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