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Table of Contents
Year : 2022  |  Volume : 4  |  Issue : 2  |  Page : 114-121

Effect of pilates ring exercises on pelvic floor muscles in female with stress urinary incontinence – Randomized control trial

Dr. D. Y. Patil College of Physiotherapy, Pune, Maharashtra, India

Date of Submission20-Apr-2022
Date of Decision22-Jun-2022
Date of Acceptance22-Aug-2022
Date of Web Publication19-Jan-2023

Correspondence Address:
Dr. Reema Joshi
Green Valley, C/1003, Kaspate Vasti, Wakad, Pune, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijptr.ijptr_63_22

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Context: Urinary incontinence (UI) is defined by the International Continence Society as “Involuntary loss of urine which is unhygienic and social embarrassment causes negative self-perception.” UI is a problem which grows silently and causes physical as well as social limitations and deteriorates the quality of life (QOL) of women.
Aims: The aim of this study is to find out the effect of Pilates exercises using the ring on the pelvic floor muscle (PFM) on PFM strength, severity of stress UI (SUI), and QOL in females with UI.
Settings and Design: This study was conducted in the Outpatient Department, Dr. D. Y. Patil College of Physiotherapy, Pune, randomized control trial.
Methods and Materials: Fifty-two females with SUI participated in the study. They were further divided into two groups Group A (experimental group [EG]) and Group B (control group [CG]). For the prepost assessment, vaginal pressure was measured by pressure manometer, core strength, severity of incontinence was assessed by using pad test (1 h) and frequency chart (7 days), QOL was measured using the International Consultation on Incontinence Questionnaire (ICIQ).
Statistical Analysis Used: Between the groups, analyses were performed using independent t-tests and the Mann–Whitney test. The core strength and the PFM strength show highly significant change with P < 0.05 in Group A compared to B, whereas the severity of incontinence on the frequency chart and QOL with ICIQ were not statically significant.
Results: EG showed a highly significant difference in PFM and core P < 0.05 in comparison to the control group. While moderate significance was seen in PFM strength and severity of the stress UI.
Conclusions: The study concludes that Pilates with a ring along with the PFM exercises is a better alternative to only PFM exercise.

Keywords: Pelvic floor muscles, Pilates, Stress urinary incontinence

How to cite this article:
Joshi R, Rathi M, Parmar N. Effect of pilates ring exercises on pelvic floor muscles in female with stress urinary incontinence – Randomized control trial. Indian J Phys Ther Res 2022;4:114-21

How to cite this URL:
Joshi R, Rathi M, Parmar N. Effect of pilates ring exercises on pelvic floor muscles in female with stress urinary incontinence – Randomized control trial. Indian J Phys Ther Res [serial online] 2022 [cited 2023 Jun 6];4:114-21. Available from: https://www.ijptr.org/text.asp?2022/4/2/114/368059

  Introduction Top

The International Continence Society defined urinary incontinence (UI) as “Involuntary loss of urine which is an unhygienic and social embarrassment and negative self-perception.“[1] The prevalence of UI is 26.07% and stress UI (SUI) is 18.4%.[2] Urethra rests on the supportive layer formed by the anterior vaginal wall and endopelvic fascia according to hammock theory; hence, along with pelvic floor muscle (PFM) weakness, there is an increase in UI which further compromises quality of life (QOL).[3] Core and the PFM muscles act in synergy and stabilize lumbopelvic rhythm; hence, an increase in abdominal strength causes hypertrophy of the muscle which in turn reduces the symptoms of SUI.[4] PFM training is a conventional form of exercise that helps to treat UI. PFM exercises along with Pilates with an assistive device like a Pilates ring can further help to strengthen core muscles by following six principles of Pilates help in increasing core muscle strength with controlled breathing pattern, concentration, centralized core muscle, controlling movement with the pace with precision and allow flow in movement which helps in providing the long-term effect of PFM rehabilitation. Pilates with a ring activates the core muscles.[5]

  Subjects and Methods Top

As per inclusion criteria, females between the age of 35 and 55 years, with grade 1 and 2 SUI were included in the study. Females who are able to commit to exercise and follow instructions and females with acute UI, rectocele, urogenital infection, pregnancy and postpartum up to 8 weeks, neurological impairment leading to incontinence, medication (eg., diuretics) led incontinence and patients with musculoskeletal disorder were excluded from the study. Ethical committee clearance was obtained and ethical Ref no was DYCPT/574-B (27)/2021. CTRI registration was done with no CTRI/2021/11/038174. The sample size was calculated using the prevalence article and using the power analysis (with alpha error = 0.05 and power of 80% and also considering dropouts, the sample size in each group is 24). In accordance with the Helsinki Declaration of 1975 was revised in 2013.

Consent was obtained from all the participants and 52 females having SUI were recruited.


Two hundred and forty-nine samples were initially screened using the pro forma, out of which 69 samples were undergone gynecological assessment. Moreover, out of which 53 samples fulfilling the inclusion and exclusion criteria were recruited in the study. They were divided into two groups using randomization using the chit method. Group A (experimental group [EG]) was given Pilates with ring intervention and Group B (control group [CG]) was given the conventional exercise [Figure 1]. Six weeks protocol 30 min/four times a week with progression made every 2 weeks according to the Frequency, Intensity, Time, Type (FITT) principle was done for Group A and Group B PFM exercise was given for 20 min/three times a week for 6 weeks. Progression was given once in 2 weeks. In Group A (EG), one subject could not continue due to pregnancy [Annexure].
Figure 1: sCONSORT flow diagram of study participants

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Outcome measures

Pad test – 1 h pad test was performed by the patients as follows:

  • The test was started without the emptying bladder
  • Preweighed pad worn by the patient was weighed on a weighing scale with a 1 h pad test
  • 500 ml sodium-free liquid is given to the female
  • Female then walks and climbs stairs after half an hour.

The following activities are performed by the female for the other half period

  1. Times – sit to stand
  2. Times – coughing
  3. Five-minute run on the spot
  4. Five times – pick an object from the floor
  5. One minute – washing hands in running water
  6. After 1 h test, the pad is removed and weighed.

Pressure manometry (reliability of Intraclass correlation coefficient 0.94)

Perineometer is a device used to measure vaginal pressure. It is a conical vaginal device of 28 mm in diameter and 108 mm in length. Its reading is measured in centimeters of water (cmH2O). The initial pressure is set to 0 and it is inserted in the vagina till 0.5 cm–1 cm such that it is from visible outside. Then, the subjects were positioned and instructed to perform PFM contraction.

International Consultation on Incontinence Questionnaire (high Cohen's kappa coefficient of 0.83) (95% confidence interval 0.74–0.89)

It is a questionnaire for evaluating the frequency, severity, and impact on QOL of UI in men and women. The women are supposed to rate the questionnaire according to the symptoms experienced in the past 4 weeks.

Frequency chart (7 days)

The patient is asked to keep a diary for the frequency of urination for 7 days (ICC reliability of 0.97).

Pressure biofeedback (with reliability of ICC 0.87)

The bulb of the pressure biofeedback was kept under the lordosis between the two Posterior superior iliac spine (PSIS). The patient was asked to perform the abdominal drawing-in maneuver. The initial pressure was kept at 40 mmHg, and the postpressure was measured.

Statistical analysis

The characteristics of the participants are mentioned in [Table 1]. Data analysis was done for Group A (n = 25) and Group B (n = 27) using the Medcalc software.
Table 1: Subjects' demographic data

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The normality of the data was checked using Shapiro–Wilk test in MedCalc software and was concluded as normally distributed if P > 0.05 or not normally distributed if P < 0.05. Accordingly, for the parametric data (the International Consultation on Incontinence Questionnaire [ICIQ] and pad test), paired t-test was used and nonparametric data (pressure manometer, frequency chart, and core strength), the Wilcoxon test was used, and the P value was obtained. Between the group analyses, the independent t-tests or the Mann–Whitney test was applied for parametric and nonparametric data. Pre- and postreading of each outcome measure was compared with the respective outcomes of the other groups. If the details were normally distributed the intragroup comparison was done using an unpaired t-test and the intergroup comparison using a paired t-test. The significance level was set at P < 0.05 and a 95% confidence interval.

  Results Top

Two hundred and forty-nine samples were screened, out of which 53 were recruited and 52 samples completed the study. [Table 1] shows the demographic data of the samples. [Table 2] shows the within-group changes in outcome measures for both Group A and Group B. The between-group comparison of pre–post mean difference and standard deviation between Group A and Group B is presented in [Table 3].
Table 2: Within-group change in outcome measures for both Group A and Group B

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Table 3: Between-group comparison of pre-post mean difference (±standard deviation) between Group A and Group B

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[Table 1] shows the characteristics of the participants, and the mean age for Group A was 41.65 and Group B was 41.85 with (P = 0.36); the body mass index for Group A is 26.61 and Group B is 26.22 with (P = 0.29); parity for Group A is 1.62 and Group B is 1.66 with (P = 0.79) which was statistically insignificant.

[Table 2] shows the vaginal pressure manometer in Group A was improved, whereas there was no significant difference in Group B. It was also seen that there was a statistically significant difference between the pre–post values of pad test of both groups (P < 0.0001). There was a significant difference in pre–post value of the frequency chart in both groups. Hence, the symptoms were reduced in both groups. P < 0.0001 shows a significant difference in Group A, and (P < 0.0001) it shows a statistically significant difference between the pre–post values in both groups. The QOL checked using ICIQ was improved after the intervention in both groups, and there was a reduction in symptoms. The QOL was also improved in both groups (P < 0.0001). Group A showed high significant change in core strength with a P < 0.0001 compared to Group B.

[Table 3] shows the between-group comparison of pre–post mean difference. It shows that the vaginal pressure manometer, core strength, and pad test were only improved in Group A (P < 0.0001). While there the urine frequency and QOL ICIQ were improved in both groups (P = 0.0001).

  Discussion Top

The present study evaluated the additional effect of the Pilates ring in strengthening PFM in comparison to conventional PFM training (PFMT).

The study done in 2014 suggested that (2014) that individual PFM muscle training is less effective than the coordination of core muscle contraction making the PFM to contract alone with it. Hence, the cocontraction is more preferable over the individual PFMT.[6]

It is observed that core muscle weakness causes the PFM weakness which in turns results in SUI.[6] Hence, core muscle strength should be improved to strengthen the PFM muscle. Synergistic action between core muscles and PFM Pilates with ring exercises helps to increase core muscle as well as PFM correlation in Group A (EG) in comparison to Group B (CG).[7],[8] There are various proposed theories to explain the effectiveness of PFM training for SUI accordingly, Sapsford et al. in 2004 mentioned that functional tasks such as lifting, nose blowing, laughing, coughing, sneezing, and Valsalva (a forced expiratory effort against a closed glottis) recruit the PFM with the abdominal muscles to increase intra-abdominal pressure, generate an expiratory force, and maintain continence.[9]

Trantafylidis 2009 suggested as UI treatment conservative PFM exercises are considered primary care due to associated low risk and cost-effectiveness.[8]

Pilates exercises help in the controlled movement of the core, that act as a corset and it activates both core muscle and synergistically the PFM.

The strength and endurance of the PFM are increased and maintained because the PFM works as a corset for the pelvic floor. It was seen that the transverse abdominis not only acts as a spinal stabilizer but also it plays a part in PFM contraction.

Transverse abdominal muscle and PFM cocontraction exercises increase the cross-sectional area of the muscle and improve strength and help to maintain continence.

It was seen that Pilates group showed an effective increase in PFM strength and core strength, whereas the control group showed lesser improvement it could be due to the activation of the core muscles in Pilates which was only performed by Group A and may have provided an additional effect on PFM recruitment and thus alleviate symptoms of SUI.[9],[10]

The control group showed comparatively less effect with PFM exercises it could be due to a lack of focus and identifying the correct muscle to contract while performing exercises. PFM muscles being dominantly the slow twitch fibers require specific muscle-appropriate endurance training. According to Culligan et al. (2010), a key distinction between Pilates and conventional treatment was the addition of pelvic exercises, which may have contributed to the Pilates group's better outcomes. The Pilates program was created to improve the strength, flexibility, and posture of the entire body. Moreover, Pilates is a noninvasive technique and was widely accepted.[10]

Resistive instrument exercises provide visual feedback to the patient and the patient is encouraged to enhance the efficiency of the exercises. The mat exercises are done on the mat or floor as the name suggests, and resistive instrument exercises require one to exercise against resistance being provided by the use of springs and a pulley.

Muscolino and Cipriani et al. in 2004 seen that functional movements could be achieved by doing resistive instrument work like Pilates ring oriented from Pilates original mat work, and it also offered assistance to the injured individual to be able to complete movements successfully or increase the challenge of gravity so the individual may be progressed.[11]

The effect of resistive instrument Pilates in clinical trials showed that the use of equipment or instruments, confidence in the treatment technique, and the use of high technology can max the sensory feedback effect. In our study, also the Pilates ring provides visual feedback and increases the confidence to do the exercise better.

Kim et al., in 2007 suggest that a resistive instrument or a magic circle combined with the Pilates bridging exercise should increase muscle activities more effectively than without a magic circle, and it is useful in management protocols designed to improve the strength of the core muscles. As the core muscle strength increases the PFM muscle also increases, which could be a reason for the improvement of the strength, symptoms, severity, and QOL in Group A.[10]

Trantafylidis in 2009 stated that the self-confidence of the female is reduced as she is unable to control the bladder which affects negatively on psychological and physical aspects and in turn reduces her QOL. A good physical and social well-being is difficult to be maintained by the female and it might lead to distress, botheration, and depression which helps in improving the QOL of female by improving physical and social activities and also enhances confidence level.[8]

  conclusion Top

As seen in this study, the core strength and the PFM strength were increased in the Pilates group and comparatively less in only the PFM exercise group. Hence, Pilates could be beneficial and optional than conventional exercises. Thus, we can conclude here that Pilates ring can be used as an additional tool in pelvic floor rehabilitation.


We would like to thank our institute for providing us all facilities to conduct the study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest

  Annexure: Protoco Top

Group A (Experimental)

  References Top

Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn 2010;29:4-20.  Back to cited text no. 1
Milsom I, Gyhagen M. The prevalence of urinary incontinence. Climacteric 2019;22:217-22.  Back to cited text no. 2
Culligan PJ, Scherer J, Dyer K, Priestley JL, Guingon-White G, Delvecchio D, et al. A randomized clinical trial comparing pelvic floor muscle training to a Pilates exercise program for improving pelvic muscle strength. Int Urogynecol J 2010;21:401-8.  Back to cited text no. 3
Ferla L, Darski C, Paiva LL, Sbruzzi G, Vieira A. Synergism between abdominal and pelvic floor muscles in healthy women: A systematic review of observational studies. Fisioterapia Mov 2016;29:399-410.  Back to cited text no. 4
Sapsford RR, Hodges PW. Contraction of the pelvic floor muscles during abdominal maneuvers. Arch Phys Med Rehabil 2001;82:1081-8.  Back to cited text no. 5
da Luz MA Jr., Costa LO, Fuhro FF, Manzoni AC, Oliveira NT, Cabral CM. Effectiveness of mat Pilates or equipment-based Pilates exercises in patients with chronic nonspecific low back pain: A randomized controlled trial. Phys Ther 2014;94:623-31.  Back to cited text no. 6
Kinchen KS, Burgio K, Diokno AC, Fultz NH, Bump R, Obenchain R. Factors associated with women's decisions to seek treatment for urinary incontinence. J Womens Health (Larchmt) 2003;12:687-98.  Back to cited text no. 7
Trantafylidis SC. Impact of urinary incontinence on quality of life. Pelviperineology 2009;28:51-3.  Back to cited text no. 8
Sapsford R. Rehabilitation of pelvic floor muscles utilizing trunk stabilization. Man Ther 2004;9:3-12.  Back to cited text no. 9
Kim SJ, Kim MH. EMG activities of core muscles during bridging exercises with and without a pilates resistive device. J Korean Prof Phys Ther Assoc 2007;14:21-7.  Back to cited text no. 10
Bernardo LM. The effectiveness of Pilates training in healthy adults: An appraisal of the research literature. Journal of bodywork and movement therapies. 2007 Apr 1;11(2):106-10.  Back to cited text no. 11


  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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