The Effect of Pelvic Floor Exercise on Urinary Incontinence and Quality of Sex Life
Phase: NA
Conditions: Pelvic Floor Muscle Weakness, Urinary Incontinence
Sponsor: Szeged University

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Title 
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Utilising synergism between the transverse abdominal and pelvic floor muscles at different 
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postures in nulliparous women: a case control study 
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Authors 
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Tímea Molnár1, Andrea Domján1, Mónika Szűcs2, Andrea Surányi 3a, József Bódis 4a 
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T Molnár: project development, data collection, manuscript writing 
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A Domján: Study designe, manuscript revision 
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M Szűcs: statistical analysis, manuscript revision 
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A Surányi: data analysis, manuscript edit and revision 
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J Bódis: study designe, manuscript revision 
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1 University of Szeged, Faculty of Health Sciences and Social Studies, Department of 
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Physiotherapy (during the study period) H-6726 Szeged Temesvári 31., Hungary, (present:  
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University of Szeged, Albert Szent-Györgyi Health Centre, Department of Orthopedics, 
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Physiotherapy 
Centre 
H-6725 
Szeged 
Semmelweis 
u. 
6.) 
email: 
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aranyne.molnar.timea@med.u-szeged.hu  
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2 University of Szeged, Faculty of Medicine, Faculty of Science and Informatics, Department 
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of Medical Physics and Informatics, H-6720 Szeged Korányi 9., Hungary, email: 
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szucs.monika@med.u-szeged.hu 
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3 University of Szeged, Faculty of Medicine, Department of Obstetrics and Gynaecology, 
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Albert Szent-Györgyi Health Center, H-6725 Szeged Semmelweis 5., Hungary, email: gaspar-
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suranyi.andrea@med.u-szeged.hu 
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4 University of Pécs, Faculty of Health Sciences, Doctoral School of Health Sciences, H-7621 
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Pécs Vörösmarty 4., Hungary, email: jozsef.bodis@aok.pte.hu 
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a: shared last authorship 
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Corresponding author: 
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Andrea Suranyi, email: gaspar-suranyi.andrea@med.u-szeged.hu -Tel.:+3662-545499 FAX: 
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+3662-545711  
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Conflict of interest 
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The authors have no conflict of interests. 
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Statement: 
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Each author’s participation in the manuscript 
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T Molnár: project development, study design, ultrasound investigation, data collection, 
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manuscript writing and editing 
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A Domján: project development, study design, manuscript revision 
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M Szűcs: data collection, statistical analysis, 
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A Surányi: study design, ultrasound investigation, manuscript writing, editing and revision 
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József Bódis: project development, manuscript revision 
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Word count: 3823 
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Table count:3 
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Figure count:3 
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Abstract  
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Background: To determine the effects of the pelvic floor muscle training (PFM-T) in 
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combination with transverse abdominal muscle (TRA) activation (cPFM-T) in female urinary 
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incontinence. 
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Methods: We enrolled nulliparous women in supine (SUG) (n = 22), sitting (SIG) (n = 19) 
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and control (COG) (n = 14) groups. We performed the 8-week cPFM-T programme. We 
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examined the effect of training on the parameters with the Kruskal–Wallis test, and the 
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pairwise comparisons with the Mann-Whitney U-test and the Wilcoxon-rank test with the 
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Bonferroni correction. 
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Results: Before training, 15 participants reported occasional urinary leakage. After cPFM-T 
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seven participants reported that urinary leakage had disappeared. Maximal isometric 
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contraction of the pelvic floor muscles (PFM) until fatigue improved significantly in the SUG 
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(p < 0.001) and SIG (p = 0.015) and not significantly in the COG (p = 0.499). Holding time 
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increased in the SUG (p = 0.972) and the SIG (p = 0.717), and decreased in the COG (p = 
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0.132). The dynamic endurance of the PFM improved significantly in the SUG (p < 0.001), 
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but not in the SIG (p = 0.798) and the COG (p = 0.153). The number of maximal fast 
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contractions within 1 minute increased in both the SUG (p < 0.001) and the SIG (p=0.813) 
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and decreased in the COG (p = 0.257). Relaxation improved significantly in the SIG (p = 
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0.011). TRA thickness increased in both training groups. 
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Conclusions: Slow-twitch fibres of the PFM can be trained effectively with PFM-T in both 
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the body positions. 
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Trial registration: This study was registered in the Hungarian National Healthcare Service 
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Center: 019234/2014/OTIG Registered 07 April 2014 
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Keywords:  
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pelvic floor muscle training, transverse abdominal muscle, ultrasound measurement, urinary 
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incontinence, vaginal surface electromyography 
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Brief summary 
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This physiotherapist-guided group training programme should be performed in both the 
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supine and the sitting positions; this results in better and more cost-effective patient 
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motivation. 
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74 
Background 
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Worldwide, an estimated 20%–30% of young women have urinary incontinence (UI), making 
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the frequency of this condition a fundamental problem [1].  
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According to Kegel, regular, specific strength training of the pelvic floor muscles (PFM) has a 
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beneficial effect on female UI and pelvic organ prolapse [2].  
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The effectiveness of Kegel’s PFM-T exercises—classified by the International Consultation 
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on Incontinence as level A evidence in Evidence Based Medicine [3, 4] has been proven in 
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numerous randomised controlled trials.  
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Several research groups have reported a co-contraction between the deep abdominal muscles 
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and the PFM [5, 6, 7, 8].  
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Together, these results suggest the necessity of involving a coordinated approach of the PFM 
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and the deep abdominal muscles in the effective treatment of UI.  
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Several studies have revealed significantly higher resting PFM activity in unsupported sitting 
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as compared to supported sitting and in a standing posture as compared to a supine position 
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[8, 9, 10, 11]. 
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Chmielewska [11] reported a significant a long-lasting contraction during unsupported sitting, 
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due to the superior recruitment by the sitting posture of the sensorimotor control system to 
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that by the supine position. They identified different coactivation patterns of the PFM and 
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abdominal muscles during sitting to those during standing and lying. 
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Sufficient evidence that regular PFM-T improves the symptoms of incontinence has been 
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reported [3, 12, 13]. However, only a few studies support the effect of the coordination of the 
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diaphragm, deep abdominal muscles and PFM on incontinence [14, 15].  
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Current evidence on skeletal muscle training and other factors (UI, supervised PFM-T 
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programme, e.t.c.) are known to have an impact on women’s participation in and adherence to 
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PFM-T [3]. 
99 
Here we aimed to investigate whether—based on trunk muscle synergism—the condition and 
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functioning of the PFM would improve in the sitting and supine postures or in the control 
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group during PFM-T with forced exhalation. 
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Methods 
104 
Participants 
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We performed our study at the Faculty of Health Sciences and Social Studies, University of 
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Szeged, Hungary between October 1, 2016 and December 1, 2016. We enrolled 58 healthy, 
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young (mean±SD: 21.27±1.46 years), nulliparous women in this trial. We recruited them 
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through an online advertisement and then selected them for the training groups and the control 
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group (Additional file 3). The participants had no previous experience of PFM-T. We divided 
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them into two study groups depending on the strength of the PFM and treated them with 
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cPFM-T in both the supine position and the sitting position. The assessment comprised one 
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phase: 3 repetitions of sustained 5-second voluntary PFM contraction with 10-second 
113 

6 
 
 
relaxation. We calculated the mean of 3 contractions and set the obtained values in ascending 
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order. The 22 participants with lower muscle strength (under 60 V) comprised the SUG and 
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the 22 participants with higher muscle strength (over 60 V) formed the SIG. Only 19 
116 
participants, however, completed the programme in the SIG (Additional file 3). We enrolled 
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these 19 participants with higher PFM tension (over 60 V) in the SIG because the PFM must 
118 
be stronger to resist gravity [16]. We created a control group (n = 14) (COG) comprising 
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seven persons with a PFM tension under 60 V and seven individuals with a PFM tension 
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over 60 V. The COG did not change their lifestyles and did not undergo PFM-T. We 
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included in the study groups participants willing to participate in the study and able to 
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contract the pelvic floor and TRA muscles correctly. Participants were required to maintain 
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their everyday activities (attending lessons, sport activities, and so on). The local ethics 
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committee (National Healthcare Service Center) approved the study (019234/2014/OTIG) and 
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we received written, informed consent from all participants. Exclusion criteria were known 
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neurological or rheumatological diseases and previous vaginal or abdominal surgery.  
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Subjective measurements  
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In the study, before and after the training programme, we used a self-administered 
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questionnaire (Additional file 7), based on three validated questionnaires (the King’s health 
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questionnaire, the Incontinence impact questionnaire and the Urogenital distress inventory) 
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[17]. We included in the questionnaire risk factors for UI (obstetric history, height and weight, 
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stress, physical activity level, sport, vaginal and abdominal surgery) and questions relating to 
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the urinary tract and anal canal (involuntary urinary leakage, cystitis, constipation) and sexual 
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activity (orgasm problems). 
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Objective measurements 
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Vaginal surface electromyography (vsEMG) 
138 
We measured changes in PFM activity with a vaginal surface electromyographic (vsEMG) 
139 
instrument (FemiScan™ MultiTrainer™, Mega Electronics, Finland), which measures the 
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electronic signals of PFM activity, using a sterile Periform™ intravaginal probe with vsEMG 
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electrodes [7]—a pear-shaped device 8 cm in length and 3.4 cm in medial–lateral diameter at 
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its peak width, but tapering at the introitus, with nickel detection surfaces on both sides and an 
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indicator to help patients to perform the tasks correctly. A correct voluntary contraction of the 
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PFM contributes to downward (posterior) movement of the indicator [18]. We positioned a 
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reference electrode on the patient’s left forearm.  
146 
Procedure 
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We tested the participants in a lying position with the hips and knees flexed, feet resting on a 
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plinth and knees supported to allow the hips and PFM to relax [7]. We instructed the 
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volunteers on the proper placement of a FemiScan™ vsEMG probe in situ within the vagina. 
150 
The same physiotherapist (T.M.) assessed all participants twice (at 0 weeks and at 8 weeks), 
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at which times PFM activities were measured in a supine position. Before each measurement, 
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the therapist instructed the participants how to perform PFM tasks. The participants were not 
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allowed to move the hips and lumbar spine. We displayed the vsEMG data as line graphs, 
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thus providing visual feedback for the participants, and recorded the values in microvolts. 
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The participants performed three tasks: 
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1. PFM relaxation state for 30 seconds;  
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2. maximal isometric contraction till fatigue: one maximum voluntary tonic contraction 
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of the PFM, held until fatigue, carried out once;  
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3. dynamic endurance: fast, sudden maximum voluntary phasic contractions of the PFM, 
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performed for one minute.  
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Transabdominal ultrasound measurement 
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We performed the TRA measurements at the same time as the vaginal measurements and 
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PFM tasks. We measured the degree of the change in the muscle thickness. We measured the 
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thickness of the TRA because Madill and McLean [7] found that the synergistic coactivation 
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between the TRA and the PFM was stronger than that between the rectus abdominis muscle 
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(RA), the external oblique muscle (EO) and the PFM. Thus we decided that it was sufficient 
168 
to measure the thickness of the TRA only, assessing it by ultrasound (US) visualisation 
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(Z.ONARE™ SP/Musculoskeletal, 8 MHz, 35-mm curved linear array transducer) on the 
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lateral abdominal wall. The same operator (A.S.), who is an expert in US evaluation, and was 
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blind to the grouping of the patients, performed all imaging procedures. The technique of 
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acquiring images of the TRA and the measurement techniques have been previously described 
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[19]. She placed the centre of the transducer in the transverse plane just superior to the iliac 
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crest in line with the mid-axillary line, performing the measurement of muscle thickness on 
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the left side of the participant at rest and during the isometric tasks before and after cPFM-T. 
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The participants were not allowed any movement of the hip and lumbar spine. We acquired 
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the following recordings: (1) the thickness of the TRA during PFM relaxation, and (2) the 
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TRA thickness during maximal isometric contraction till PFM fatigue. We measured the 
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thickness of the TRA at the point where the muscle was at its thickest. 
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Pelvic floor muscle training 
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A physical therapists (T.M.) supervised the training, and carried out the evaluation. We 
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divided the participants into two study groups depending on the strength of the PFM and 
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treated them with cPFM-T in both supine (n = 22) (SUG) and sitting (n = 19) (SIG) positions. 
185 

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We also set up one control group (n = 14) (COG). The treatment for the SUG and the SIG 
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comprised 8 sessions, with a 1-hour cPFM-T session each week in a group and 15 minutes of 
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individual home training, six times a week for a total of 8 weeks of treatment. Before the 
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cPFM-T, we instructed all participants in the anatomy of the PFM and the lower urinary tract, 
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the mechanism of continence and unsupported sitting posture. We discouraged the slumped 
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sitting posture since unsupported sitting postures require greater PFM activity than supported 
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sitting postures [9]. All training sessions comprised warming-up, gradual muscle 
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strengthening and relaxation exercises. We found palpation and visualisation to be very 
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powerful tools for re-educating muscles and very helpful, especially in the training of 
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invisible muscles [20, 21]. During the training sessions, the physiotherapist taught awareness 
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through palpation and visualisation. Any woman can feel both TRA and PFM activity at the 
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medial anterior superior iliac spina (ASIS), because the initial intravaginal pressure is 
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predominated by PFM activity and the later increase in pressure (up to 70% maximum 
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pressure) is produced by the combined activation of the PFM, the RA, the internal oblique 
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muscle (IO) and the TRA [22]. It is possible for anybody to feel the different levels of PFM 
200 
contractions by TRA/PFM co-contraction at the medial ASIS (through the abdominal wall). 
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The RA muscle had to be relaxed.  
202 
I. 
In the first 4 weeks of cPFM-T all study groups (n = 41) did exercises in the supine 
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position with the hip and knees flexed, feet resting on the plinth, a hip width apart.  
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II. 
In the second 4 weeks the participants performed exercises, but while the SUG (n = 
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22) did exercises in the supine position with the hips and knees flexed, feet resting on 
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the plinth, the SIG (n = 19) did exercises while sitting upright without support, feet 
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resting on the plinth. 
208 

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The Additional file 8 provides a detailed exercise regimen (based on the Sapsford’s method 
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[23]) and progression, including prerequisites, exercise position, instructions, feedback and a 
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home exercises set for each week.  
211 
Statistical analysis 
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We report our data as mean±SD or median [1st quartile–3rd quartile] and sample size for each 
213 
parameter and study group. We examined the effect of training on the parameters with the 
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Kruskal–Wallis test. We performed the pairwise comparisons with the Mann–Whitney U-test 
215 
and the Wilcoxon-rank test with the Bonferroni correction. We performed all statistical 
216 
analyses using R statistical programme (version 3.5.1, R Foundation for R statistical 
217 
computing). We considered values of p < 0.05 to be statistically significant. A statistician (M. 
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SZ) performed the evaluation. 
219 
Results 
220 
Questionnaire results 
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The participants were aged between 18 years and 25 years, with a body mass index (BMI) of 
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19.77 kg/m2–23.32 kg/m2. In Additional file 1(Table 1) we list the characteristics of 
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participants.  
224 
At the beginning of the training programme 15 participants (4 SUG, 8 SIG and 3 COG 
225 
participants) complained of urinary leakage during stress (coughing, sneezing, laughing, nose 
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blowing). After the training programme urinary leakage disappeared in 7 participants (3 SUG 
227 
and 4 SIG participants), while the symptoms of the COG remained unchanged. All 
228 
participants experienced the leakage of a few drops of urine, but rarely urinary loss (first 
229 
degree SI). 
230 

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Women with a sexual partner (n = 31) reported positive changes after the training programme 
231 
in their sexual life.  
232 
20 participants (10 SUG, 8 SIG and 2 COG participants) complained of air flow to the vagina 
233 
in unusual positions. After the training programme only 5 participants (2 SUG, 1 SIG and 2 
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COG participants) reported unchanged conditions. 
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6 participants (3 SUG and 3 SIG participants) suffered from constipation, which was in all 
236 
cases resolved by the end of the training programme. 
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Electromyographic and ultrasound results 
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We present the data in Additional file 2. The maximal isometric contraction of the PFM till 
239 
fatigue improved significantly in both study groups; however, after cPFM-T, this increase was 
240 
higher in the SUG. The tonic contraction of the PFM improved in the COG, but the 
241 
improvement was not significant (p = 0.499) (Additional file 4, Fig. 2. A). Although in both 
242 
study groups, the holding time of the maximal isometric contraction of the PFM till fatigue 
243 
and the thickness of the TRA during the maximal isometric contraction of the PFM till fatigue 
244 
both increased, these changes were not significant (Additional file 4, Fig. 2. B). The latter 
245 
parameter decreased significantly in the COG (Additional file 4, Fig. 2. C) (Additional file 2, 
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Table 2). 
247 
On the other hand, while the strength of the maximal fast contractions of the PFM within one 
248 
minute increased significantly in the SUG, it decreased in the SIG and the COG; this 
249 
decrease, however, was not significant (Additional file 5, Fig. 3. A). In both study groups, the 
250 
number of maximal fast contractions within a minute increased, but the increase was 
251 
significant only in the SUG. This parameter decreased in the COG (Additional file 2, Table 2) 
252 
(Additional file 5, Fig. 3. B).  
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In both study groups, the values for relaxation of the PFM decreased but the decrease was 
254 
significant only in the SIG (p = 0.011). This value increased in the COG (Additional file 6, 
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Fig. 4. A). The thickness of the TRA during relaxation of the PFM decreased in the SUG (p = 
256 
0.422) and the COG (p = 0.209), but not in the SIG (p = 0.717). Neither of these changes were 
257 
significant (Additional file 6, Fig. 4. B) (Additional file 2, Table 2). 
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Discussion 
259 
Our study demonstrated that an eight-week period of cPFM-T with forced exhalation, 
260 
performed by young nulliparous women in both the supine posture and the sitting posture, 
261 
using trunk muscle synergies, is effective in improving cases of incontinence. 
262 
Furthermore, the holding period, rapid reaction and resting function of the PFM—as well as 
263 
the thickness of TRA—improved due to both the modification of body position and the 
264 
exhalation technique. Improvements in the holding function of the PFM were significant in 
265 
both the supine position and the sitting position, but improvements in the rapid reaction of the 
266 
PFM were significant only in the supine position, while those in the resting function of the 
267 
PFM were significant only in the sitting position. The thickness of the TRA improved in both 
268 
the supine position and the sitting position. 
269 
Assessments of the PFM can be used to determine which structural or functional features are 
270 
deficient, and to inform the design of subsequent training regimens to address these 
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dysfunctions. A diversity of exercises, possibly tailored to the abilities of each woman, may 
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be used and proposed training includes raising the number of repetitions of contractions 
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[24]—a recommendation endorsed by our results. 
274 
Sapsford [23] advocated a new approach to the rehabilitation of urinary incontinence—motor 
275 
relearning for diaphragmatic, deep abdominal muscles and the PFM rather than selective 
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muscle strengthening.  
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Thompson et al. [25] suggested careful monitoring of Sapsford’s complex rehabilitation 
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training, because abdominal muscles are more active than PFMs in symptomatic women. 
279 
These results suggest that a coordinated approach involving both deep abdominal muscles and 
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PFM is necessary. 
281 
The correct breathing technique is very important in PFM-T. The diaphragm is a respiratory 
282 
muscle participating in the stabilisation of the lumbar spine by enhancing abdominal pressure 
283 
[26], which in turn stabilises the lumbar spine. Hodges et al. [27] reported synergism between 
284 
the diaphragm and the TRA. We also utilised this synergism by forced exhalation in our study. 
285 
Neumann and Gill [6] suggested that the activation of deep abdominal muscles is essential for 
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an effective contraction of the PFM, because their continent participants were unable to 
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contract the PFM effectively while maintaining relaxation of the TRA and the IO. Similarly, 
288 
Madill and McLean [22] found that the patterns of abdominal muscle activity appear to occur 
289 
due to voluntary PFM contractions in healthy continent women.  
290 
As a representation of vaginal closure force, the isometric contraction was considered to be 
291 
greater in the supine than in the standing position. Subsequent studies, however, have 
292 
determined that women are able to perform equally strong PFM contractions in either body 
293 
position [7, 8, 11].  
294 
The PFM is a striated muscle, with two thirds of its fibres are type I (slow-twitch fibres), 
295 
responsible for the resting tone of the levator muscle and one third of its fibres, type II (fast-
296 
twitch fibres), responsible for sudden, fast but powerful contractions. The activity of the slow 
297 
fibres is necessary for the resting potential and the retention of urine and stool, while the fast 
298 
fibres are responsible for resistance during sudden abdominal pressure [28]. We monitored the 
299 
activity of these two fibre types (retention and rapid function) in our study with vsEMG 
300 
measurements and trained both types in weaker and stronger PFM-T. 
301 

14 
 
 
 The fact that SUI happens most frequently in the upright position informed our study of the 
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functional (static and dynamic) parameters occurring in everyday life. The holding function of 
303 
the PFM is important for the patients—that is, they need to be able to get to the toilet in time 
304 
before their urine starts leaking. The quality of breathing plays an important role in PFM 
305 
training. It is necessary to teach participants the correct abdominal breathing technique which 
306 
activates the TRA. In our study, we activated the TRA and voluntary contraction of the PFM 
307 
with strong exhalation techniques during both measurements and training. Using biofeedback 
308 
(TRA ultrasound imaging and vsEMG curves of PFM) we visualised the co-contraction of the 
309 
two muscles with the participants. Our vsEMG findings indicate that the static isometric 
310 
contraction force of the PFM increased significantly in both study groups—and the holding 
311 
time of static isometric contraction of the PFM increased slightly—with forced exhalation. In 
312 
the COG, the static strength of the PFM increased slightly, but this increase was not 
313 
significant and was characterised by a short retention time. The thickness of TRA during 
314 
maximal isometric contraction of the PFM till fatigue improved in both training groups, but in 
315 
neither group was this improvement significant. The COG claimed that this parameter 
316 
decreased significantly because, during our study, they had spent much more time in a sitting 
317 
position and were therefore in an enforced inactive lifestyle. Another study obtained similar 
318 
results for musculus multifidus [29]. 
319 
Hung et al. [14] 2010 investigated the effects of combining voluntary PFM- and deep 
320 
abdominal muscle training in different body positions. The TRA activity was significantly 
321 
greater in the sitting and standing positions than in the supine position. Chmielewska et al. 
322 
[11] also reported that long-lasting contractions in the unsupported sitting position utilised the 
323 
sensorimotor control system significantly compared with those in the supine position. 
324 
However, in our study, cPFM-T in both the weaker PFM (in the SUG) and the stronger PFM 
325 

15 
 
 
(in the SIG) led to significant development in long-lasting contractions regardless of the body 
326 
position of the measure. 
327 
Chmielewska et al. [11] measured the rapid activity of the PFM with vsEMG in the supine 
328 
position and in the sitting position, finding no significant differences between the PFM 
329 
average peak amplitudes in the investigated positions, while we found these values to be 
330 
significantly improved in the supine position. In our study, only in the supine position did the 
331 
strength and repetition of dynamic fast contractions increase\ significantly; in the sitting 
332 
position, changes in dynamic fast contractions were not significant. The fast activity of the 
333 
PFM is responsible for resistance during sudden abdominal pressure. In the COG, dynamic 
334 
strength and repetition decreased and did not manifest significant changes.  
335 
Capson et al. [8] and Chmielewska et al. [11] measured the relaxation tone of the PFM in the 
336 
supine position and in the sitting position. They deduced that gravity forces increase the 
337 
pressure on the PFM in the vertical position, increasing its tone and leading to a higher resting 
338 
activity of the PFM in the sitting position than in the supine position. During our measures, 
339 
the SIG participants found it easier to relax in the horizontal position. Based on our results, 
340 
practising relaxation exercises can be beneficial not only in the horizontal position but also in 
341 
the vertical position. Improvement in the relaxation ability of the PFM is also a beneficial 
342 
result, because especially during urination, for a healthy, normal urination mechanism it is 
343 
necessary to consciously relax the PFM. The relaxation state of the PFM improved 
344 
significantly due to gravity forces only in the SIG. 
345 
We observed that the conditioning capabilities of the PFM improved in the SUG during the 8 
346 
week period of cPFM-T. The ability to sustain isometric contractions improved significantly, 
347 
while holding time also improved, but this improvement was not significant. There was also a 
348 
significant improvement in dynamic endurance and repetitions. Therefore we recommend a 
349 
more intense strengthening of the TRA in the horizontal body position. 
350 

16 
 
 
In the case of the SIG, the maximal isometric contraction of the PFM till fatigue also 
351 
improved significantly, together with the holding time, but the latter improvement was not 
352 
significant. The dynamic endurance decreased and the number of repetitions improved 
353 
slightly, but these changes were not significant. The relaxation state of the PFM improved 
354 
significantly due to gravity forces. The resting tone of the TRA remained unchanged after 8 
355 
weeks. Thus, even more intense TRA activation is required in the vertical position, as a 
356 
reliance on the enhanced gravitational forces caused by the lumbopelvic posture or on the 
357 
activated TRA induced by strong exhalation is insufficient to induce the necessary changes in 
358 
the functioning of the TRA. 
359 
In the case of the COG, all parameters decreased—particularly the thickness of TRA during 
360 
maximal isometric contraction of the PFM till fatigue, which decreased significantly—by 
361 
reason of sedentary lifestyle. 
362 
We also established that young nulliparous women might also be affected by urinary leakage 
363 
(27%) as confirmed by the results of Haslam et al. [1]. 
364 
In the case of the SUG, both training exercises and measurements were performed in the 
365 
supine position, whereas the SIG participants were measured in the lying position but 
366 
performed all the exercises in the sitting position. Since SUI takes place most frequently in 
367 
the vertical position, we should not measure and strengthen the static and dynamic functions 
368 
of the PFM only in the supine position. We recommend that during cPFM-T, isometric and 
369 
relaxation tasks should be performed both in the supine position and in the sitting position.  
370 
According to Sapsford et al. [5], the antigravity posture requires more intense PFM activity. 
371 
Furthermore, Chmielewska et al [11] reported a significant difference between the sustained 
372 
1-minute contraction of the PFM in the supine position and that in sitting position, while we 
373 
found that the maximal isometric sustained contraction of PFM till fatigue significantly 
374 
improved both in the supine position and in the sitting position. 
375 

17 
 
 
Group training and individual training, according to recent research, are equally effective, and 
376 
group training is more cost-effective [30]. Furthermore, due to differences in knowledge and 
377 
behaviour, physiotherapist-guided training can help and motivate patients in persistent PFM-T 
378 
[31].  
379 
 
380 
Conclusions 
381 
TRA relaxion is easier in the horizontal position and strengthening is more effective in the 
382 
horizontal body position. Physiotherapist-guided group training is more efficient. 
383 
The authors suggest that during PFM training the isometric tasks should be performed both in 
384 
the supine position and in the sitting position, the dynamic endurance tasks of the PFM should 
385 
be performed at the beginning of the training only in the supine position and more intensive 
386 
strengthening of the TRA should be performed in the supine position to achieve maximal 
387 
PFM contraction. 
388 
 
389 
Abbreviations 
390 
ANOVA 
analysis of variance 
ASIS 
anterior superior iliac spine 
cPFM-T 
combined pelvic floor muscle training 
COG 
control group 
EO 
external oblique muscle 
IO 
internal oblique muscle 
PFM 
pelvic floor muscles 
PFM-T 
pelvic floor muscle training 
RA 
rectus abdominis muscle 

18 
 
 
SD 
standard deviation 
SIG 
sitting group 
SUI 
stress urinary incontinence 
SUG 
supine group 
TRA 
transverse abdominal muscle 
RCT 
randomised controlled trial 
UI 
urinary incontinence 
US  
Ultrasound 
vsEMG 
vaginal surface electromyography 
 
391 
Declarations 
392 
Ethics approval and consent to participate 
393 
The protocol and consent forms were approved by ethics committee of the Hungarian 
394 
National Healthcare Service Center. The title of the ethics approval: Non-interventional study 
395 
"Effect of PFM on Urinary Incontinence and Sexual Quality of Life". The number of the 
396 
ethics approval: 019234/2014/OTIG Registered 07 April 2014. The name of the Ethics 
397 
Committe: Scientific and Research Ethics Committee of the Health Science Council. The 
398 
adress of the Ethics Committee: Hungary, 1051 Budapest, Zrínyi street 3. Phone number: 
399 
+36(1)8869329. E-mail: amd@ogyei.gov.hu. All participants provided written informed 
400 
consent. 
401 
Consent for publication 
402 
Not applicable. 
403 
Availability of data and materials 
404 

19 
 
 
The datasets used and/or analysed during the current study are available from the 
405 
corresponding author on reasonable request. 
406 
Competing interests 
407 
All financial and non-financial competing interests must be declared in this section. 
408 
Funding 
409 
The project has been supported by the European Union, co-financed by the European Social 
410 
Fund. EFOP-3.6.1-16-2016-00008. The role of the funding body in the design of the study 
411 
and collection, analysis, and interpretation of data and in writing the manuscript should be 
412 
declared. 
413 
Authors’ contributions 
414 
Each author’s participation in the manuscript 
415 
T M: project development, study design, ultrasound investigation, data collection, manuscript 
416 
writing and editing 
417 
A D: project development, study design, manuscript revision 
418 
M Sz: data collection, statistical analysis, 
419 
A S: study design, ultrasound investigation, manuscript writing, editing and revision 
420 
J B: project development, manuscript revision 
421 
Acknowlegements 
422 
Not applicable. 
423 
Author informaiton 
424 
This may include details about the authors' qualifications, current positions they hold at 
425 
institutions or societies, or any other relevant background information. Please refer to authors 
426 
using their initials. 
427 
Legend to the tables 
428 

20 
 
 
TABLE 1. Participant characteristics 
429 
TABLE 2. PFM activity while resting during tonic and phasic contractions in the COG, the 
430 
SIG and the SUG, and the thickness of TRA during isometric contraction of PFMs until 
431 
fatigue and in a relaxed state 
432 
 
433 
Legend to the figures 
434 
FIGURE 1. Flow chart of study participants 
435 
FIGURE 2. (A) vsEMG values of the maximal isometric contraction of PFMs till fatigue; (B) 
436 
holding time of maximal isometric contraction of PFMs till fatigue; (C) the thickness of TRA 
437 
during maximal isometric contraction of PFMs till fatigue. 
438 
FIGURE 3. (A) EMG values of strength of maximal fast contractions within 1 min. (B) 
439 
Number of maximal fast contractions within 1 min. 
440 
FIGURE 4. (A) Relaxation values for PFMs. (B) Thickness of TRA during relaxation of 
441 
PFMs. 
442 
 
443 
References 
444 
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445 
2004;18;100(20):71–73. 
446 
2. Kegel AH Progressive resistance exercise in the functional restoration of the perineal 
447 
muscles. Am J Obstet Gynecol. 1948;56(2):238–248. 
448 
3. Dumoulin C, Hay-Smith J Pelvic floor muscle training versus no treatment or inactive 
449 
control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 
450 
2010;20;(1):CD005654. 
451 

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4. Thüroff WJ, Abrams P, Andersson K-E, Artibani W, Chapple RC, Darke JM, Hampel 
452 
C, Neisuis A, Schröder A, Tubaro A EAU Guidelines on urinary incontinence. Eur 
453 
Urol. 2011;59:387–400. 
454 
5. Sapsford RR The pelvic floor. A clinical model for function and rehabilitation. 
455 
Physiotherapy. 2001;87:620–30. 
456 
6. Neumann P, Gill V Pelvic floor and abdominal muscle interaction: EMG activity and 
457 
intra-abdominal pressure. Int Urogynecol J Pelvic Floor Dysfunct. 2002; 13(2):125–
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132. 
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7. Madill SJ, McLean L Quantification of abdominal and pelvic floor muscle synergies 
460 
in response to voluntary pelvic floor muscle contractions. J Electromyogr Kinesiol. 
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2008;18(6):955–964. 
462 
8. Capson AC, Nashed J, Mclean L The role of lumbopelvic posture in pelvic floor 
463 
muscle activation in continent women. J Electromyogr Kinesiol. 2011;21(1)166–177. 
464 
9. Sapsford RR, Richardson CA, Stanton WR Sitting posture affects pelvic floor muscle 
465 
activity in parous women: an observational study. Aust J Physiother. 2006;52(3):219–
466 
222. 
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10. Sapsford RR, Richardson CA, Maher CF, Hodges PW Pelvic floor muscle activity in 
468 
different sitting postures in continent and incontinent women. Arch Phys Med Rehabil. 
469 
2008;89(9):1741–1747. 
470 
11. Chmielewska D, Stania M, Sobota G, Kwasna K, Blaszczak E, Taradaj J, Juras G 
471 
Impact of different body positions on bioelectrical activity of the pelvic floor muscles 
472 
in nulliparous continet women. BioMed Res Int. 2015; doi: 10.1155/2015/905897. 
473 
12. Bø K, Mørkved S, Frawley H, Sherburn M Evidence for benefit of transversus 
474 
abdominis training alone or in combination with pelvic floor muscle training to treat 
475 

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female urinary incontinence: a systematic review. Neurourol Urodyn. 2009;28:368–
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373. 
477 
13. Nie XF, Ouyang YQ, Wang L, Redding SR A meta-analysis of pelvic floor muscle 
478 
training for the treatment of urinary incontinence. Int J Gynaecol Obstet. 
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2017;138(3):250-255. 
480 
14. Hung H-C, Hsiao S-M, Chih, S-Y, Lin H-H, Tsauo J-Y An alternative intervention for 
481 
urinary incontinence: Retraining diaphragmatic, deep abdominal and pelvic floor 
482 
muscle function coordinated function. Man Ther. 2010;15:273–279. 
483 
15. Sriboonreung T, Wongtra-ngan S, Eungpinichpong W, Laopaiboon M Effectiveness 
484 
of pelvic floor muscle training in incontinent women at Maharaj Nakorn Chiang Mai 
485 
Hospital: a randomized controlled trial. J Med Assoc Thai. 2011;94:1–7. 
486 
16. Bø K, Finckenhagen HB Is there any difference in measurement of pelvic floor muscle 
487 
strength in supine and standing position? Acta Obstet Gynecol Scand. 2003;82:1120–
488 
1124. 
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17. Da Roza T, de Araujo MP, Viana R, Viana S, Jorge RN, Bø K, Mascarenhas T Pelvic 
490 
floor muscle training to improve urinary incontinence in young, nulliparous sport 
491 
students: a pilot study. Int Urogynecol J. 2012;23(8):1069–1073. 
492 
18. Bø K, Kvarstein B, Hagen R, Larsen S Pelvic floor muscle exercise for the treatment 
493 
of female stress urinary incontinence: Validity of vaginal pressure measurements of 
494 
pelvic floor muscle strength and the necessity of supplementary methods for control of 
495 
correct contraction. Neurourol Urodyn. 1990;9:479–487. 
496 
19. Whittaker LJ, Warner BM, Stokes M Comparison of the sonographic features of the 
497 
abdominal wall muscles and connective tissues in individuals with and without 
498 
lumbopelvic pain. J Orthop Sports Phys Ther. 2013;43(1):11–19. 
499 

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20. Carrière B Sensory awareness- feeling the pelvic floor. In: Carrière B editor. Fitness 
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for the pelvic floor. 1st ed. Stuttgart-New York: Georg Thieme Verlag; 2002. p 24–30. 
501 
21. Shamsi M, Mirzaei M, HameiRad M Comparison of muscle activation imbalance 
502 
following core stability or general exercises in nonspecific low back pain: a quasi-
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randomized controlled trial. BMC Sports Sci Med Rehabil. 2020;12:24 
504 
doi:10.1186/s13102-020-00173-0- eCollection 2020.  
505 
22. Madill SJ, McLean L Relationship between abdominal and pelvic floor muscle 
506 
activation and intravaginal pressure during pelvis floor muscle contraction in healthy 
507 
continent women. Neurol Urodyn. 2006;25:722–730. 
508 
23. Sapsford RR Rehabilitation of pelvic floor muscles utilizing trunk stabilization. Man 
509 
Ther. 2004;9:3–12. 
510 
24. Dumoulin C, Glazener C, Jenkinson D Determining the pelvic floor muscle training 
511 
regimen for women with stress urinary incontinence. Neurourol Urodyn. 
512 
2011;30:746–753. 
513 
25. Thompson JA, O’Sullivan PB, Briffa NK, Neumann P Difference in muscle activation 
514 
patterns during pelvic floor muscle contraction and valsalva manouevre. Neurourol 
515 
Urodyn. 2006;25:148–155. 
516 
26. Kapandji IA The lumbar spine In: Kapandji IA editor. The physiology of the joints 
517 
trunk and the vertebral column. London: Churchill Livingstone; 2008. p 84–141. 
518 
27. Hodges PW, Butler JE, Mckenzie DK, Gandevia SC Contraction of the human 
519 
diaphragm during rapid postural adjustments. J Physiol. 1997;505(Pt 2):539–548. 
520 
28. Gosling JA, Dixon JS, Critchley HOD, Thompson SA A comparative study of the 
521 
human external sphincter and periurethral levator ani muscle. Br J Urol. 1981;53:35-
522 
41. 
523 

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29. Finta R, Nagy E, Bender T The effect of diaphragm training on lumbar stabilizer 
524 
muscles: a new concept for improving segmental stability in the case of low back pain. 
525 
Pain Research. 2018. 11:3031–3045. doi: 10.2147/JPR.S181610. 
526 
30. Dumoulin C, Morin M, Mayrand MH, Tousignant M, Abrahamowicz M Group 
527 
physiotherapy compared to individual physiotherapy to treat urinary incontinence in 
528 
aging women: study protocol for randomized controlled trial. Trials. 2017;18(1):544. 
529 
31. Hay-Smith EJ, McClurg D, Frawley H, Dean SG Exercise adherence: integrating 
530 
theory, evidence and behavior change techniques. Physiotherapy. 2016;102(1):7–9. 
531 
 
532 
Additional file 1 
533 
Table1. Participant Characteristics 
534 
Age (years) 
21.00 [20.00–22.00] (SUG) 
21.00 [20.00–22.00] (SIG) 
21.50 [21.00–23.00] (COG) 
Number of participants (positions) 
22 (SUG) 
19 (SIG) 
14 (COG) 
BMI (kg/m2)  
21.85 [20.77–22.95] (SUG) 
21.30 [20.00–22.20] (SIG) 
22.00 [19.77–23.32] (COG) 
Number of participants doing regular 
physical activity more than twice a week 
9 (SUG) 
9 (SIG) 
5 (COG) 
BMI  
SUM  
SUG  
SIG 
COG 

25 
 
 
(n = 55) 
(n = 22) (n = 19) 
(n = 14) 
Normal BMI 18-24  
45 
18 
16 
11 
Overweight BMI 25-29  
9 
3 
3 
3 
Underweight BMI <18  
1 
1 
0 
0 
 
535 
Values are median [1st - 3rd] quartiles for age and BMI and numbers of participants. 
536 
BMI: body mass index; SUG: the supine study group; SIG: the sitting study group; COG: the 
537 
control group 
538 
Additional file 2 
539 
Table 2. PFM activity while resting and during tonic and phasic contractions in COG, 
540 
SIG and the SUG as well as the thickness of TRA during isometric contraction of PFM 
541 
until fatigue and in a relaxed state 
542 
 
Before training 
After training 
p-value 
 
 
median [Q1 – Q3] 
Maximal isometric contraction of PFM till fatigue (tonic) (µV) 
COG 
56.25 [44.23–83.62] 
58.65 [54.27–89.07] 
0.499 
SIG 
91.20 [63.55–124.20] 
115.60 [84.50–131.80] 
0.015 
SUG 
42.90 [27.73–53.42] 
59.00 [50.10–73.85] 
<0.001 
Holding time of PFM (s) 
COG 
21.25 [14.58–27.50] 
17.00 [12.50–19.41] 
0.132 
SIG 
17.00 [12.75–27.50] 
19.50 [15.50–23.00] 
0.717 
SUG 
19.50 [16.50–29.75] 
21.25 [13.25–28.62] 
0.972 
Dynamic endurance of PFM (phasic) (µV) 

26 
 
 
COG 
88.16 [62.84–97.22] 
77.05 [60.23–87.83] 
0.153 
SIG 
122.00 [95.30–142.20] 
115.16 [94.68–128.42] 
0.798 
SUG 
53.15 [35.61–64.28] 
70.97 [56.10–83.80] 
<0.001 
Number of repetitions of fast contractions of PFM (repetitions) 
COG 
33.00 [29.25–36.00] 
31.00 [29.25–33.75] 
0.257 
SIG 
29.00 [22.00–39.00] 
30.00 [23.00–35.50] 
0.813 
SUG 
26.00 [21.75–33.50] 
32.00 [27.25–39.75] 
<0.001 
Relaxation state of PFM (µV) 
COG 
8.60 [6.48–17.98] 
10.55 [3.85–19.40] 
0.851 
SIG 
21.40 [8.35–27.05] 
12.40 [3.00–19.45] 
0.011 
SUG 
13.40 [9.20–20.75] 
13.25 [6.83–18.50] 
0.465 
TRA (cm) during relaxation state of PFM 
COG 
0.38 [0.33–0.44] 
0.31 [0.27–0.34] 
0.209 
SIG 
0.26 [0.23–0.32] 
0.26 [0.23–0.31] 
0.717 
SUG 
0.28 [0.26–0.31] 
0.27 [0.25–0.31] 
0.422 
TRA (cm) during maximal isometric contraction of PFM till fatigue 
COG 
0.63 [0.61–0.74] 
0.49 [0.45–0.57] 
0.007 
SIG 
0.51 [0.38–0.63] 
0.56 [0.41–0.75] 
0.231 
SUG 
0.53 [0.44–0.73] 
0.58 [0.46–0.68] 
0.570 
Values are median [1st –3rd] quartiles for isometric contractions, resting of the PFM and the 
543 
TRA and phasic contractions of the PFM.  
544 
Key: SUG: number of participants in the supine study group; SIG: number of participants in 
545 
the sitting study group; COG: number of participants in the control group; PFM: pelvic floor 
546 
muscles; TRA: transverse abdominal muscle 
547 

27 
 
 
Additional file 3 
548 
FIGURE 1. Flow chart of study participants 
549 
 
550 
 
551 
 
552 
 
553 
 
554 
 
555 
 
556 
 
557 
 
558 
 
559 
 
560 
 
561 
 
562 
 
563 
Additional file 4 
564 
FIGURE 2. (A) vsEMG values of maximal isometric contraction of the PFM till fatigue; (B) 
565 
holding time of maximal isometric contraction of the PFM till fatigue; (C) the thickness of the 
566 
TRA during maximal isometric contraction of the PFM till fatigue. 
567 
Assessed for 
eligibility (n=58) 
Excluded (n=0) 
Allocated to 
intervention (n = 44) 
Allocated to control 
group (n = 14) 
Lost during follow-up (n = 3) 
- 
Acute low back pain: 1 
- 
Losing motivation: 2 
Lost during follow-up (n = 0) 
 
Analyzed (n = 
41)  
SUG (n = 22) 
SIG (n = 19) 
Analyzed  
(n = 14) 

28 
 
 
 
568 
Additional file 5 
569 
FIGURE 3. (A) EMG values of strength of maximal fast contractions within 1 min (B) 
570 
Number of maximal fast contractions within 1 min 
571 
 
572 
 
573 
Additional file 6 
574 
FIGURE 4. (A) Relaxation values for the PFM (B) Thickness of the TRA during relaxation 
575 
of the PFM 
576 
 
577 

29 
 
 
Additional 7 
578 
Questionnaire 
579 
Questionnaire 
580 
1. Name: 
581 
2. Age: 
582 
3. Height: 
583 
4. Body weight: 
584 
5. Sports?        YES        NO 
585 
6. If so, what sport?……………………………………………………. 
586 
7. How many times a week, and what time does the sport 
587 
entail?……………………………………............................ 
588 
8. Do you smoke?   YES         NO 
589 
9. Do you take any medicine?     YES        NO 
590 
10. If so, what?......................................................................................... 
591 
11. Are you suffering from any gynaecological or urological disease?  YES     NO 
592 
12. If so, from what illness do you suffer? 
593 
13. Are you suffering from any coughing disease (hay fever, asthma, chronic bronchitis 
594 
and so on)?         YES        NO 
595 
14. How much fluid do you drink daily? 
596 
 a) 0–1 L 
597 
b) 1–2 L 
598 
c) 2–3 L 
599 
15. Menstrual cramps on a 1–10 scale where 1 is a very mild and 10 is a very strong, 
600 
almost unbearable, pain! 
601 
1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10 
602 

30 
 
 
16. Do you experience leakage of urine drops?   YES        NO 
603 
17. If yes, to what extent?  
604 
a) mild: 1–2 drops  
605 
b) medium: 10–15 drops  
606 
c) large volume: 15–30 drops  
607 
18. When does urine leak?  
608 
a) during jumping, coughing 
609 
b) climbing stairs, during lifting 
610 
c) at rest, without any activity 
611 
d) Other: 
612 
19. Do you have stool or gas retention problems? YES        NO 
613 
20. Do you suffer from haemorrhoids? YES        NO 
614 
21. Do you suffer from constipation? 
615 
a) sometimes 
616 
b) very often 
617 
c) almost never or very rarel 
618 
22. Does your vagina feel dilated?   YES             NO 
619 
23. Do you feel the airflow in your vagina?  YES        NO 
620 
24. . If so, when does it occur? 
621 
a) during sexual intercourse 
622 
b) during change in position (line up) 
623 
c) Other: 
624 
25. After swimming or bathing in the tub, do you still feel water dripping from your 
625 
vagina for a long time?         YES             NO 
626 
26. Do you have a sexual life? YES           NO 
627 

31 
 
 
27. If so, how often? 
628 
a) 1 time per month 
629 
b) 1 time per week 
630 
c) 2–4 times per week 
631 
d) 5–7 times per week 
632 
e) occasionally 
633 
f) Other: …………………… 
634 
28. Do you feel pain when penetrating a tampon or sexual intercourse? YES      NO 
635 
29. Sexual libido on a scale of 1 to 10, where 1 is low and weak and 10 is strong libido!  
636 
0 - 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10 
637 
30. Frequency of orgasm on a 1–10 scale, where 1 means very rarely and 10 is almost 
638 
always during sexual intercourse!  
639 
0 - 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10 
640 
 
641 
Additional file 8 
642 
Detailed exercise regimen and estimated progression in the present trial (Sapsford, 2004; 
643 
Hung, 2010) 
644 
Stage 
Exercise regimen 
I. Before the training programme: Patient 
education 
 
 Teaching about the anatomy of the PFM, 
risk factors, symptoms of PFM dysfunction 
and feeling PFM contractions through 
palpation and visualisation. 
Position: supine 
Instruction: Try to lift your PFM as if you 
want to hold your urine or faeces. 
Home exercise: Awareness through feeling 
PFM contractions  

32 
 
 
Feedback: palpation, mirror and during 
urination 
II. Week 1: Diaphragmatic breathing, tonic 
TRA and PFM activation, warm-up, 
voluntary concentric and isometric PFM 
contractions 
Group position: supine 
Instructions: Try to raise the abdomen while 
your chest expands only minimally during 
inhalation, then lower your abdomen during 
exhalation; try to lift your lower abdomen 
cranially and keep pulling it in towards your 
spine; tensing exercises for the muscles (hip 
extensor, adductor) surrounding the pelvic 
floor; lift PFM gradually (25%, 50%, 75% 
and 100%) and try to hold it; try to relax 
PFM as far as possible by diaphragmatic 
breathing and hip movements. Spinal and 
pelvic movements are prohibited. 
Feedback: in front of a mirror to see lower 
abdominal and rib movements; tactile input 
at the medial ASIS by both the therapist and 
the participant; participant’s subjective 
feeling of tensing response around the 
perineal region. 
Home exercise: in supine position: 
Diaphragmatic breathing 30 repetitions × 2 
sets/day; holding the TRA contraction as 
long as possible (target: 40 s) × 2 sets/day; 
contracting the gluteal and hip adductor 15 
repetitions; pulling PFM up gradually (25%, 
50%,75% and 100%), 5 repetitions and hold 
at different levels for 5–10 s × 2 sets/day. 
Make sure PFM are relaxed. 
III. Week 2: PFM voluntary eccentric and 
quick contraction 
Prerequisites: the participant can perform the 
tasks of Week 1. 
Group position: supine 

33 
 
 
Instruction: Repeat the home exercises of 
Week 1 as a warm-up; try to let PFM down 
slowly from 25%, 50%, 75% and 100% and 
hold at different levels; try to pull PFM up 
quickly as far as possible and make sure 
PFM are relaxed. 
Feedback: tactile input, the medial ASIS is 
palpated by both the therapist and the 
participant to check the TRA/PFM co-
contraction; participant’s subjective feeling 
of tensing response around the perineal 
region. 
Home exercise: in supine position: 
Diaphragmatic breathing 30 repetitions × 2 
sets/day; holding the TRA contraction as 
long as possible (target: 40 s) × 2 sets/day; 
contracting the gluteal and hip adductor 15 
repetitions; maximal PFM contraction 5 
repetitions; pulling PFMs up gradually 25%, 
50%,75% and 100%, 5 repetitions; hold at 
different PFM levels for 5–10 s; pull up and 
let down from 50% to 100%, 5 repetitions; 
pull PFM up quickly at 100% and relax for 
30 s, 5 repetitions. All repetitions × 2 
sets/day. Make sure PFM are relaxed. 
IV. Week 3: 
Prerequisites: the participant can perform the 
tasks of Weeks 1 and 2 
Group Position: supine 
Instruction: Try to keep the PFM contraction 
at 100% combined with slow movement of 
the limbs and trunk; pull the PFM up quickly 
at 100% together with fast limb movements. 
Feedback: tactile input, the medial ASIS is 

34 
 
 
palpated by both the therapist and the 
participant to feel the TRA/PFM co-
contraction; participant’s subjective feeling 
of tensing response around the perineal 
region. 
Home exercise: in supine position: same as 
the home exercise of Week 2. 
V. Week 4: 
Prerequisites: tonic TRA/PFM contraction 
can be maintained easily together with limb 
and trunk movements 
Group position: lying on the side 
Instruction: Try to keep PFM contraction at 
100% combined with slow limb and trunk 
movements, pull PFM up quickly at 100% 
together with fast limb and trunk movements. 
Feedback: tactile input, the medial ASIS is 
palpated by both the therapist and the 
participant to feel TRA/PFM co-contraction; 
participant’s subjective feeling of tensing 
response around the perineal region. 
Home exercise: SUG in supine and SIG in 
sitting position: same as the home exercise of 
Week 2. 
VI. Week 5: 
Prerequisites: TRA/PFM contraction can be 
maintained easily together with limb and 
trunk movements 
Group Position: on hands and knees 
Instruction: Keep PFM contraction at 100% 
combined with slow limb and trunk 
movements; pull PFM up quickly at 100% 
together with fast limbs movements. 
Feedback: tactile input, the medial ASIS is 
palpated by both the therapist and the 

35 
 
 
participant to feel TRA/PFM co-contraction; 
participant’s subjective feeling of tensing 
response around the perineal region. 
Home exercise: SUG in supine and SIG in 
sitting position: same as the home exercise of 
Week 2. 
VII. Week 6: 
Prerequisites: TRA/PFM contraction can be 
maintained easily together with limb and 
trunk movements 
Group Position: sitting 
Instruction: Keep PFM contraction at 100% 
combined with slow limb and trunk 
movements; pull PFM up quickly at 100% 
together with fast limb movements. 
Feedback: tactile input, the medial ASIS is 
palpated by both the therapist and the 
participant to feel TRA/PFM co-contraction; 
participant’s subjective feeling of tensing 
response around the perineal region. 
Home exercise: SUG in supine and SIG in 
sitting position: same as the home exercise of 
Week 2. 
VIII.Week 7: 
Prerequisites: The TRA/PFM contraction 
can be maintained easily together with limb 
and trunk movements 
Group Position: standing 
Instruction: Keep the PFM contraction at 
100% combined with slow limb and trunk 
movements; pull the PFM up quickly at 
100% together with fast limb movements. 
Feedback: tactile input, the medial ASIS is 
palpated by both the therapist and the 
participant to feel the TRA/PFM co-

36 
 
 
contraction; participant’s subjective feeling 
of tensing response around the perineal 
region. 
Home exercise: SUG in supine and SIG in 
sitting position: same as the home exercise of 
Week 2. 
IX. Week 8: 
Prerequisites: The TRA/PFM contraction 
can be maintained easily together with limb 
and trunk movements 
Group Position: walking, steps, unstable 
Instruction: Keep the PFM contraction at 
100% combined with slow limb and trunk 
movements; pull the PFM up quickly at 
100% together with fast limbs movements. 
Feedback: tactile input, the medial ASIS is 
palpated by both the therapist and the 
participant to feel the TRA/PFM co-
contraction; participant’s subjective feeling 
of tensing response around the perineal 
region. 
Home exercise: SUG in supine and SIG in 
sitting position: same as the home exercise of 
Week 2. 
X. After the training programme 
The participants are advised to continue the 
programme for another 4 weeks to achieve 
sufficient muscle strength. Thereafter they 
are required to do the PFM-T 3 times per 
week, which is essential for maintaining the 
achieved level. 
 
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