INTRODUCTION:

Urinary incontinence (UI) is the unintentional passing of the urine and is defined by the International Incontinence Society as an “Involuntary loss of urine which is objectively a demonstrable, Social and Hygienic Problem”. It is a disorder of the reservoir function of the lower urinary tract, comprising the bladder, urethra, and sphincter muscles (1).

Urinary incontinence is not just a medical problem but affects the emotional, psychological and social life of the individuals. This problem is observed both in men and women, but tends to be more common among the latter. Women above the age of 60 years are more prone to this condition than men, due to weakening of pelvic floor muscles. Women who have developed urinary incontinence during pregnancy are more likely to have it after pregnancy also (2). Incontinence is a common disorder, as up to 35% of the population over the age of 60 years is estimated to be affected by this globally. The known risk factors include age, delivery (vaginal/caessarean section), pregnancy, number of children, uncontrolled diabetes mellitus, stroke, spinal cord injury and obesity. Other risk factors include damage to pelvic floor muscles, constipation, smoking, and genetics. The prevalence of urinary incontinence increases with age, though ageing is not a cause for urinary incontinence. In few cases, anatomical or physiological changes in the lower urinary tract cause urinary incontinence in old patients (3)(4). Urology care foundation results showed that women after menopause were more prone to develop urinary incontinence (5). due to drop in estrogen level, a hormone playing a vital role in bladder control and menstrual cycle. However, estrogen taking does not help in reducing urinary incontinence.

Fall is another common risk among aged population (6). The WHO defines “The Falls is an event which results in a person coming to rest inadvertently on the ground or floor or other lower level”. Fall is a second leading cause for death after the road traffic accidents and is a major cause for injury, fracture and death among older people. Fall is often associated with the urinary incontinence (7). The falls in urinary incontinence occur because of the inability to maintain the center of gravity within the base of support. Generating effective response to postural disturbances demands high amount of muscular force and is getting affected during aging, as muscles get weak (8)leading to the risk of falling. The prevalence of falls in Indian older adults ranges from 14% to 53%. The risk factor for falls include: older age, gait deficit, malnutrition, visual impairment, muscle weakness, impaired balance and the risk of fall increases as the age.

The pelvic floor muscles and trunk muscles are involved in controlling continence (9), besides maintaining the center of gravity in its base of support. Generally, elderly women get affected by incontinence and risk of fall due to weakening of these muscles (10). In general, fall is the important cause for fracture among aged population. Other injuries due to fall are hematoma, contusion, joint dislocation and soft tissue injury. The Berg Balance Scale was developed to measure balance among older people with balance impairment by assessing the performance of functional task. In this study, Berg Balance is used to assess the balance of the subjects. The Berg Balance Scale consists of 14 items which includes simple mobility tasks and difficult tasks. Each item is scored on a 5-point ordinal scale, where “0” indicates an ability to complete the task and “4” indicates complete the task independently. The maximum score of 45 indicates high risk of fall. The Urogenital Distress Inventory (UDI)-6 and Incontinence Impact Questionnaire (IIQ)-7 were used to assess the symptoms of distress and impact on daily life in women with stress continence (4).

The OTAGO exercise program is a safe, effective, practical, and eminently feasible and low- cost fall prevention strategy which is benefit for older citizens. OTAGO exercise programme was developed and tested in four controlled trails by research team at the university of OTAGO medical school, New Zealand, led by Professor John Campbell. The OTAGO exercise program is a set of leg muscles strengthening and balance retraining exercise which is used in reducing the number of falls by 35% in both males and females. The OTAGO exercise increases the muscle strength, gait, balance and confident level and functional activities. SAIL is fall prevention and balance retraining programme (11) used to improve strength, balance and confidence for adults 65 older. It is usually offered 2-3 times a week. It can be done sitting and standing (12). Each class includes warm-up aerobics, balance activities, strengthening and stretch exercise

Pelvic floor consists of 12 striated muscles which arranged in 3 layers. The function of pelvic floor muscle is to provide structural support for the pelvic structures urethra, sphincter, vagina, and rectum. The pelvic floor exercises involve repetitive contraction which improves strength and muscle tone. The movements in the exercises include inward and outward contraction of pelvic floor. The effectiveness of the exercises determined by the force and intensity of contraction of the muscles.

AIM:

This study intends to compare the combination of Pelvic Floor Muscle Strengthening Exercise (PFMSE) with OTAGO exercise and Stay Active and Independent for Life (SAIL) exercises separately for managing UI and fall risk among women.

BACKGROUND OF THE STUDY:

In India, 21.8% women suffer from UI and the prevalence of falls among Indian older women ranges from 14% to 53%. Pelvic muscle weakness is a common cause for both of these conditions. Therefore, pelvic floor strengthening exercises have been opted as common regime and OTAGO exercises and SAIL exercises have been combined in separate sets of subjects for comparing the effectiveness of these exercises in managing the risk of fall and UI among women.

METHODOLOGY:

After obtaining the approval from the Institutional Review Board from the Faculty of Physiotherapy, Dr.MGR Educational and Research University this experimental study was conducted. Out of 50 female subjects, 30 were selected based on the inclusion and exclusion criteria. The subjects who fulfilled the inclusion criteria comprise: females of age 45-65 years, with urinary continence, Berg balance score within 45, Patients who are able to walk for 20 meters at least, Married women who are married. The exclusion criteria comprised: Females with recent lower limb fracture, visual impairment, auditory impairment, Individual with lower extremity impairment, Recent lower limb surgery, Women unable to contract the pelvic floor muscle, Urogenital infection, Pelvic organ prolapsed, Uncontrolled hypertension, Recent abdominal surgery. The study was conducted at Udhavum Karangal, Chennai. The study was a comparative study with pre and post interventional type. The subjects were grouped into two by simple convenient sampling method. The outcome measures included Berg Balance Scale, Urogenital Distress Inventory short form 6 and Incontinence Impact Questionnaire 7.

PROCEDURE:

As per the selection criteria, 30 patients who fulfill the Berg Balance Scale (BBS), Urogenital Distress Inventory Questionnaire – 6 (UDI - 6), Incontinence Impact Questionnaire - 7 (IIQ - 7) and subjects who scored 45 in Berg Balance Scale were included in this study. After obtaining permission from the Institutional Review Board and Informed Consent from the patients, they were enrolled for the study and divided into two groups of 15 each. Group “A”: subjects received PFMSE and OTAGO exercises and Group “B” subjects received PFMSE and SAIL exercise for a period of 6 months from January 2016 to June 2016.

PELVIC STRENGTHENING EXERCISE:

Long Hold For Strength:

The patient was instructed to lie on the back with the knees bent and legs comfortably apart or kneel on the hands and knees. The patient were asked to close the eyes and feel the Pelvic Floor muscles working, tighten them around the front passage, vagina and back passage as strongly as possible and hold for three to five seconds. By doing this, the patient should feel the Pelvic Floor muscles ‘lift up’ inside them and feel a definite ‘let go’ as the muscles relax. If the patient can hold longer (but no more than a maximum of eight seconds), then do so. Remember, the squeeze must stay strong and the patient should feel a definite ‘let go’. Repeat up to ten times or until the patient feel fatigue. Rest for a few seconds in between each squeeze.

Quick Squeeze For Power:

The patients were instructed to Squeeze and lift the Pelvic Floor muscles as strongly and as quickly as possible. Do not try to hold on to the contraction, just squeeze and let go. Rest for a few seconds in between each squeeze. Repeat this 10 to 20 times or until the patient feel fatigue. If they can, do this exercise one to three times per day.

Clam Leg Lift:

The patient was instructed to lie on the side. Rest the head on their arm or hand. Bend hips to approximately 45 degrees and bend knees at 90 degree make sure one hip is lying above the other. The patient should now be well aligned – their feet should be in line with their back.

STAY ACTIVE AND INDEPENDENT FOR LIFE (SAIL):

Toe And Heel Lifts (Sit With Feet Close To Chair):

Toe Lifts: Lift toes of both feet as high as possible (keep heels on floor). Hold it for 20-30 Seconds and relax feet on floor. Do 2-3 more times.

Heel Lifts:

Lift heels of both feet up together (keep toes on floor).hold it for 20-30 Seconds and relax feet on floor. Do 2-3 more times.

Marching On The Spot (Sitting):

March on the spot, raising each knee high. Continue for 5-10 seconds. Rest and repeat for another 5-10 seconds.

Letters In The Air (Sitting):

Make a letter “A” in air with one leg. Rest and do the same with the other leg. Rest and make a letter “B” in air with one leg. Rest and do the same with the other leg.

Tap Dancing (Sitting):

Tap one heel forward and return, sideways and return. Do the same with other foot. Do 2–3 more times with each foot. Tap once with one heel, then once with other heel. Repeat alternating feet 2 - 3 more times.

Buttock Walk (Sitting):

Lift and shift one buttock forward, then other buttock forward (scooting) to move forward in chair. Do the same going backward. Do 2-3 more times forward and backward.

OTAGO EXERCISE:

Knee Bends:

The patient was instructed to stand up tall facing the bench with both hands on the bench. Place the feet and shoulder-width apart. Squat down half way bending their knees. The knees go over the toes. When the patient feels their heel start to lift, straighten up, repeat 2-3times.

Toe Raises:

The patient was instructed to stand up tall beside the bench. Hold on and look ahead .The feet and shoulder-width apart and come back onto the heels, raising the front foot off the floor. Lower the feet to the ground and repeat this 2-3 times.

Calf Raises:

The patient was instructed to stand up tall facing the bench. Hold on and look ahead. The feet and shoulder-width apart and come up on their toes. Lower the heels to the ground. Repeat this 2-3times.

One Leg Stand:

The patient was instructed to stand up tall beside the bench. Hold on and look ahead. Stand on one leg. Try to hold this position 10 seconds. Take rest and stand on other leg.

Heel Toe Walking:

The patient was instructed to stand up tall beside the bench. Hold on and look ahead. Place one foot directly in front of the other so they form a straight line. Place the foot behind directly in front .Repeat for 10 more steps.

DATA ANALYSIS:

The collected data was tabulated and analyzed using inferential statistics. Mean and Standard Deviation were used to assess all the parameters. Paired t-test was used for comparing the pre and post treatment values for Berg Balance Scale, Urinary Distress Inventory-6 , Incontinence Impact Questionnaire-7 within the group. The student independent t-test was applied for assessing the difference between the above values between Group A and Group B.

RESULT:

The mean values of BBS score, UDI - 6 score and IIQ – 7 score for Group A before and after the treatment regime are presented in Table1.A significant increase in the BBS score was recorded from pre-test to post-test evaluation in the Group A subjects. Meanwhile, UDI - 6 and IIQ – 7 scores of the same subjects showed significant decrease. These outcomes indicate the positive impact of the combination of OTAGO exercise and PFME in fall prevention and Urinary Incontinence among women. Table 2 illustrates the BBS, UDI – 6, and IIQ – 7 scores for Group B subjects. Similar to the OTAGO exercise and PFME effect, a significance increase in BBS and decrease in UDI - 6 and IIQ – 7 scores were recorded among women of Group B. However, the extent of difference in values of BBS, UDI - 6 and IIQ – 7 were comparatively small to that of Group A subjects. Therefore, it is apparent that the extent of improvement in maintaining balance and urinary continence is better in Group A.

In order to compare the effectiveness of the two combinations of exercises, pre-test and post test scores of BBS, UDI – 6, and IIQ – 7 were analyzed using t- test. The pre-test values for the above parameters did not differ significantly between Group A and Group B subjects (Table 3). Interestingly, all the three parameters recorded significant difference in their values among Group A and Group B women (Table 4). From these results, it can be inferred that the percentage of improvement in balance and strength of the pelvic Floor Muscle in Group A was greater than those of Group B.

Along with exercise patient education is also important. After complete session of treatment we gave a home exercise programme with demonstration. This study focused on to compare the effectiveness of OTAGO and SAIL along with Pelvic Floor exercise and its performance on patients with Urinary Incontinence and fall risk.

Our data supported alternate hypothesis, indicating the that OTAGO exercise along with Pelvic Floor Muscle Exercise was more effective than SAIL exercise along with Pelvic Floor Exercise in women with Urinary Incontinence and Falls risk.

TABLE 1: EVALUATION OF OTAGO EXERCISE IN TERMS OF BERG BALANCE SCALE SCORE (BBS), UROGENITAL DISTRESS INVENTORY-6 (UDI – 6) AND INCONTINENCE IMPACT QUESTIONNAIRE-7 (IIQ-7)

Group A	pre test		post test		T-test	Significance
Group A	Mean	SD	mean	SD	T-test	Significance
BBS	32.00	4.94	40.73	2.84	8.55	0.000
UDI-6	12.2	1.74	8.4	0.98	13.5	0.000
IIQ-7	19.6	3.79	11.85	2.17	9.65	0.000

(***p<0.001)

The above table reveals the Mean, Standard deviation (S.D), t-value and p-value of the Berg Balance Scale, Urinary Distress Inventory-6, Incontinence Impact Questionnaire-7 score between Pre- test and Post-test within GROUP- A. This table shows statistically significant difference in Berg Balance Scale score, Urinary Distress Inventory -6, Incontinence Impact Questionnaire-7 score between pre-test and post-test values.

TABLE 2: EVALUATION OF SAIL EXERCISE IN TERMS OF BERG BALANCE SCALE SCORE (BBS), UROGENITAL DISTRESS INVENTORY-6(UDI – 6) AND INCONTINENCE IMPACT QUESTIONNAIRE-7 (IIQ-7)

Group B	Pre test		post test		T-test	Significance
Group B	Mean	SD	Mean	SD	T-test	Significance
BBS	31.00	4.55	34.86	4.15	10.27	0.000
UDI-6	11.2	1.32	9.3	1.44	1.29	0.000
IIQ-7	17.7	2.12	15.8	2.09	11.29	0.000

This table shows statistically significant difference in Berg Balance Scale score, Urinary Distress Inventory -6, Incontinence Impact Questionnaire-7 score between pre-test and post-test values

TABLE 3: COMPARISON OF BERG BALANCE SCALE, UROGENITAL DISTRESS IMPACT-6, INCONTINENCE IMPACT INVENTORY-7 BETWEEN GROUPA and GROUP B IN PRE-TEST

	Group A		Group B		T-test	Significance
	PRE-TEST		PRE-TEST
	Mean	SD	Mean	SD
BBS	32.00	4.94	31.00	4.55	0.576	0.569
UDI-6	12.2	1.74	11.2	1.32	1.773	0.87
IIQ-7	19.6	4.38	20.1	3.75	0.358	0.723

The above table reveals the Mean, Standard deviation (SD), t-value and p-value of the Berg Balance Scale, Urogenital distress Inventory-6, Incontinence Impact Questionnaire-7 score between GROUP A and GROUP B in pre-test. In the Berg Balance Scale score, there is no significant difference between the GROUP A pre-test (32.00) and GROUP B pre –test (31.00) values. In the Urogenital Distress Inventory -6, there is no significant difference between the GROUP A pre-test (12.2) and GROUP B pre-test (11.2) values. In the Incontinence Impact Questionnaire, there is no significant difference between the GROUP A pre-test (19.6) and GROUP B pre-test (20.1) values. The table shows that there is no significant difference in the pre- test values of Berg Balance Scale, Urogeniotal Distress Inventory-6, Incontinence Impact Questionnaire-7 score between GROUP A and GROUP B. (***<0.005). Both the group shows no significant difference in the pre test values of Berg Balance Scale, Urogenital Distress Inventory-6 and Incontinence Impact Questionnaire-7 between GROUP A and GROUP B.

TABLE 4: COMPARISON OF BERG BALANCE SCALE, UROGENITAL DISTRESS INVENTORT-6, INCONTINENCE IMPACT QUESTIONNAIRE-7 BETWEEN GROUP A and GROUP B IN POST-TESTS

	Group A		Group B		T-test	Significance
	POST-TEST		POST-TEST
	Mean	SD	Mean	SD
BBS	40.73	2.84	34.86	4.15	4.51	0.000
UDI-6	7.73	1.22	9.33	1.44	3.27	0.003
IIQ-7	15.86	2.09	12.06	2.25	4.78	0.000

The above table reveals the Mean, Standard deviation (SD), t-value and p-value of the Berg Balance Scale, Urogenital Distress Inventory-6, Incontinence Impact Questionnaire-7 score between GROUP A and GROUP B in post- test. In the Berg Balance Scale, there is a significant difference between the GROUP A post-test (40.73) and GROUP B post-test (34.86) values. In the Urogenital Distress Inventory-6, there is a significant difference between the GROUP A post-test (7.73) and GROUP B post-test (9.33) values. In the Incontinence Impact Questionnaire-7, there Is a significant difference between the GROUP A post-test (15.86) and GROUP B post-test (12.06) values. This table shows that there is a significant difference in the post test values of Berg Balance Scale, Urogenital Distress Inventory-6 and Incontinence Impact Questionnaire-7 between GROUP A and GROUP B.

DISCUSSION:

The purpose of this Study was to find the Effectiveness of OTAGO exercise (13) and Stay Active and Independent for Life exercises along with Pelvic Floor Strengthening Exercise in women with Urinary Incontinence and Falls risk. Group A showed significant changes may be due to the application of OTAGO exercise and Pelvic Floor Exercise. Group B also showed mild changes due to the application of Stay Active and Independent for Life exercises along with Pelvic Floor Exercises. The OTAGO and Stay Active and Independent for Life exercises improve balance and prevents fall and fall related injuries (13). Pelvic Floor exercises improve strength and prevent leakage of urine and improve Urinary Incontinence. It was evident from the mean score that both groups showed improvement in Berg Balance Scale score because of treatments. Between groups analysis revealed that percentage of improvement in BBS score was more in OTAGO exercise along with Pelvic Floor Exercise group which further showed more improvement than SAIL exercise along with Pelvic Floor Exercise group. The data analysis and statistic interference have brought to check the effectiveness of OTAGO exercise along with Pelvic Floor Exercise and SAIL exercise along with Pelvic Floor Exercise on the variables of the study which are falls, falls related injuries and Urinary Incontinence. The OTAGO exercise along with Pelvic Floor Exercise has an effect in improving balance and strength of the Pelvic Floor muscle in patient with Urinary Incontinence and Falls risk. This is also supported by the study of Chiarelli et al , the Falls is associated with the symptoms of overactive bladder. Balmforth et at, suggested that Pelvic Floor muscle training facilitate the effective automatic motor unit firing of the pelvic floor muscle, which prevent the leakage of urine and pelvic floor descending while increase in intra-abdominal pressure and also improve urethral stability. Strength and balance deficit can be improved with rehabilitation. There is a good evidence that strength and balance based exercise programme reduce falls in community dwelling older adults. In the present study OTAGO exercise along with Pelvic Floor exercise is found to be relatively more effective on Urinary incontinence, reduce falls and falls related injuries (13).

These results of study are also supported by the New Zealand Falls Prevention Research Group designed and tested a community based strength and balance retraining programme, combined with a walking programme known as OTAGO exercise programme (10). This group has published result from OTAGO exercise programme is that participant in the OTAGO exercise programme reduces falls and falls related injuries by about a third in older community dwelling people. In addition, augmented reality based OTAGO exercise group result in increased stability and mobility, which helps in perform of activity of daily living and social activity.

In this study, we assumed that the augmented reality programme represented repeated feedback and the OTAGO training represented a goal of objects, which they could achieve by succession at each level and that self-pride increased. The increase in self-pride was related to self-efficacy. Therefore, repetitive training using the augmented relative OTAGO exercise for fall prevention leads to a decrease in the fear of falls in elder women and even change in their behavior. Subjects in the present study have similar baseline values of all dependent variables suggesting that both groups had similar distribution of patients. Statistical analysis reveals that there are significant changes in all the baseline values. These include improve in balance and strength of the Pelvic Floor muscle.

CONCLUSION:

The present study has concluded that the OTAGO exercise along with PFME is more effective in improving Urinary Incontinence and reducing Falls and Falls related injuries among women with risks of Urinary Incontinence and Falls than SAIL exercises along with PFME.

Ethical Consideration: This study was conducted after obtaining the approval from the Institutional Review Board of faculty of Physiotherapy.

Conflict of Interest: None

Fund: Self funded project

ACKNOWLEDGEMENT:

I would like to thank the management of Dr.MGR Educational and Research Institute and Faculty of Physiotherapy for providing the necessary infrastructure to complete this study

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Received on 01.09.2018 Modified on 03.10.2019

Research J. Pharm. and Tech. 2019; 12(3): 1105-1110.

DOI: 10.5958/0974-360X.2019.00181.1