sustainability of response to knack maneuver for urinary incontinence
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Sustainability of Response to Knack Maneuver for Urinary Incontinence. Janis M. Miller, Lee Park, Meg Tolbert, Ruta Misiunas, John JO DeLancey University of Michigan NIH (ORWH & NICHD): P50 HD044406 and UM Pelvic Floor Research Group. Knack Maneuver*. - PowerPoint PPT PresentationTRANSCRIPT
Sustainability of Response Sustainability of Response to Knack Maneuver for to Knack Maneuver for Urinary IncontinenceUrinary Incontinence
Janis M. Miller, Lee Park, Meg Janis M. Miller, Lee Park, Meg Tolbert, Ruta Misiunas, John JO Tolbert, Ruta Misiunas, John JO
DeLanceyDeLancey
University of MichiganUniversity of Michigan
NIH (ORWH & NICHD): P50 HD044406 NIH (ORWH & NICHD): P50 HD044406 and UM Pelvic Floor Research Groupand UM Pelvic Floor Research Group
Knack Maneuver*Knack Maneuver*
The The trick trick or or skillskill of using the pelvic floor muscles of using the pelvic floor muscles at the moment of expected urinary leakageat the moment of expected urinary leakage
Date: 14th century (per Merriam Date: 14th century (per Merriam Webster)Webster)
aa :: a clever trick or stratagem a clever trick or stratagem bb :: a clever way of doing something a clever way of doing something cc :: a a special ready capacity special ready capacity that is hard to that is hard to
analyze or teachanalyze or teach
*Miller, 1998
Other terms for the KnackOther terms for the Knack squeeze when you sneeze, squeeze when you sneeze, Kegel when you cough,Kegel when you cough, quick Kegel, quick Kegel, perineal blockage for stress (Bocier, 1990) perineal blockage for stress (Bocier, 1990) perineal lock (Cammu, 1991)perineal lock (Cammu, 1991) bracing,bracing, pelvic clutch, pelvic clutch, muscle clenchingmuscle clenching motor learning program motor learning program (Hay-Smith, 2007)(Hay-Smith, 2007)
Knack vs Kegel ExerciseKnack vs Kegel Exercise
Knack: one contraction selectively Knack: one contraction selectively timed with an event that would timed with an event that would otherwise elicit leakageotherwise elicit leakage
Kegel exercise: repetitive Kegel exercise: repetitive contractions as exercise for contractions as exercise for strengtheningstrengthening
PFMT usually incorporates PFMT usually incorporates bothboth, , though may use only the Knack or though may use only the Knack or only strengthening exercises (Kegels) only strengthening exercises (Kegels)
What muscles are What muscles are employed?employed?
PFM include…PFM include… Levator ani (pubococcygeal portion)Levator ani (pubococcygeal portion) Urethral striated muscleUrethral striated muscle
Both are activated on volitional effortBoth are activated on volitional effort
*DeLancy anatomical fig
Kegel improves urethral Kegel improves urethral pressurepressure
*DeLancy anatomical fig
KEGEL MRIKEGEL MRI
*DeLancy anatomical fig
Mechanism vs OutcomeMechanism vs Outcome
Showing closureShowing closure or stabilization of structures or stabilization of structures …………is different from showing that is different from showing that
“Knack” performed at the moment of “Knack” performed at the moment of expected urinary leakage, actually expected urinary leakage, actually prevents that leakage.prevents that leakage.
Theoretical mechanism Theoretical mechanism demonstrable, but so what?demonstrable, but so what?
Does it work? Does it work? Problems:Problems:
Can’t measure urethral closure pressure and Can’t measure urethral closure pressure and quantify urinary leakage quantify urinary leakage simultaneouslysimultaneously
Can’t measure pelvic muscle stabilization Can’t measure pelvic muscle stabilization quantify urinary leakage quantify urinary leakage simultaneouslysimultaneously
Knack & Urinary Knack & Urinary IncontinenceIncontinence
You can ask a woman You can ask a woman to cough, do the to cough, do the Knack, and catch any Knack, and catch any leakage on a paper leakage on a paper towel, all at the same towel, all at the same timetime
PTT & Knack goalPTT & Knack goal
No Knack cough
Knack cough (area reduction not good enough)
Knack cough
(area reduction with clinical relevance)
Knack & UI Evidence Base*Knack & UI Evidence Base*
*Miller 1998
OASIS Wetted Area by Percent Reduction
0
25
50
75
100
0 50 100 150 200
Wetted area (cm2) leaked on coughing without Knack
% R
edu
ctio
n w
ith
Kn
ack
Age > 59, not childbearing Age > 59, not childbearing yearsyears
Across the age spectrum, but not pregnantAcross the age spectrum, but not pregnant
IRIS Phase I Wetted Area by Percent Reduction
0
25
50
75
100
0 50 100 150 200
Wetted area (cm2) leaked on coughing without Knack
Per
cen
t R
edu
ctio
n w
ith
K
nac
k
PERL Wetted Area by Percent Reduction
0
25
50
75
100
0 20 40 60 80 100 120 140 160 180
Wetted area (cm2) leaked on coughing w ithout Knack
Per
cen
t re
du
ctio
n w
ith
K
nac
k
pools on towel
Pregnant (about 32-35 wks Pregnant (about 32-35 wks gestation)gestation)
*Miller 2008
Knack works for many in Knack works for many in controlled conditions with no controlled conditions with no
distractionsdistractions
Even under these very controlled Even under these very controlled conditions, conditions, not all women are not all women are helpedhelped
Can the effect be sustained in the Can the effect be sustained in the real world environment?real world environment?
……. And over time?. And over time? Is it a substantial enough effect to Is it a substantial enough effect to
make a difference to women?make a difference to women?
Knack in Everyday LifeKnack in Everyday Life
“ “Substantial Improvement” criteriaSubstantial Improvement” criteria At least 50% improvement on minimally 2 At least 50% improvement on minimally 2
of three outcome measuresof three outcome measuresPTT ≥ 50% reduction in leakage PTT ≥ 50% reduction in leakage volumevolume
Diary Diary ≥≥ 50% 50% reduction in leakage episodesreduction in leakage episodes
Self-report Self-report ≥≥ 50% 50% ““What percent of improvement are you What percent of improvement are you
experiencing?”experiencing?”
Substantial Improvement: Substantial Improvement: ≥≥50% 50% improvement improvement
on at least 2 of 3 measureson at least 2 of 3 measures
Knack in Everyday LifeKnack in Everyday LifeShort-termShort-term
Phase I: 10-minute Video teachingPhase I: 10-minute Video teaching RCTRCT N=133N=133 F/U to 1 mo with cross-over to 3 moF/U to 1 mo with cross-over to 3 mo
Results: 53% of the women were Results: 53% of the women were substantially improvedsubstantially improved
Knack in Everyday LifeKnack in Everyday LifeShort-termShort-term
Phase II: Nurse face-to-face teaching Phase II: Nurse face-to-face teaching during exam and f/u educ handoutduring exam and f/u educ handout Pre- and post-test designPre- and post-test design N = 111N = 111 F/U to 3-moF/U to 3-mo
Results: 53% of the women were Results: 53% of the women were substantially improvedsubstantially improved
Knack in Everyday Life: Knack in Everyday Life: Long-Term (1 year)Long-Term (1 year)
Phase IIIPhase III Recruitment Pool: all participants from Recruitment Pool: all participants from
Phase I & II who had substantial Phase I & II who had substantial improvement at the short-term evaluation. improvement at the short-term evaluation.
N = 57 found/agreed to additional N = 57 found/agreed to additional evaluationevaluation
Results: 79% retained substantial Results: 79% retained substantial improvement to 1 yearimprovement to 1 year
ConclusionConclusion Teaching the Knack may help many, Teaching the Knack may help many,
per 10 minute video or in person per 10 minute video or in person instruction, even without dedicated instruction, even without dedicated exerciseexercise
ConclusionConclusion
We can let women know that about We can let women know that about ½ are helped, and about ½ are ½ are helped, and about ½ are notnot
Retention of effect long term looks Retention of effect long term looks promising (probably needs more promising (probably needs more data) data)
Early LACK OF RESPONSE should be Early LACK OF RESPONSE should be followed up, with reevaluation no followed up, with reevaluation no later than 1-mo to 3-mo, and later than 1-mo to 3-mo, and alternative therapy offered alternative therapy offered