Sustainability of Response to Knack Maneuver for Urinary Incontinence

1. 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

2. Knack Maneuver* The trick or skill of using the pelvic floor muscles at the moment of expected urinary leakage • Date: 14th century (per Merriam Webster) • a: a clever trick or stratagem • b: a clever way of doing something • c: a special ready capacity that is hard to analyze or teach *Miller, 1998

3. Other terms for the Knack • squeeze when you sneeze, • Kegel when you cough, • quick Kegel, • perineal blockage for stress (Bocier, 1990) • perineal lock (Cammu, 1991) • bracing, • pelvic clutch, • muscle clenching • motor learning program (Hay-Smith, 2007)

4. Knack vs Kegel Exercise • Knack: one contraction selectively timed with an event that would otherwise elicit leakage • Kegel exercise: repetitive contractions as exercise for strengthening • PFMT usually incorporates both, though may use only the Knack or only strengthening exercises (Kegels)

5. What muscles are employed? • PFM include… • Levator ani (pubococcygeal portion) • Urethral striated muscle • Both are activated on volitional effort

7. *DeLancy anatomical fig

8. Kegel improves urethral pressure

9. *DeLancy anatomical fig

10. KEGEL MRI

11. *DeLancy anatomical fig

12. Mechanism vs Outcome • Showing closure • or stabilization of structures • ……is different from showing that “Knack” performed at the moment of expected urinary leakage, actually prevents that leakage.

13. Theoretical mechanism demonstrable, but so what? • Does it work? • Problems: • Can’t measure urethral closure pressure and quantify urinary leakage simultaneously • Can’t measure pelvic muscle stabilization quantify urinary leakage simultaneously

14. Knack & Urinary Incontinence • You can ask a woman to cough, do the Knack, and catch any leakage on a paper towel, all at the same time

15. PTT & Knack goal No Knack cough Knack cough (area reduction not good enough) Knack cough (area reduction with clinical relevance)

16. Knack & UI Evidence Base* *Miller 1998

17. Age > 59, not childbearing years

18. Across the age spectrum, but not pregnant

19. Pregnant (about 32-35 wks gestation)

20. *Miller 2008

21. Knack works for many in controlled conditions with no distractions • Even under these very controlled conditions, not all women are helped • Can the effect be sustained in the real world environment? • …. And over time? • Is it a substantial enough effect to make a difference to women?

22. Knack in Everyday Life • “Substantial Improvement” criteria • At least 50% improvement on minimally 2 of three outcome measures • PTT ≥ 50% reduction in leakage volume • Diary ≥ 50% reduction in leakage episodes • Self-report ≥ 50% • “What percent of improvement are you experiencing?”

23. Substantial Improvement: ≥50% improvement on at least 2 of 3 measures

24. Knack in Everyday LifeShort-term • Phase I: 10-minute Video teaching • RCT • N=133 • F/U to 1 mo with cross-over to 3 mo • Results: 53% of the women were substantially improved

25. Knack in Everyday LifeShort-term • Phase II: Nurse face-to-face teaching during exam and f/u educ handout • Pre- and post-test design • N = 111 • F/U to 3-mo • Results: 53% of the women were substantially improved

26. Knack in Everyday Life: Long-Term (1 year) • Phase III • Recruitment Pool: all participants from Phase I & II who had substantial improvement at the short-term evaluation. • N = 57 found/agreed to additional evaluation • Results: 79% retained substantial improvement to 1 year

28. Conclusion • Teaching the Knack may help many, per 10 minute video or in person instruction, even without dedicated exercise

29. Conclusion • We can let women know that about ½ are helped, and about ½ are not • Retention of effect long term looks promising (probably needs more data) • Early LACK OF RESPONSE should be followed up, with reevaluation no later than 1-mo to 3-mo, and alternative therapy offered