assoalho pélvico (MAPs) tem sido considerada uma das principais causas da incontinência urinária por esforço (IUE). Dessa maneira, o tratamento fisioterapêutico, classicamente, se voltou para o fortalecimento desses músculos. Nesse estudo foi hipotetizado que, além da fraqueza dos MAP, essa disfunção também pode estar relacionada à uma alteração no padrão de resposta reflexa desses músculos. Objetivo: Os objetivos deste estudo foram comparar o tempo de resposta da contração e a força dos MAPs induzidos pela tosse entre mulheres continentes e com IUE e, realizar uma revisão de literatura sobre o uso do biofeedback para treinamento muscular do assoalho pélvico em mulheres com essa disfunção. Métodos: Estudo I: Foi realizada uma revisão sistemática com uma busca nas bases de dados Science Direct, Embase, MEDLINE, Pedro, SciELO, CINAHL e LILACS por ensaios clinicos randomizados que tivessem o biofeedback (BF) como instrumento terapeutico para a IUE. Estudo II: Esse foi um estudo transversal que avaliou os MAPs durante a tosse de 20 mulheres saudáveis e 20 mulheres com IUE. A avaliação clínica consistiu na aplicação dos questionários que avaliaram a gravidade da incontinência urinária e a qualidade de vida. A captação dos sinais foi realizada com um sistema de aquisição com 4 canais (EMG System do Brasil Ltda®) para captar os sinais obtidos por meio da dinamometria vaginal, da eletromiografia (EMG) do músculo obliquo externo direito e da acelerometria. Para análise estatística foram utilizados os testes de Shapiro-Wilk, t independente ou Mann-Whitney test de acordo com a distribuição dos dados e a análise de covariância (ANCOVA) com test post hoc de Bonferrone. A significância estatística considerada para todos os testes foi de p<0,05. Resultados: Estudo I: o treinamento dos MAPs com BF não foi melhor do que o grupo controle (sem treinamento e orientação, estimulação elétrica vaginal). No entanto, estes resultados contraditórios e a má qualidade dos estudos provavelmente não são clinicamente significativos. Estudo II: A resposta de contração dos MAPs foi significativamente diferente entre os grupos para o tempo de ativação dos MAPs (F=19.51, P <0.0001,p2=0.61), Tempo de ativação do músculo obliquo externo (F=11.41, P < 0.002, p2=0.23) e tempo do pulso da tosse (F=4.21, P < 0.04, p2=0.10). Conclusão: A revisão sistemática fornece evidências de que a treinamento dos MAPs com BF não oferece benefícios terapêuticos superiores a outros tipos de intervenções no tratamento da IUE feminina. O estudo tranversal mostrou que mulheres com IUE apresentam atraso na resposta da contração dos MAPs induzidos pela tosse.

Bakgrund: Förlossningsskador kan ge fysiska och psykiska besvär. Skadorna är olika omfattande och eftervården är viktig för att rehabilitera kvinnan. Fysioterapeuters kompetens lämpar sig för undersökning och behandling av förlossningsskador. Dock är professionen inte en självklar del av eftervården och det finns kunskapsluckor om fysioterapeuters upplevelser och erfarenheter av att arbeta med förlossningsskador. Syfte: Syftet med den här studien var att beskriva fysioterapeuters upplevelser och erfarenheter inom den svenska sjukvården av att arbeta med kvinnor som har förlossningsskador. Metod: Studien var en semi-strukturerad kvalitativ intervjustudie som inkluderade fem deltagare som arbetar med förlossningsskador. Deltagarna rekryterades via Fysioterapeuternas hemsida på kompetenskartan för kvinnors hälsa och Facebookgruppen "Fysioterapeuter inom kvinnors hälsa”. Ändamålsenligt bekvämlighetsurval tillämpades. Databearbetning av intervjumaterialet gjordes genom en kvalitativ innehållsanalys. Resultat: Analysprocessen resulterade i fyra kategorier: Fysioterapeutens roll i patientmötet, Känslomässigt arbete, Framgångsfaktorer inom vården av förlossningsskador och Utmaningar inom vården av förlossningsskador med elva tillhörande subkategorier. Konklusion: Fysioterapeuterna har en betydande roll och kompetens som kan göra skillnad för patienter med förlossningsskador. De drivs av ett stort engagemang och vill se vidare utveckling av området samt stärka fysioterapeutens roll inom vården av förlossningsskador. Det behövs vidare forskning för att fylla kunskapsluckan av fysioterapeuters arbete med förlossningsskador. / Background: Pelvic floor dysfunction (PFD) after giving birth causes physical and mental discomfort. The injuries vary and the healthcare afterward is important for the mother´s rehabilitation. The competence of physiotherapists is suitable for the examination and treatment of PFD after giving birth. However, the profession is not established in this area. There are knowledge gaps about the physiotherapist's views and experiences of working with PFD after giving birth. Purpose: The purpose of this study was to describe the physiotherapist's views and experiences of working in Swedish healthcare with women with PFD after giving birth. Method: The study was a semi-structured qualitative interview study that included five participants who work with PFD after giving birth. The participants were recruited via the competence map for women's health on Fysioterapeuternas' website and via the Facebook group “Fysioterapeuter inom kvinnors hälsa”. Samples of convenience was applied. Data processing of the interview material was done through a qualitative content analysis. Results: The analysis process resulted in four categories: The physiotherapist's role when meeting patients, Emotional work, Successful factors in the healthcare of PFD after giving birth and Challenges in the healthcare of PFD after giving birth divided into eleven subcategories.  Conclusion: Physiotherapists have a significant role and the competence to make a difference for patients with PFD after giving birth. They are driven by commitment and want to see a further development of women’s health as well as strengthen the physiotherapist's role in maternity care. Further research is needed to fill the knowledge gap of physiotherapists' work with PFD after giving birth.

Bakgrund: Bäckenbottenskador är vanligt förekommande vid vaginala förlossningar och kan orsaka många besvärande symtom. Den fysiska påfrestningen påverkar även kvinnors välmående och kan leda till psykisk ohälsa. Syfte: Syftet var att beskriva psykologiska konsekvenser av bäckenbottenskador i samband med förlossning för kvinnor. Metod: Syftet besvarades genom att göra en allmän litteraturstudie baserad på nio kvalitativa artiklar. Artiklarna kvalitetsgranskades och analyserades, därefter skapades en övergripande huvudkategori och tre underkategorier. Resultat: Huvudkategorin var Förlossningsskador medför psykiskt lidande, och dess underkategorier Känsla av skuld och skam, Förlust av kvinnlighet och sexualitet och Besvikelse över vårdens bristande information och stöd. I resultatet framkom att psykologiska konsekvenser såsom oro, skam, ångest, hopplöshet, depression och posttraumatiskt stressyndrom, är en följd av bäckenbottenskador och dess somatiska besvär. Vidare framkom att kvinnor inte fick den vård de var i behov av och upplevde att vården försummade dem och orsakade ytterligare psykisk påfrestning. Konklusion: Litteraturstudien bidrar till en ökad förståelse om hur bäckenbottenskador påverkar kvinnors psykiska välmående. Det behövs utveckling av riktlinjer vad gäller uppföljning och behandling av förlossningsskador. Vidare forskning krävs om hur bäckenbottenskador och sekundärt psykiskt trauma kan förebyggas, repareras, behandlas och rehabiliteras. / Background: Pelvic floor injuries are common due to vaginal delivery and can cause many troublesome symptoms. The physical symptoms affect women’s well-being and can lead to psychological morbidity. Aim: The aim was to describe the psychological consequences of pelvic floor injuries in relation to childbirth for women. Method: The aim was answered by conducting a general literature study based on nine qualitative articles. The articles were quality-tested and analysed, then one overreaching head category were created and three under categories. Results: The head category was Birth injuries causes psychological suffering, and it’s under categories Feeling guilt and shame, Loss of femininity and sexuality and Disappointment with the lack of information and support in healthcare. Women experienced psychological consequences such as shame, anxiety, hopelessness, depression and post-traumatic stress syndrome, secondary to pelvic floor injuries. It was also found that women didn’t receive the care they needed and felt that healthcare professionals neglected them and caused further psychological distress. Conclusion: The general literature study contributes to an increased understanding of how pelvic floor injuries affect women’s mental well-being. There is a need for development of guidelines as to monitoring and treatment of birth injuries. Further research is needed on how pelvic floor injuries and secondary to it psychological trauma can be prevented, repaired, treated and rehabilitated.

The diploma thesis deals with the problem of global pelvic floor dysfunction in patients with cystic fibrosis. The theoretical part is devoted to individual components of dysfunction, thus urinary and fecal incontinence, prolapse and sexual issues. In particular, it focuses on the mechanism of formation and prevalence of individual components and also contains information on the musculoskeletal abnormalities most commonly found in patients with cystic fibrosis. There is also mentioned the impact of incontinence on the quality of life of patients. The experimental part describes a questionnaire survey, hypotheses derived from it and their results with comments. There is also statistical processing of the data and graphical representation of the results. Other important findings from the survey are also listed. The thesis follows the previous bachelor thesis and aims to draw attention to the given issue and break the wall of silence from the ranks of patients and health professionals.

Résumé : Introduction : Parmi les structures anatomiques impliqués dans la statique pelvienne, la continence urinaire et anale, le muscle élévateur de l’anus (MEA), le sphincter urétral (SU) et son innervation ont un rôle déterminant. Au cours de la grossesse, de l’accouchement par voie vaginale, de la chirurgie radicale pelvienne, des lésions des muscles du plancher pelvien ou de son innervation peuvent survenir. Ces lésions sont à l’origine de dysfonctions du plancher pelvien telle que le prolapsus uro-génital ou l’incontinence urinaire. Une meilleure connaissance de l’anatomie musculaire et nerveuse pelvi-périnéale est nécessaire pour diminuer la survenue et traiter ces troubles fonctionnels. Classiquement les muscles du plancher pelvien sont décrits comme entièrement striés sous contrôle somatique (nerf du MEA et/ou nerf pudendal (NP)). La dissection Anatomique Assisté par Ordinateur (DAAO) en utilisant des marqueurs nerveux et musculaires spécifiques peut aujourd’hui compléter les données établies par la dissection conventionnelle classique de sujets anatomiques.Objectif : L’objectif était de décrire l’innervation (origine, topographie, trajet, rapports, fonction) et la structure musculaire du MEA, de décrire l’innervation (origine, topographie, trajet, rapports, fonction) du sphincter urétral pour mettre en perspective les implications potentielles dans les dysfonctions du plancher pelvien.Méthodes : Nous avons étudié 9 fœtus humains (6 féminins et 3 masculins). Des coupes histologiques sériées de 5 µm d’épaisseur ont été effectuées dans les régions pelviennes de 7 fœtus âgés de 18 à 40 semaines de gestation. Pour chaque niveau de coupe, des lames ont été colorées puis traitées en immunohistochimie pour détecter : l’ensemble des fibres nerveuses (anticorps anti-protéine S100), les fibres autonomes cholinergiques (anti-VAChT), les fibres autonomes adrénergiques (anti-TH), les fibres autonomes nitrergiques (anti-nNOS), les fibres somatiques (anti-PMP 22), les fibres sensorielles (anti-CGRP), les fibres musculaires lisses (anti-SMA) et les fibres musculaires striées (anti-MYOG). Les coupes ont ensuite été numérisées par un scanner de haute résolution optique et les images ont été reconstruites en 3D avec le logiciel Winsurf®. Un fœtus additionnel a été entièrement destiné à réaliser de la microscopie électronique afin de confirmer nos résultats au niveau architectural musculaire.Résultats : Nous avons observé une innervation à la fois autonome (plexus hypogastrique inférieur (PHI)) et somatique (nerf du MEA et NP) du MEA. Nous avons individualisé des zones de cellules musculaires lisses au sein du plancher pelvien notamment de la partie médiane sous contrôle autonome (PHI) que nous nommons « compartiment médian musculaire lisse ».Nous avons systématisé le plancher pelvien musculaire en une zone médiale lisse sous contrôle nerveux autonome réalisant une interface entre les viscères pelviens, et une zone musculaire striée latérale sous contrôle nerveux somatique.Enfin, nous avons mis en évidence une double innervation à la fois somatique et autonome du sphincter urétral.Conclusion : La DAAO a permis de mettre en évidence une innervation pelvi-périnéale complexe avec l’intrication du système nerveux somatique et autonome. La fonction du contingent musculaire lisse pelvien reste à préciser. / Abstract : Levator ani muscle (LAM), urethral sphincter (US), and their innervation play a major role in pelvic status, urinary continence and anal continence. During pregnancy, vaginal delivery, pelvic radical surgery, damage of pelvic floor muscles or of their innervation may occur. These lesions are responsible for pelvic floor dysfunction such as urogenital prolapse or urinary incontinence. Better knowledge of pelvi-perineal muscle and nerve anatomy is needed to reduce the occurrence and treat these pelvic floor dysfunctions. Classically pelvic floor muscles are described as entirely striated under somatic control (levator ani nerve (LAN) and /or pudendal nerve (PN)). Computer Assisted Anatomical Dissection (CAAD) using specific nerve and muscle markers can nowadays complete data established by conventional dissection of anatomical subjects.The objective was to describe the innervation and the muscular structure of the levator ani muscle, to describe nerve supply of the urethral sphincter in order to better understand pelvic floor dysfunction.Methods : We studied nine human fetuses (6 female and 3 male). Serial histological sections of 5 μm of thickness were performed in the lumbar and pelvic regions of seven human fetuses aged 18 to 40 weeks of gestation. For each level, slides were stained and then treated in immunohistochemistry to detect: general nerve fibers (anti-protein S100), autonomic cholinergic fibers (anti-VAChT), autonomic adrenergic fibers (anti-tyrosine hydroxylase), autonomic nitrergic fibers (anti-nNOS), somatic nerve fibers (anti-peripheral myelin protein 22), sensory fibers (anti-CGRP), smooth muscle fibers (anti-SMA) and striated muscle fibers (anti-MYOG). The slides were then digitized by a high-resolution optical scanner and the images were reconstructed in 3D using the Winsurf® software. One fetus was entirely reserved for electronic microscopy in order to confirm our results.Results: We observed that LAM innervation is supplied by both autonomic (inferior hypogastric plexus (IHP)) and somatic (LAN and PN). We have individualized areas of smooth muscle cells in the pelvic floor, particularly the median part controlled by the autonomic system that we named “smooth muscle medial compartment”.We systematized within the pelvic floor muscle a smooth medial part under an autonomic nervous control as interface between the pelvic viscera and a lateral striated muscle part under somatic nervous control.Finally, we have demonstrated a dual innervation both somatic and autonomic sphincter urethral.Conclusion : CAAD has demonstrated complex pelvic-perineal innervation with the interaction of the somatic and autonomic nervous system. The function of the pelvic smooth muscle contingent remains to be clarified.

Bakgrund: Förlossningsskador kan leda till fysiska och psykiska besvär. Det finns brister och stora variationer i förlossningsvården i Sverige. Det saknas evidensbaserade riktlinjer för fysioterapi inom området och vilka insatser som har effekt är inte helt klarlagt. Kvinnornas egna upplevelser och erfarenheter spelar stor roll i arbetet för att fylla de kunskapsluckor som finns idag.  Syfte: Syftet med studien var att undersöka fem kvinnors personliga upplevelser och erfarenheter av fysioterapeutiska åtgärder efter att de drabbats av förlossningsskador grad 3–4 och på så sätt öka förståelsen för fysioterapeutiska åtgärder hos fysioterapeuter inom detta område.  Metod: Studien hade en kvalitativ deskriptiv design. Deltagarna var fem kvinnor som drabbats av förlossningsskador av grad 3–4. Rekryteringen skedde via Facebook-gruppen ”Allt om förlossningsskador”. Semistrukturerade intervjuer genomfördes och intervjumaterialet bearbetades genom en kvalitativ innehållsanalys. Resultat: Analysen resulterade i fyra kategorier: Minskad funktion i det vardagliga livet, Brister inom förlossningsvården, Upplevelser av fysioterapeutiska åtgärder och Informanternas förslag till förbättring inom kvinnohälsa samt tio subkategorier.   Konklusion: Studien visade att kvinnorna upplevde att det saknas kunskap och kompetens gällande fysioterapi vid förlossningsskador. Resultatet tyder på att de viktigaste faktorerna i mötet med dessa kvinnor är utförligt information, tydliga instruktioner och bra bemötande av patienten. Behovet av vidare forskning och nya riktlinjer gällande fysioterapi vid förlossningsskador är stort och den fysioterapeutiska grundutbildningen bör inkludera en mer omfattande del om kvinnohälsa. / Background: Women with perineal tears after childbirth often suffer from physical and psychological issues. There are some varieties and deficiencies in the Swedish health care system of maternity care, and there is an absence of evidence-based guidelines in the physiotherapeutic field of maternity care. The women’s perspectives play a major role to fill the gaps of knowledge that exist today.  Purpose: The purpose of this study was to investigate views and experiences of physiotherapy from women with third- and fourth-degree perineal tears to establish a higher knowledge for physiotherapeutic methods.   Method: The study was a semi-structured qualitative interview study that included five women with third- and fourth-degree perineal tears. The participants were recruited through the Facebook group “Allt om förlossningsskador”. Analyzing of the interview material was done through a qualitative content analysis.  Results: The analysis resulted in four categories: Reduced function in everyday life, Deficiencies in maternity care, Experiences of physiotherapeutic measures and The informants’ proposals for improvement in women’s health with ten subcategories.  Conclusion: The study showed that the women felt that there is a lack of knowledge and competence regarding physiotherapy after perineal tears. The results indicate that the most important factors in the meeting with these women are detailed information, clear instructions and good treatment of the patient. Further research and new guidelines regarding physiotherapy for women with perineal tears is needed and the physiotherapeutic education should involve more about women health and rehabilitation of pelvic floor injuries.

No description available.

Around 80% of women experience vaginal tears during labor when the diameter of the vagina must increase from ~2.5 cm to ~9.5 cm to allow the passage of a full-term baby. Vaginal tears vary from superficial cuts of the mucosal lining to tears propagating through the entire vaginal wall and into the surrounding tissues and organs. Complications associated with vaginal tears include postpartum hemorrhaging, fecal incontinence, urinary incontinence, and dyspareunia. Beyond the agonizing pain, these complications are emotionally and psychologically traumatic for women. Prevention, evaluation, and treatment of vaginal tears and subsequent conditions are limited due to the lack of studies examining the mechanical behavior of the pelvic floor tissues. Therefore, the mechanical response of healthy and torn vaginal tissue is investigated here to establish quantitative metrics for maternal healthcare. Toward this end, swine and rat vaginal tissue is subjected to biaxial loads until tearing to reveal its mechanical properties. The resulting large inhomogeneous deformations are measured by the digital image correlation optical method to calculate material strain. The influence of these strains near to and far from the immediate vicinity of the tears on the tearing behavior is studied. Coupling mechanisms of the mechanical properties in the circumferential and axial directions as well as their effect on the nature of tear resistance is studied. Collagen fibers, the component within tissue responsible for its strength under tension, are imaged using a multiphoton microscopy technique known as second-harmonic generation imaging to investigate the change in organization with mechanical loading. Furthermore, imaging is performed in the near-regions of tears to reveal the relationship between collagen fibers and tearing resistance. The data collected through these studies provide new knowledge on the nonlinear elastic behavior of vaginal tissue, the geometrical and micro-structural characteristics of tears, and the mechanisms that contribute to the formation and propagation of tears. The mechanical properties and tearing mechanisms of vaginal tissue will be crucial in developing new prevention and treatment methods for maternal trauma following childbirth. Episiotomy, late-term stretching, surgical treatment with graft materials and other protocols will all benefit from a mechanically-informed perspective. It is our hope that this work will raise awareness to the serious complexities of pelvic floor trauma and encourage a more refined and systematic approach to the inspection, imaging, and treatment of all vaginal tears following delivery. This work was supported in part by the National Science Foundation fund #1511603 and the Institute for Critical Technology and Sciences at Virginia Tech. / Doctor of Philosophy / Every year nearly three million women give birth vaginally with 80% experiencing vaginal tears. These injuries sustained during delivery vary with severity and are associated with several conditions, including pelvic floor disorders. These disorders are a set of long-term conditions of the pelvic region presently affecting one-fourth of adult women in the United States. Pelvic floor disorders are: pelvic organ prolapse - a pelvic organ such as the uterus "falls" from its natural position, urinary incontinence - difficulty controlling urination, and fecal incontinence - difficulty controlling bowel movements. Pelvic floor disorders lower the quality of life for women not only physically due to pain and daily discomfort, but also mentally as the disorders are generally perceived as an embarassing and private matter. The pelvic floor represents a complex system of muscles, organs, and support structures that work together to ensure everything stays in place and is functioning properly. Injury to any of these structures poses the risk of developing a disorder. As a central supporting organ, injuries to the vagina may be particularly worrisome. Surprisingly, little is known about the magnitude of forces and/or stretching that is placed on the pelvic floor during delivery, how much force and/or stretching is required for an injury, or how various injuries relate to future complications. The goal of this research is to describe how much the normal, healthy vagina stretches to various forces including forces that will result in injuries. The research further examines the stretching of injured vaginas to quantify any observable differences due to this injury. Finally, the relationships between the biological components of the vagina, such as collagen, and the forces placed on the vagina are examined. The result of this work will provide doctors and engineers with guidelines for understanding the conditions that produce vaginal injuries. The relationships examined between the tissue makeup and forces exerted onto the tissue may also aid in identifying any irregularities that would place a woman at risk for injury. Many of the medical procedures surrounding childbirth as well as surgical treatment for pelvic floor disorders will benefit from knowing how far the vagina can stretch before being injured. It is our hope that this work will raise awareness to the serious complexities of pelvic floor injuries and encourage a more refined and systematic approach to the inspection, imaging, and treatment of all vaginal tears following delivery. This work was supported in part by the National Science Foundation fund #1511603 and the Institute for Critical Technology and Sciences at Virginia Tech.

Background: Pelvic floor muscle (PFM) training is recommended as first line conservative management for stress urinary incontinence (SUI). The fundamental issue of how to optimally contract the PFM has not previously been investigated. An effective voluntary PFM contraction is known to positively influence the bladder neck and urethra which are urethrovesical (UV) structures associated with continence. The PFM may be globally or selectively contracted according to cue to instruction. The main research question was to investigate which cue to instruction for a PFM contraction has the potential to optimise position of UVSs following a brief period of practice in continent nulliparous pre-menopausal women (aiming to provide normative data) and parous menopausal women with previously unreported SUI. Hypotheses: Posterior or combined cues for instruction of PFM contraction are more influential in optimising UV position (UVP) during PFMC following brief practice than an anterior cue. Posterior or combined cues are equally influential in altering UVP. Aims: Preliminary aim was to investigate the reliability and suitability of 2-DRTUS and angle of urethral inclination (AUI) for imaging of selective contraction of the PFM and ease of reading images by a non diagnostic imaging researcher. Principal aim was to investigate if there is an optimal cue to instruction for a PFM contraction in two groups of women. Study 1: pre menopausal nulliparous continent women (to provide normative data) and Study 2: post menopausal parous stress incontinent women. Secondary aims were investigation of posture; ability to selectively contract the PFM contraction; and cue preference. Method: Study 1: Twenty women who were able to effectively and selectively contract were taught the following cues: anterior; posterior; anterior and posterior combined. Following 4 weeks of practice, perineal 2-D RTUS images of three PFMC for each cue were captured in supine and standing twice (for repeatability analysis) five minutes apart. Two raters measured AUI. Data analysis was undertaken using a Customized General Linear Model (GLM) ANOVA with Bonferroni correction for interactions between all variables; subject, cue, posture and test. Seventeen data sets were available for analysis. Study 2: Methodology was based on Study 1. Twenty-one women were taught the study cues, followed the practice protocol and underwent data collection in the supine position. Twenty-one sets of data were available for analysis. Results: Reliability: ICC [1,3] for intra rater reliability was 0.957 [CI 95%: 0.946 to 0.967 p=0.000], inter rater reliability [2,1] 0.820 [CI 95%: 0.768 to 0.861] and for repeatability [1,3] 0.781 [CI 95%: 0.690 to 0.849 p=0.000] (continent) and 0.954 [CI 95%:0.931 to 0.971 p=0.000] (incontinent). Principal results Study 1: anterior vs posterior cues (difference) 3.979˚ (CI 95%: [0.503 to 7.455 p=0.021]); anterior vs combined 3.777˚ (CI 95%: [-0.099 to 6.853 p= 0.059]) posterior vs combined cues -0.602˚ (CI 95%: [-2.874- 4.078 p=1.00]). Aggregated data from tests 1 and 2: anterior vs posterior 4.240° (CI 95%: [1.213 to 7.267 p=0.003]); anterior vs posterior 3.756° (95%CI: [0.729 to 6.783 p=0.009]); posterior vs combined-6.48° (95% CI: [-3.511 to 2.542 p=1.000]). Principal results Study 2: anterior vs posterior 3.936˚ (95%CI: [0.863 to 7.008p=0.008]; 4.946˚ anterior vs combined (95%CI: [1.873 to 8.018 p=0.001]); posterior vs combined 1.010° (95%CI: -[2.062 to 4.082 p=1.000]). Aggregated analysis was anterior vs posterior 3.703˚ (95%CI: [1.639 to 5.761 p=0.000]); anterior vs combined 5.089˚ (95%CI: [3.0287 to 7.1503 p=0.000]) and posterior and combined 1.389° (95%CI: [-0.672 to 3.450 p=0.309]). Secondary results: 2-D RTUS and the AUI were found to be suitable for investigating selective PFM contraction. Posture: supine vs standing (difference) 9.496˚ (p=0.000); (posture did not affect absolute AUI). Three continent (13%) and 2 incontinent (7%) subjects were unable to selectively contract the PFM. Cue preference in both studies was posterior or combined. Conclusions: AUI was significantly narrower/optimal when instruction for PFM contraction included a posterior cue, in both continent and stress incontinent women. This is proposed to be due to optimal recruitment of puborectalis. Puborectalis may be more important in urinary continence than widely recognized. This study has provided seminal information with respect to optimal cue to contraction for a PFM contraction and will change practice. Investigation of the potential impact of these findings clinically is required. It is proposed that further understanding will lead to standardisation of PFM instruction, ease of comparability between PFM research studies, and will clarify PFM instructions for the media and lay public.

9 Abstract Title: Influence of Power Plate machine vibrations on m. levator ani contraction. Objectives: In my thesis I would like to follow up on my bachelor`s thesis in which I was analyzing the importance of exercise on the Power Plate machine from a theoretical point of view. I set the objective of my thesis, in co-operation with professionals in this area, to find out whether Power Plate machines have any impact on the pelvic floor contractions, especially on the m. levator ani. Methods: Theoretical part of my thesis was conducted using the research (exploration of facts) method. For theoretical input I mainly used my bachelor`s thesis which was being followed up with. Majority of studies regarding WBVT (whole body vibration training) influence on human body is available from foreign sources. The practical part of my research was conducted via the quantitative quasiexperimental method. The works was further performed with use of the explanation (empirical and generally theoretical) methods and interpretation methods. For the data analysis were used the basic descriptive statistics, analysis of variance with repetition with Geisser-Greenhouse adjustment and paired t-test. Interpretation method was used to generalize the research outcomes, to confront them with existing knowledge, and to debate their...