The Integral Theory System for pelvic floor rehabilitation (PFR) differs from traditional methods in four major ways:

1. It addresses symptoms of urgency, nocturia, frequency, abnormal emptying and pelvic pain in addition to stress incontinence
2. It introduces two new techniques , squatting and reverse pushdown exercises so as to strengthen the 3 directional muscle forces.
3. It combines electrotherapy, hormones, fast and slow twitch exercises.
4. It is designed to seamlessly fit into a patient’s daily routine.

The regime consists of four visits in three months. The Pictorial Diagnostic Algorithm (fig 1-11) guides diagnosis of anatomical defects in the anterior, middle and posterior zones of the vagina. Hormone replacement therapy (HRT) is administered to thicken epithelium and prevent collagen loss. Electrotherapy is given for 20 minutes a day for the first four weeks to improve neuromuscular transmission. The patients do slow twitch muscle exercises - squatting or sitting on a rubber ‘fit’ ball - for a total of 20 minutes per day.

First Visit

The patient is instructed in a Kegel exercise routine, two lots of twelve, three times per day. The exercises are performed in bed, face downwards, morning and night with legs apart, according to the methods of Bo (1990). The remaining 24 squeezes are performed at lunchtime or during visits to the toilet. It is helpful for the patient to visualise squeezing the sides of a lemon inwards, or to pretend she is cutting off her urine stream. Endocavity electrical stimulation of 20 minutes per day is prescribed for four weeks. With any anterior zone defect, the probe is placed just inside the introitus on alternate days and in the posterior fornix every other day. The aim is to strengthen both PCM and LP. With pure posterior zone defects, the probe is placed in the posterior fornix only. Squatting or sitting on a ‘fit ball’ for a total of 20 minutes per day if possible is encouraged as a universal slow-twitch exercise. The aim is to integrate this activity into the patient’s daily routine. For instance, the patient is encouraged to substitute squatting for bending at all times. If a patient has arthritis, she may sit on the end of a chair with legs apart or on a fitball. Compliance is vastly improved by explaining the principles behind the exercises, and encouraging patients to plan and record their daily routine.

Second Visit

In patients without a cystocoele, a reverse downward thrust is taught on the second visit. The patient presses upwards with the probe or a finger placed approximately 2 cm inwards from the introitus, and strains downwards. The downward thrust is now alternated with the Kegel squeezes, each three times per day. The downward-acting exercises strengthen the fast twitch fibres of all three directional muscle forces.

Third Visit

The attendant checks the patient compliance (diary), discusses how she has incorporated the programme into her daily routine, and reinforces the aims and principles of the programme.
At the three month review (fourth visit), in consultation with the patient, a decision is made whether to proceed to surgery, or continue with Maintenance PFR.

Maintenance PFR

By the end of three months, it is assumed that the patients have incorporated the exercises into their normal routine. Squeezing is alternated with the downward thrust, a total of six sets of 12 exercises per day. Squatting is by now an acquired habit. Electrotherapy is performed five days per month. The patient is advised to continue this routine for the rest of her life.

Comments

Almost 70% of patients who completed the treatment seemed unwilling to perform the reverse pushdown exercises. Squatting, Kegel and electrotherapy were well received.
Results of the First study (Petros & Skilling, 2001)

Sixty patients completed the study. Improvement was defined as >50% improvement in their symptoms (see Table 1).