Yoga-Eutonia in genuine Stress Incontinence

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Yoga- Eutonia in Genuine Stress Incontinence-An Exploratory Study*

Milani, R*" Valli, Giordana, & Bhole, M. V *

Abstract:

51 G S I women were given Yoga-Eutonia rehabilitation therapy twice a week for 3 months. Each session was of 90 minutes. In this therapy emphasis was given on working with in an eutonic condition, the perineal muscles correcting breathing movements, understanding the nature of forces developed in various psycho-physiological conditions involving breathing and selected yoga breathing techniques, viz. Uddiyana, agnisara, aswini.

95% of the patients showed symptomatic improvement after therapy even though it could not be confirmed by P C test and stress test.

Possible explanations for this disparity are discussed.

Follow up studies in 29 patients after 12 months revealed sustained symptomatic improvement in 13 patients ( 45% ) and negative stress test in 18 patients ( 62% ).

Introduction:

Genuine Stress Incontinence (G. S. I. ) is viewed as a clinical syndrome resulting out of genito-urinary and/or non genito-urinary causes rather than a disease process. Apart from the extreme phases of life in both the sexes, this condition very often results after child-birth in middle aged women.

A) Behaviour modification therapies comprising:

i) perineal muscle contractions;

ii) bladder training drill, and

iii ) bio-feedback.

B) Drug therapy;

C) Functional electrical stimulation;

D) Acupuncture, and

E) Surgical correction including transvescical injection of phenol. Following are the various treatment procedures in vogue today with varying success rates and relapses.

The system of Yoga can be viewed as a behavioural modification therapy where the individual is educated to establish an internal contact with different parts' of the body, developing proprioceptive and viscerot:eptive awareness and, if required, to correct the same through suitable techniques comprising postures (A SAN AS); manoeuvres involving mechanics of breathing (PRANAY AMA) and tackling the internal organs ( KRIY AS ).

Educating patients to differentiate between hypertonic, hypotonic and eutonic condition is emphasised in "Eutonia Training" for the management of various functional disorders by G. Alexander.

There are no references about the use of Yoga and Eutonia methods in the management of G. S. I.

The responses of fifty one positively motivated middle aged female volunteers of OSI to Yoga-Eutonia training-cum-treatment programme in a pilot study are presented in this paper.

Material & Methods:

Patients of GSI attending the gynaecological clinic at Monza hospital were explained about the project. 51 of

them, who volunteered for the Yoga-Eutonia treatment, were taken for study after theJinitial investigation of stress test, Perineal Contraction (PC) test and severity of trouble.

1) The training-cum-treatment sessions were of 90 minutes duration, twice a week, for 3 months. Patients were taken in groups of 6 to 8 in one batch for better individual attention and effective team work.

2) The training-cum-treatment programme was divi ded into two parts. First part comprised acquainting the patients with the anatomy and pscho-physyiology of , the pelvic and perineal regions. Second part comprised imparting instructions in Yoga-Eutonic techniques and and studying and evaluating their effect by the patients themselves. Detailed work-out of the Yoga-eutonia training-cum-treatment programme is given in the appendix.

1)Stress test and PC test were repeated at the end of three months and again after twelve months to study the residual effect of this treatment.

Yoga-Eutonia Training-Cum-Treatment - Objectives:

I) To help the patients to establish contact with their perineal and pelvic regions and other structures inside through cutaneous proprioceptive and visceroceptive sensory irputs and to come out of one's psycho-social, cultural, educational and religious inhibitions .and blocks.

2) To educate the patients to explore their perineal and genital area visually and manually with the help of anatomical charts, minor and internal bio-feedback.

3) To experiencing breathing movements during natural breathing and during various actions in different areas of the body to decide their nature and to correct them, if found wrong.

4) To experience perineal and pelvic movements in different directions and to learn to differentiate between contraction, relaxation, stretching and tensionln the muscles through proprioception and mannual examination.

5) To experience intra-abdominal pressure and the direction of its working during various actions involving breathing and non-breathing movements.

6) To help the patients to understand mechanics of breathing and to educate them to work with. the same with the help of various yogic techniqaes, viz. asanas, pranayarna, kriyas, mudras and bandhas.

RESULTS:

I. A) On admission and after 3rd months of training cum-treatment through Yoga-Euftonia techniques.

1. In respect of severity of symptoms, initially 23 patients were in mild category and 28 patients were in severe category.

At the end of three months, 16 out of 23 and 12 out of 28 ( i. e. 55%) patients were relieved of incontinence while 5/ 3 and 15/28 (i. e. 40%) showed definite improvement in symptoms. Only 3 patients (t. e. 5%) did not show any change. Thus 95% of patients were benefited by Yoga-eutonia training-cum-treatment programme.

2. In respect of stress test, initially all the patients were positive. 23 patients had scores less than three and 28 patients had scores more than three. Clinically surgery was indicated in 15 patients. However, patients decided to give a trial to' this treatment.

After three months, ~9 patients ( 76.5% ) became -ve (i. e. 17 aut af 23 and 22 out of 28 ). Relatively better responses to stress test were seen in 22 aut of 29 patients having scores more than 3 in the first test.

3. In relation to' Perineal Contraction (P C) Test, 17 out of 20 patients (85%) in the categary af 4-5 and 17 aut af 21 (81 % ) in the category af 2-3 and 5 aut af 10 in 0-1 category showed negative stress test after 3 months. Except 3 patients in 0-1 category, all the ather patients showed relief or improvement.

B) Follow-up Studies after one Year :

1. Only 29 .patients reported f(}f follow-up studies after .one year.

2. Out of them 13 patients (45%> were found dry, i. e. without incontinence; 18 patients (62%, were negative in stress test; and 12 patients (41 %) were both dry and negative. 3, 8 out of 29 (27% ) had deteriorated while 'if patients showed relapse in stress test.

OBSERVATIONS :

(I) By the Clinicians :

1. Even though patients became continent and dry after Yoga-Eutonia rehabilitative therapy, the .( Perineal Contraction) PC test 'did not reveal significant improvement. It means that the control of perineal movement is more important to become continent rather than the strength of its contraction, i. e. a woman having a good control over her perineal muscles under stressful condition will remain more continent and dry, even if her PC test is 2 or 3 in comparison to another woman having no control over the perineal area.

2. During second stress test after three months, during coughing and sneezing, the patients were able to develop the intra-abdominal force to work towards the diaphragm thus preventing leakage of urine. This was a very important observation of this study.

Women able to develop proper breathing movements together with control over perineal muscles in stressful condition will be able to get maximum positive effects from this therapy.

3. In some patients only a correspondence was noticed between the contraction of the perineal muscles and urethral closing pressure. This means that the mechanism responsible for continence is not directly involved with the urethra.

4. Several patients failed to show improvement in stress test, even though showed symptomatic relief in OSI after Yoga-Eutooia therapy. Probably these patients were much conscious and anxiolls of their perineal area during the stress test, but this may not be happening during ordinary coughing and sneezing.

5. No differences were noticed between recovered and improved women in respect of parameters related to urodynamics.

6. Almost all women showed better awareness of the muscles involved in perineal contractions thus exhibiting improved knowledge about the structure and function in this region. This became evident during the clinical examination. and exploration after the therapy session. Patients were also able to recognize and differentiate urethral opening from the clitoris which was absent in the first examination.

II. By the Yoga-Eutonia Instructor-cum-Therapist and Advisor in Yoga Therapy.

A. On admission to the therapy sessions :

1) In the initial phase, before starting Yoga Eutonia training, most of the patients were strongly inhibited in respect of their proprioceptive and visceroceptive perceptions from the pelvic and perineal regions. Similarly they had never explored the vaginal wall, vaginal opening, urethral opening, clitoris and/or the cervix by touching or seeing.

2 ) Patients were unable to differentiate between tension and contraction in the muscles of the pelvic floor.

3) Almost none of the patients were able to experience the breathing movements in resting condition and even during certain acts like coughing, sneezing, deep breathing etc. Similarly they were unable to find out and decide the nature of the intra-abdominal pressure and the direction of its working during various acts involving breathing manipulation.

4) 32 out of 51 had paradoxical breathing movements during resting condition and they got worst during deep breathing, coughing, straining at defecation, sneezing etc.

5) 19 out of 51 had proper breathing movements during natural breathing, but it became paradoxical dunng dc:ep breathing, coughing, sneezing, straining after defecation.

6) Almost all the patients did not exhibit any breathing movements in hypogastric and perineal regions even during deep breathing.

7) Most of the patients were seen to develop intra-abdominal pressure working from abovedownwards during acts of coughing, talking, sneezing etc.

B. During the Course of the Therapy Session

1) Initially patients were found to get confused as experiencing breathing movements, differentiating muscular contractions from tone and tension and understanding the direction of the force generated in the intra-abdominal cavity due to pressure manipulations were altogether new and strange for them. Therefore they were educated with the help of demonstrations, anatomical and physiological charts and by making them to work on partners instead of oneself.

2. Due to muscle conditions, it was difficult for the patients to develop a particular posture and/

or breathing pattern as visualised by the therapist. However, working slowly and patiently proved

effective.

C. Towards the end of Yoga-Eutonia Training Period of 3 Months :

I. Except for one patient, all the patients, could exhibit, feel and manipulate breathing movement in the hypo-gastric and perineal region.

2. 45 patients could develop eutonia in the back muscles and in the perineal muscles during micturation, defecation, talking, coughing etc.

3. 43 patients were able to correct the nature of of breathing movements during deep breathing,

coughing, sneezing, talking, straining during the attempt of defecating, micturition, etc.

DISCUSSIONS :

I. Y oga-Eutonia programme emphasises developing awareness of different body parts and to correct and integrate various psycho-physiological functions. The salient features of this therapy can be summarised as under:

a) Developing Eutonic conditions of the pelvic muscles and to learn to work condition instead of developing and an hypertonic state of the muscles.

b) Developing experiential awareness of breathing movements, the nature of various forces

generated inside the abdominal and thoracic cavities during different conditions of breathing, correcting breathing movements and using different' kind of breathing techniques to improve incontinence.

c) Self-evaluation of the ability to contract and manipulate levator-ani muscles, walls of the vaginal canal and urethral sphincter in an eutonic condition.

d) It is postulated that this programme helps the patient to work at various levels of the brain and spinal column via sensory-motor ,cortex, hypothalamus, limbic system, cerebellum, medulla oblongata and pons

e) It is felt that that the emphasis on developing an ability and attitude of experiencing various happenings as an observer or a witness helps the patient to improve the condition.

This is achieved by developing proprioceptive and visceroceptive awareness and this could be looked upon- as working through "internal biofeedback" in contrast to external bio.feed back techniques in vogue today.

f) The followin Yoga technique requires a special mention as they are seldom mentioned in medical literature.

i) Uddiyana; ii) Agnisara Kriya; iii) Aswini Mudra; iv ) Tadagi Mudra; v ) Kapalbhati.

CONCLUSIONS:

Within the limitations of the present study, it can be said that Yoga-eutonia rehabilitative training-cum treatment programme twice a week for 3 months does benefit patients of genuine stress incontinence even if the patients do not show improvement in perineal contraction test. This shows that patients learn to control and manipulate perineal muscles and related events, specially the direction of the working of the intra-abdominal pressure to. one's advantage.

The improvement in clinical picture was seen even after 12 month.

ACKNOWLEDGEMENTS:

Project grants to carry out this work and CO-operation from the patients is gratefully acknowledged Last author is speciaJly grateful to Late Swami Digambarji, Director, Kaivalyadhama for his encouragement to co operate in this project and to Shri O. P. Tiwari, Secretary for granting leave to visit Italy.